IQ driving QI: the Asia Pacific Consortium on Osteoporosis (APCO): an innovative and collaborative initiative to improve osteoporosis care in the Asia Pacific

Asia Pacific Consortium on Osteoporosis (APCO) comprises of clinical experts from across the Asia Pacific region, uniting to develop solutions to problems facing osteoporosis management and care. The vision of APCO is to reduce the burden of osteoporosis and fragility fractures in the Asia Pacific region.

INTRODUCTION

The Asia Pacific (AP) region comprises 71 countries with vastly different healthcare systems. It is predicted that by 2050, more than half the world's hip fractures will occur in this region. The Asia Pacific Consortium on Osteoporosis (APCO) was set up in May 2019 with the vision of reducing the burden of osteoporosis and fragility fractures in the AP region.

METHODS

APCO has so far brought together 39 clinical experts from countries and regions across the AP to develop solutions to challenges facing osteoporosis management and fracture prevention in this highly populous region of the world. APCO aims to achieve its vision by engaging with relevant stakeholders including healthcare providers, policy makers and the public. The initial APCO project is to develop and implement a Framework of pan-AP minimum clinical standards for the screening, diagnosis and management of osteoporosis.

RESULTS AND CONCLUSIONS

The Framework will serve as a platform upon which new national clinical guidelines can be developed or existing guidelines be revised, in a standardised fashion. The Framework will also facilitate benchmarking for provision of quality of care. It is hoped that the principles underlying the formation and functioning of APCO can be adopted by other regions and that every health care facility and progressively every country in the world can follow our aspirational path and progress towards best practice.

Randomized, active-controlled study of once-weekly alendronate 280 mg high dose oral buffered solution for treatment of Paget's disease

Daily oral tablet bisphosphonate therapy for Paget's disease of bone may cause serious upper gastrointestinal adverse events. A once-weekly alendronate 280 mg oral buffered solution was compared with an alendronate 40 mg/day tablet. While both were similarly effective, the tablet appeared to be better tolerated in this study.

INTRODUCTION

Although daily doses of oral bisphosphonates are a generally safe and effective treatment for Paget's disease of bone (PDB), some patients may experience upper gastrointestinal adverse events (UGI AEs) or find the dosing requirements inconvenient and become noncompliant. A once-weekly (OW) oral dose of bisphosphonate in buffered solution (OBS) may be as effective, better tolerated, and more convenient.

METHODS

Sixty-three patients were randomized to either alendronate (ALN) 280 mg OW OBS (n = 42) or an ALN 40 mg/day tablet (n = 21) during a 6-month, randomized, double-blind, active-controlled trial. The primary endpoint was the mean percent decrease in total serum alkaline phosphatase (total ALP) from baseline at 6 months.

RESULTS

There were no significant differences in total ALP between groups during the 6-month period. There was a higher incidence of clinical AEs in the ALN 280 mg OW OBS (79%) vs. the ALN 40 mg/day tablet group (67%), including drug related AEs (48% and 10%, respectively), which led to study discontinuation (19.0% and 10%, respectively).

CONCLUSIONS

Although ALN 280 mg OW OBS was similarly effective as ALN 40 mg/day in reducing total ALP in patients with PDB, the ALN 40 mg/day tablet appears to be better tolerated than ALN 280 mg OW OBS.

Alendronate prevents bone loss in patients with acute spinal cord injury: a randomized, double-blind, placebo-controlled study

CONTEXT

Patients who sustain an acute spinal cord injury (SCI) experience rapid dramatic reductions in bone mineral density (BMD), especially marked in sublesional areas and sometimes leading to hypercalcemia and hypercalciuria, as well as increased fracture risk.

OBJECTIVE

In this prospective, double-blind, randomized, placebo-controlled study, we evaluated the hypothesis that oral alendronate administration would preserve BMD when administered soon after acute SCI.

PATIENTS AND INTERVENTION

Thirty-one patients with acute SCI were randomly allocated to receive oral alendronate 70 mg/wk or placebo, within 10 d of acute SCI, for 12 months.

MAIN OUTCOME MEASUREMENTS

At entry and at 3, 6, 12, and 18 months, total body bone density, lumbar and hip BMD, ultrasound of the calcaneus, 24-h urinary calcium, and serum C-telopeptide (betaCTX) were measured.

RESULTS

At study entry, patients in the two groups were well matched for age, gender, severity of neurological deficit, BMD, urinary calcium, and betaCTX. BMD indices declined steadily in the placebo group, and this effect was attenuated significantly by alendronate. After 12 months, there was a 5.3% difference (P<0.001) in total body BMD and a 17.6% difference (P<0.001) in the total hip BMD between the two groups. Alendronate compared with placebo induced significant (P<0.001) reductions in urinary calcium excretion and serum betaCTX. No treatment-related side effects were noted.

CONCLUSIONS

We conclude that alendronate therapy, 70 mg/wk, initiated soon after acute SCI, prevents bone loss and is not associated with side effects.

Hip fracture mortality and morbidity--can we do better?

AIMS

To determine the mortality and morbidity from fractures of the neck of femur in Christchurch Hospital and to determine the extent that hip fracture patients are investigated and treated for osteoporosis.

