Effects of tirzepatide, a novel dual GIP and GLP-1 receptor agonist, on lipid profiling in patients with type 2 diabetes

Background/Introduction

In a Phase 2 trial, tirzepatide (TZP) dose-dependently reduced HbA1c, body weight and serum triglycerides in moderately obese type 2 diabetes (T2D) patients.

Purpose

To understand changes in fasting serum lipids with TZP, lipidomics profiling of multiple lipid classes was conducted.

Methods

Patients (n=314) were randomized to receive weekly subcutaneous TZP, dulaglutide, or placebo for 26 weeks. Shotgun lipidomic analysis was performed in positive electrospray using a Sciex Triple TOF 5600 mass spectrometer operating in MS/MSALL mode and sphingomyelin (SPM) data were acquired in positive electrospray TOF mode. Data were assessed using MMRM.

Results

At 26 weeks, total cholesterol esters (CE), phosphatidylcholines (PC) and phosphatidylinositols (PI) increased with placebo; dulaglutide treatment did not affect any lipid class (Table). With TZP 10 and 15 mg, total triacylglycerides (TAG), diacylglycerides (DAG), phosphatidylethanolamines (PE), PC and PI dose-dependently decreased at 4, 12 and 26 weeks, whereas total CE and phosphatidylserines (PS) levels did not change at any timepoint. At 26 weeks, individual, but not total, SPM and ceramide (Cer) changes were observed with TZP 15 mg. Most saturated, long chain SPM (14:0, 20:0, 21:0, 22:0, 23:0, 24:0) and Cer (22:0, 23:0, 24:0) were reduced by 8–16% and 14–20%, respectively. Conversely, unsaturated SPM (24:1,24:2) increased by 6.5% and 11.4%, and unsaturated glycosylated Cer 16:0 lactosyl and 24:1 hexosyl increased by 22.4% and 19.3%, respectively. TZP 10 and 15 mg decreased total SPM by 4–6% at 4 weeks, and total Cer between 8% and 13% at 4 and 12 weeks.

Conclusions

Tirzepatide dose-dependently reduced levels of total TAG, DAG, PE, PC, and PI at all timepoints, whereas levels of saturated long chain SPM and Cer were reduced and those of some unsaturated SPM and glycosylated Cer increased at 26 weeks. Net improvements in lipidomics profiling with tirzepatide warrant further evaluation of potential benefits on cardiovascular events and NASH.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Eli Lilly and Company

Dulaglutide decreases plasma aminotransferases in people with Type 2 diabetes in a pattern consistent with liver fat reduction: a post hoc analysis of the AWARD programme

AIMS

To evaluate the effects of dulaglutide vs placebo on liver and glycaemic/metabolic measurements in a population with Type 2 diabetes and in a subgroup with non-alcoholic fatty liver/non-alcoholic steatohepatitis.

METHODS

A total of 1499 participants from AWARD-1, AWARD-5, AWARD-8 and AWARD-9 clinical trials were included in this analysis (dulaglutide 1.5 mg, n=971 and placebo, n=528). Thresholds of alanine aminotransferase levels ≥30 IU/l in men and ≥19 IU/l in women were used to determine the subgroup who had non-alcoholic fatty liver/non-alcoholic steatohepatitis. Objectives included changes from baseline to 6 months in: (1) alanine aminotransferase, aspartate transaminase and gamma-glutamyl transpeptidase levels in the overall population and (2) alanine aminotransferase, aspartate transaminase, gamma-glutamyl transpeptidase and glycaemic/metabolic measurements (e.g. HbA_1c , fasting serum glucose, body weight, lipids and homeostatic model assessment) in the non-alcoholic fatty liver/non-alcoholic steatohepatitis subgroup.

RESULTS

In the overall population at 6 months, dulaglutide significantly reduced alanine aminotransferase, aspartate transaminase and gamma-glutamyl transpeptidase levels vs placebo [least squares mean treatment differences: -1.7 IU/l (95% CI -2.8, -0.6), P=0.003; -1.1 IU/l (95% CI -2.1, -0.1), P=0.037; -6.6 IU/l (95% CI -12.4, -0.8), P=0.025, respectively]. In the subgroup with non-alcoholic fatty liver/non-alcoholic steatohepatitis (alanine aminotransferase levels greater than or equal to the upper limit of normal), mean baseline liver enzyme values were 38.0 IU/l, 27.8 IU/l and 43.9 IU/l for alanine aminotransferase, aspartate transaminase and gamma-glutamyl transpeptidase, respectively. In this population, more pronounced reductions from baseline in alanine aminotransferase were observed with dulaglutide vs placebo (-8.8 IU/l vs -6.7 IU/l). In the subgroup of people with alanine aminotransferase levels less than the upper limit of normal, changes from baseline in alanine aminotransferase did not significantly differ between treatment groups (0.0 IU/l vs 0.7 IU/l).

