Compliance in primary prevention with statins and associations with cardiovascular risk and death in a low-risk diabetes population

Background

Contemporary data exploring cardiovascular risk associated with primary prevention statin treatment according to compliance, in a low-risk diabetes population are limited.

Purpose

To investigate whether primary prevention with statins and high adherence to statins reduce the associated risk of cardiovascular events or death in a low-risk diabetes population.

Methods

By use of Danish nationwide registers, we included 59,985 patients with newly diagnosed diabetes aged 40–79 years between 1 January 2005 until 31 June 2010 with no atherosclerotic cardiovascular disease, heart failure or chronic kidney failure prior to 18 months following diabetes diagnosis (index). Individuals were considered treated with statins if they were in treatment at diabetes diagnosis or initiated treatment within the first 6 months following diabetes diagnosis. Among individuals who were treated within the first 6 months, we calculated the proportion of the days covered (PDC) of statins within one year prior to index. We standardized 5-year risks of the combined end-point of myocardial infarction, ischemic stroke or all-cause mortality according to age at index, sex, atrial fibrillation, chronic obstructive pulmonary disease, cancer, ethnicity, year at index, highest attained educational level and claimed prescriptions of antidiabetic, antihypertensive, non-statin lipid-lowering drugs and anticoagulant drugs. Reported were standardized 5-year risk differences of the composite outcome between untreated vs. treated, including PDC, by sex and age-group.

Results

Following 6 months from the diagnosis of diabetes, 38,029 (63%) individuals were treated with statins, and among individuals treated with statins 23,894 (63%) individuals had a PDC-level of ≥80%. Any use of statins was associated with a lower standardized 5-year risk of the composite outcome (not covered: 15.1% 95% confidence intervals [CI] 14.7–16.0; covered 11.0% [CI 10.7–11.4]), corresponding to a risk difference of 4.1% [CI 3.5–4.6]. The standardized 5-year risks differed by sex, but the risk reductions were similar between men (4.3% [CI 3.5–5.0]) and women (3.9% [CI 3.1–4.7]), and the standardized risk reduction increased with advancing age-group (age 40–49 1.1% [0.2–1.9], 50–59 2.4% [1.5–3.3], 60–69 4.2% [3.2–5.2], 70–79 8.3% [6.7–9.9]. A statin PDC-level of <80% was associated with an increased standardized risk difference (reference PDC≥80%; PDC=60–80% 1.6% [CI 0.7–2.5]; PDC=40–60% 2.1% [CI 0.9–3.3], PDC=20–40% 4.1% [CI 2.8–5.5], PDC<20% 3.2% [CI 2.0–4.5]).

Conclusions

In 18-month surviving low-risk patients with diabetes, use of statins was associated with a lower 5-year risk of cardiovascular events or death, but a high adherence was important to maintain this effect. The reduced risk associated with statins was similar in men and women, and the magnitude of associated risk reduction increased with advancing age.

Standardized 5-year risk differences

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Danish Heart Foundation

Recommendations on echocardiography following surgical aortic valve replacement (SAVR): time for revision?

Background

ESC guidelines recommend annual echocardiographic evaluation following biological surgical aortic valve replacement (SAVR), and 5 years following mechanical SAVR. Conversely, increased life expectancy result in increasing demand on health care resources.

Purpose

To assess aortic reintervention rates at 1-year, 3-year and 5-year following biological and mechanical SAVR in relation to estimated echocardiographic controls.

Methods

From the nationwide Danish Register of Surgical Procedures, we identified all patients ≥40 years with isolated biological or mechanical SAVR +/− concomitant coronary artery bypass graft surgery (CABG) during 2000–2016. In 90-day reintervention-free survivors we assessed aortic valve reintervention rates at 1-year, 3-years and 5-years until December 31st, 2017. We further assessed cumulative risk of reintervention by age (<60, 60–69, 70–79, ≥80 years at SAVR) accounting for the competing risk of death during the study period.