METHODS

All patients treated for a fractured hip at Christchurch Hospitals between May 1998 and April 1999 were identified. Their radiographs were reviewed and each fracture was classified. Dates of death were recorded where applicable. Surviving patients were contacted at least twelve months after their fracture and asked questions relating to functional outcome following surgery. The numbers of patients who had ever had a bone density scan, treatment for osteoporosis and/or a measurement of vitamin D were recorded.

RESULTS

There were 331 fractures among 329 patients (242 women, 87 men), mean age of 79.7 (standard deviation 10.5) years. Twelve-month mortality was 26%. Men had a higher mortality rate than women for all fracture types that was independent of age. Follow up of the 231 surviving patients 12-24 months later revealed 27% still had pain and 60% had worsened mobility that they attributed to the fracture. Worsened mobility affected people living at home more than people living in institutional care. 32 people (15%) had had a vitamin D concentration measured and in 22 of these (69%) levels were below the reference range.

CONCLUSIONS

The mortality and morbidity after hip fracture is high, especially in men. There were few significant correlates with greater morbidity except for fixation by hemi arthroplasty. More attention to hip fracture prevention is needed. Few subjects were on any therapy for osteoporosis other than calcium supplements. Vitamin D deficiency is an important but under-recognised condition.

Effects of diary food supplements on bone mineral density in teenage girls

BACKGROUND

Bone mineral density (BMD) is largely genetically determined and this influence is most powerful in the period of rapid skeletal development in childhood and late adolescence but environmental factors such as exercise and dietary calcium intake may influence up to 20%.

AIMS OF THE STUDY

The aims of the study were to examine healthy late adolescent females for the effects and benefits of a high calcium intake from dairy product foods on bone mineral density, body composition, lipids and biochemistry. The secondary aim is determine whether a high intake of dairy product foods in the diet is acceptable for this age group long term.

METHODS

Ninety-one teenage girls who participated in a two-year randomised controlled study on the effect of dairy food supplementation on dietary patterns, body composition and bone density in post-pubertal teenage girls were approached one year after the cessation of the study to determine the effects of the cessation of dairy supplements on bone mineral density, dietary habits, biochemical markers, body composition and blood lipids. Bone mineral density and bone mineral content were assessed at the hip, spine and total body. Anthropometric data were collected, and exercise, Tanner, dietary assessment, preference and compliance questionnaires were administered. Lipid profiles, hydroxyproline excretion and urinary calcium and sodium excretion measurements were performed.

RESULTS

There were no significant differences between the 2 groups for height, weight, lean and fat mass. The supplemented group had significantly higher calcium, phosphorus and protein intake during the supplementation period (p < 0.001). No differences were seen between the groups 12 months after supplementation finished. There were no significant differences in exercise level, preference or acceptability of dairy products or in the lipids and bone markers between baseline the end of supplementation and 1 year follow-up. There was a significant increase in trochanter (4.6%), lumbar spine (1.5%) and femoral neck (4.8%) BMD (p < 0.05) in the high calcium group at the end of supplementation. There was an increase in bone mineral content at the trochanter (p < 0.05) and lumbar spine; however the latter was not statistically significant, in the high calcium group at the end of supplementation. There was no difference in vertebral height or width at any stage of the study, indicating no influence on bone size.

CONCLUSIONS

In this 3 year study (2 years of supplementation, 1 year follow-up), teenage girls, aged 15-18 years, were able to significantly increase their BMD at the trochanter, femoral neck and lumbar spine when supplemented with dairy product foods to a mean calcium intake of 1160 mg/d. There was also an effect seen on the BMC particularly at the trochanter and to a lesser extent at the lumbar spine. The dietary calcium intake achieved did not adversely affect body weight, fat and lean mass or blood lipid profiles. Twelve months after the supplementation finished the girls had returned to their baseline diet, indicating self-selection of a high dairy product diet may be hard to achieve.

Alendronate in early postmenopausal women: effects on bone mass during long-term treatment and after withdrawal. Alendronate Osteoporosis Prevention Study Group

We studied the effect on bone mass of alendronate treatment for 5 yr and its withdrawal. Four hundred and forty-seven postmenopausal women with normal bone mass entered a 3-yr randomized trial followed by a 2-yr open label extension. Three hundred and eleven women completed the first 3 yr, and 263 consented to continue and completed the extension. We are reporting data from groups using the dose of alendronate currently approved for osteoporosis prevention (5 mg) or from the group in which alendronate treatment was withdrawn: 52 women received alendronate (5 mg) for 5 yr (group I), 56 received 3 yr of placebo followed by alendronate (5 mg) for 2 yr (group II), and 52 received alendronate (20 mg) for 2 yr followed by 3 yr off therapy (group III). In group I, alendronate (5 mg) increased bone mineral density (BMD) at the spine and trochanter by 2.5-3.2% (P < 0.001 vs. baseline) and stabilized total body and femoral neck BMD (change vs. baseline, P = NS) over 5 yr. By the end of 5 yr, BMD was comparable at the spine, hip, and total body in groups I and III. The 3-yr decrease in BMD after withdrawal of alendronate (20 mg) in group III was 1.8-5.7% (P < 0.01 vs. baseline) and similar to the 3-yr decrease in BMD in group II during the initial 3 yr. In conclusion, alendronate (5 mg) for 5 yr or alendronate (20 mg) for 2 yr followed by 3 yr off therapy prevented postmenopausal bone loss. After withdrawal of alendronate (20 mg), bone loss resumed at the normal early postmenopausal rate.