CONCLUSIONS

Once-weekly dulaglutide improved alanine aminotransferase, aspartate transaminase and gamma-glutamyl transpeptidase levels compared with placebo in a pattern consistent with liver fat reductions. Our results add further weight to the notion that glucagon-like peptide-1 receptor agonists may provide benefit in lowering liver fat in addition to their other metabolic actions.

Forward osmosis treatment of effluents from dairy and automobile industry - results from short-term experiments to show general applicability

Forward osmosis (FO) is a potential membrane technology to treat wastewater energy efficiently with low fouling. In laboratory-scale experiments, six effluents from a dairy and an automobile production plant were tested to find out if FO is an applicable treatment technology. Permeate flux and reverse salt flux were determined in nine test series with three subsequent 5 h experiments each. In between, the membrane was cleaned with deionized water. Membrane performance tests before each experiment were used to monitor membrane performance and fouling. Samples were analysed and the T/M-value was introduced to indicate which substances caused fouling. Dairy cheese brine was a suitable DS. Here, permeate fluxes were 21.0 and 15.1 L/(m²·h). Automobile cooling tower water and wastewater from cathodic dip painting were also used as DS. However, permeate fluxes were below 1.1 L/(m²·h). The tested FS, reverse osmosis concentrate from dairy wastewater treatment, rinsing water and wastewater from automobile cathodic dip painting, as well as wastewater from automobile paint shop pre-treatment, showed good performance regarding the permeate flux of between 7.9 and 19.4 L/(m²·h). Membrane performance test showed that some of the effluents lead to permeate flux reduction due to fouling. Different cleaning-in-place methods were examined. Eventually, permeate flux was restored.

Basal insulin peglispro: Overview of a novel long-acting insulin with reduced peripheral effect resulting in a hepato-preferential action

Basal insulin peglispro (BIL) is a novel basal insulin with a flat, prolonged activity profile. BIL has been demonstrated in a dog model, in healthy men and in patients with type 1 diabetes (T1D) to have significant hepato-preferential action resulting from reduced peripheral activity. In the IMAGINE-Phase 3 clinical trial program, more than 6000 patients were included, of whom ~3900 received BIL. Of the 7 pivotal IMAGINE trials, 3 studies were double-blinded and 3 were in T1D patients. BIL consistently demonstrated a greater HbA1c reduction, less glycaemic variability and a clinically relevant reduction in the rates of nocturnal hypoglycaemia across comparator [glargine and isophane insulin (NPH)] studies. Trials using basal/bolus regimens had higher rates of total hypoglycaemia with BIL due to higher rates of daytime hypoglycaemia. Severe hypoglycaemia rates were similar to comparator among both patients with T1D or type 2 diabetes (T2D). T1D patients lost weight compared with glargine (GL). Patients with T2D tended to gain less weight with BIL than with glargine. Compared to glargine, BIL was associated with higher liver fat, triglycerides and alanine aminotransferase (ALT) levels, including a higher frequency of elevation of ALT ≥3 times the upper limit of normal, but without severe, acute drug-induced liver injury. Injection site reactions, primarily lipohypertrophy, were more frequent with BIL. In conclusion, BIL demonstrated better glycaemic control with reduced glucose variability and nocturnal hypoglycaemia but higher triglycerides, ALT and liver fat relative to conventional comparator insulin. The hepato-preferential action of BIL with reduced peripheral activity may account for these findings.

Different effects of basal insulin peglispro and insulin glargine on liver enzymes and liver fat content in patients with type 1 and type 2 diabetes

AIMS

To compare effects of basal insulin peglispro (BIL), a hepatopreferential insulin, to insulin glargine (glargine) on aminotransferases and liver fat content (LFC) in patients with type 1 and type 2 diabetes (T1D, T2D).

MATERIALS AND METHODS

Data from two Phase 2 and five Phase 3 randomized trials comparing BIL and glargine in 1709 T1D and 3662 T2D patients were integrated for analysis of liver laboratory tests. LFC, measured by magnetic resonance imaging (MRI) at baseline, 26 and 52 weeks, was analyzed in 182 T1D patients, 176 insulin-naïve T2D patients and 163 T2D patients previously treated with basal insulin.

