Injection therapy for the treatment of erectile dysfunction: a comparison between alprostadil and a combination of vasoactive intestinal polypeptide and phentolamine mesilate.

OBJECTIVE: To compare two injectable treatments, alprostadil 5-20 microg powder for injection and a combination of vasoactive intestinal polypeptide (VIP) and phentolamine in patients with erectile dysfunction (ED). DESIGN AND METHODS: This was an open multicentre, randomised crossover study comprising two phases. The first phase established the dose of each drug required to produce an erection suitable for sexual intercourse (grade 3 erection). In phase 2, responders to both drugs received, in random order, four doses of VIP/phentolamine, presented as ampoules, and four doses of alprostadil, presented as powder for injection. This was followed by four doses of VIP/phentolamine, presented in an autoinjector. In both phases, patient preference was assessed for each preparation. RESULTS: 187 patients were recruited. In the first phase, both treatments were effective, (83% alprostadil vs. 73% VIP/phentolamine, p = 0.002) but more patients preferred VIP/phentolamine (69 vs. 31%, p = 0.011). In phase 2 (n = 107), the proportion of injections that produced a grade 3 erection was similar for all three treatments (83-85%), but both presentations of VIP/phentolamine (ampoule and auto-injector) were preferred by significantly more patients (p < 0.001). Compared with both presentations of VIP/phentolamine, alprostadil produced a higher frequency of pain (28% of injections vs. 3% for each VIP/phentolamine presentation; p < 0.001) and a lower frequency of facial flushing (3 vs. 16-17%; p < 0.001). CONCLUSIONS: VIP/phentolamine and alprostadil were effective treatments for ED, however the VIP/phentolamine combination was preferred by more patients, which may be because it was much less likely to cause pain.

Targets and self monitoring in hypertension: randomised controlled trial and cost effectiveness analysis.

OBJECTIVES: To assess whether blood pressure control in primary care could be improved with the use of patient held targets and self monitoring in a practice setting, and to assess the impact of these on health behaviours, anxiety, prescribed antihypertensive drugs, patients' preferences, and costs. DESIGN: Randomised controlled trial. SETTING: Eight general practices in south Birmingham. PARTICIPANTS: 441 people receiving treatment in primary care for hypertension but not controlled below the target of < 140/85 mm Hg. INTERVENTIONS: Patients in the intervention group received treatment targets along with facilities to measure their own blood pressure at their general practice; they were also asked to visit their general practitioner or practice nurse if their blood pressure was repeatedly above the target level. Patients in the control group received usual care (blood pressure monitoring by their practice). PRIMARY OUTCOME: change in systolic blood pressure at six months and one year in both intervention and control groups. SECONDARY OUTCOMES: change in health behaviours, anxiety, prescribed antihypertensive drugs, patients' preferences of method of blood pressure monitoring, and costs. RESULTS: 400 (91%) patients attended follow up at one year. Systolic blood pressure in the intervention group had significantly reduced after six months (mean difference 4.3 mm Hg (95% confidence interval 0.8 mm Hg to 7.9 mm Hg)) but not after one year (mean difference 2.7 mm Hg (- 1.2 mm Hg to 6.6 mm Hg)). No overall difference was found in diastolic blood pressure, anxiety, health behaviours, or number of prescribed drugs. Patients who self monitored lost more weight than controls (as evidenced by a drop in body mass index), rated self monitoring above monitoring by a doctor or nurse, and consulted less often. Overall, self monitoring did not cost significantly more than usual care (251 pounds sterling (437 dollars; 364 euros) (95% confidence interval 233 pounds sterling to 275 pounds sterling) versus 240 pounds sterling (217 pounds sterling to 263 pounds sterling). CONCLUSIONS: Practice based self monitoring resulted in small but significant improvements of blood pressure at six months, which were not sustained after a year. Self monitoring was well received by patients, anxiety did not increase, and there was no appreciable additional cost. Practice based self monitoring is feasible and results in blood pressure control that is similar to that in usual care.

Systematic review and modelling of the investigation of acute and chronic chest pain presenting in primary care.