Alendronate prevents postmenopausal bone loss in women without osteoporosis. A double-blind, randomized, controlled trial. Alendronate Osteoporosis Prevention Study Group

BACKGROUND

Preventing bone loss associated with menopause and aging and maintaining the normal micro-architecture of bone provide important opportunities for the prevention of osteoporosis and fractures.

OBJECTIVE

To determine the safety and efficacy of alendronate, an aminobisphosphonate, for preventing postmenopausal bone loss.

DESIGN

3-year double-blind, randomized, placebo-controlled trial.

SETTING

15 osteoporosis centers throughout the world.

PARTICIPANTS

447 women who had recently experienced menopause (6 to 36 months before study entry).

INTERVENTION

Participants were randomly assigned to one of five regimens: oral placebo; oral alendronate, 1, 5, or 10 mg/d; or oral alendronate, 20 mg/d for 2 years followed by placebo during the third year (20/0 mg/d).

MEASUREMENTS

Bone mineral density was measured by dual-energy x-ray absorptiometry. Bone turnover and bone quality were assessed with biochemical markers and bone histomorphometry.

RESULTS

Alendronate at 5, 10, and 20/0 mg/d increased bone mineral density from baseline at the lumbar spine, femoral neck, and trochanter by 1% to 4% and in the total body by 0.3% to 1.0%; placebo led to losses of 2% to 4% at these sites. Alendronate, 1 mg/d, attenuated losses relative to those seen with placebo. Alendronate decreased markers of bone resorption to a new steady state by 3 months and decreased markers of bone formation by 6 to 12 months. Bone quality remained normal. At all dosages studied, alendronate had a safety and tolerability profile similar to that of placebo.

CONCLUSIONS

In early postmenopausal women, alendronate given for 3 years at dosages of 5 mg/d or greater prevented the loss of bone mineral density at the spine and hip and in the total body. Alendronate seems to be a safe and effective nonhormonal option for prevention of postmenopausal bone loss.

The effect of socioeconomic status on bone density in a male Caucasian population

We have examined the effect of socioeconomic status (SES) on bone density (BMD) in 201 males, aged 20-60 years. Males of lower SES (groups 4-6 vs. 1-3) from the total sample had significantly higher BMD (p < 0.05) at L2-4 and femoral neck. The difference was small but was not explained by differences in age, weight, calcium intake, family history, activity, or smoking. 45% of SES 4-6 males were involved in manual labor compared with 11% of those in SES 1-3, however, this also did not appear to account for the difference.

The added effectiveness of early geriatrician involvement on acute orthopaedic wards to orthogeriatric rehabilitation

AIMS

To evaluate the effect of regular input by a geriatrician to an orthopaedic ward.

METHOD

A geriatrician saw all patients aged over 65 years admitted to an acute orthopaedic ward-this was compared to an adjacent orthopaedic ward which had consultation only service, and also to both wards in the preceding year. All subjects over the age of 65 years with fractured neck of femur admitted over a 4 month period were enroled. Main outcome measures were length of stay, cost, discharge destination.

RESULTS

In the year prior to study, patients in both wards had a mean total stay of 28 days. On the intervention ward the mean stay was reduced to 20.7 days, and on the control ward to 27 days. The cost per case on the intervention ward was NZ$9400, and on the control ward was NZ$11 500. Eleven percent went to a higher care level on the intervention ward, compared with 23% on the control ward.

CONCLUSION

Geriatrician input on a twice weekly basis to all patients over 65 years of age on an orthopaedic ward, saves bed days, reduces costs and produces an improved outcome.

Effect of losartan on haematology and haemorheology in elderly patients with essential hypertension: a pilot study

This small open study in elderly patients with essential hypertension investigated the effects of the angiotensin II AT1 receptor antagonist on red blood cell haematology and haemorheology. Administration of losartan over a 1-year period was not associated with a significant reduction in haemoglobin or plasma erythropoietin (EPO) concentrations and haemorheological indices remained unchanged. These findings are in contrast to similar studies with angiotensin-converting enzyme (ACE) inhibitors that have shown a significant reduction in erythropoietic activity and a decrease in blood viscosity. Our results indicate therefore that blocking the angiotensin II AT1 receptor does not affect erythropoiesis. Losartan has no adverse haemorheological effects and was associated with a small and statistically insignificant decrease in blood viscosity.

Historical assessment of risk factors in screening for osteopenia in a normal Caucasian population

BACKGROUND

Bone mineral density (BMD) can predict fracture, however, the common use of historical risk factors to predict low BMD is unproven.

AIMS

To identify significant historical risk factors for osteopenia. To establish predicting equations for BMD and test their ability to identify those who should be referred for BMD scanning.

