Improved glycaemic control with dipeptidyl peptidase-4 inhibition in patients with type 2 diabetes: vildagliptin (LAF237) dose response

OBJECTIVE

A novel treatment option for diabetic patients is the enhancement of incretin hormone activity by inhibition of the enzyme dipeptidyl peptidase-4 (DPP-4). This study was designed to establish a dose of the DPP-4-inhibitor vildagliptin (LAF237) that was effective in reducing HbA1c levels and was safe and well tolerated in patients with type 2 diabetes.

PATIENTS AND METHODS

The study of 279 patients with type 2 diabetes consisted of a 4-week run-in phase where patients received placebo and a 12-week active treatment phase where they received one of the following dosages of vildagliptin: 25 mg twice daily, 25, 50 or 100 mg once daily (qd), or placebo.

RESULTS

There was a statistically significant reduction in HbA1c levels in the vildagliptin 50 mg qd (p=0.003) and 100 mg qd groups (p=0.004) compared with the placebo group. The mean 4-h postprandial glucose level was significantly reduced from placebo in the vildagliptin 50 mg qd group (p = 0.012) and mean 4-h postprandial insulin was significantly increased from baseline vs. placebo in the vildagliptin 100 mg qd group (p=0.022). The assessment of beta-cell function (HOMA-B) was significantly increased in the vildagliptin 100 mg qd treatment group (p=0.007). The incidence of adverse events was similar in all treatment groups including placebo.

CONCLUSIONS

Vildagliptin, at 50 and 100 mg qd, was effective in reducing HbA1c levels compared with placebo in patients with type 2 diabetes. Vildagliptin at dosages up to 100 mg qd appeared safe and well tolerated.

Selective reduction of multifetal pregnancy using high-intensity focused ultrasound in the rabbit model

OBJECTIVE

High-order multifetal pregnancies carry a significant risk of obstetric complications and poor pregnancy outcome. Selective reduction has traditionally been performed using transabdominal and transvaginal ultrasound-guided intracardiac injection of potassium chloride. We have previously shown that high-intensity focused ultrasound (HIFU) can create a coagulative tissue necrosis in the sheep fetus. The objective of this study was to investigate the feasibility of non-invasive selective fetal reduction using HIFU in a rabbit model.

METHODS

A protocol for HIFU-induced tissue coagulation was developed in the rabbit model. The fetal heart was targeted with ultrasound-guided tissue ablation by a HIFU beam. Five time-mated does between 20-29 days' gestation underwent transabdominal fetal cardiac ablation in a total of 11 fetuses. The HIFU system consisted of a 7-MHz high-power transducer, operated at 2000 W/cm2. The fetal heart rate was observed using real-time ultrasound with Doppler flow velocimetry. All lesions were assessed macroscopically and by histological analysis.

RESULTS

Severe bradycardia leading to asystole was observed in all targeted fetuses with ultrasound examination. Dissection of fetuses demonstrated a necrotic intrathoracic lesion similar in size to the HIFU focus (approximately 1 x 9 mm). None of the surrounding fetuses was found to have bradycardia during the procedure or a macroscopic lesion on dissection.

CONCLUSION

In this pilot study HIFU seems promising to ablate even highly vascularized tissue in the fetus.

A prospective study of the use of nitrous oxide inhalation sedation for dental treatment in anxious children

AIM

To determine baseline data in relation to procedures undertaken during nitrous oxide inhalation sedation sessions within the Hospital Dental Service.

STUDY DESIGN

A prospective study.

METHODS

Data was collected over a twelve-month period for patients attending the Department of Paediatric Dentistry, Dundee Dental Hospital, Dundee, Scotland, for dental treatment using nitrous oxide inhalation sedation. Overall behaviour and the outcome of treatment were assessed by the dentist providing sedation using the Frankl and Houpt Behaviour Rating Scales respectively.

