Efficacy and safety of adjunctive mitomycin C during Ahmed Glaucoma Valve implantation:A prospective randomized clinical trial

Purpose To evaluate the efficacy and safety of intraoperative mitomycin C (MMC) in eyes undergoing Ahmed Glaucoma Valve implantation. Design Randomized controlled clinical trial. Participants Sixty patients with refractory glaucoma. Intervention Sixty eyes of 60 patients with refractory glaucoma were randomized to receive intraoperative MMC (0.5 mg/ml for 5 minutes) (n = 34) or balanced salt solution (n = 26) during Ahmed Glaucoma Valve implantation. Main outcome measures Surgical success was defined according to 2 different criteria: (1) postoperative intraocular pressure (IOP) between 6 and 21 mmHg, with or without antiglaucoma medications, and (2) IOP reduction of at least 30% relative to preoperative values. Eyes requiring additional glaucoma surgery, developing phthisis, or showing loss of light perception were classified as failures. Success rates in both groups were compared using Kaplan-Meier survival curves and the log rank test. Other outcome measures were mean IOP, number of glaucoma medications, and complications. Results After a mean follow-up of 12.3 months, Kaplan-Meier survival analysis showed a probability of success of 59% at 18 months for the MMC group and 61% for the control group when the first criterion for success was used (IOP between 6 and 21 mmHg). When an IOP reduction of at least 30% was used as the criterion to define success, the Kaplan-Meier survival analysis demonstrated a probability of success at 18 months of 62% for the MMC group and 67% for the control group. There were no significant differences in survival rates between the 2 groups with either criterion (P = 0.75 and P = 0.37, respectively). After 15 days postoperatively, the mean IOP did not significantly differ for both MMC and control eyes. Mean numbers of postoperative antiglaucoma medications were similar in MMC-treated eyes and controls. There was no significant difference between the incidences of postoperative complications in both groups. Conclusion Mitomycin C did not increase the short- or intermediate-term success rates of Ahmed Glaucoma Valve implantation. © 2004 by the American Academy of Ophthalmology.

Clinical risk management and the ethics of open disclosure : part 1 : benefits and risks to patient safety

Patient safety experts and other authorities have strongly postulated the open disclosure of errors and adverse events to patients as an essential component of effective clinical risk management in health care. Commentators also contend that ‘when things go wrong’, openly disclosing such events to the patient and his or her nominated support person is simply ‘the right thing to do’. Despite the obvious importance of the issue of open disclosure and its possible implications for the nursing profession, it has not been comprehensively addressed in the nursing literature. A key aim of this article (the first of a two-part discussion) is to contribute to the positive project of redressing this oversight by providing a brief overview of what open disclosure is and what its intended purpose, aims, and rationale are. Consideration is also given to the risks and benefits of open disclosure as a public policy and whether it will succeed in achieving the anticipated outcomes envisaged. In a second article (to be presented as Part II), the ethics of open disclosure and its possible implications for the nursing profession are explored.

Efficacy, safety and tolerability of terbinafine for Tinea capitis in children: Brazilian multicentric study with daily oral tablets for 1, 2 and 4 weeks

Background: Tinea capitis is a common skin disease seen predominantly in children. The standard therapies for this disease are griseofulvin and ketoconazole. Nevertheless, these drugs have drawbacks in that they are only fungistatic and require treatment for at least 6 weeks. Previous studies with oral terbinafine for the treatment of Tinea capitis have shown that this agent is effective when given for 4 weeks, comparable to an 8-week regimen with griseofulvin. To date there is no data on the use of oral terbinafine in Brazilian children. Objectives: To assess the efficacy, safety and tolerability of oral terbinafine in short-term treatments (1-, 2- and 4-week treatment) of Tinea capitis in children. Patients and methods: One hundred and thirty-two children aged 1-14 years were enrolled in this study, but only 107 were considered for the final efficacy analysis. Diagnosis included clinical assessment and examination by Wood's light. Confirmation was obtained by direct microscopy and culture for fungus. Terbinafine dosage (125 or 250 mg/day) was adjusted according to patient weight. Efficacy was evaluated both by clinical and mycological assessment. Safety and tolerability variables included data on adverse reaction and clinical laboratory evaluations. Results: Mycological evaluation in the follow-up visit at week 12 showed negative direct microscopy and culture results in 48.6, 60.5 and 69.7% patients in groups 1-, 2- and 4-week, respectively (n.s.). At week 12, 84.8% patients in group 4-week achieved clinical cure with a significant difference compared to groups 1- and 2-week, 54.3 and 60.5%, respectively (P < 0.01). Adverse reactions were present in 4.8, 6.8 and 10.9% of patients in groups 1-, 2- and 4-week, respectively. Terbinafine was not associated with clinically relevant increases in liver function tests. Conclusions: Terbinafine is an effective, well tolerated and safe antifungal agent for the treatment of Tinea capitis m children. The shorter duration of treatment resulted in lower cure rates. However, it is important to note that depending on the severity of the disease, a 1-week-only treatment can also be effective in this indication.