METHODS

Three hundred and twenty female and 131 male volunteers underwent questionnaire assessment of risk factors and BMD by dual photon absorptiometer at hip and spine. Significant risk factors (P < 0.05) were used to construct a linear regression model to predict BMD. This was cross validated on a second sample of 107 females and 131 males selected from the electoral roll analysing the ability to detect those subjects with BMD in the lower third of the age matched normal range.

RESULTS

In women lower BMD at the spine was associated with increased age, decreased weight, smoking, and delayed menarche. Lower femoral BMD was associated with increased age, decreased weight, family history, inactivity, and smoking. In men lower BMD at the lumbar spine was associated with lower weight, and inactivity. Lower BMD at the femur was associated with increased age, decreased weight, family history, and low calcium intake. When cross validated on the second sample, the models produced sensitivity of 86-89% and sensitivity of 25-46%. Referring those with these risk factors could save 10-23% on scanning. Measuring BMD at the site in question remains the only accurate way of assessing an individual's risk of osteopenia.

Asymptomatic low bone mineral density in otherwise healthy people: four year follow up

AIM

To determine the effect of screening a normal population for low bone density on lifestyle, subsequent bone density and fracture risk.

METHOD

A cross sectional study of 726 subjects screened for low bone density identified 60 with bone density greater than one standard deviation below an age and sex matched mean. Those who accepted further assessment were followed clinically and with repeat bone densitometry for up to four years. Those declining assessment were contacted four years later and questioned about lifestyle changes and fractures. They were offered repeat bone densitometry.

RESULTS

Twenty five subjects accepted intervention and were advised on lifestyle modification and treated with calcium supplements (18) calcitriol (5) or oestrogen (1). 22 of the 35 subjects who initially declined intervention volunteered to have their bone density repeated. Bone density increased in the group accepting intervention compared to the 22 subjects in the group who initially declined assessment (p < 0.05). Several laboratory investigations had a low yield. Lifestyle modification in the group declining assessment did not significantly affect subsequent bone density. Fractures occurred infrequently in both groups.

CONCLUSION

After screening the normal population for low bone density, significant improvements in bone density can be achieved in patients accepting further intervention.

A comparison of elderly patients with proximal femoral fractures and a normal elderly population: a case control study

AIM

To assess the importance of bone density and other risk factors in elderly subjects with hip fractures.

METHOD

Thirty-six subjects with femoral neck fracture were compared with 72 community controls in this case control study. Variables compared included: history of falls, previous fracture, body mass index, hand grip strength, blood pressure, medication use, cigarette smoking, alcohol intake, visual acuity, age at menopause, mental status quotient, mobility index and mid thigh circumference. Bone mineral density was measured at the hip (DPA absorptiometer) in the 36 subjects with hip fracture and 36 community controls.

RESULTS

Fracture patients had significantly (p < 0.01) reduced bone mineral density at femoral neck (0.64 vs 0.74 g/cm2) and trochanteric regions (0.55 vs 0.66 g/cm2). They also had significantly (p < 0.05) lower body mass index, weaker hand grip strength, smaller mid thigh circumference, reduced mobility and more previous fractures. After controlling for age and sex stepwise logistic regression identified handgrip strength, mobility status and falls in that ranking as risk factors for fracture. Bone mineral density was correlated with mobility status and grip strength.

CONCLUSION

Patients with hip fracture have lower bone mineral density than controls. Mobility, grip strength and muscle bulk appear to be important in fracture aetiology and could operate either through bone density or risk of falling.

Factors affecting bone mineral density in high school girls

OBJECTIVES

first to establish a local normal range for hip and spine bone density in the teenage years. Secondly to determine what factors might affect bone mineral density at this age.

METHODS

bone mineral density (DPX absorptiometer) at the hip and spine in a cohort of 138 high school girls; mean age 16.4 yr (SD 0.34). Anthropometric factors, calcium intake, physical activity and other lifestyle and medical data were documented in each subject.

RESULTS

in this group of 16 year old schoolgirls mean bone mineral density at the hip, 1.01 (0.13) was not significantly different from 20-25 year old New Zealand females, but bone mineral density at lumbar spine, 1.17 (0.12), was significantly lower. Positive correlations of bone mineral density with weight, height, physical activity and calcium intake were demonstrated. Weight was clearly the best predictor of bone mineral density variability. Calcium intake and physical activity showed no predictive value at the spine but contributed significantly at all regions of the femur and particularly at the trochanter.

CONCLUSIONS

it appears that peak bone mass can be modified by nutrition and exercise. Adolescents should be encouraged into regular exercise programmes and to maintain adequate body mass and calcium intakes.

Trial of Sinemet CR4 in patients with Parkinson's disease

OBJECTS

to compare the efficacy of Sinemet CR4 (CR4), a slow release levodopa preparation, with that of standard Sinemet in patients with Parkinson's disease and motor fluctuations.

METHODS

forty-five patients with Parkinson's disease of mild to moderate severity and motor fluctuations were entered into the 12 month trial. After a four week baseline period of optimal therapy, standard Sinemet was completely substituted by CR4 over 12 weeks, and clinical status monitored regularly over another 36 weeks. Evaluation was based on standard rating scales and patient's and physician's opinion ratings.

