Directly observed treatment for tuberculosis in pharmacies compared with self-administered therapy in Spain.

OBJECTIVES: To compare directly observed treatment (DOT) of tuberculosis through pharmacy offices with self-administered treatment (SAT) in patients at risk for non-adherence. METHODS: Prospective study for DOT (1999-2002) and retrospective study for SAT (1996-1998) in patients at risk for non-adherence (human immunodeficiency virus [HIV] infection, alcoholism, illicit drug use, immigrant or homeless status and/or previous failure to complete). Patients in the DOT programme received medication as out-patients twice a week in pharmacies that supervised adherence and provided socio-sanitary support to patients. RESULTS: There were 101 and 112 patients in the DOT and SAT groups, respectively. Demographic and clinical characteristics were similar in both groups. Differences were observed in risk factors for non-adherence (more immigrants and fewer intravenous drug users in the DOT vs. the SAT groups; P < 0.05). In the DOT group, 76 patients (75.2%) completed treatment and were cured compared to only 30 patients (26.7%) in the SAT group (P < 0.001). Implementation of DOT increased the cost of treatment by 400 Euro per patient compared to SAT. CONCLUSION: In patients at risk for non-adherence, DOT implemented through pharmacy offices was better than SAT; however, completion rates were still low.

Intoxicación por litio desencadenada por un proceso febril. A propósito de un caso / Lithium intoxication triggered by a process of high temperature. Concerning a case

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[Lethal nemalinic myopathy and congenital arthrogryposis]. / Miopatía nemalínica letal y artrogriposis congénita.

INTRODUCTION: Nemalinic myopathy (NM) is a non progressive congenital disorder of skeletal muscle, characterized by rod like formations present in muscle fibres, whilst congenital multiple arthrogryposis (CMA) is a syndrome characterized by contractures and articular rigidity which may be due to many causes, including NM. CLINICAL CASE: A boy of 0 h of premature life, with CMA was assessed on the suspicion of neuromuscular disease with normal preliminary studies. Muscle biopsy eventually showed the typical rod like formations of NM. The clinical course was unsatisfactory and he died at the age of five months from respiratory problems. CONCLUSIONS: Diagnosis of NM requires a high index of suspicion and muscle biopsy. At the present time genetic counselling cannot be given after a sporadic case.

Magnetic resonance imaging of the pharynx in OSA patients and healthy subjects.

Obstructive sleep apnoea (OSA) occurs because of recurrent narrowing and occlusion of the velopharynx (VP) during sleep. The specific cause of OSA is unknown. Cephalometric radiography, fibreoptic nasopharyngoscopy, acoustic reflection techniques, and computerized tomography have limitations (dynamic and tridimensional evaluation) in the mechanism of occlusion investigation. Static and dynamic examination of the soft tissue structures surrounding the upper airway during the respiratory cycle in wakefulness and sleep, can lead to a better understanding of the process. Ultrafast magnetic resonance imaging (one image per 0.8 s) was used to study the upper airway and surrounding soft tissue in 17 patients with OSA during wakefulness and sleep, and in eight healthy subjects whilst awake. The major findings of this investigation in the 25 subjects were as follows: 1) the VP was smaller in apnoeic patients, only during part of the respiratory cycle; 2) the variation in VP area during the respiratory cycle was greater in apnoeic patients than in controls, particularly during sleep, suggesting an increased compliance of the VP in these patients; 3) VP narrowing was similar in the lateral and anterior-posterior dimensions, both in controls and apnoeic patients while awake; apnoeic patients during sleep have a more circular VP upon reaching the minimum area; 4) there was an inverse relationship between dimensions of the lateral pharyngeal walls and airway area, probably indicating that lateral walls are passively compressed or stretched as a result of changes in the airway calibre; and 5) soft palate and parapharyngeal fatpads were larger in apnoeic patients, although their role in the genesis of OSA is uncertain. It was concluded that changes in the velopharynx area and diameter during the respiratory cycle are greater in apnoeic patients than in normal subjects, particularly during sleep. This suggests that apnoeic patients have a more collapsible velopharynx, this being the main mechanism of obstruction.

[Acute respiratory insufficiency as initial manifestation of brain stem lesions]. / Insuficiencia respiratoria aguda como primera manifestación de lesiones del tronco cerebral.

We describe three patients with different brainstem lesions (bulbar angioma, bulbar infarct, and Arnold-Chiari malformation) who debuted with acute respiratory insufficiency. Other neurological manifestations had gone unobserved in all three cases. Respiratory insufficiency worsened notably during sleep to the point that mechanical ventilation was required or death occurred (Ondine s curse). The patient with a bulbar angioma is stable with only assisted ventilation by a nasal route at night, with good quality of life. Our conclusions are that: a) central nervous system anomalies need to be investigated as possible causes of respiratory insufficiency when lungs are normal; b) the respiratory control of patients with brainstem lesions should be studied, particularly at night (polysomnography), and c) even when awake-state ventilation is adequate, nighttime assisted ventilation may be required.