OBJECTIVES: To ascertain the value of a range of methods - including clinical features, resting and exercise electrocardiography, and rapid access chest pain clinics (RACPCs) - used in the diagnosis and early management of acute coronary syndrome (ACS), suspected acute myocardial infarction (MI), and exertional angina. DATA SOURCES: MEDLINE, EMBASE, CINAHL, the Cochrane Library and electronic abstracts of recent cardiological conferences. REVIEW METHODS: Searches identified studies that considered patients with acute chest pain with data on the diagnostic value of clinical features or an electrocardiogram (ECG); patients with chronic chest pain with data on the diagnostic value of resting or exercise ECG or the effect of a RACPC. Likelihood ratios (LRs) were calculated for each study, and pooled LRs were generated with 95% confidence intervals. A Monte Carlo simulation was performed evaluating different assessment strategies for suspected ACS, and a discrete event simulation evaluated models for the assessment of suspected exertional angina. RESULTS: For acute chest pain, no clinical features in isolation were useful in ruling in or excluding an ACS, although the most helpful clinical features were pleuritic pain (LR+ 0.19) and pain on palpation (LR+ 0.23). ST elevation was the most effective ECG feature for determining MI (with LR+ 13.1) and a completely normal ECG was reasonably useful at ruling this out (LR+ 0.14). Results from 'black box' studies of clinical interpretation of ECGs found very high specificity, but low sensitivity. In the simulation exercise of management strategies for suspected ACS, the point of care testing with troponins was cost-effective. Pre-hospital thrombolysis on the basis of ambulance telemetry was more effective but more costly than if performed in hospital. In cases of chronic chest pain, resting ECG features were not found to be very useful (presence of Q-waves had LR+ 2.56). For an exercise ECG, ST depression performed only moderately well (LR+ 2.79 for a 1 mm cutoff), although this did improve for a 2 mm cutoff (LR+ 3.85). Other methods of interpreting the exercise ECG did not result in dramatic improvements in these results. Weak evidence was found to suggest that RACPCs may be associated with reduced admission to hospital of patients with non-cardiac pain, better recognition of ACS, earlier specialist assessment of exertional angina and earlier diagnosis of non-cardiac chest pain. In a simulation exercise of models of care for investigation of suspected exertional angina, RACPCs were predicted to result in earlier diagnosis of both confirmed coronary heart disease (CHD) and non-cardiac chest pain than models of care based around open access exercise tests or routine cardiology outpatients, but they were more expensive. The benefits of RACPCs disappeared if waiting times for further investigation (e.g. angiography) were long (6 months). CONCLUSIONS: Where an ACS is suspected, emergency referral is justified. ECG interpretation in acute chest pain can be highly specific for diagnosing MI. Point of care testing with troponins is cost-effective in the triaging of patients with suspected ACS. Resting ECG and exercise ECG are of only limited value in the diagnosis of CHD. The potential advantages of RACPCs are lost if there are long waiting times for further investigation. Recommendations for further research include the following: determining the most appropriate model of care to ensure accurate triaging of patients with suspected ACS; establishing the cost-effectiveness of pre-hospital thrombolysis in rural areas; determining the relative cost-effectiveness of rapid access chest pain clinics compared with other innovative models of care; investigating how rapid access chest pain clinics should be managed; and establishing the long-term outcome of patients discharged from RACPCs.

A systematic review of the evidence for rapid access chest pain clinics.

To determine the impact of rapid access chest pain clinics (RACPC) on patient management, a systematic search (1966-2000) was performed of electronic databases, recent conference abstracts, citations of all identified studies, and by contact with other researchers. Studies of any design were included. Assessment of eligibility, methodological quality of studies and data abstraction was conducted independently by two reviewers. Outcome measures were sought in terms of admission rate of patients without acute coronary syndrome detection rate of acute coronary syndrome unrecognised by the GP, timing of specialist assessment of patients with stable angina and speed and accuracy of detection of those with non-cardiac chest pain. Nine relevant studies were found, but all had methodological flaws when considered as evaluative studies. All clinics described reviewed patients within 24 hours of referral. Only three studies made comparisons with control groups, none of which were randomised, and a further three provided follow-up data only. Limited data were found for all four outcome measures, indicating possible benefits of RACPCs. However, all findings could be explained by potential biases in the original studies. In conclusion, the evidence base for the introduction of rapid access chest pain clinics is poor. The introduction of these clinics should include a randomised prospective evaluation of their worth.

Effects of haloperidol or SCH-23390 on ethanol-induced conditioned taste aversion.