RESULTS

Data was available for 312 patients (F:169; M:143) with a median age of 11.0 (inter-quartile range 8.8, 12.7) years. Overall, 93% of patients successfully completed treatment using sedation. The majority of treatments comprised dental extractions; 19.8% and 41.3% were primary and permanent tooth extractions respectively. Regarding permanent teeth, nearly 50% were first permanent molar extractions compared with just over 30% for first premolars. Nearly three-quarter of cases were treated using a mixture of 30% nitrous oxide and 70% oxygen, with a median sedation time of 35.7 minutes. Only 7% of cases failed to commence or complete treatment and overall, there was a greater failure rate amongst visiting Community Dental Officers, compared with Hospital-based clinicians.

CONCLUSION

Extraction of first permanent molar teeth can be successfully achieved using inhalation sedation. There is both a need for further postgraduate training in sedation techniques as well as the necessity to train further Specialists in Paediatric Dentistry to undertake care within the Community Dental Service.

Nitrous oxide inhalation sedation: what do patients, carers and dentists think about it?

AIM

To determine the acceptability and efficacy of nitrous oxide inhalation sedation for dental treatment to children and to compare these results with the responses of both the accompanying adult and the treating dentist.

STUDY DESIGN

A prospective, questionnaire-based survey was used.

METHODS

Fifty consecutive patients (ASA I and II) attending the Department of Paediatric Dentistry, Edinburgh Dental Institute, between 2002 and 2003 for dental treatment using nitrous oxide inhalation sedation were recruited for the study. Each patient, the accompanying adult and the dental sedationist completed a short questionnaire which sought details about the acceptability and efficacy of the sedation technique. Overall behaviour and the outcome of treatment were assessed by the dentist providing sedation using the Frankl and Houpt Behaviour Rating Scales respectively.

RESULTS

Three sets of questionnaires were completed for fifty patients (M:27; F:23), mean age 10.4 years (range: 5.3-15.8 years). Acceptance of both local analgesia and dental treatment was perceived as greater amongst patients and carers compared with treating dentists (chi2 = 11.31, P = 0.004, 2 df and chi2 = 22.52, P < 0.001, 2 df respectively). Furthermore, dentists observed that inhalation sedation helped fewer male patients with local analgesia and fewer female patients with dental treatment (chi2 = 6.83, P < 0.009, 1 df and chi2 = 3.85, p < 0.050, 1 df respectively). A greater proportion of dentists observed that patients would manage treatment without sedation and would not require sedation for future dental treatment than both patients and their accompanying carer (chi2 = 8.00, P < 0.018, 2 df and chi2 = 18.61, P < 0.001, 2 df respectively). In general, the majority of patients were co-operative and successfully completed dental treatment with inhalation sedation.

CONCLUSION

Dentists' perception of nitrous oxide inhalation sedation was generally less enthusiastic than that of patients and carers.

Partial caries removal and cariostatic materials in carious primary molar teeth: a randomised controlled clinical trial

OBJECTIVE

To determine the durability and effectiveness of a black copper cement (BCC) and a conventional glass ionomer cement (GIC) when used to restore primary molars following partial caries removal (PCR) and to compare these results with conventional cavity preparation and restoration.

DESIGN

Split-mouth randomised controlled clinical trial.

SETTING

Department of Paediatric Dentistry, Dundee Dental Hospital, Dundee, 1998-1999.

SUBJECTS

Patients with previously unrestored, matched carious cavities in non-pulpally involved primary molars.

INTERVENTIONS

Three treatment groups: (1) Partial caries removal followed by lining with BCC and restoration with GIC (PCR:BCC); (2) Partial caries removal and restoration with GIC alone (PCR:GIC), and (3) Complete caries removal and conventional restoration (CR). Restoration durability and effectiveness was assessed both clinically and radiographically over 24 months.Main outcome measures Median survival time (MST) of restorations.

RESULTS

Forty-four patients (F: 31; M: 13), mean age 6.8 years (range: 3.7-9.5), had 120 restorations placed (PCR:GIC: 43; CR: 41; PCR:BCC: 36). Eighty-six molars (29 patients) (PCR:GIC: 30; CR: 29; PCR:BCC: 27) were reviewed at 24 months. The median survival times (MST) with 25% and 75% quartiles in parenthesis were as follows: PCR:BCC, MST = 24 months (6, 24); PCR:GIC, MST = 24 months (24, 24) and CR, MST = 24 months (24, 24). The MST for PCR:BCC restorations was significantly less than for PCR:GIC and CR restorations (W = 1163.5, P = 0.028 and W = 1081.0, P = 0.004 respectively).