Results

The population of 90-day reintervention-free survivors included 10,526 patients with biological SAVR (CABG 39.7%) and 3,677 patients with mechanical SAVR (CABG 23.8%). Reintervention rates at 1-year, 3-years and 5-years were comparable across type of SAVR, and generally low (Figure). Accounting for the competing risk of death, reintervention rates at 5-years were 1.4% (95% CI 1.1–1.6) for biological SAVR and 1.5% (95% CI 1.1–1.9) for mechanical SAVR, respectively. In age-stratified competing risk analyses, we observed the highest rates in patients aged 40–59 years (4% [95% CI 1.8–6] at 5 years for biological SAVR, and 2% [95% CI 1.3–3] for mechanical SAVR). Following biological SAVR, annual echocardiographic controls would yield a total of 34,516 scans in our population in the first 5 years following surgery. This contrasts to a total of 66 reinterventions following biological SAVR in our population between years 1–5 of which the majority was preceded by a hospital admission with a primary diagnosis of endocarditis within the last 90 days prior to the reintervention; which are unlikely to have been diagnosed at the annual assessment scan.

Conclusion(s)

In this nationwide study, reintervention rates following biological or mechanical SAVR were very low within the first five years after surgery suggesting a discrepancy between ESC recommendations on echocardiographic controls following SAVR, the benefit for patients, and the associated resource burden on the health care system.

Figure 1

Funding Acknowledgement

Type of funding source: None

Assessment of the hypothalamo-pituitary-adrenal axis in patients treated with radiotherapy and chemotherapy for childhood brain tumor

The impact of cranial irradiation (CIR) and chemotherapy on the hypothalamo-pituitary (HP)-adrenal (HPA) axis was assessed in a population-based follow-up study of patients treated for childhood brain tumor not directly involving the HP axis. HPA function was evaluated and compared with that in healthy controls (n = 17), measuring basal cortisol and the peak cortisol response to an insulin tolerance test (ITT) and an ACTH test(.) The cortisol cut-off level was 500 nmol/liter. The biological effective dose (BED) of radiotherapy was determined for the HP region and spine and was expressed in Gray units, as BED gives a means of expressing the biological effects of different dosage schedules in a uniform way. Seventy-three children (46 males and 27 females), less than 15 yr of age when diagnosed during 1970-1997 in the Eastern part of Denmark, were included. The median age at time of radiotherapy was 8.4 yr (range, 0.8-14.9). The median length of follow-up was 15 yr (range, 2-29). Fourteen patients (19%) had basal cortisol levels below 500 nmol/liter and did not respond with a peak cortisol above the cut-off level to either an ACTH test (30 or 60 min) or an ITT, and thus, they had insufficiency of the HPA axis. Even though a peak cortisol above 500 nmol/liter was reached in the rest of the cohort (n = 59) after either an ACTH test (30 or 60 min) or an ITT, they had significantly lower peak cortisol levels compared with controls (P = 0.0099). Thirteen patients failed the ACTH test (30 min), but passed the ACTH test (60 min), implying a risk of misinterpreting the cortisol capacity of the patient if only the ACTH test (30 min) is obtained. The basal cortisol levels and the cortisol levels in the ACTH test (30 min) and the ACTH test (60 min) were significantly lower in the patient group compared with controls. There was a significant correlation between the peak cortisol after the ITT compared with the peak cortisol after the ACTH test (30 or 60 min; r(s) = 0.56; P = 0.0006), but 48% failed the ITT, and there was discordance in 10 of 33 (30%) patients who passed the ACTH but failed the ITT, indicating the recommendation of continuous use of the ITT as the gold standard for evaluation of the HPA axis. Stepwise backward multiple linear regression analysis showed that the best-fit model to predict the peak cortisol level after an ITT included BED (P = 0.04) and length of follow-up (P = 0.06). In contrast, age at RT, chemotherapy, BED to the spine, and gender were not included in the model. In conclusion, these data suggest that CIR for a childhood brain tumor may affect the HPA axis, resulting in secondary adrenal insufficiency, whereas adjuvant chemotherapy does not seem to add to the deleterious effect of CIR. We recommend life-long surveillance of the HPA axis and performing regular ITTs.

