Well-being at onset of hormone replacement therapy: comparison between two continuous combined regimens

OBJECTIVES

To compare the effect on well-being of two continuous combined hormone replacement therapies (HRTs) in women starting treatment ('starters') and women switching from mainly sequential HRT ('switchers').

METHODS

This was a randomized, double-blind, 1-month trial, in which 249 postmenopausal women were treated with either conjugated estrogen plus medroxyprogesterone acetate (CE/MPA 0.625 mg/5 mg) or 17beta-estradiol plus norethisterone acetate (E2/NETA 2 mg/1 mg) continuously. Twelve items for measuring climacteric symptoms and well-being were reported daily on a validated symptom scale.

RESULTS

Women taking CE/MPA reported lower scores for breast tenderness (p = 0.005), depression (p = 0.019), irritability (p = 0.004) and tension (p = 0.048), compared with women taking E2/NETA. Compared with pretreatment, both groups developed side-effects during the first week: breast tenderness, swelling and depression (p < 0.05). Starters, but also switchers, improved in sweats (p < 0.001 and p = 0.030). Compared with pretreatment ratings, switchers reported higher scores for breast tenderness (p < 0.001), depression (p = 0.050) and negative effects on daily life (p < 0.001), whereas starters reported only physical side-effects (p < 0.05). A history of premenstrual syndrome (PMS) predicted high scores for swelling (p = 0.023), depression (p = 0.024), tension (p = 0.009), irritability (p = 0.027), headache (p < 0.001) and negative effects on daily life (p < 0.001).

CONCLUSIONS

CE/MPA 0.625 mg/5 mg is better tolerated than E2/NETA 2 mg/1 mg, and starters react differently from switchers. Side-effects occur more quickly than benefits with HRT, and are more frequent in women with previous PMS.

Increased neonatal thyrotropin in Down syndrome

AIM

Down syndrome (DS) is frequently associated with thyroid dysfunction. The aim of this study was to investigate the blood concentration of thyrotropin (TSH) observed at neonatal screening of infants with DS and its possible association with development of hypothyroidism during childhood.

METHODS

TSH levels from neonatal screening of 73 children (34 F) with DS born in 1986-1996 were studied retrospectively and compared with those of controls. The DS children were followed up regarding thyroid function to the age of 10 years in this descriptive study.

RESULTS

The DS infants had a higher mean TSH level and a higher TSH standard deviation score (SDS) than controls (7.0 +/- 7.45 mU/L vs. 3.9 +/- 2.43 mU/L and 1.1 +/- 2.67 vs. 0, respectively). The differences were mainly attributable to higher values in the male DS children. The TSH level at screening did not predict thyroid dysfunction during childhood.

CONCLUSION

Infants with DS, especially boys, showed elevated levels of TSH at neonatal screening, indicating the occurrence of mild hypothyroidism already in early life. The TSH levels could not predict development of manifest thyroid disease later in childhood.

Rate of progression of severity of valvular aortic stenosis

Twenty-six patients with valvular aortic stenosis were followed up for an average period of 9 years after the initial evaluation when the valvular disease had been considered too mild for surgical treatment. The valve area was 0.7-1.9 (mean 1.2) cm2 at the first study and 0.3-2.0 (mean 0.9) cm2 at the second. The mean annual decrease was about 0.1 cm2 in ten and less in the remaining patients. Advanced age and low physical working capacity at the first investigation were associated with rapid progression of the severity of the stenosis, but rapid progression was not predictable. At follow-up the combination of 1) calcifications of the valve on chest X-ray, 2) low physical working capacity and 3) negative/biphasic T wave in V6 after exercise was present in 100% of the severe stenoses (much less than 0.6 cm2) and in 10% of the mild (much greater than 1.0 cm2). The rate of progression of valvular aortic stenosis in adults is usually slow, but moderate stenoses may become severe within a few years.

Amputations in diabetic patients in Gotland and Umeå counties 1971-1980

In two counties of Sweden, Gotland and Umeå, lower leg or thigh amputations were performed during 1971-1980 in 111 and 71 diabetic patients, respectively. These figures correspond to 20.5 and 6.5 per 100 000 inhabitants and year, respectively. The corresponding incidence for Umeå city and the rural area surrounding Umeå was 3.1 and 13.8/100 000 inhabitants and year, respectively. The lower frequency of amputations in Umeå was probably the consequence of a restricted period of systematic search for early signs of gangrene, as a part of a research program, but other factors could also be of importance and these are discussed. The death rate of the patients was high in both series, after 2 years only about one third of the patients were still alive.