CONCLUSION

There were no differences in the proportions of restorations lost between restoration types, although PCR:BCC restorations did have significantly more abscess/sinus formation over the 24-month study period.

An audit of the implementation of guidelines in relation to the prevention of dental caries

AIM

To determine the implementation of national clinical guidelines in relation to the targeted prevention of dental caries in the permanent teeth of 6-16-year-olds presenting for dental care amongst training grade staff working within the Hospital Dental Service.

METHODS

Patient records were reviewed prospectively with regard to caries risk assessment, behaviour modification and tooth protection. Following dissemination of the results and reinforcement of fundamental points from the guideline, a second audit was conducted one month later. The results were assessed by chi2 (chi2) analysis.

RESULTS

One hundred patient records were reviewed in both Audit One (M:52; F:48) and Audit Two (M:61; F:39). Caries risk assessment was poorly recorded in both Audits One and Two (13% and 17%, respectively). There was an improvement in radiographic reporting between the first and second audit, from 53% to 80% (chi2 = 16.36, P = 0.001). Dietary advice and toothbrushing instruction were recorded in 36% and 41% of records in Audit One, whilst in Audit Two this had improved to 68% and 92%, respectively (chi2 = 20.51, P = 0.001 and chi2 = 58.38, P = 0.001). There was a statistically significant improvement in the prescription of fissure sealants in Audit Two (chi2 = 38.97, P = 0.001), although not in the prescription of topical fluoride application (chi2 = 1.71, P = 0.192).

CONCLUSION

Amongst training grade staff, there appears to be failure of implementation of certain aspects of SIGN guidelines for caries prevention. Clinical audit, however, would appear to improve guideline implementation.

Surgical removal of supernumerary teeth and the fate of incisor eruption

AIM

The aims of this study were firstly to determine the fate of unerupted permanent maxillary incisor teeth following supernumerary tooth removal and secondly to make recommendations regarding the management of such incisor teeth following supernumerary tooth extraction.

STUDY DESIGN

This is a retrospective study.

METHODS

Records of children attending the Departments of Paediatric Dentistry, Edinburgh Dental Institute, Lothian Primary Care NHS Trust and Dundee Dental Hospital, Tayside University Hospitals Trust between 1995 and 2002 were examined with regard to non-eruption of one or both maxillary central incisors in association with supernumerary teeth requiring surgical removal. Subsequent permanent maxillary incisor eruption was recorded and in those cases of incisor non-eruption, further surgical interventions were noted.

RESULTS

In all 118 sets of patient records were included in the study (87 males, 31 females) with a mean age at presentation of 8.8 years (range 5.3-11.6 years). Failure of eruption of the associated permanent maxillary central incisor teeth occurred in 27% of cases, in relation to both conical and tuberculate supernumerary teeth. All tuberculate supernumerary teeth associated with non-eruption cases were palatally placed and 59% were adjacent to maxillary incisors with near complete apex formation. To facilitate incisor eruption in these cases, 41% required surgical exposure of the non-erupted incisor tooth and 59% required surgical exposure with bonding of an orthodontic bracket and gold chain for orthodontic traction.

CONCLUSION

Non-erupted permanent maxillary incisor teeth with near complete apical formation, associated with palatally placed, tuberculate-shaped supernumerary teeth, may benefit from having an orthodontic bracket and gold chain placed at the same time as the surgical procedure to remove the supernumerary tooth to facilitate future orthodontic traction.

Development and Validation of a Radioligand Binding Assay to Measure Insulin Specific IgG Subclass Antibodies in Human Serum

The objective was to develop and validate a radioligand binding assay for insulin antibodies (IABs) of the IgG1, IgG2, IgG3, and IgG4 subclasses in human serum. The validation studies focused on determining specificity, capacity, linearity, sensitivity, and precision of each assay. It was seen that our assay for IAB IgG subclasses is specific and has sufficient capacity to measure each of the subclasses in human serum. Moreover, the linear region and limits of detection and quantitation for each assay are clearly determined.