A population-based study of thyroid function after radiotherapy and chemotherapy for a childhood brain tumor

The effect of craniospinal irradiation (CSI) vs. cranial irradiation (CIR) only with or without chemotherapy (CT) on the hypothalamus/pituitary (HP) thyroid axis was assessed in a population-based study of patients treated for a childhood brain tumor not directly involving the HP axis. Thyroid function was evaluated and compared with that in healthy controls (n = 27), measuring TSH, free T4, total T4, total T3, and TRH. The biological effective dose (BED) of radiotherapy, determined for the HP region and spine and expressed in grays (Gy) as BED, gives a means of expressing the biological effects of different dosage schedules in a uniform way. Seventy-one children (45 males and 26 females), less than 15 yr of age when diagnosed between 1970-1997 in the eastern part of Denmark, were included. Twenty-nine had received CSI, and 42 had received CIR only. The median age at time of radiotherapy was 8.4 yr (range, 0.8-14.9). The median length of follow-up was 12.0 yr (range, 2.0-28.0). There was no significant difference between CSI and the CIR only patients with respect to median BED to the HP region. Primary hypothyroidism was found in 24%, of whom 71% had been treated with CSI and 29% with CIR only; 73% had compensated hypothyroidism, and 27% had overt primary hypothyroidism. Central hypothyroidism was found in 6%. Free T4 and total T3 were significantly lower in the CSI and CIR only groups compared with controls. As the CIR only group had significantly higher median basal TSH levels compared with controls and as the CSI compared with the CIR only group and controls had significantly higher median basal TSH levels, we speculate that this was probably due to scattered irradiation from both cranial and spinal fields to the thyroid gland. There was a significant relation between basal TSH and time of follow-up (r(s) = -0.39; P = 0.001). Stepwise backward multiple linear regression analysis showed that the best-fit model to predict basal TSH was free T4 (P < 0.0001), the length of follow-up (P = 0.02), and total T3 (P = 0.06). In contrast, age at radiotherapy, BED to the HP region and spine, and whether the patient had been treated with CT were not included in the model. The TRH test showed significantly exaggerated and prolonged TSH responses for the CSI and CIR only groups compared with controls, indicating HP dysfunction. In conclusion, these data suggest that both CSI and CIR for childhood brain tumor may affect the HP-thyroid axis, resulting in hypothyroidism. CT had no significant influence on HP-thyroid function. We recommend prolonged surveillance of pituitary-thyroid function in long-term survivors of childhood brain tumor and institution of thyroid hormone replacement if the levels of TSH and free T4 are above and below the normal range, respectively, to ensure normal growth and metabolism.

Growth hormone response to a growth hormone-releasing hormone stimulation test in a population-based study following cranial irradiation of childhood brain tumors

Children with brain tumors are at high risk of developing growth hormone deficiency (GHD) after cranial irradiation (CI) if the hypothalamus/pituitary (HP) axis falls within the fields of irradiation. The biological effective dose (BED) of irradiation to the HP region was determined, since BED gives a means of expressing the biological effect of various irradiation treatment schedules in a uniform way. Hypothalamic versus pituitary damage as cause of GHD was distinguished in 62 patients by comparing the growth hormone (GH) peak response to an insulin tolerance test (ITT)/arginine stimulation test and the GH response to a growth hormone-releasing hormone (GHRH) stimulation test. Peak GH response to a GHRH test was significantly higher (median 7.3 mU/l; range: 0.5--79.0 mU/l) than that of an ITT/arginine test (median 4.7 mU/l; range: 0.01--75.0 mU/l) (p = 0.017). Peak GH after a GHRH test was significantly inversely correlated to follow-up time (r(s) = -0.46, p < 0.0001) and to BED (R(s) = -0.28, p = 0.03), and both were found to be of significance in a multivariante regression analysis. We speculate that a significant number of patients developed hypothalamic radiation-induced damage to the GHRH secreting neurons, and secondary to this the pituitary gland developed decreased responsiveness to GHRH following CI in childhood.