Efficacy and safety of the Betamethasone valerate 0.1% plaster in mild-to-moderate chronic plaque psoriasis: a randomized, parallel-group, active-controlled, phase III study

Corticosteroids are a versatile option for the treatment of mild-to-moderate psoriasis due to their availability in a wide range of potencies and formulations. Occlusion of the corticosteroid is a widely accepted procedure to enhance the penetration of the medication, thereby improving its effectiveness. Betamethasone valerate (BMV) is a moderately potent corticosteroid that is available as a cream, ointment, and lotion. A ready-to-use occlusive dressing, which provides a continuous sustained release of BMV, has been developed for the treatment of psoriasis.

Cardiovascular adverse events during adjuvant endocrine therapy for early breast cancer using letrozole or tamoxifen: safety analysis of BIG 1-98 trial

PURPOSE: Previous analyses of adjuvant studies of aromatase inhibitors versus tamoxifen, including the Breast International Group (BIG) 1-98 study, have suggested a small numerical excess of cardiac adverse events (AEs) on aromatase inhibitors, a reduction in the incidence of hypercholesterolemia on tamoxifen, and significantly higher incidence of thromboembolic AEs on tamoxifen. The purpose of the present study is to provide detailed updated information on these AEs in BIG 1-98. PATIENTS AND METHODS: Eight thousand twenty-eight postmenopausal women with receptor-positive early breast cancer were randomly assigned (double-blind) between March 1998 and May 2003 to receive 5 years of adjuvant endocrine therapy with letrozole, tamoxifen, or a sequence of these agents. Seven thousand nine hundred sixty-three patients who actually received therapy are included in this safety analysis, which focuses on cardiovascular events. AE recording ceased 30 days after therapy completion (or after switch on the sequential arms). RESULTS: Baseline comorbidities were balanced. At a median follow-up time of 30.1 months, we observed similar overall incidence of cardiac AEs (letrozole, 4.8%; tamoxifen, 4.7%), more grade 3 to 5 cardiac AEs on letrozole (letrozole, 2.4%; tamoxifen, 1.4%; P = .001)--an excess only partially attributable to prior hypercholesterolemia--and more overall (tamoxifen, 3.9%; letrozole, 1.7%; P < .001) and grade 3 to 5 thromboembolic AEs on tamoxifen (tamoxifen, 2.3%; letrozole, 0.9%; P < .001). There was no significant difference between tamoxifen and letrozole in incidence of hypertension or cerebrovascular events. CONCLUSION: The present safety analysis, limited to cardiovascular AEs in BIG 1-98, documents a low overall incidence of cardiovascular AEs, which differed between treatment arms.

Safety, pharmacokinetics, and antiretroviral activity of multiple doses of ibalizumab (formerly TNX-355), an anti-CD4 monoclonal antibody in HIV-1 infected adults

Context: Despite tremendous strides in HIV treatment over the past decade, resistance remains a major problem. A growing number of patients develop resistance and require new therapies to suppress viral replication. ^ Objective: To assess the safety of multiple administrations of the anti-CD4 receptor (anti-CD4) monoclonal antibody ibalizumab given as intravenous (IV) infusions, in three dosage regimens, in subjects infected with human immunodeficiency virus (HIV-1). ^ Design: Phase 1, multi-center, open-label, randomized clinical trial comparing the safety, pharmacokinetics and antiviral activity of three dosages of ibalizumab. ^ Setting: Six clinical trial sites in the United States. ^ Participants: A total of twenty-two HIV-positive patients on no anti-retroviral therapy or a stable failing regimen. ^ Intervention: Randomized to one of two treatment groups in Arms A and B followed by non-randomized enrollment in Arm C. Patients randomized to Arm A received 10 mg/kg of ibalizumab every 7 days, for a total of 10 doses; patients randomized to Arm B received a total of six doses of ibalizumab; a single loading dose of 10 mg/kg on Day 1 followed by five maintenance doses of 6 mg/kg every 14 days, starting at Week 1. Patients assigned to Arm C received 25 mg/kg of ibalizumab every 14 days for a total of 5 doses. All patients were followed for safety for an additional 7 to 8 weeks. ^ Main Outcome Measures: Clinical and laboratory assessments of safety and tolerability of multiple administrations of ibalizumab in HIV-infected patients. Secondary measures of efficacy include HIV-1 RNA (viral load) measurements. ^ Results: 21 patients were treatment-experienced and 1 was naïve to HIV therapy. Six patients were failing despite therapy and 15 were on no current HIV treatment. Mean baseline viral load (4.78 log 10; range 3.7-5.9) and CD4+ cell counts (332/μL; range 89-494) were similar across cohorts. Mean peak decreases in viral load from baseline of 0.99 log10(1.11 log10, and 0.96 log 10 occurred by Wk 2 in Cohorts A, B and C, respectively. Viral loads decreased by >1.0 log10 in 64%; 4 patients viral loads were suppressed to < 400 copies/mL. Viral loads returned towards baseline by Week 9 with reduced susceptibility to ibalizumab. CD4+ cell counts rose transiently and returned toward baseline. Maximum median elevations above BL in CD4+ cell counts for Cohorts A, B and C were +257, +198 and +103 cells/μL, respectively and occurred within 3 Wks in 16 of 22 subjects. The half-life of ibalizumab was 3-3.5 days and elimination was characteristic of capacity-limited kinetics. Administration of ibalizumab was well tolerated. Four serious adverse events were reported during the study. None of these events were related to study drug. Headache, nausea and cough were the most frequently reported treatment emergent adverse events and there were no laboratory abnormalities related to study drug. ^ Conclusions: Ibalizumab administered either weekly or bi-weekly was safe, well tolerated, and demonstrated antiviral activity. Further studies with ibalizumab in combination with standard antiretroviral treatments are warranted.^