RESULTS

Alanine aminotransferase (ALT) increased in patients treated with BIL, was higher than in glargine-treated patients at 4-78 weeks (difference at 52 weeks in both T1D and T2D: 7 international units/litre (IU/L), P < .001), and decreased after discontinuation of BIL. More BIL patients had ALT ≥3× upper limit of normal (ULN) than glargine. No patient had ALT ≥3× ULN with bilirubin ≥2× ULN that was considered causally related to BIL. In insulin-naїve T2D patients, LFC decreased with glargine but was unchanged with BIL. In T1D and T2D patients previously treated with basal insulin, LFC was unchanged with glargine but increased with BIL. In all three populations, LFC was higher after treatment with BIL vs glargine (difference at 52 weeks: 2.2% to 5.3%, all P < .01).

CONCLUSIONS

Compared to glargine, patients treated with BIL had higher ALT and LFC at 52-78 weeks. No severe drug-induced liver injury was apparent with BIL treatment for up to 78 weeks.

Macro- and microvascular outcomes in patients with type 2 diabetes treated with rapid-acting insulin analogues or human regular insulin: a retrospective database analysis

To investigate the risk of macro- and microvascular complications in patients with type 2 diabetes receiving rapid-acting insulin analogues (IA) or human regular insulin (HI).General practice diabetes patients with continuous prescription of any IA or HI for ≥3 years were selected from the German Disease Analyzer database (IMS Health). Logistic and Cox regression models were applied to analyze the incidence and time to onset of vascular outcomes (IA vs. HI).2764 patients on IA (insulin lispro, glulisine, aspart) and 4193 patients on HI were included (age, mean [SD]: 61.0 [11.3] and 64.7 [10.5] years, follow-up [Q1,Q3]: 4.6 [3.7,6.1] and 4.7 [3.7,5.9] years). No significant differences were detected between IA and HI regarding the incidence of vascular complications (OR [95%CI]: macrovascular 0.92 [0.72-1.18], microvascular 0.95 [0.77-1.17]) or regarding time to their onset, after adjustment for sex, age, comorbidities and time on IA/HI, or by propensity-score-based matching. However, in an additional short-term analysis (median [Q1,Q3] follow-up (IA 2.9 [1.2,4.6], HI 2.4 [0.8,4.4] years) of a larger sample (no continuous insulin treatment required) with more comorbidities, time to onset of macrovascular complications was significantly longer for AI than HI (HR 0.88 [0.81-0.97], p=0.009; microvascular complications: no difference).After long-term continuous treatment with IA or HI under real-life conditions, there was no different risk of macro- or microvascular complications, contradicting previous short-term analyses. Further prospective studies are needed to clarify whether selection bias may have been introduced by using strict entry criteria.

The KID Study. I: Structural baseline characteristics of the Federal Insurance for Salaried Employees' Institution (BfA) diabetic patients in inpatient rehabilitation. Kissingen Diabetes Intervention Study

% of type I diabetics are not administering insulin according to the intensified conventional therapy schedules, only 16.8% of all type II diabetics are treated with diet only. Type II diabetics are much too often treated with pre-mixed insulins of too high dosage (26.2%) or with oral hypoglycemics (46.2%) of which 90% were sulphonylureas and nearly exclusively glibenclamide. Oral hypoglycemics with extrapancreatic activity or combined therapies were not common among the patients.

The KID Study. II: Socioeconomic baseline characteristics, psycho-social strain, standard of current medical care and education of the Federal Insurance for Salaried Employees' Institution (BfA) diabetic patients in inpatient rehabilitation. Kissingen Diabetes Intervention Study