Gonadal status in male survivors following childhood brain tumors

The effect of radiotherapy (RT) and chemotherapy (CT) on gonadal function was assessed in males treated for a childhood brain tumor not directly involving the hypothalamus/pituitary (HP) axis in a population-based study with a long follow-up time. All males <15 yr at the time of diagnosis (median: 9.0 yr, range: 0.8 to 14.9 yr) and diagnosed from January 1970 through February 1997 in the eastern part of Denmark and [gte]18 yr at the time of follow-up (median: 25.8 yr, range:18.5 to 39.3 yr) were included. Thirty males fulfilled the criteria. The median age at time of RT was 9.0 yr (range: 0.8 to 14.9 yr) and the median length of follow-up was 18 yr (range: 2.0 to 28.0 yr). The biological effective dose of RT was determined to the HP region and to the spine and expressed in gray because the biological effective dose gives a means of expressing the biological effect on normal tissue of different dosage schedules in a uniform way. Levels of serum FSH, luteinizing hormone (LH), sexual hormone-binding globulin, testosterone, and inhibin B were measured and compared with healthy age-matched male controls (n = 347), and the patients had a GnRH stimulation test performed with determination of peak FSH and LH. Patients treated with RT + CT (n = 13), compared with patients treated with RT only (n = 17), had significantly higher median peak FSH (8.33 vs. 3.79 IU/L, P = 0.03) and median peak LH (20.0 vs. 12.8 IU/L, P = 0.03), and significantly lower median inhibin B (86.0 vs. 270 pg/ml, P = 0.03), and median inhibin B/FSH ratio (12.8 vs. 107.9, P = 0.04), which indicates gonadal damage. Inhibin B and inhibin B/FSH ratio were also significantly lower in the RT + CT group, compared with controls (median: 86.0 vs. 215 pg/ml, P = 0.02), (median:12.8 vs. 67; P = 0.01), respectively. We found a significantly inverse correlation between basal FSH and inhibin B and FSH and total testicular volume (r(s) = -0.83; P < 0.0001), (r(s) = -0.67; P < 0.0001), respectively, and a significant correlation between inhibin B and total testicular volume (r(s) = 0.63; P < 0.0001). Stepwise backward multiple linear regression analysis showed the best-fit model to predict inhibin B levels included total testicular volume (P = 0.002) and CT (P = 0.09). Median basal LH in the RT-only group was significantly lower, compared with controls (3.44 vs. 2.45 IU/L; P = 0.0001) indicating secondary hypogonadism, and in both the RT + CT group and the RT-only group, levels of testosterone were significantly lower, compared with our reference population (12.8 vs. 21.9 nmol/L; P = 0.001, and 14.7 vs. 21.9 nmol/L; P = 0.0003), respectively. In conclusion these data suggest that cranial irradiation for a childhood brain tumor may affect the HP axis, and adjuvant CT can reduce inhibin B indicating primary gonadal damage. Thus, such patients may have normal or even low levels of FSH despite damage to the seminiferous epithelium, and because the fertility status by a semen analysis for psychological reasons can be difficult to obtain in this group of patients, we suggest inhibin B as the most useful direct serum marker of spermatogenesis in the follow-up of individuals who have received both cranial irradiation and gonadotoxic chemotherapy. However, because the number of patients with RT + CT and RT only are small, these data must be confirmed in further studies.

Cranial radiotherapy of childhood brain tumours: growth hormone deficiency and its relation to the biological effective dose of irradiation in a large population based study

OBJECTIVE

The study was to determine the incidence of GH deficiency (GHD) following cranial radiotherapy (RT) for a childhood brain tumour in a large population based study and analyse the biological effective dose (BED) to the hypothalamus/pituitary (HP) region as a risk factor.

DESIGN

BED was assessed by use of the linear-quadratic (LQ) model, which gives a means of expressing the biological effect of various treatment schedules in a uniform way. In patients aged >/= 18 years (n = 53) GH status was assessed by an insulin-tolerance test (ITT) (n = 34), however, in patients with seizure disorders (n = 19), and in 20 children aged < 18 years GH status was assessed by an arginine test. Cut-off levels for GHD, indicating GH substitution, were defined by a peak GH response of < 9 mU/l and < 15 mU/l for patients >/= 18 and < 18 years, respectively.

PATIENTS

Ninety-one children aged < 15 years eligible for the study, diagnosed between 1970 and 1997 in the Eastern part of Denmark, the Faroe Islands and Greenland, with a primary brain tumour not directly involving the HP axis. 84% (n = 76) agreed to participate. Three patients were excluded due to hypothyroidism detected at time of testing.