RESULTS

forty-two patients completed the study. The mean optimum total daily dosage of Sinemet CR4 was 702 mg, significantly greater than the mean optimum daily dose of standard Sinemet--496 mg (p less than 0.01). Median number of doses per day was less, being 3 and 4 respectively (p less than 0.01). There was reduction in tremor (p less than 0.01) and rigidity (p less than 0.05) with Sinemet CR4 therapy compared with standard Sinemet, but no difference in disability scores, bradykinesia, gait, or postural instability. Twenty-five patients rated the change to Sinemet CR4 from standard Sinemet as "more helpful", 15 "about the same", and two "less helpful". There were no serious or unexpected adverse effects.

CONCLUSIONS

it was concluded that Sinemet CR4 was at least as effective as standard Sinemet, and it seemed particularly helpful in those patients with wearing-off who require frequent doses of standard Sinemet throughout the day.

The effect of parathyroidectomy on bone mineral density in primary hyperparathyroidism

Bone mineral density was studied before, and at one year after successful parathyroidectomy in six postmenopausal, three premenopausal females and one male with primary hyperparathyroidism. Dual photon absorptiometry was used to measure bone mineral density at the lumbar spine in all subjects, and at three areas of the hip in eight of the subjects. There was no significant change in bone mineral density at the lumbar spine after one year. Bone mineral density increased 7.4% at the femoral neck from 0.822 (SEM 0.053) g/cm2 to 0.895 (0.04) g/cm2; p less than 0.01, 8.7% at Wards triangle from 0.681 (0.065) g/cm2 to 0.745 (0.07) g/cm2; p less than 0.02. A 5.6% increase at the trochanteric region from 0.785 (0.053) g/cm2 to 0.803 (0.053) g/cm2 was not significant. These results indicate that significant increases occur in bone mineral density at the hip, but not at the lumbar spine at one year after parathyroidectomy in patients with primary hyperparathyroidism.

A community study of vitamin B12 and folate levels in the elderly

OBJECTIVE

To measure the prevalence of low serum vitamin B12, folate, and red cell folate levels and their relationship with other nutritional indices.

DESIGN

Prospective survey of elderly subjects using radioisotope dilution assays.

SETTING

Primary care medical center, Christchurch, New Zealand.

PATIENTS

257 elderly subjects (age 65 years and over), residing in their own homes or in residential homes, were randomly selected. Of these, 204 (79%) participated. The study population was comparable to the elderly population of New Zealand.

MAIN OUTCOME MEASURES

Vitamin B12, serum, and red cell folate levels.

RESULTS

The prevalence rates for low levels of serum vitamin B12, folate, and red cell folate were 7.3%, 1%, and 3.3%, respectively. The elderly cohort had lower vitamin B12 (P less than 0.001) but higher serum and red cell folate levels (P less than 0.001) than our normal reference range (age 18-65 years). Red blood cell folate levels showed positive correlations with nutritional indices and mental test scores. No correlations were found between vitamin B12 levels and diet or other nutritional indices.

CONCLUSIONS

Low folate levels in older people living at home are infrequent findings. In contrast low vitamin B12 levels are more common. Poor diet and undernutrition may contribute to low folate levels, but these factors are less important for the low B12 levels found.

Erythrocyte sedimentation rates in the elderly: a community study

One hundred and ninety-four elderly subjects living in the community were randomly selected in order to define a reference range for erythrocyte sedimentation rate (ESR) for this age group. Mean (S.D) values were 4.1 (2.9) mm in one hour and 7.2 (2.6) mm in one hour for men and women respectively. Values ranged from 0-44 mm in one hour. The ESR showed significant independent correlations with fibrinogen, haemoglobin (male and female) and albumin levels (male only). A new algorithm for determination of the upper limit of normal for age is proposed: Females ESR = Age/3 + 10 Male ESR = Age/3.

Effects of age and sex on bone density at the hip and spine in a normal Caucasian New Zealand population

We have studied a normal adult caucasian population (462 females, 264 males age range 20-84) using dual photon absorptiometry to establish patterns of bone reduction at the spine and hip. Subjects were either randomly selected from the electoral roll or volunteers. Bone mineral density reduction at the lumbar spine in females appeared to increase at 40 years and was sustained until 60 years. In males bone mineral density at the spine was preserved. The density at the hip in females decreased throughout adult life beginning before the menopause. In males bone density was preserved at the femoral neck and trochanteric region but not at Wards triangle where reduction occurred throughout life. When compared with other normal populations there was higher bone mineral density at the spine in postmenopausal New Zealand females but no significant difference at the hip.

Effect of sulindac on angiotensin converting enzyme inhibitor-induced cough: randomised placebo-controlled double-blind cross-over study

The effect of sulindac on ACE inhibitor-induced cough was studied in eight hypertensive subjects in a randomised placebo-controlled double blind cross-over trial. There was no significant improvement in cough or sense of well-being. Blood pressure, renal function, plasma renin and ACE activity were unchanged. Sulindac however, appears to be effective in some individuals in reducing ACE inhibitor-induced cough with acceptable tolerance and few side effects. Further work is needed to elucidate the mechanism of sulindac's interaction with ACE inhibitors.