Adenocarcinoma of the prostate: an expensive way to die

The costs of radical prostatectomy and radiation therapy for localized carcinoma of the prostate are well known, the costs of terminal care for men with metastatic disease less so. We sought to determine the costs of terminal care incurred with prostate cancer in the last year of life. A retrospective chart review was conducted at five military medical centers identifying 32 patients who had died from prostate cancer from 1995 to 1997. The data investigated were: duration of metastatic disease, days hospitalized in the last year of life, palliative procedures (surgery or radiation), chemotherapy and need for transfusions. The mean duration of symptomatic metastatic disease was 3.4 y. The mean duration of hospitalization in the last year of life was 19 days. Seven patients (22%) required channel transurethral resection of the prostate (TURP). Three patients (9%) required either percutaneous nephrostomies or stenting. The mean number of transfusions required was 5.4. Eighteen patients (56%) underwent bilateral simple orchiectomy (BSO), 14 (44%) used LHRH agonists and 11 (34%) used anti-androgens. The mean total cost of hospitalization, studies, outpatient visits to physicians, palliative procedures and hormonal therapy was US dollars 24660 in the last year of life. Comparatively, the cost of radical prostatectomy is US dollars 12250 and three-dimensional conformal radiation therapy is US dollars 13823. Our estimation of costs due to metastatic disease is at best an underestimation. Men dying of prostate cancer incur significant costs in the last year of life. Based upon recent epidemiological data the cost of death due to prostate cancer in the US is over three quarters of a billion dollars a year.

Complete embedding and close step-sectioning of radical prostatectomy specimens both increase detection of extra-prostatic extension, and correlate with increased disease-free survival by stage of prostate cancer patients

The objectives of this work were to evaluate the efficacy of controlled close step-sectioned and whole-mounted radical prostatectomy specimen processing in prediction of clinical outcome as compared to the traditional processing techniques. Two-hundred and forty nine radical prostatectomy (RP) specimens were whole-mounted and close step-sectioned at caliper-measured 2.2-2.3 mm intervals. A group of 682 radical prostatectomy specimens were partially sampled as control. The RPs were performed during 1993-1999 with a mean follow-up of 29.3 months, pretreatment PSA of 0.1-40, and biopsy Gleason sums of 5-8. Disease-free survival based on biochemical or clinical recurrence and secondary intervention were computed using a Kaplan-Meier analysis. There were no significant differences in age at diagnosis, age at surgery, PSA at diagnosis, or biopsy Gleason between the two groups (P<0.05). Compared with the non-close step-sectioned group, the close step-sectioned group showed higher detection rates of extra-prostatic extension (215 (34.1%) vs, 128 (55.4%), P<0.01), and seminal vesicle invasion (50 (7.6%) vs 35 (14.7%), P<0.01). The close step-sectioned group correlated with greater 3-y disease-free survival in organ-confined (P<0.01) and specimen-confined (P<0.01) cases, over the non-uniform group. The close step-sectioned group showed significantly higher disease-free survival for cases with seminal vesicle invasion (P=0.046). No significant difference in disease-free survival was found for the positive margin group (P=0.39) between the close step-sectioned and non-uniform groups. The close step-sectioned technique correlates with increased disease-free survival rates for organ and specimen confined cases, possibly due to higher detection rates of extra-prostatic extension and seminal vesicle invasion. Close step-sectioning provides better assurance of organ-confined disease, resulting in enhanced prediction of outcome by pathological (TNM) stage.

The way forward for dental sedation and primary care?

OBJECTIVES

Firstly to determine the current provision of sedation in primary dental care in an area of Scotland without local secondary care support and secondly, to investigate dental practitioners' desire for formal postgraduate training in sedation techniques.

DESIGN

A prospective postal questionnaire-based study.

SETTING

Grampian Primary Care NHS Trust, UK, 2001.

SUBJECTS

Questionnaires were sent to all NHS dental practitioners and community dental service clinicians (N = 194] employed through Grampian Primary Care NHS Trust, Scotland during March - April 2001. The questionnaires sought details about personal status and the use and perceived need for conscious sedation techniques in practice in addition to the stated desire for postgraduate training in sedation techniques.