MEASUREMENTS

Serum GH and levels of serum insulin-like growth factor-I (s-IGF-I) and serum insulin-like growth factor binding protein-3 (s-IGFBP-3) were measured. BED was assessed to the HP region.

RESULTS

The median age at the time of RT was 8.7 years (range: 0.8-14.9 years) and the median time of follow-up was 15 years (range: 2-28 years). Fifty-eight patients (80%) had GHD and they had received a median BED of 77.5 Gy to the HP region, whereas the median BED was 54.5 Gy for 15 patients without GHD (P = 0.002). Peak GH and BED were correlated (rs = -0.53, P < 0001). Median IGF-I SDS and IGFBP-3 SDS were -2.5 (-5.2-0.7 SDS) and -1.7 (-5.8-0.9 SDS), respectively, and IGF-I SDS was correlated to peak GH (rs = 0.45, P < 0.001). Peak GH and length of follow-up were related (rs = -0.28, P = 0.018). Stepwise backward multiple linear regression analysis showed that the best-fit model to predict the peak GH release following ITT/arginine stimulation included BED (P < 0.0001) and length of follow-up (P = 0.05).

CONCLUSIONS

The data of this study suggest that the majority of long-term survivors of brain tumours develop GH deficiency following radiotherapy in childhood and that the adverse effects of radiotherapy may be directly related to the biologically effective dose. With longer follow-up fewer patients might respond normally to GH stimulation tests.

Cryopreservation of semen from pubertal boys with cancer

BACKGROUND

The possibility of cryopreservation of semen from adolescents has until now received only little attention. Therefore, we have investigated the possibility of cryopreservation of semen in adolescent boys with cancer.

PROCEDURE

Forty-five boys, aged 13-18 years, admitted because of cancer during the period January 1, 1995 to July 31, 1998 were eligible. Semen was obtained after masturbation in the majority of the cases. In three boys, semen was preserved after penile vibration or electroejaculation in general anaesthesia. The semen samples were analysed for concentration, motility, and morphology according to the WHO guidelines. The sample was transferred into straws prior to cryopreservation at 196 degrees C in liquid nitrogen.

RESULTS

Twenty-one boys delivered a semen sample for cryopreservation. Four boys were offered and accepted sperm banking but were not able to produce a sample. In 20 cases time did not allow an attempt of sperm banking, the boy was not assessed to be mature enough to deliver a semen sample, or the procedure was not accepted. The boys delivered 1-3 samples, and the total number of spermatozoa ranged from 0-210 millions. Median percentage of motile sperm was 50% (range 9-86%). Semen quality improved with age; however, a 13- year- old boy produced 75 million spermatozoa with 38% motile cells.

CONCLUSIONS

Pubertal maturation should be assessed in all boys admitted for cancer, and the possibility of sperm banking should be discussed with the patient and his parents.

Dosimetry and growth hormone deficiency following cranial irradiation of childhood brain tumors

BACKGROUND

Dosimetry of the hypothalamus-pituitary (HP) region could allow prediction of the risk of growth hormone deficiency (GHD) following cranial irradiation.

PROCEDURE

Nineteen children (15 boys) with a median age of 6.3 years (range 1.7-16.5) at the time of irradiation of a brain tumor not involving the HP axis were followed for 1.2-6.3 years (median 3.4) from radiotherapy (RT). The dose to a standardized anatomical model including the HP region was calculated from dose-volume histograms of 10% to 100% in steps of 10% of the HP model based on data from a computer-based treatment planning system. If GHD was suspected from insulin-like growth factor-I, serum insulin-like growth factor binding protein-3, and/or height velocity measurements, an arginine stimulation test was performed. GHD was defined by a peak GH <15mU/liter.

RESULTS

Ten patients developed GHD 10-26 months from irradiation. Cox regression analysis identified the 90% dose-volume of the HP box as the strongest predictor of development of GHD (P = 0.03). The median dose to the 90% dose-volume of the HP region was 37.5 Gy (range 2. 3-55.3). The cumulated risk of GHD 2.5 years after radiotherapy for children receiving more than and less than 37.5 Gy to the HP region was 87% and 33%, respectively (P = 0.036).

CONCLUSIONS

Dosimetry of a defined HP volume provides the opportunity to 1) calculate the exact dose delivered to this region, 2) predict the risk of GHD and, 3) in the future revise the treatment planning and thus reduce the risk of endocrine adverse effects.