Comparative study of norfloxacin and trimethoprim for the treatment of elderly patients with urinary tract infection

One hundred elderly hospitalised patients, aged 70 to 97 years (mean 81.7 years; SD 7.1 years) with a urinary tract infection were entered into a randomised study to compare the efficacy, safety and tolerance of norfloxacin 400 mg twice daily for three days with trimethoprim 300 mg once daily for three days. Forty-two of 49 patients (86%) were cured with norfloxacin, compared with 35 of 51 (69%) with trimethoprim (p less than 0.05). No patient reported any side effects during treatment. Two patients treated with norfloxacin and three treated with trimethoprim developed a disturbance of liver function. Three deaths occurred within 28 days of treatment with trimethoprim but were unrelated to the treatment. In this study norfloxacin proved superior to trimethoprim for the treatment of uncomplicated urinary tract infections in elderly hospitalised patients.

A comparison of long acting nifedipine and enalapril in elderly hypertensives: a randomised, single-blind, cross-over study

The effects of nifedipine and enalapril on blood pressure (BP), heart rate, plasma and urine electrolyte, plasma renin activity (PRA), aldosterone and catecholamines, were studied in ten elderly hypertensive subjects in a randomised, single-blind, cross-over trial. Both nifedipine and enalapril were effective in lowering supine and erect systolic and diastolic BP, with nifedipine causing a significant (P less than 0.05) rise in heart rate. Arterial pressure rose to pre-treatment levels on withdrawal of both drugs. Plasma glucose fell significantly (P less than 0.02) on enalapril therapy, whilst no other biochemical changes were observed. PRA, aldosterone and adrenaline rose on nifedipine therapy whereas PRA showed a greater rise on enalapril with a fall in plasma aldosterone and no change in plasma adrenaline. Plasma noradrenaline was not altered by either agent. Unacceptable side effects occurred in patients taking nifedipine resulting in discontinuation of therapy in 2 patients and death in another. Nifedipine or enalapril monotherapy is effective in lowering BP in the elderly hypertensives. Although more experience is needed, the side effect profile of both agents especially enalapril, appears satisfactory.

Effect of opiate, general anaesthesia and surgery on plasma atrial natriuretic peptide levels in man

1. Animal data suggest that opiates, halothane anaesthesia and activation of the sympathetic system stimulates release of atrial natriuretic peptide (ANP). To examine whether this is so in man, venous ANP levels were measured in five patients undergoing elective cholecystectomy. 2. Plasma levels of cortisol, aldosterone, norepinephrine and epinephrine increased 3-6 fold during the study. Cortisol-aldosterone relationships were close in all patients (r = 0.73-0.97), whereas plasma renin activity and aldosterone correlations were strong in only two subjects. 3. Baseline plasma ANP concentrations were within the normal range and were not altered by opiate injection, anaesthesia, or surgery. 4. Unlike experimental animals, man exhibits little or no ANP response to opiates, halothane, or surgical stimulation of the sympathetic nervous system.

Cough with angiotensin converting-enzyme inhibitors

Since there are isolated case reports linking cough with angiotensin converting-enzyme (ACE) inhibitor treatment, we reviewed the case notes of patients attending a hypertension outpatient clinic. Of 126 patients, 37 were on medications other than ACE inhibitors, and none complained of cough. In contrast, 12 of 89 patients receiving an ACE inhibitor had noted cough. The symptoms remained when one ACE inhibitor was substituted for another, but disappeared when the drug was withdrawn. Cough was sufficiently irritating to require cessation of treatment in two patients. We conclude that cough is not uncommon during treatment with ACE inhibitors.

Failure of conventional chemotherapy in aggressive lymphomas

Between 1975 and 1982 in 2 centres in Glasgow, 53 previously untreated patients with aggressive non-Hodgkin's lymphomas received chemotherapy consisting of one of the following regimens-CVP, MOPP, CHOP or BACOP. Twenty nine patients (55%) entered complete remission (CR), 20 (38%) had partial remission (PR) and 4 (7%) had progressive disease (PD). Of the 29 patients in CR, 9 have relapsed and died, 5 died of infection, 4 died of non-malignant causes, and 11 (21%) remain alive and disease free. The median survival for the CR group is 40 months. All of the patients in the PR and PD group are dead, median survival 11 months. These chemotherapy regimens will cure only the minority of patients with aggressive lymphomas and the use of more intensive regimens is indicated.

A clinical and pharmacokinetic phase I study of 1,2,4-triglycidylurazol (TGU, NSC 332488)

Twenty-six patients with advanced malignancies received TGU given as an intravenous (i.v.) bolus in physiological saline at 3 weekly intervals. The starting dose was 30 mg/m2 with standard graded escalations to 900 mg/m2. Myelosuppression occurred at 800 mg/m2, with a mean nadir of 2.0 +/- 0.8 X 10(9)/l and a mean nadir platelet count of 41 +/- 31 X 10(9)/l. At 800 or 900 mg/m2 nausea and vomiting was WHO grade 0 in 5, grade I in 6, grade II in 11 and grade III in 10 courses of therapy. Alopecia did not occur. TGU was given by i.v. infusion at 800 mg/m2 in 2 patients, both of whom developed severe thrombophlebitis. Five patients given TGU by i.v. bolus developed mild phlebitis. No renal, hepatic or cardiac toxicity was noted. Two patients had partial responses; both had adenocarcinoma of unknown primary origin, one of whom had been resistant to prior therapy with FAM. An HPLC analytical method was developed with a sensitivity of 250 ng/ml. The data from 7 patients studied best fit a one compartment pharmacokinetic model with an exponential decay and a t1/2 of only 2.1 min. In conclusion, the dose limiting toxicity of TGU appears to be myelosuppression and we would recommend a dose of 800 mg/m2 given as an intravenous bolus every 4 weeks for future phase II trials.