Fishing effort control regulations influence on stability, safety and operability of small fishing vessels: study of a series of stability related accidents occurred in Spain between 2004 and 2007

Entre los años 2004 y 2007 se hundieron por problemas de estabilidad cinco pesqueros españoles de pequeña eslora, de características parecidas, de relativamente poca edad, que habían sido construidos en un intervalo de pocos años. La mayoría de los tripulantes de esos pesqueros fallecieron o desaparecieron en esos accidentes. Este conjunto de accidentes tuvo bastante repercusión social y mediática. Entre ingenieros navales y marinos del sector de la pesca se relacionó estos accidentes con los condicionantes a los diseños de los pesqueros impuestos por la normativa de control de esfuerzo pesquero. Los accidentes fueron investigados y publicados sus correspondientes informes; en ellos no se exploró esta supuesta relación. Esta tesis pretende investigar la relación entre esos accidentes y los cambios de la normativa de esfuerzo pesquero. En la introducción se expone la normativa de control de esfuerzo pesquero analizada, se presentan datos sobre la estructura de la flota pesquera en España y su accidentalidad, y se detallan los criterios de estabilidad manejados durante el trabajo, explicando su relación con la seguridad de los pesqueros. Seguidamente se realiza un análisis estadístico de la siniestralidad en el sector de la pesca para establecer si el conjunto de accidentes estudiados supone una anomalía, o si por el contrario el conjunto de estos accidentes no es relevante desde el punto de vista estadístico. Se analiza la siniestralidad a partir de diversas bases de datos de buques pesqueros en España y se concluye que el conjunto de accidentes estudiados supone una anomalía estadística, ya que la probabilidad de ocurrencia de los cinco sucesos es muy baja considerando la frecuencia estimada de pérdidas de buques por estabilidad en el subsector de la flota pesquera en el que se encuadran los cinco buques perdidos. A continuación el trabajo se centra en la comparación de los buques accidentados con los buques pesqueros dados de baja para construir aquellos, según exige la normativa de control de esfuerzo pesquero; a estos últimos buques nos referiremos como “predecesores” de los buques accidentados. Se comparan las dimensiones principales de cada buque y de su predecesor, resultando que los buques accidentados comparten características de diseño comunes que son sensiblemente diferentes en los buques predecesores, y enlazando dichas características de diseño con los requisitos de la nueva normativa de control del esfuerzo pesquero bajo la que se construyeron estos barcos. Ello permite establecer una relación entre los accidentes y el mencionado cambio normativo. A continuación se compara el margen con que se cumplían los criterios reglamentarios de estabilidad entre los buques accidentados y los predecesores, encontrándose que en cuatro de los cinco casos los predecesores cumplían los criterios de estabilidad con mayor holgura que los buques accidentados. Los resultados obtenidos en este punto permiten establecer una relación entre el cambio de normativa de esfuerzo pesquero y la estabilidad de los buques. Los cinco buques accidentados cumplían con los criterios reglamentarios de estabilidad en vigor, lo que cuestiona la relación entre esos criterios y la seguridad. Por ello se extiende la comparativa entre pesqueros a dos nuevos campos relacionados con la estabilidad y la seguridad delos buques: • Movimientos a bordo (operatividad del buque), y • Criterios de estabilidad en condiciones meteorológicas adversas El estudio de la operatividad muestra que los buques accidentados tenían, en general, una mayor operatividad que sus predecesores, contrariamente a lo que sucedía con el cumplimiento de los criterios reglamentarios de estabilidad. Por último, se comprueba el desempeño de los diez buques en dos criterios específicos de estabilidad en caso de mal tiempo: el criterio IMO de viento y balance intenso, y un criterio de estabilidad de nueva generación, incluyendo la contribución original del autor de considerar agua en cubierta. Las tendencias observadas en estas dos comparativas son opuestas, lo que permite cuestionar la validez del último criterio sin un control exhaustivo de los parámetros de su formulación, poniendo de manifiesto la necesidad de más investigaciones sobre ese criterio antes de su adopción para uso regulatorio. El conjunto de estos resultados permite obtener una serie de conclusiones en la comparativa entre ambos conjuntos de buques pesqueros. Si bien los resultados de este trabajo no muestran que la aprobación de la nueva normativa de esfuerzo pesquero haya significado una merma general de seguridad en sectores enteros de la flota pesquera, sí se concluye que permitió que algunos diseños de buques pesqueros, posiblemente en busca de la mayor eficiencia compatible con dicha normativa, quedaran con una estabilidad precaria, poniendo de manifiesto que la relación entre seguridad y criterios de estabilidad no es