Dopaminergic systems are thought to play an important role in the motivational effects of ethanol. The present experiments examined the effects of haloperidol (a D2 antagonist) and SCH-23390 (a D1 antagonist) on the acquisition of ethanol-induced conditioned taste aversion. In four separate experiments, adult male Swiss-Webster mice were acclimated to a 2-h/day water restriction regimen. Subsequently they received four conditioning trials consisting of 1-h access to either 0.2 M NaCl (experiments 1-3) or 0.15 % w/v saccharin (experiment 4). After flavor access on trials 1-3, subjects received either haloperidol (0.1, 0.15, or 0.3 mg/kg), SCH-23390 (0.05 mg/kg), or saline followed 30 min later by 0, 2, or 4 g/kg ethanol. Ethanol-flavor pairings reduced subsequent flavor intakes, indicating the development of conditioned taste aversion. Neither haloperidol of SCH-23390 reduced flavor intakes in the absence of ethanol. However, both haloperidol and SCH-23390 reduced ethanol-conditioned aversion depending on ethanol dose and conditioned flavor. These results are consistent with the notion that dopaminergic processes are important for the development of ethanol-induced conditioned taste aversion, and the notion that dopaminergic receptor systems influence both positive and negative motivational effects of ethanol.

Mouse strain differences in oral operant ethanol reinforcement under continuous access conditions.

The present experiment examined ethanol self-administration in C57BL/6J (C57) and DBA/2J (DBA) mice using a continuous access operant procedure. Adult male C57 and DBA mice were initially trained to perform a lever press response to obtain access to 10% w/v sucrose solution. Subsequently, the mice were placed in operant chambers on a continuous (23 hr/day) basis with access to food (FR1), 10% v/v ethanol (FR4), and water from a sipper tube. C57 mice displayed greater rates of responding on the ethanol-associated lever compared with DBA mice. Responding on the food lever was the same in both strains, but DBA mice consumed greater amounts of water. C57 mice consistently displayed both prandial and nonprandial episodes (bouts) of ethanol responding. DBA mice did not respond for ethanol in bouts. Following 50 consecutive sessions, ethanol concentration was altered every 5 days. Response patterns were determined using 0, 5, 10, 20, and 30% v/v ethanol concentrations. C57 mice displayed concentration-dependent responding on the ethanol lever showing that ethanol was functioning as an effective reinforcer in this strain. In contrast, responding on the ethanol lever by DBA mice did not change as a function of ethanol concentration. Saccharin (0.2% w/v) was subsequently added to the ethanol mixture, and responding was examined at 0, 5, 10, and 20% ethanol concentrations. Overall, ethanol lever responding was increased in both strains. As before, C57 mice showed higher levels of ethanol responding, compared with DBA mice. C57 mice also showed higher responding for saccharin alone. These results are consistent with findings that suggest orally administered ethanol is a more effective reinforcer in C57 mice than in DBA mice. Furthermore, C57 mice engage in ethanol-reinforced responding over a broader range of conditions than DBA mice.

Reduced sensitivity to ethanol reward, but not ethanol aversion, in mice lacking 5-HT1B receptors.

Various serotonergic receptor systems are thought to influence the motivational effects of ethanol. This experiment characterized the acquisition of ethanol-induced conditioned taste aversion and ethanol-induced conditioned place reference in mutant knockout mice lacking 5-HT1b receptors. In the taste conditioning procedure, adult homozygous knockout mice (-/-) and homozygous wild-type mice (+/+) received access to 0.2 M NaCl solution, followed immediately by intraperitoneal injection of 0 to 4 g/kg of ethanol. Ethanol produced dose-dependent conditioned taste aversion that was the same in both genotypes. In the place conditioning procedure, knockout and wild-type mice received six pairings of a tactile stimulus with ethanol (2 g/kg, i.p.). A different tactile stimulus was paired with saline. Ethanol produced increases in locomotor activity, with wild-type mice showing higher levels of ethanol-stimulated activity than knockout mice during conditioning trials 5 and 6. Wild-type mice demonstrated conditioned place preference for the ethanol-paired stimulus. In contrast, knockout mice showed no evidence of place conditioning. These results are generally consistent with an important role for serotonergic systems in ethanol reward and specifically indicate that 5-HT1b receptors are important for ethanol's rewarding effects but not for ethanol's aversive effects.

Dose- and conditioning trial-dependent ethanol-induced conditioned place preference in Swiss-Webster mice.