Renal, hemodynamic, and hormonal responses to atrial natriuretic peptide infusions in normal man, and effect of sodium intake

The effect of 60-min constant iv infusions of alpha-human atrial natriuretic peptide (alpha hANP; 200 micrograms), sufficient to increase the steady state venous plasma alpha hANP concentration to levels found in patients with some circulatory disorders, was studied in six normal men equilibrated on a high sodium diet (200 mmol daily) and again when equilibrated on a low sodium intake (10 mmol daily). In each instance, the responses to alpha hANP were compared to those to control infusions given on the preceding day. The mean steady state plasma immunoreactive ANP concentration during the infusions was 320 pmol/liter and was the same during both diets. Thus, the MCR of alpha hANP was unaffected by major changes in sodium intake. Compared to control day observations, infusions of alpha hANP induced a more than 3-fold increase in sodium excretion and at least a 2-fold increase in urine volume and calcium and magnesium excretion in subjects ingesting 200 mmol sodium daily. During the low sodium diet, alpha hANP was still diuretic and induced comparable magnesium excretion, but the natriuresis was only 11% of that during the high salt diet. No significant changes in blood pressure or heart rate occurred during alpha hANP infusions during either diet, although during both diets there was a significant rise in plasma norepinephrine (P less than 0.02), which persisted well beyond the disappearance of immunoreactive ANP from plasma. Despite this sympathetic activation, renin and aldosterone production was reduced by alpha hANP. During low salt intake, alpha hANP significantly decreased PRA (mean pretreatment, 1.79; posttreatment, 1.25 nmol/liter/h; P less than 0.03), angiotensin II (mean pretreatment, 49; posttreatment, 28 pmol/liter; P less than 0.008), and plasma aldosterone (mean pretreatment, 554; posttreatment 307 pmol/liter; P less than 0.007), whereas values during control infusions did not change. Similar percent decreases in PRA and aldosterone also occurred during the high salt diet. Plasma cortisol and arginine vasopressin did not change during the alpha hANP infusions on either diet. We conclude that steady state levels of alpha hANP in plasma, similar to those in patients with some circulatory disorders, significantly increase sodium excretion and inhibit all elements of the renin-angiotensin-aldosterone system. The natriuretic, but not the hormonal or chronotropic, effects of alpha hANP are reduced by sodium depletion in normal man.

Influence of polysorbate 80 (Tween 80) and etoposide (VP-16-213) on the pharmacokinetics and urinary excretion of adriamycin and its metabolites in cancer patients

Polysorbate 80 (Tween 80) is present in the IV pharmaceutical preparation of VP-16-213 marketed as VePesid (Bristol-Myers) (etoposide 100 mg, benzylalcohol 150 mg, polyethylene glycol 300 3250 mg, citric acid 10 mg, Tween 80 400 mg and absolute alcohol to 5 ml per 100 mg ampule of VP16), to increase its miscibility with blood. We have examined the effects of 400 mg/m2 Tween 80 IV and 100 mg/m2 VP16 on the pharmacokinetics of Adriamycin (ADR, 30 or 40 mg/m2). ADR and metabolite concentrations were measured by HPLC. ADR plasma profiles were best fitted to a bi-exponential decay and a two-compartment open model. Tween 80 did not alter the values of the two ADR half-lives, nor did it affect metabolite kinetics of their urinary excretion. However, in a similar manner and consistently in all patients, both Tween 80 and VP16 increased the volume of distribution of the central compartment for ADR up to 3-fold, decreased the AUC of ADR up to 2-fold and increased its clearance by exactly the same amount. These effects were due to reduced plasma ADR concentrations during the early phase of its kinetics. Urinary excretion of ADR was also increased. In conclusion, VP16 is likely to affect the kinetics of drugs administered with it: early plasma concentrations will fall due to a general physiological effect of Tween 80 on the apparent volume of circulation.

TNO-6 has no effect in gastrointestinal cancer: N-acetyl-glucosaminidase shows renal damage

Twenty-five patients, 16 with gastric cancer and nine with colonic cancer, received TNO-6 30 mg m-2 every four weeks. No objective tumour response was recorded. Nausea and vomiting occurred in 21 patients and was severe in 17. Severe marrow suppression developed in five patients. Renal function was unaffected in all but one patient who developed renal failure, probably as a result of septicaemia. However, the renal tubular enzyme N-acetyl-beta-D-glucosaminidase was measured in six patients and showed a rise in all. In this study TNO-6 had no anti-tumour activity in gastrointestinal malignancy, but produced significant renal tubular damage.