Migratory timing, marine survival and growth of anadromous brown trout Salmo trutta in the River Imsa, Norway

The aim of the paper was to study sea migration, growth and survival of brown trout Salmo trutta of the River Imsa, 1976-2005. The migratory S. trutta were individually tagged and fish leaving or entering the river were monitored daily in traps located near the river mouth. The mean annual duration of the sea sojourn was 6-9 months for first-time migrants moving to sea between January and June. It was 8-18 months for those migrating to sea between July and December. Veteran migrants stayed 12 months or less at sea and most returned to the river in August. Early ascending fish stayed the longest in fresh water because most returned to sea in April to May. The day number of 50% cumulative smolt descent correlated negatively with mean water temperature in February to March and the February North Atlantic Oscillation index (NAOI). Mean annual sea growth during the first 2 years after smolting was higher for S. trutta spending the winter at sea than those wintering in the River Imsa. First year's sea growth was lower for S. trutta descending in spring than autumn. For first-time migrants, it correlated negatively with the February NAOI of the smolt year. Sea survival was higher for spring than autumn descending first-time migratory S. trutta with a maximum in May (14.9%). Number of anadromous S. trutta returning to the river increased linearly with the size of the cohort moving to sea, with no evidence of density-dependent sea mortality. Sea survival of S. trutta smolts moving to sea between January and June correlated positively both with the annual number of Atlantic Salmo salar smolts, the specific growth rate at sea, and time of seaward migration in spring. This is the first study indicating how environmental factors at the time of seaward migration influence the sea survival of S. trutta.

Thermal growth performance of juvenile brown trout Salmo trutta: no support for thermal adaptation hypotheses

Using thermal growth data from eight populations of anadromous and lake-feeding brown trout Salmo trutta, hypotheses of adaptation to local optima and countergradient variation in growth were tested. The adaptation to local optima hypothesis suggests that natural selection can shift optimal performance temperatures to match the prevailing temperature in a new or changed thermal niche. In contradiction, the countergradient variation hypothesis suggests that populations from hostile environments perform better than conspecifics from benign environments at all temperatures. In this study, growth capacity varied between populations but there was no significant correlation between any of the estimated thermal performance parameters (e.g. lower and upper thermal growth limits, optimal temperature for growth and maximum growth capacity) and natural climatic conditions among populations. Hence, S. trutta growth response to temperature lends no support for either of the two suggested thermal adaptation hypotheses. Instead, growth capacity among populations tended to correlate positively with female size at maturity.

Asymmetric competition drives lake use of coexisting salmonids

To what degree are population differences in resource use caused by competition and the occupation of adjacent positions along environmental gradients evidence of competition? Habitat use may be the result of a competitive lottery, or restricted by competition. We tested to what extent population differences in habitat use of two salmonids, cutthroat trout (Oncorhynchus clarki) and Dolly Varden charr (Salvelinus malma) were influenced by interspecific competition. We hypothesized that the depth distribution of Dolly Varden charr would be affected by competition from the more littoral and surface-oriented cutthroat trout, and that the depth distribution of cutthroat trout would be little affected by competition from Dolly Varden charr. Sympatric populations of cutthroat trout and Dolly Varden charr were created by reciprocal transfers of previously allopatric populations in two experimental lakes. We found evidence of asymmetric competition, as Dolly Varden charr were displaced from littoral habitats when sympatric with cutthroat trout, whereas cutthroat trout remained unaffected by the presence of Dolly Varden charr. Evolved differences between the species, and differences between experimental lakes, also contributed to population differences in habitat use, but asymmetric competition remained as the main driver of different depth distributions in sympatry.

Modeling the cost-effectiveness of a new treatment for MS (natalizumab) compared with current standard practice in Sweden

OBJECTIVE

To estimate the cost-effectiveness of a new treatment (natalizumab) for multiple sclerosis (MS) compared with current standard therapy with disease-modifying drugs (DMDs) in Sweden.

