Arrhythmias and mortality after myocardial infarction in diabetic patients - Relationship to diabetes treatment

OBJECTIVE- To assess the relationship between clinical course after acute myocardial infarction (AMI) and diabetes treatment. RESEARCH DESIGN AND METHODS- Retrospective analysis of data from all patients aged 25-64 years admitted to hospitals in Perth, Australia, between 1985 and 1993 with AMI diagnosed according to the International Classification of Diseases (9th revision) criteria was conducted. Short- (28-day) and long-term survival and complications in diabetic and nondiabetic patients were compared. For diabetic patients, 28-day survival, dysrhythmias, heart block, and pulmonary edema were treated as outcomes, and factors related to each were assessed using multiple logistic regression. Diabetes treatment was added to the model to assess its significance. Long-term survival was compared by means of a Cox proportional hazards model. RESULTS- Of 5,715 patients, 745 (12.9%) were diabetic. Mortality at 28 days was 12.0 and 28.1% for nondiabetic and diabetic patients, respectively (P < 0.001); there were no significant drug effects in the diabetic group. Ventricular fibrillation in diabetic patients taking glibenclamide (11.8%) was similar to that of nondiabetic patients (11.0%) but was lower than that for those patients taking either gliclazide (18.0%; 0.1 > P > 0.05) or insulin (22.8%; P < 0.05). There were no other treatment-related differences in acute complications. Long-term survival in diabetic patients was reduced in those taking digitalis and/or diuretics but type of diabetes treatment at discharge had no significant association with outcome. CONCLUSlONS- These results do not suggest that ischemic heart disease should influence the choice of diabetes treatment regimen in general or of sulfonylurea drug in particular.

Topical penetration of commercial salicylate esters and salts using human isolated skin and clinical microdialysis studies

Aims The penetration of active ingredients from topically applied anti-inflammatory pharmaceutical products into tissues below the skin is the basis of their therapeutic efficacy. There is still controversy as to whether these agents are capable of direct penetration by diffusion through the tissues or whether redistribution in the systemic circulation is responsible for their tissue deposition below the application site. Methods The extent of direct penetration of salicylate from commercial ester and salt formulations into the dermal and subcutaneous tissue of human volunteers was determined using the technique of cutaneous microdialysis. We also examined differences in the extent of hydrolysis of the methylester of salicylate applied topically in human volunteers and in vitro skin diffusion cells using full-thickness skin and epidermal membranes. Results The present study showed that whilst significant levels of salicylate could be detected in the dermis and subcutaneous tissue of volunteers treated with the methylsalicylate formulation, negligible levels of salicylate were seen following application of the triethanolamine salicylate formulation. The tissue levels of salicylate from the methylsalicylate formulation were approx. 30-fold higher than the plasma concentrations. Conclusion The absorption and tissue concentration profiles for the commercial methylsalicylate formulation are indicative of direct tissue penetration and not solely redistribution by the systemic blood supply.

The nurse lecturer role in clinical practice conceptualized: helping clinical teachers provide optimal student learning

Despite the fairly wide reporting in the literature of the ma ny roles of clinical supervision by the nursing teacher, little attention has been given to conceptualizing the relative priorities these roles take during the process of supervising nursing students in clinical practice. The purpose of this paper is to consider the manifestations and implications of conflicting roles when nurse lecturers undertake clinical supervision. Previously published research will provide working examples of issues in a conceptual framework for clinical teaching.

Long-term clozapine treatment identifies significant improvements in clinical and functioning scales

The majority of clinical drug trials only cover a small number of variables over a short period of time on a small group of people. The objective of this study was to track a large group of people over a long period of time, using a diverse range of variables with a naturalistic design to assess the ‘real world’ use of clozapine. Fifty-three people with treatment-resistant schizophrenia were recruited into a 2-year study which assessed the subjects using the following scales: Positive and Negative Syndrome Scale (PANSS), Clinical Global Impression Scale (CGI), Life Skills Profile (LSP), and Role Functioning Scale (RFS). Discharge, leave, and ward movement rates were also monitored. All subjects were inpatients at a tertiary psychiatric facility. Thirty-three percent of the group was discharged. Seventythree percent moved to less cost-intensive wards, and the leave rate increased by 105”/0. Sixty-seven percent of the study group were identified as responders by the 24-month time point. Twenty-four percent of the group had their CGI scores reduced to 2 or better 0, =O.OOOl). Significant improvements were identified in the RFS (p = 0.02) and LSP (p = 0.0001). Long-term clozapine treatment has identified a significant group of responders on a variety of measures.

Providing evidence-based answers to clinical questions - A pilot information service for general practitioners

Objective: To pilot a clinical information service for general practitioners. Methods: A representative sample of 31 GPs was invited to submit clinical questions to a local academic department of general practice. Their views on the service and the usefulness of the information were obtained by telephone interview. Results: Over one month, nine GPs (29% of the sample, 45% of those stating an interest), submitted 20 enquiries comprising 45 discrete clinical questions. The median time to search for evidence, appraise it and write answers to each enquiry was 2.5 hours (range, 1.0-7.4 hours). The median interval between receipt of questions and dispatch of answers was 3 clays (range, 1-12 days). Conclusions: The GPs found the answers useful in clinical decision making; in four out of 20 cases patient management was altered.

Cannabis use and psychosis: a review of clinical and epidemiological evidence

Objective: This paper evaluates evidence for two hypotheses about the relationship between cannabis use and psychosis: (i) that heavy cannabis use causes a 'cannabis psychosis', i.e, a psychotic disorder that would not have occurred in the absence of cannabis use and which can be recognised by its pattern of symptoms and their relationship to cannabis use; and (ii) that cannabis use may precipitate schizophrenia, or exacerbate its symptoms. Method: Literature relevant to drug use and schizophrenia is reviewed. Results: There is limited clinical evidence for the first hypothesis. If 'cannabis psychoses' exist, they seem to be rare, because they require very high doses of tetrahydrocannabinol, the prolonged use of highly potent forms of cannabis, or a preexisting (but as yet unspecified) vulnerability, or both. There is more support for the second hypothesis in that a large prospective study has shown a linear relationship between the frequency with which cannabis had been used by age 18 and the risk over the subsequent 15 years of receiving a diagnosis of schizophrenia. Conclusions: It is still unclear whether this means that cannabis use precipitates schizophrenia, whether cannabis use is a form of 'self-medication', or whether the association is due to the use of other drugs, such as amphetamines, which heavy cannabis users are more likely to use. There is better clinical and epidemiological evidence that cannabis use can exacerbate the symptoms of schizophrenia.