The Kissingen Diabetes Intervention Study (KID) evaluated 1050 diabetic patients of the German Federal Insurance for Salaried Employees' Institution (BfA) admitted for inpatient rehabilitation. A single-center prospective, longitudinal study collected data concerning baseline characteristics of patient cohort, socioeconomic factors and mode of intervention at the time of admission, discharge and outcome 6 and 12 months after discharge with consecutively obtained random tests. This cohort of patients is especially interesting for aspects of health policy because it is composed of rather young diabetics engaged in professional work. The data suggest that on the one hand considerably fewer type I diabetics than type II diabetics are married, but that on the other hand constant relationships are equally common in both groups when not considering the marital status. 70% of all diabetics have regular working hours, only 10% of the type II diabetics and negligible 3.9% of the type 1 diabetics work nightshifts. Nevertheless, 29.4% of the type I diabetics and 36.4% of the type II diabetics were unfit for work for at least 4 weeks in the 6 months prior to admission. Only 35.5% of all diabetics see their doctor once or twice monthly. The disease was first diagnosed by the general practitioner in 70% of all cases. Thorough information concerning the disease was provided only in 33.7% of type II diabetics and 26.1% of type I diabetics. 50.6% of type I diabetics and 68.4% of type II diabetics did not receive any education during the all important first year after diagnosis. Most of the diabetic education which had taken place was provided by general hospitals but also by specialized diabetes hospitals and rehabilitation hospitals. 65.6% of all type II diabetics do not monitor urine glucose and those who do so, monitor only once to twice weekly or less. Fortunately 96.3% of all type I diabetics monitor blood glucose, but only 41.0% of them monitor as frequently as is appropriate. 28.3% receive material for monitoring glucose levels only after asking for this. In 32% of the type II diabetics monitoring urine glucose, the general practitioner does not discuss the results with them. Regular controls of glycolysated hemoglobin is part of the diabetic management in 84.4% of all type I diabetics, but carried out in only 34.9% of all type II diabetics, among which the checking of fasting glucose dominates laboratory controls with 50.9%. However, blood lipids are monitored in half of the patients. Huge deficits have been found in the monitoring of urinary albumin excretion in type I diabetics, but especially in type II diabetics. Fear of the future and depression are the predominant strains in everyday life for type I diabetics as well as for type II diabetics. Next most important is the fear of hypoglycemias for type I diabetics, who also feel significantly more restricted in leisure time activities than type II diabetics do. No difference was found between the two groups concerning the demands of treatment. Differences were marked in that more type I than type II diabetics complain of strain in professional life due to their disease, and that a higher proportion of type II diabetics feel impaired by physical complaints (higher incidence of multimorbidity) and consider their relationships more strained by the diabetes than type I diabetics. Surprisingly, problems with accepting the disease and problems in the doctor-patient relationship were of similarly low importance in both groups. We will soon report the changes of the parameters discussed here found after inpatient rehabilitation with intensive diabetic education, promotion of physical activities and psychological measures.

The risk allele load accelerates the age-dependent decline in beta cell function

AIMS/HYPOTHESIS

Among the novel type 2 diabetes risk loci identified by genome-wide association studies, TCF7L2, HHEX, SLC30A8 and CDKAL1 appear to affect beta cell function. In the present study we examined the effect of these genes' risk alleles on the age-dependent decline in insulin secretion.

METHODS

The SNPs rs7903146 (TCF7L2), rs7754840(CDKAL1), rs7923837 (HHEX) and rs13266634 (SLC30A8) were genotyped in 1,412 non-diabetic patients, who were subsequently grouped according to their number of risk alleles. All participants underwent an OGTT. Insulin secretion was assessed by validated indices and proinsulin conversion by calculating AUC(proinsulin)/AUC(insulin).

RESULTS

The number of risk alleles revealed a Gaussian distribution, with most participants carrying four risk alleles. Stratification into groups with low (LAL, up to three alleles), median (MAL, four alleles) and high (HAL, five to eight alleles) allele load resulted in MAL and HAL participants displaying significantly lower insulin secretion and proinsulin conversion than LAL participants (p <or= 0.0014 and p = 0.0185, respectively). In the overall cohort, age was negatively associated with insulin secretion and proinsulin conversion (both p < 0.0001). MAL and HAL participants showed a significantly more pronounced decline in insulin secretion with increasing age than LAL participants (p <or= 0.0325; analysis of covariance), and after stratification for BMI this relationship was maintained in obese, but not non-obese, participants. Proinsulin conversion decreased with increasing age in MAL and HAL, but not LAL, participants (p <or= 0.0003 vs p = 0.2).

CONCLUSIONS/INTERPRETATION

The risk allele load significantly accelerates the age-dependent decline in beta cell function, and this might be of particular importance in obese people.

Variation in the FTO gene influences food intake but not energy expenditure

Polymorphisms in the FTO (fat mass- and obesity-associated) gene are associated with obesity. The mechanisms how genetic variation in this gene influences body weight are unknown. Body weight is determined by energy intake/storage and energy expenditure. In this study, we investigated whether genetic variation in FTO influences energy expenditure or food intake in carefully phenotyped subjects. In 380 German subjects, insulin sensitivity was measured by a hyperinsulinemic euglycemic clamp. Lean body mass and body fat were quantified using the bioimpedance method. Indirect calorimetry was used to estimate the metabolic rate. Food intake was assessed using food diaries (mean 11+/-1 d) in 151 subjects participating in a lifestyle intervention program to prevent diabetes. All subjects were genotyped for the FTO single nucleotide polymorphism (SNP) rs8050136. The risk allele of SNP rs8050136 was associated with higher body fat-related parameters (all p< or =0.04, additive inheritance model). Energy expenditure was not affected by the SNP. However, the risk allele of rs8050136 was significantly associated with higher energy intake (p=0.01, dominant inheritance model) during dietary restriction. Our data suggest that the increased body weight in carriers of the risk allele of FTO SNP rs8050136 is a consequence of increased food intake, but not of impaired energy expenditure.