METHODS

A Markov model was constructed to illustrate disease progression based on functional disability (the Expanded Disability Status Scale (EDSS)). The effectiveness of natalizumab was based on a 2-year clinical trial in 942 patients (AFFIRM). The effectiveness of current DMDs was estimated from a matched sample of 512 patients in the Stockholm MS registry. Patients withdrawing from treatment were assumed to follow the disease course of 824 patients with relapsing-remitting disease at onset in the Ontario natural history cohort. Costs and utilities are based on a recent observational study in 1339 patients. All data sets were available at the patient level. Main results are presented from the societal perspective, over a 20-year time frame, in 2005 Euros (euro1 = 9.25 SEK).

RESULTS

In the base case, treatment with natalizumab was less expensive and more effective than treatment with current DMDs. When only healthcare costs were considered, the cost per quality-adjusted life year gained with natalizumab was euro38 145. Results are sensitive only to the time horizon of the analysis and assumptions about effectiveness of natalizumab beyond the trial.

CONCLUSIONS

This cost-effectiveness analysis used registry data, cohort and observational studies to extrapolate the efficacy findings of natalizumab from the AFFIRM clinical trial to measure effectiveness in clinical practice. The analysis results suggest that for the population considered, natalizumab provides an additional health benefit at a similar cost to current DMDs from a societal perspective.

Children developing type 1 diabetes before 6 years of age have increased linear growth independent of HLA genotypes

AIMS/HYPOTHESIS

High birthweight and increased childhood growth are risk factors for type 1 diabetes. Relative birthweight is associated with HLA genotypes that confer a high risk of diabetes. Our aims were to test whether young children prior to clinical onset of type 1 diabetes have increased: (1) birthweight or birth length standard deviation scores (SDS); (2) height development SDS; or (3) BMI SDS during first 18 months of life and whether these parameters are related to HLA genotypes or mid-parental height (MPH).

METHODS

Birthweight, birth length, weight and height were obtained from 58 type 1 diabetes children and 155 controls matched for HLA or not in the Diabetes Prediction in Skåne study.

RESULTS

Birth length SDS corrected for MPH was increased in children developing diabetes compared with all (p < 0.048) and with non-HLA- (p < 0.050) but not with HLA-matched controls. Children developing diabetes had increased height gain at 0 to 18 months of age (p < 0.005). Diabetic children were significantly taller from 6 to 18 months of age when correcting for MPH compared with non-HLA-matched as well as HLA-matched controls, but BMI was not increased.

CONCLUSIONS/INTERPRETATION

Birth length SDS was associated with diabetes risk HLA. When corrected for MPH, children developing diabetes were taller at birth than non-HLA- but not taller than HLA-matched controls. Diabetic children had increased MPH-corrected height up to 18 months of age compared with both HLA- and non-HLA-matched controls. High-risk HLA affects prenatal growth, but other factors may explain the increased postnatal linear growth in children developing diabetes.

Thinlip grey mullet Liza ramada (Mugilidae) caught in a

Two individuals of thinlip grey mullet Liza ramada were collected in a southern Norwegian brook (58° 22’ N, 8° 37’ E) on 12th September 2007. The fish were 8.7 and 9.0 cm in total length, 6 and 7 g in total mass, and most probably in their first year of life. The nearest known spawning area of the species is south of the English Channel, meaning that they had probably moved at least 900 km across the North Sea during their first growth season. To our knowledge, this is the first published observation of the catadromous thinlip grey mullet from a Scandinavian freshwater course.

Implementation of surfactant treatment during continuous positive airway pressure

OBJECTIVE

To study the effects of implementing a method for surfactant administration by transient intubation, INSURE (i.e. INtubation SURfactant Extubation) during nasal continuous positive airway pressure (nCPAP) for moderately preterm infants with respiratory distress syndrome (RDS).

STUDY DESIGN

A descriptive, retrospective, bi-center study in Stockholm, Sweden, comparing mechanical ventilation (MV) rates, surfactant use, treatment response and outcome of all inborn infants with gestational age 27 to 34 weeks and RDS, (n=420), during the 5-year periods before and after the introduction of the INSURE-strategy at one of the centers (Karolinska Huddinge) in 1998. The other center (Karolinska Solna) continued conventional surfactant therapy in conjunction with MV throughout the study.