Insulin-like growth factor-I and insulin-like growth factor binding protein-3 during maintenance chemotherapy of acute lymphoblastic leukemia in children

PURPOSE

To assess the effect of maintenance chemotherapy (MT) on growth factors and growth in children with acute lymphoblastic leukemia (ALL).

PATIENTS AND METHODS

Twenty-one children (10 girls, 11 boys) with standard risk pre-B ALL treated with chemotherapy had serum insulin-like growth factor-I (IGF-I), serum IGF binding protein-3 (IGFBP-3) levels, and linear growth and weight data measured every 3 months during MT. The levels of the cytotoxic metabolites of methotrexate (MTX) and 6-mercaptopurine (6MP) (i.e., erythrocyte MTX polyglutamates [E-MTX], and erythrocyte 6-thioguanine nucleotides [E-6TGN]), s-aminotransferases, and white blood counts (WBC) were measured at least monthly.

RESULTS

At the beginning of MT, the median IGF-I standard deviation scores (SDS) and IGFBP-3 SDS were -0.52 and -0.09, respectively, which declined during MT to -1.67 (P < 0.001) and -1.82 (P < 0.001), respectively. At the time of diagnosis, the median height SDS was -0.4, which declined during MT to a median height SDS of -0.9 at cessation of therapy. No significant correlations were found between growth factor levels, growth and body mass index (BMI) versus the doses of MTX, and 6MP, E-MTX, E-6TGN, s-aminotransferases, or WBC.

CONCLUSIONS

A significant decline in IGF-I, IGFBP-3, and growth retardation may not be directly related to the treatment intensity during MT.

Pen injected apomorphine against off phenomena in late Parkinson's disease: a double blind, placebo controlled study

The effect, therapeutic dose range, and pharmacokinetics of apomorphine, given as subcutaneous injections by a single use pen, were evaluated in the treatment of off phenomena in 22 patients with idiopathic Parkinson's disease. At study entry a placebo controlled apomorphine test was performed, and apomorphine doses were then individually titrated (mean 3.4 (range 0.8-6.0) mg) and compared with placebo in a double blind cross over phase. With apomorphine compared with placebo the mean daily duration of off periods was reduced by 51% as assessed by the patients and by 58% as assessed by the staff. The severity of off periods was also significantly reduced. The effect was unchanged after a maintenance phase of eight weeks. At study termination 13 of 14 patients were able to inject themselves and 11 of 14 patients found that their feeling of freedom had increased. The most common adverse events were nausea, subcutaneous nodules, and increased frequency of involuntary movements. Pharmacokinetics were linear and did not change with repeat dosing. The tmax ranged from five to 45 minutes (16 patients). It is concluded that pen injected apomorphine is a valuable treatment for patients with advanced Parkinson's disease with on-off phenomena.

[Quality of cryopreserved ejaculate in Hodgkin disease]

Each year approximately 70 males are diagnosed with Hodgkin's disease (HD) in Denmark. Most of these are less than 50 years of age. Since chemotherapy and radiotherapy may induce infertility in about 80% of patients, it has become routine to offer cryopreservation of semen prior to initiation of treatment. In 41 men aged 17-42 years at diagnosis we evaluated the quality of semen (according to the WHO criteria) prior to cryopreservation and after thawing. The median sperm concentration at the time of diagnosis was 33 x 10(6)/ml (range: 0.3-458 x 10(6)/ml) and positively correlated to age (rs = 0.36 p = 0.02) and to the histopathological classification (highest for patients with nodular sclerosis (p = 0.04) but not to semen volume, stage or presence of B-symptoms. The percentage of motile spermatozoa (range: 0-90%, median value 72%) was correlated to the sperm concentration; but not to any of the other parameters studied. Prior to freezing, 19 of 41 patients had normal semen quality according to the WHO criteria, whereas following thawing this was the case for only 14 semen samples. Ten of 23 patients with nodular sclerosis HD had normal semen quality (according to the WHO criteria) after thawing whereas this was the case for only 2 of 15 patients with mixed cellularity HD (p = 0.05). Cryopreservation of semen may secure the possibility of fathering children for patients with HD following therapy, and is to be recommended.