RESULTS

One hundred and thirty-six questionnaires were returned (70%). Forty-nine per cent of respondents reported current sedation use, with intravenous sedation the favoured technique (82%), followed by oral sedation (33%) and inhalation sedation (19%). Seventy-four per cent of participants considered that there was a need for sedation in their own practice and 68% were interested in further postgraduate training in sedation techniques.

CONCLUSION

Nearly three-quarters of practitioners who responded felt that there was a need for sedation in their own practice, although less than half were able to offer sedation to their patients. Nearly 70% of practitioners felt there was a need for postgraduate training in sedation techniques.

Cultural beliefs of Asian Americans associated with terminal illness and death

OBJECTIVES

Cultural competence often focuses on the skills of the professional; whereas, this article focuses on the needs of the patient.

DATA SOURCES

Research studies, review articles, book chapters, and clinical practice.

CONCLUSIONS

Patients benefit from health care professionals that are attuned and able to nurture patients in a process of identifying their needs regarding terminal illness and death. The health care professional's ability and sensitivity to be culturally aware, knowledgeable, and open directly influences the patient's quality of life and death.

IMPLICATIONS FOR NURSING PRACTICE

As the population becomes more diverse, health care professionals must develop cultural competence to add value to themselves, the profession of nursing, and health care in the future.

Black copper phosphate cement: does it have a future?

The aim of this study was to compare the in vitro compressive strength and solubility of a black copper cement with one established restorative material (a conventional glass ionomer cement) and two temporary restorative materials (a zinc phosphate and a zinc polycarboxylate cement). The mean compressive strength of black copper cement varied with the powder: liquid ratio, with an intermediate ratio having a comparable strength to that of the zinc polycarboxylate cement (the best material in this respect). The solubility of the black copper cement at all mixing ratios was significantly greater than that of all other test materials.

Activation of PTHrP gene expression in squamous carcinoma cell lines by mutant isoforms of the tumor suppressor p53

We have evaluated the status of p53 expression in three squamous carcinoma cell lines that express high levels of PTHrP mRNA and protein and also cause hypercalcemia when grown in nude mice. All three of these lines possess a single p53 allele, each of which harbors a missense point mutation that gives rise to it mutant p53 protein with a denatured conformation. Using site-directed mutagenesis, we created a p53 expression construct bearing a missense mutation at codon 158, identical to that expressed by one of the cell lines. This construct and p53 constructs expressing representative denatured conformation mutants were then used to develop stably transfected lines, which expressed increased levels of PTHrP mRNA. Promoter-specific RNase protection indicated that this increase was due primarily to transcripts originating from the two TATA promoters, and not the GC-rich initiator element within the PTHrP gene. Cotransfection of mutant p53 expression vectors with a series of reporter constructs under the control of the human PTHrP promoter region showed that mutant p53 isoforms activated constructs containing multiple promoter elements and flanking sequences, but failed to activate constructs with individual promoters in isolation. These findings suggest that the activation of PTHrP gene expression by mutant p53 isoforms displaying a denatured conformation is dependent on interactions with sequences in the PTHrP gene regulatory region beyond the basal TATA promoters.

Referral of children to a general anaesthetic dental service in Tayside

OBJECTIVE

To determine the adequacy of child referral for dental general anaesthesia (DGA) by local dental practitioners, given the recent guidance document to dentists from the General Dental Council and in addition, to determine the subsequent treatment and factors which influence treatment selection.

DESIGN

A prospective study.

SETTING

Department of Paediatric Dentistry, Dundee Dental Hospital, Dundee.

SUBJECTS

Children [n = 84] who were referred for dental extractions under general anaesthetic over a three month period.

RESULTS

Non-surgical dental extractions under general anaesthetic were requested in nearly 90% of referrals. In the majority of cases, the referral was deemed inadequate; e.g. the medical history was not mentioned in the majority of cases (85.7%) despite nearly one-fifth of patients having a relevant medical history. In general, referring practitioners under-estimated the extent of disease, requiring treatment plans to be changed in 76% of cases; all changes represented an increase in the number of dental extractions undertaken. The most common reasons for general anaesthetic use were: multiple dental extractions (73.8%); the patient's anxiety (63.1%); and patient's age (41.7%). As an alternative to general anaesthesia, treatment was undertaken successfully using inhalation sedation in nearly 15% of cases.

