Comparison of potency of inhaled beclomethasone and budesonide in New Zealand: retrospective study of computerised general practice records.

OBJECTIVE: To determine whether inhaled budesonide and beclomethasone are equipotent in the treatment of asthma in primary care. DESIGN: Retrospective study of computerised clinical records from 28 general practices in New Zealand. SUBJECTS: 5930 patients who received 16 725 prescriptions for inhaled budesonide or beclomethasone from 1 July 1994 to 30 June 1995. SETTING: General practices on the database of the Royal New Zealand College of General Practitioners Research Unit. Linked information from secondary care was available for a subset of the practices. MAIN OUTCOME MEASURE: Mean prescribed daily inhaled corticosteroid dose. RESULTS: The daily prescribed dose was higher for patients receiving inhaled budesonide (mean 979 microg) than beclomethasone (mean 635 microg), a difference of 344 microg (95% confidence interval 313 to 376 microg). This difference was consistent in all age bands and with different types of inhalation device. Evidence of systematic prescribing of higher doses of budesonide to patients with more severe asthma was not found. CONCLUSIONS: In primary care in New Zealand evidence suggests that budesonide is less potent than beclomethasone. Consideration of validated, established, and other possible markers of asthma severity did not support confounding by severity as a reason for the higher prescribed doses of budesonide. Pending further epidemiological evaluation, international asthma guidelines may need to be modified on the equivalence of inhaled corticosteroid doses. Furthermore, the comparative potency of newly developed inhaled steroids in clinical trials will need to be confirmed in appropriately designed epidemiological studies based in general practice.

The diagnosis and initial treatment of asthma in young children in New Zealand and the United Kingdom.

AIMS: To conduct a pilot study to test methodology in ascertaining if there are differences between New Zealand and the UK in the symptom and circumstance set that influences a general practitioner in the initial diagnosis of asthma, and to ascertain the treatment prescribed at the time that the diagnosis is made. METHODS: Questionnaires were mailed to 110 general practitioners in each country. General practitioners from the Otago region in New Zealand and from the Nottingham region in Britain were contacted. A follow-up reminder was sent to all non-responders three weeks after the initial mail out. Questions were asked about the symptoms and signs that were considered important, as well as other influences (e.g., passive smoking) when making a diagnosis of asthma in a child under the age of five years. The doctors were also asked what treatment they prescribed at the time of the actual diagnosis of asthma. RESULTS: British doctors considered night cough (p = 0.05) and cough associated with emotion (p = 0.004) more diagnostic of asthma. New Zealand doctors rated cough associated with temperature change (p = 0.05) as being important and they had a lower threshold in diagnosing asthma with respect to history of similar attacks (p = 0.008) compared to their British counterparts. More New Zealand doctors reported using prophylactic/anti-inflammatory agents as first line therapy (59% vs 28%; p = 0.002). CONCLUSIONS: We conclude that there are only minor differences in general practitioners' diagnostic criteria for asthma in the two countries with reference to this small sample. We believe, however, that differing diagnostic criteria could account for different reported incidences of childhood asthma in some countries. There is need for internationally accepted diagnostic criteria.

Asthma-related prescribing patterns with four different corticosteroid inhaler devices.

Four types of corticosteroid inhaler devices are available in New Zealand for first-line treatment of asthma, including two aerosol systems [Autohaler (3M Healthcare Ltd, Loughborough, U.K.; 3M Pharmaceuticals (Australia Pty Ltd, Sydney, Australia) and MDI (Glaxo Wellcome PLC, Ware, U.K.)] and two dry powder systems [Diskhaler (Glaxo Wellcome) and Turbuhaler (Astra AB, Sodertalje, Sweden)]. Rates of asthma-related health care consumption and treatment outcomes associated with use of the different inhalers are unknown. In this retrospective survey, asthma-related primary health care consultation and prescription patterns were compared in a large general practice population for each corticosteroid inhaler device prescribed as first-line treatment. An electronic search of a computerized clinical database yielded the medical records of 5704 patients with physician-diagnosed asthma who were prescribed either the Autohaler, Diskhaler, MDI or Turbuhaler as their sole corticosteroid inhaler device in the previous 12 months. The mean daily inhaled corticosteroid dose was lowest for the Autohaler (569 micrograms day-1; 95% CI: 538-605), followed by the Diskhlaer (638 micrograms day-1; 95% CI: 609-670) and MDI (665 micrograms day-1; 95% CI: 638-673), and was highest for the Turbuhaler (990 micrograms day-1; 95% CI: 954-1029, P < 0.001). A relatively high proportion of patients aged 19-49 years in the Turbuhaler and Diskhaler groups (29% and 23%, respectively) received at least one inhaled corticosteroid prescription including a daily dose greater than 1500 micrograms compared with the MDI group (4%). In the Diskhaler group the mean daily inhaled corticosteroid dose prescribed for adult patients was similar to that for the Turbuhaler group (904 micrograms day-1 and 1058 micrograms day-1, respectively). These data suggest that in New Zealand the dry powder corticosteroid inhaler devices are prescribed for adults at significantly higher doses than the aerosol inhaler devices. Clinical databases of this type yield valuable information on drug utilization in large patient populations and usefully assess clinical prescribing practices.