[Acute lymphoblastic leukemia in children. A retrospective study: 1970-1991]

From January 1970 through December 1991, 94 girls and 130 boys with a median age of 4.8 years were diagnosed with non-B cell acute lymphoblastic leukaemia (ALL) at the University Hospital, Rigshospitalet. Intensive risk-group adapted therapy based on age and white-cell count (WBC) at diagnosis, the presence of a mediastinal mass, central nervous system (CNS) or testicular leukaemia, T-cell disease, and certain cytogenetic translocations have been used since July 1981. Ninety-seven percent of all patients achieved complete remission (all patients diagnosed since July 1986). Ninety patients relapsed, all within five years from diagnosis: 59 in bone-marrow (BM), 20 in CNS (no BM-involvement), nine in testes (all isolated), one in the eye, and one in a lymph node. The five-year event-free survival increased from 0.20 to 0.72 from the first to the last five-year period (p < 0.0001). Age and WBC at diagnosis were of prognostic significance during the period 1970-1981, but not during the last 10-year period, when risk-adapted therapy was applied. Following a relapse, patients with an isolated testicular focus had the best five-year survival as compared to patients with CNS- and/or BM-involvement (1.00 vs 0.19; p = 0.003). Patients relapsing following cessation of therapy had a better prognosis than did patients relapsing on therapy (five-year survival 0.58 vs 0.17; p = 0.002). Identification of new risk factors, more individualized therapy and monitoring of minimal residual disease is expected to have increasing influence on the management of children with ALL.

Methotrexate and 6-mercaptopurine maintenance therapy for childhood acute lymphoblastic leukemia: dose adjustments by white cell counts or by pharmacokinetic parameters?

In a consecutive study of 14 boys and 17 girls with non-B-cell ALL who were > or = 1 year of age at diagnosis, the degree of myelosuppression during the last year of MTX/6MP maintenance therapy was analyzed in relation to the erythrocyte concentration of MTX polyglutamates and 6-thioguanine nucleotides (E-MTX and E-6TGN, the respective major cytotoxic metabolites of MTX and 6MP). For each patient, E-MTX and E-6TGN levels were measured 2-15 (median, 6) and 2-17 (median, 7) times, respectively. From these measurements, arithmetic means of E-MTX and E-6TGN were calculated (mE-MTX and mE-6TGN, respectively). Since MTX and 6MP probably work synergistically, the product of mE-MTX and mE-6TGN was calculated for each patient (mE-MTX x 6TGN). The degree of myelosuppression was registered as the mean WBC determined following cessation of the therapy minus the mean WBC measured during the therapy (mWBCshift). The mean WBCs measured on therapy (mWBC(on)) and off therapy were highly correlated (r = 0.48, P = 0.009). The median mWBCshift was 2.7 x 10(9)/l (range, 1.4-4.8 x 10(9)/l). In a multivariate regression analysis, the best-fit model to predict the mWBCshift included mE-MTX x 6TGN, age at drug withdrawal, and mWBC in the order given [mWBCshift = 4.3 + 0.00089 x (mE-MTX x 6TGN) - 0.097 x age - 0.41 x mWBC(on); global rs = 0.66, P = 0.0002]. Thus, the patients with higher mE-MTX x 6TGN values, the younger patients, and the patients with the lowest WBC during therapy had the most pronounced degree of myelosuppression as measured by mWBCshift. These results indicate that E-MTX and E-6TGN may give a better reflection of the treatment intensity than do the WBCs alone.

Human pharmacokinetics of an analogue of atrial natriuretic factor

The pharmacokinetics of ANP-270, a 26 amino acid analogue of alpha human natriuretic factor (alpha-hANF) with a prolonged effect on isolated arterial preparations, has been studied in 40 healthy males, in a double-blind placebo controlled investigation. Placebo or ANP-270 0.3, 1.5 or 3.0 micrograms/kg were given by intravenous bolus injection, each to groups of 10 subjects. Blood samples were assayed for ANP-270 by a specific sandwich ELISA. The disappearance of ANP-270 from plasma followed a two-compartment decay, with mean distribution and elimination half-lives of 2.6 min (n = 30) and 10.6 min (n = 20), respectively. These estimates were similar to those obtained by other investigators for alpha-hANF. Their brevity explains the lack of a prolonged effect of ANP-270 in vivo compared to alpha-hANF.