CONCLUSION

Dental extractions under general anaesthetic are still a common reason for referral. Referring practitioners frequently provide inadequate information, in addition to under-estimating the treatment required. Alternative forms of anxiety management are available and should be considered for children requiring dental extractions.

Parathyroid hormone-related protein maintains mammary epithelial fate and triggers nipple skin differentiation during embryonic breast development

Prior reports have demonstrated that both parathyroid hormone-related protein (PTHrP) and the type I PTH/PTHrP receptor are necessary for the proper development of the embryonic mammary gland in mice. Using a combination of loss-of-function and gain-of-function models, we now report that PTHrP regulates a series of cell fate decisions that are central to the survival and morphogenesis of the mammary epithelium and the formation of the nipple. PTHrP is made in the epithelial cells of the mammary bud and, during embryonic mammary development, it interacts with the surrounding mesenchymal cells to induce the formation of the dense mammary mesenchyme. In response, these mammary-specific mesenchymal cells support the maintenance of mammary epithelial cell fate, trigger epithelial morphogenesis and induce the overlying epidermis to form the nipple. In the absence of PTHrP signaling, the mammary epithelial cells revert to an epidermal fate, no mammary ducts are formed and the nipple does not form. In the presence of diffuse epidermal PTHrP signaling, the ventral dermis is transformed into mammary mesenchyme and the entire ventral epidermis becomes nipple skin. These alterations in cell fate require that PTHrP be expressed during development and they require the presence of the PTH/PTHrP receptor. Finally, PTHrP signaling regulates the epidermal and mesenchymal expression of LEF1 and (β)-catenin, suggesting that these changes in cell fate involve an interaction between the PTHrP and Wnt signaling pathways.

Loss of heterozygosity frequency at the Trp53 locus in p53-deficient (+/-) mouse tumors is carcinogen-and tissue-dependent

Mutagenic carcinogens rapidly induced tumors in the p53 haploinsufficient mouse. Heterozygous p53-deficient (+/-) mice were exposed to different mutagenic carcinogens to determine whether p53 loss of heterozygosity (LOH) was carcinogen-and tissue-dependent. For 26 weeks, C57BL/6 (N4) [corrected] p53-deficient (+/-) male or female mice were exposed to p-cresidine, benzene or phenolphthalein. Tumors were examined first for loss of the wild-type p53 allele. p-cresidine induced p53 LOH in three of 13 bladder tumors, whereas hepatocellular tumors showed p53 LOH in carcinomas (2/2), but not in adenomas (0/3). Benzene induced p53 LOH in 13 of 16 tumors examined. Finally, phenolphthalein induced p53 LOH in all tumors analyzed (21/21). Analysis of the p-cresidine-induced bladder tumors by cold single-strand conformation polymorphism (SSCP) analysis of exon 4-9 amplicons failed to demonstrate polymorphisms associated with mutations in tumors that retained the p53 wild-type allele. p-cresidine induced a dose-related increase in lacI mutations in bladder DNA. In summary, these data demonstrate that loss of the wild-type allele occurred frequently in thymic lymphomas and sarcomas, but less frequently in carcinomas of the urinary bladder. In the bladder carcinomas other mechanisms may be operational. These might include (i) other mechanisms of p53 inactivation, (ii) inactivating mutations occurring outside exons 4-9 or (iii) p53 haploinsufficiency creating a condition that favors other critical genetic events which drive bladder carcinogenesis, as evidenced by the significant decrease in tumor latency. Understanding the mechanisms of p53 LOH and chemical carcinogenesis in this genetically altered model could lead to better models for prospective identification and understanding of potential human carcinogens and the role of the p53 tumor suppressor gene in different pathways of chemical carcinogenesis.

Restoration of primary teeth: a study of copper phosphate cement

OBJECTIVE

To determine the survival of 'PD' Black Copper Cement when used as a dental filling material in carious primary teeth.

DESIGN

A prospective study.

SETTING

Dundee Dental Hospital, Dundee.