T-cell lymphoblastic lymphoma of the uterus complicated by Chlamydia trachomatis pneumonia

This is the first documented case of a T-cell lymphoblastic lymphoma arising in the uterus. At presentation, the patient also had a life-threatening pneumonia due to Chlamydia trachomatis which responded to erythromycin and tetracycline. Cytotoxic therapy produced partial tumour regression, but the patient died 14 weeks after diagnosis, probably as a result of intercurrent infection.

Chronic polyarticular gout in the elderly: a report of six cases

This report describes six elderly patients with previously undiagnosed and untreated chronic polyarticular gout, five of whom were seen at a Geriatric Rehabilitation and Assessment Unit within a 3-month period. All were on long-term diuretic therapy. Four patients had coexisting osteoarthritis. Three patients were unable to recall any prior history of attacks of acute arthritis and four patients were significantly disabled from gout. Chronic polyarticular gout in these patients was previously misdiagnosed and inadequately treated, resulting in otherwise preventable disability.

Alfacalcidol as a modulator of growth of low grade non-Hodgkin's lymphomas

Ten patients with low grade non-Hodgkin's lymphoma (seven follicular small cleaved and three small lymphocytic) were treated with 1 microgram oral alfacalcidol (1 alpha-hydroxycholecalciferol) daily. Of the seven patients with lymphomas of follicular small cleaved subtype, one achieved complete and three partial remission, whereas none of three patients with small lymphocytic lymphomas responded. In seven of the 10 patients, 1,25(OH)2D3 receptors were measured in tissue from lymph nodes, and a positive correlation between the presence and amount of receptor and response to alfacalcidol was found. These preliminary data suggest that alfacalcidol has appreciable antitumour activity in low grade non-Hodgkin's lymphomas.

Comparison of serum and cerebrospinal fluid levels of methotrexate in man during high-dose chemotherapy for aggressive non-Hodgkin's lymphoma

The relationship between plasma and cerebrospinal fluid levels of methotrexate was studied in five patients, four with aggressive non-Hodgkin's lymphoma and one with mixed epithelial mesothelial tumour, who were treated with high-dose methotrexate (1.5 g/m2) as part of combination chemotherapy. Cerebrospinal fluid was sampled for 24 h via a permanent indwelling lumbar catheter. No complications were observed with this technique. In two patients with central nervous system involvement adequate "cytotoxic" levels (greater than 10(-6) M) were obtained for greater than 12 h. The remaining three patients, with no direct evidence of central nervous system involvement, never attained adequate cytotoxic methotrexate levels in the cerebrospinal fluid. Serum levels were therapeutic in all patients. These results suggest that patients with central nervous system tumour involvement may receive adequate doses of methotrexate in the cerebrospinal fluid. Patients with occult central nervous system tumour involvement may not attain adequate cerebrospinal fluid levels. A 24-h serum methotrexate level of greater than 10(-5) M may indicate that patients have achieved therapeutic cerebrospinal fluid levels of methotrexate. Cranial irradiation following chemotherapy is still recommended in this tumour group until adequate cytotoxic levels of methotrexate can be obtained in all patients for prolonged periods.

Randomised trial of intravenous high dose metoclopramide and intramuscular chlorpromazine in controlling nausea and vomiting induced by cytotoxic drugs

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Effect of metoclopramide on aldosterone and regulatory factors in man

To determine the role of known secretagogues in the aldosterone response to dopamine blocking agents, plasma levels of ACTH, angiotensin II, potassium and plasma catecholamines were measured in five normal male subjects before and after intravenous injection of saline or 10 mg metoclopramide. There were no consistent changes in hormone levels after saline injection. After metoclopramide, plasma aldosterone increased three-fold to peak values at 20 min post-injection. A significant increase in aldosterone was observed within 10 min during which period there was no significant change in plasma ACTH, plasma renin activity AII or K. Plasma levels of cortisol, noradrenaline, adrenaline and dopamine showed no significant changes after injection of metoclopramide which induced a ten-fold rise in plasma prolactin. These results provide direct evidence that factors other than the plasma concentration of ACTH, AII and K--or fluctuations in plasma catecholamines--are likely to be responsible for the acute increase in plasma aldosterone after metoclopramide injection in normal man.

A sensitive radioimmunoassay for measuring plasma anti-diuretic hormone in man

A radioimmunoassay has been developed which permits the measurement of plasma antidiuretic hormone (arginine vasopressin (AVP), in the normal and subnormal range. Plasma was first extracted with octadecasilyl-silica to remove non-hormonal immunoreactivity, then assayed using a sensitive antibody and mono-iodinated AVP. After centrifugation of blood, we found AVP levels to be highest in the lowest layer of plasma--presumably because platelets are a reservoir for the hormone. In normal volunteers the range of plasma AVP was 0.8-14.3 pmol/l, and water loading generally lowered AVP levels. Appropriate increments in measured AVP were observed during intravenous infusion of the peptide, and during insulin-induced hypoglycaemia. Extremely low levels were found in cranial diabetes insipidus, whereas in some patients with bronchial carcinoma and hyponatraemia, AVP values were elevated. The sensitivity of the method and its practicability should make it useful both in clinical medicine and in research.