unívoca, y la necesidad de que éstos evolucionen y se adapten a los nuevos diseños de buques pesqueros para continuar garantizando su seguridad. También se concluye que la estabilidad es un aspecto transversal del diseño de los buques, por lo que cualquier reforma normativa que afecte al diseño de los pesqueros o su forma de operar debería estar sujeta a evaluación por parte de las autoridades responsables de la seguridad marítima con carácter previo a su aprobación. ABSTRACT Between 2004 and 2007 five small Spanish fishing vessels sank in stability related accidents. These vessels had similar characteristics, had relatively short age, and had been built in a period of a few years. Most crewmembers of these five vessels died or disappeared in those accidents. This set of accidents had significant social and media impact. Among naval architects and seamen of the fishing sector these accidents were related to the design constraints imposed by the fishing control effort regulations. The accidents were investigated and the official reports issued; this alleged relationship was not explored. This thesis aims to investigate the relationship between those accidents and changes in fishing effort control regulations. In the introduction, the fishing effort control regulation is exposed, data of the Spanish fishing fleet structure and its accident rates are presented, and stability criteria dealt with in this work are explained, detailing its relationship with fishing vessel safety. A statistical analysis of the accident rates in the fishing sector in Spain is performed afterwards. The objective is determining whether the set of accidents studied constitute an anomaly or, on the contrary, they are not statistically relevant. Fishing vessels accident rates is analyzed from several fishing vessel databases in Spain. It is concluded that the set of studied accidents is statistically relevant, as the probability of occurrence of the five happenings is extremely low, considering the loss rates in the subsector of the Spanish fishing fleet where the studied vessels are fitted within. From this point the thesis focuses in comparing the vessels lost and the vessels that were decommissioned to build them as required by the fishing effort control regulation; these vessels will be referred to as “predecessors” of the sunk vessels. The main dimensions between each lost vessel and her predecessor are compared, leading to the conclusion that the lost vessels share design characteristics which are sensibly different from the predecessors, and linking these design characteristics with the requirements imposed by the new fishing control effort regulations. This allows establishing a relationship between the accidents and this regulation change. Then the margin in fulfilling the regulatory stability criteria among the vessels is compared, resulting, in four of the five cases, that predecessors meet the stability criteria with greater clearance than the sunk vessels. The results obtained at this point would establish a relationship between the change of fishing effort control regulation and the stability of vessels. The five lost vessels complied with the stability criteria in force, so the relation between these criteria and safety is put in question. Consequently, the comparison among vessels is extended to other fields related to safety and stability: • Motions onboard (operability), and • Specific stability criteria in rough weather The operability study shows that the lost vessels had in general greater operability than their predecessors, just the opposite as when comparing stability criteria. Finally, performance under specific rough weather stability criteria is checked. The criteria studied are the IMO Weather Criterion, and one of the 2nd generation stability criteria under development by IMO considering in this last case the presence of water on deck, which is an original contribution by the author. The observed trends in these two cases are opposite, allowing to put into question the last criterion validity without an exhaustive control of its formulation parameters; indicating that further research might be necessary before using it for regulatory purposes. The analysis of this set of results leads to some conclusions when comparing both groups of fishing vessels. While the results obtained are not conclusive in the sense that the entry into force of a new fishing effort control in 1998 caused a generalized safety reduction in whole sectors of the Spanish fishing fleet, it can be concluded that it opened the door for some vessel designs resulting with precarious stability. This evidences that the relation between safety and stability criteria is not univocal, so stability criteria needs to evolve for adapting to new fishing vessels designs so their safety is still guaranteed. It is also concluded that stability is a transversal aspect to ship design and operability, implying that any legislative reform affecting ship design or operating modes should be subjected to assessing by the authorities responsible for marine safety before being adopted.