SUBJECTS

Fifty children with carious primary molars had 82 dental restorations placed in the initial study. For the follow-up study, 45 restorations were available.

RESULTS

Over 65% of the Black Copper Cement restorations placed in the initial study failed. Modification of restoration technique reduced the total loss of filling material to 18% of cases.

CONCLUSION

To take advantage of the cariostatic properties of black copper cement may require it to be used as a lining under a less soluble restorative material.

Prostate cancer in men age 50 years or younger: a review of the Department of Defense Center for Prostate Disease Research multicenter prostate cancer database

PURPOSE

Prostate cancer in men age 50 years or younger traditionally has accounted for approximately 1% of those diagnosed with prostate cancer. Prior studies of prostate cancer in men of this age led many clinicians to believe that they have a less favorable outcome than older men. Most of these studies were conducted before the advent of prostate specific antigen (PSA) screening programs. We evaluated a surgically treated cohort of men age 50 years or younger to determine whether disease recurred more frequently among them than in those 51 to 69 years old in the PSA era.

MATERIALS AND METHODS

We reviewed the medical records of 477 men who underwent radical prostatectomy between 1988 and 1997. Age, ethnicity, preoperative PSA, clinical and pathological stage, margin and seminal vesicle involvement, and recurrence were compared between 79 men age 50 years or younger (study group) and 398, 51 to 69 years old (comparison group). Disease-free survival rates were compared using Kaplan-Meier and Cox regression techniques.

RESULTS

There were 6 (7.6%) recurrences in the study group (79) and 107 (26.9%) in the comparison group (398). The disease-free survival curves were significantly different (log-rank p = 0.010). Age remained a significant prognostic factor (Wald p = 0.033) in multivariate Cox regression analyses that controlled for race, clinical and pathological stage, and pretreatment PSA. Similar results were found when the comparison group was limited to 116 patients 51 to 59 years old (log-rank p = 0.034, Wald p = 0.069).

CONCLUSIONS

These data suggest that patients in the PSA era who underwent radical prostatectomy and were age 50 years or younger have a more favorable disease-free outcome compared to older men.

Nateglinide alone and in combination with metformin improves glycemic control by reducing mealtime glucose levels in type 2 diabetes

OBJECTIVE

To evaluate the efficacy and tolerability of nateglinide and metformin alone and in combination in type 2 diabetic patients inadequately controlled by diet, focusing on changes in HbA1c, fasting plasma glucose (FPG), and mealtime glucose excursions.

RESEARCH DESIGN AND METHODS

In this randomized double-blind study, patients with an HbA1c level between 6.8 and 11.0% during a 4-week placebo run-in received 24 weeks' treatment with 120 mg nateglinide before meals (n = 179), 500 mg metformin three times a day (n = 178), combination therapy (n = 172), or placebo (n = 172). HbA1c and FPG were evaluated regularly, and plasma glucose levels were determined after Sustacal challenge at weeks 0, 12, and 24. Hypoglycemia and other adverse events were recorded.

RESULTS

At study end point, HbA1c was reduced from baseline with nateglinide and metformin but was increased with placebo (-0.5, -0.8, and +0.5%, respectively; P < or = 0.0001). Changes in FPG followed the same pattern (-0.7, -1.6, and +0.4 mmol/l; P < or = 0.0001). Combination therapy was additive (HbA1c -1.4% and FPG -2.4 mmol/l; P < or = 0.01 vs. monotherapy). After Sustacal challenge, there was a greater reduction in mealtime glucose with nateglinide monotherapy compared with metformin monotherapy or placebo (adjusted area under the curve [AUC]0-130 min -2.1, -1.1, and -0.6 mmol x h(-1) x l(-1); p < or = 0.0001). An even greater effect was observed with combination therapy (AUC0-130 min -2.5 mmol x h(-1) x l(-1); P < or = 0.0001 vs. metformin and placebo). All regimens were well tolerated.

CONCLUSIONS

Nateglinide and metformin monotherapy each improved overall glycemic control but by different mechanisms. Nateglinide decreased mealtime glucose excursions, whereas metformin primarily affected FPG. In combination, nateglinide and metformin had complementary effects, improving HbA1c, FPG, and postprandial hyperglycemia.