The motivational effects of ethanol were examined in Swiss-Webster mice using an unbiased place conditioning, design. Adult male Swiss-Webster mice received six 5-min pairings of a tactile stimulus with different doses of ethanol (1, 2, 3, or 4 g/kg. IP). A different tactile stimulus was paired with saline injections. A 60-min preference test was given after the first four conditioning trials and an additional 30-min preference test after the sixth conditioning trial. During conditioning, ethanol initially produced locomotor stimulation at the 2 g/kg dose and locomotor depression at the 4 g/kg dose. However, after repeated ethanol exposure, all doses produced overall increases in activity relative to saline, suggesting sensitization to ethanol's stimulant effect. After four conditioning trials ethanol-induced conditioned place preference was noted in mice receiving 3 and 4 g/kg ethanol. After two additional conditioning trials all ethanol doses produced conditioned place preference. These results indicate that ethanol has dose-dependent rewarding effects measured in an unbiased place-conditioning paradigm using a standard outbred mouse strain. Further, additional place-conditioning trials enhance the development of preference at lower (1 or 2 g/kg) ethanol doses.

Mianserin enhancement of ethanol-induced conditioned place preference.

This experiment examined the influence of mianserin, a 5-HT(2) receptor antagonist, on the rewarding effect of ethanol in a place conditioning paradigm. Swiss-Webster mice received four pairings of a tactile stimulus with drug treatment consisting of two i.p. injections separated by a 30min interval. Drug treatment groups were as follows: saline (10mg/kg) followed by ethanol (2mg/kg); mianserin (10mg/kg) followed by ethanol; mianserin followed by saline. A different stimulus was paired with two saline injections. During conditioning, ethanol produced increases in locomotor activity that were reduced by mianserin. Mianserin alone reduced activity levels. As expected, group saline-ethanol showed a nonsignificant trend towards conditioned place preference. However, mianserin enhanced the acquisition of ethanol preference, whereas mianserin alone did not produce either place preference or aversion. The results are consistent with the notion that serotonergic systems are important in the response to ethanol, and further suggest that 5-HT(2) receptor blockade increases the rewarding effects of ethanol.

Nicotine-induced conditioned place preference and conditioned place aversion in mice.

The motivational effects of nicotine were examined in mice using an unbiased place conditioning design. Swiss-Webster mice received four 15-min parings of a tactile stimulus with different doses of nicotine (0.25-2.0 mg/kg, IP). A different tactile stimulus was paired with saline injections. During conditioning, nicotine produced locomotor depression at the 2.0-mg/kg dose, with the greatest reduction in activity occurring during the latter part of each nicotine conditioning session. After four trials, nicotine produced increases in locomotor activity during the initial part of the nicotine sessions at doses 0.5 mg/kg or above. Upon testing, nicotine-induced conditioned place preference was noted in mice receiving 0.5 mg/kg nicotine. Conditioned place aversion was noted in mice receiving 2.0 mg/kg nicotine whereas doses of 0.25 and 1.0 mg/kg produced no conditioning. These results indicate that nicotine has dose-dependent rewarding and aversive effects measured in an unbiased place conditioning paradigm using mice.

Topical griseofulvin in the treatment of dermatophytoses.

Whether griseofulvin, which pioneered oral antifungal therapy, works topically has long been an open question. The effectiveness of a 1% griseofulvin spray formulation and the vehicle alone against experimentally induced Trichophyton mentagrophytes lesions on the forearms of 16 healthy volunteers and in the treatment of 100 tinea pedis patients (various dermatophytes) was evaluated in a double-blind study. After treatment of the 58 induced lesions twice daily for 14 days with topical griseofulvin (28) or placebo (30), 89% of lesions receiving griseofulvin were mycologically negative compared with 30% in the placebo group (P < 0.0001). In the tinea pedis patients who applied medication once daily for 4 weeks the mycological cure was 79.2% on the fourth week and 80.9% 2 weeks post-treatment. Resurgence of dermatophytes quickly followed the end of treatment in the placebo group only, which had a mycological cure rate of 34% (week 6). Administration of a topical formulation of griseofulvin thus may be an effective treatment for interdigital dermatophyte infections.

Distribution of griseofulvin in the rat: comparison of the oral and topical route of administration.

Effective penetration of griseofulvin across the dermal barrier has been achieved using an anhydrous solvent system of benzyl alcohol (10%), acetone (40%), and isopropanol (50%). There were quantitative differences in the relative accumulation of griseofulvin in skin compared with internal organs, when the topical and oral routes of administration were compared. The topical route enhanced localized concentrations of griseofulvin at the site of application, and these persisted for several days. After daily topical application a steady state was reached at day 3, when the diffusion across the skin barrier and epidermal loss seemed to equal the total amount applied to the skin surface. The application of griseofulvin topically, required a much smaller amount of drug to achieve similar integumentary levels compared with the amount required orally.