Renal and hormonal effects and tolerance of an ANP analogue in healthy man

The effect of an analogue of atrial natriuretic peptide (P-ANP) on glomerular filtration rate (GFR), renal plasma flow (RPF), urinary flow rate, urinary sodium excretion, tubular function estimated by the lithium clearance technique, and plasma levels of sodium and water homeostatic hormones, has been studied in 40 healthy males. Placebo or P-ANP 0.3, 1.5, or 3.0 micrograms.kg-1 bwt were given as an intravenous bolus injection to different groups. P-ANP did not cause any immediate change in GFR or RPF, but significant dose-dependent increases in filtration fraction, urinary flow rate and urinary excretion rate of sodium were detected during the first 30 min after administration. Proximal absolute and fractional tubular reabsorption and distal absolute tubular reabsorption of sodium did not change after injection of P-ANP, while the distal fractional reabsorption of sodium was reduced in a dose dependent manner during the first 30 min. Plasma angiotensin II and aldosterone were significantly increased 30 and 150 min after dosage, whereas plasma atrial natriuretic peptide, plasma arginine vasopressin, and urinary excretion of prostaglandin E2 were unchanged. Cyclic guanosine monophosphate both in plasma and urine were increased in a dose-dependent manner. P-ANP cause a significant reduction in diastolic blood pressure and an increase in pulse rate. Two subjects had vasovagal syncope 30-60 min after injection of P-ANP. It is concluded that P-ANP has natriuretic, diuretic and hypotensive properties in healthy man.

Oral supplementation of myoinositol: effects on peripheral nerve function in human diabetics and on the concentration in plasma, erythrocytes, urine and muscle tissue in human diabetics and normals

28 young diabetics with short disease duration participated in a double-blind study by taking 6 g of myoinositol or placebo daily for 2 months. The aim was to demonstrate a possible beneficial effect of this compound on subclinical diabetic neuropathy. Measurement of vibratory perception threshold, motor and sensory conduction velocity and amplitude of nerve potential did not disclose any effect of the myoinositol given. In accordance with this, no indication for a lack of myoinositol in human diabetic blood or tissue could be found. The concentration of myoinositol in the plasma and erythrocyte of 4 human diabetics was normal or high, even though the loss of urinary myoinositol was greater than in the case of 4 normals. Further, an analysis of the content of free and lipid-bound myoinositol in muscle biopsies taken from the 4 diabetics did not give any indication of deficiency. The content of myoinositol in their muscle tissue remained uninfluenced by oral supplementation of myoinositol.

Carbamazepine: a clinical biopharmaceutical study

In a biopharmaceutical study of carbamazepine, the F-CBZ, DAK preparation, which contained small particles with minor variation in size, had a more rapid dissolution rate than Tegretol, which contained larger particles of more variable size. Accordingly, carbamazepine had a more rapid absorption rate from F-CBZ, DAK than from Tegretol in a comparative absorption test involving single-dose administration of 200 mg to 8 healthy volunteers. The clinical significance of the difference in absorption rates for the steady state levels of carbamazepine and carbamazepine-10,11-epoxide, and the frequency of side-effects in relation to tablet intake, were evaluated in a double-blind, randomized, double-dummy cross-over trial of 35 days' duration, in 21 well-adjusted epileptic patients. 9 patients were treated with Tegretol alone and 12 with Tegretol combined with other antiepileptic drugs. A lower steady state plasma level of carbamazepine was found at 08.00 h during treatment with F-CBZ, DAK in comparison with Tegretol. The difference was small. There was no difference in the type and frequency of side-effects or seizures between the 2 preparations. The frequency of epileptic fits was not correlated with the plasma level of carbamazepine or the epoxide. Side-effects, however, had a tendency to be correlated with the concentration of the epoxide. Thus, the particle size influenced the absorption rate of carbamazepine, without having a significant correlation wih the frequency of side-effects. The difference in the minimum plasma level of carbamazepine between treatments with the two preparations was modest, and appeared to be without clinical significance.