Trends in antihypertensive prescribing.

AIM: To identify trends in the prescribing of antihypertensive medications and measure the changes in government and patient expenditure resulting from any identified change. METHODS: The computerised records of 16 069 patients from six Otago practices from 1991-3 were examined. Those patients prescribed any antihypertensive medication in all 3 years were selected for investigation. The antihypertensives prescribed were assigned to one of seven classes. The cohort was then divided into two groups; those remaining on the same class of medication for the three years and those changing medication class at any stage. Reasons for any change were identified. The direct costs of the prescribing decisions taken were evaluated. RESULTS: 914 patients were prescribed antihypertensive in all 3 years. Of these 579 (63.3%) remained on the same class of medication, while 335 (36.7%) changed class. A clinical reason was identified for medication change class. A clinical reason was identified for medication change in 98% of cases available for examination. There was no significant shift in expenditure for those remaining on the same medication, while costs for those remaining on the same medication, while costs increased by 20.6% for those changing. CONCLUSION: For this cohort increased expenditure on antihypertensive was driven by those changing medication. Although these changes were prompted by clinical reasons, better health outcomes for patients cannot be assumed due to lack of objective indicators.

Antibacterial and immunostimulatory properties of chemotactic N-formyl peptide conjugates of ampicillin and amoxicillin.

N-Formyl dipeptide conjugates of ampicillin and amoxicillin related to the chemotactic peptide N-formyl-L-methionyl-L-leucyl-L-phenylalanine were synthesized and assessed for antibacterial activity and affinity for the chemotactic peptide receptor of differentiated human promyelocytic leukemia (HL-60) cells. The conjugates and parent beta-lactam antibiotics showed similar antibacterial activities against Escherichia coli and Staphylococcus aureus. The affinity of each conjugate for the chemotactic peptide receptor was determined in a competitive binding assay, using 3H-labeled N-formyl-L-methionyl-L-leucyl-L-phenylalanine. All conjugates bound to the receptor, but with affinities ranging from 1/3 to 1/100 that of the tritiated substrate. There was good correlation between receptor affinity and stimulation of chemotaxis. The peptide-antibiotic conjugates also stimulated the oxidative metabolism of the HL-60 cells by inducing the production of superoxide and hydrogen peroxide as determined by Luminol- and Lucigenin-enhanced chemiluminescence. These conjugates, based on N-formyl-L-methionyl-L-leucyl-L-phenylalanine, thus combine both potent antibacterial and immunostimulatory properties within the same molecule.

Synthesis and quantitative structure-activity relationships of antiallergic 2-hydroxy-N-1H-tetrazol-5-ylbenzamides and N-(2-hydroxyphenyl)-1H-tetrazole-5-carboxamides.

The synthesis and antiallergic activity of a series of 2-hydroxy-N-1H-tetrazol-5-ylbenzamides and isomeric N-(2-hydroxyphenyl)-1H-tetrazole-5-carboxamides is described. A relationship between structure and intravenous antiallergic activity in the rat passive cutaneous anaphylaxis (PCA) test has been established using a Hansch/Free-Wilson model and used to direct studies toward potent derivatives. The contribution of physicochemical properties to activity is discussed. One member of this series, N-(3-acetyl-5-fluoro-2-hydroxyphenyl)-1H-tetrazole-5-carboxamide (3f), which was selected for further evaluation, has an ID50 value of 0.16 mg/kg po and is 130 times more potent than disodium cromoglycate (DSCG) on intravenous administration.

Frames and heuristics in doctor-patient discourse.

The medical interview can be viewed as a verbal exchange between two people trying to solve a problem. Research in linguistics and cognitive psychology casts interesting and useful light on such discourse. Using the concepts 'frames' and 'heuristics' from these fields, we viewed, transcribed and analyzed taped sessions between a family practice physician and sixteen patients to examine how those patients understood their illness. To be an effective teacher the physician must discover not only the causes of the patient's medical problem, but also something of the conceptual structure that supports the patient's perceptions and understanding of his problem. This paper presents a method to understand these conceptual structures and how they function.