RESULTS

Implementation of INSURE at Karolinska Huddinge reduced the number of infants requiring MV by 50% (P<0.01), resulted in earlier surfactant administration and increased overall surfactant use. INSURE-treatment improved oxygenation and the treatment response was sustained over time with only 17% of the infants requiring >1 dose of surfactant. At Karolinska Solna, the MV rates were unaltered between the first and second 5-year period.

CONCLUSION

Implementing a strategy of surfactant administration by transient intubation during nCPAP reduces the need for MV without adverse effects on outcome and may be an option to more effectively treat RDS, particularly in a care setting where transfer is necessary to provide MV.

The European Medicines Agency (EMEA) guideline on oncology drug development

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Background: The scientific assessment and positive opinion of the EMEA is mandatory for the approval of new oncology drugs in the European Union. One of the tasks of the EMEA is to provide guidance on the conduct of the various tests and trials necessary for approval. The EMEA has recently revised its guideline on the clinical development of new anticancer drugs. The revised version includes specific guidance on the development of non-cytotoxic (i.e., cytostatic) agents ( http://www.emea.europa.eu/pdfs/human/ewp/020595en.pdf ). Specific guidance is given about methodological issues using progression-free survival (PFS) as primary endpoint in confirmatory trials for registration ( http://www.emea.europa.eu/pdfs/human/ewp/26757506en.pdf ). Methods: The key elements of the revised guideline are described with particular reference to requirements for approval. Results: The early stages of clinical drug development have to be tailored according to the assumed pharmacology of the individual compound as defined in non-clinical studies. The integration of information from exploratory (phase I-II) and confirmatory (phase III) studies is of primary importance. In general, phase III trials should be designed with the aim of establishing the benefit risk balance of the drug, in a well-characterized target population. These studies should be randomized controlled and, where possible, blinded or include blinded evaluation. Acceptable primary endpoints include overall survival (OS) and PFS or disease-free survival (DFS). It is acknowledged that there are situations where PFS can be considered as a primary endpoint that measures clinical benefit. Adherence to protocol-defined schedules for tumor assessments, typically by imaging techniques, is important and deviations should be reported. Independent, blinded review and confirmation of best tumor response and progression should be undertaken if PFS is the primary endpoint. Conclusions: The current revision of the EMEA guideline provides useful clinical regulatory guidance for the development of cytostatic agents. When recommended guidelines are considered suboptimal, sponsors are encouraged to seek regulatory scientific advice.

No significant financial relationships to disclose.

Milk for small infants

This study investigated weight patterns of infants born SGA, in relation to two different feeding regimens during hospital stay. We compared 21 SGA infants prescribed 200 mL/kg milk on day 2, with 21 infants, prescribed 170 mL/kg on day 9. The infants fed according to the proactive nutrition policy tolerated large volumes of milk and showed lower weight loss.

CONCLUSION

A proactive nutrition policy demonstrably reduces weight loss in SGA infants.

Latitude, socioeconomic prosperity, mobile phones and hip fracture risk

INTRODUCTION

Epidemiological observations suggest that sunlight exposure is an important determinant of hip fracture risk. The aim of this ecological study was to examine the relationship between latitude and hip fracture probability.

METHODS

Hip fracture incidence and mortality were obtained from literature searches and 10-year hip fracture probability computed from fracture and death hazards.

RESULTS

There was a significant association between latitude and 10-year hip fracture probability. For each 10 degrees change in latitude from the equator (e.g., from Paris to Stockholm), fracture probability increased by 0.3% in men, by 0.8% in women and by 0.6% in men and women combined. There was also a significant association between economic prosperity and hip fracture risk as judged by gross domestic product (GDP)/capita or the use of mobile phones/capita. A US $10,000 higher GDP/capita was associated with a 1.3% increase in hip fracture probability. The association between latitude and hip fracture probability persisted after adjusting for indices of economic prosperity.

CONCLUSIONS

These findings provide support for an important role of sunlight exposure in the global variation of hip fracture risk. In addition, there is a need to identify the factors related to socioeconomic prosperity that may provide mechanisms for the variation in hip fracture probability worldwide.