Polymorphisms in the TCF7L2, CDKAL1 and SLC30A8 genes are associated with impaired proinsulin conversion

AIMS/HYPOTHESIS

Variation within six novel genetic loci has been reported to confer risk of type 2 diabetes and may be associated with beta cell dysfunction. We investigated whether these polymorphisms are also associated with impaired proinsulin to insulin conversion.

METHODS

We genotyped 1,065 German participants for single nucleotide polymorphisms rs7903146 in TCF7L2, rs7754840 in CDKAL1, rs7923837 and rs1111875 in HHEX, rs13266634 in SLC30A8, rs10811661 in CDKN2A/B and rs4402960 in IGF2BP2. All participants underwent an OGTT. Insulin, proinsulin and C-peptide concentrations were measured at 0, 30, 60, 90 and 120 min during the OGTT. Insulin secretion was estimated from C-peptide or insulin levels during the OGTT using validated indices. We used the ratio proinsulin/insulin during the OGTT as indicator of proinsulin conversion.

RESULTS

In our cohort, we confirmed the significant association of variants in TCF7L2, CDKAL1 and HHEX with reduced insulin secretion during the OGTT (p<0.05 for all). Variation in SLC30A8, CDKN2A/B and IGF2BP2 was not associated with insulin secretion. The risk alleles of the variants in TCF7L2, CDKAL1 and SLC30A8 reduced proinsulin to insulin conversion (p<0.05 for all), whereas the risk alleles in HHEX, CDKN2A/B and IGF2BP2 were not associated with reduced proinsulin to insulin conversion (p>0.6).

CONCLUSIONS/INTERPRETATION

Diabetes-associated variants in TCF7L2 and CDKAL1 impair insulin secretion and conversion of proinsulin to insulin. However, both aspects of beta cell function are not necessarily linked, as impaired insulin secretion is specifically present in variants of HHEX and impaired proinsulin conversion is specifically present in a variant of SLC30A8.

InDuo, a novel combined insulin injection and blood glucose monitoring device - effective and save as other devices, and patient preference

BACKGROUND AND AIM

Frequent blood glucose (BG) monitoring and insulin administration are necessary in intensive insulin regimes. A new integrated system, InDuo is a compact and portable combined insulin doser and BG monitor, designed to overcome some of the limitations of current insulin therapy. The aim of the study was to compare InDuo and a non-integrated system (HumaPen Ergo and Accu-Chek Sensor Meter) for efficacy and safety, and to evaluate patients preference.

MATERIALS AND METHODS

The trial design was a multicentre, randomised, 12-week, open-label, comparative, two period crossover. One hundred and ten patients with diabetes, treated with a basal bolus regime, were included. The subjects were assigned to use either InDuo or the non-integrated system. After six weeks of treatment, the subjects were transferred to the alternative system. To assess efficacy, fasting plasma glucose (FBG), 7-point blood glucose profile, serum fructosamine and HbA1c were measured. Serum fructosamine and FBG were measured at baseline and at six and 12 weeks; HbA1c was measured at baseline and week 12. Safety endpoints were number and severity of hypoglycaemic episodes, adverse events and adverse device effects. Patient preference was assessed by a comparative device questionnaire at 12 weeks.

RESULTS

Analysis with an ANOVA mixed model showed no difference after each treatment between serum fructosamine or between FBG levels. HbA1c decreased during the trial from 7.5 % +/- 1.2 to 7.1 % +/- 0.8 at 12 weeks. The safety profiles were similar for both treatments for hypoglycaemic episodes. The incidence of adverse events was also similar. There were 10 adverse device effects reported: eight for the Innovo device in the InDuo, one for the InDuo device and one for the Accu-Chek Sensor Meter. The comparative device questionnaire at 12 weeks showed patients strongly preferred InDuo to HumaPen Ergo and Accu-Chek Sensor Meter (all p < 0.0001). Of those preferring InDuo, more than 60 % classified their choice as very or extremely strong. Both memory functions in InDuo(R) (i. e., for insulin dosage and for blood glucose readings) were used by more than 70 % of the patients.

CONCLUSION

Treatment with the InDuo system was as effective and safe as treatment with the non-integrated system. Almost 75 % preferred using InDuo to the non-integrated HumanPen Ergo and Accu-Chek Sensor Meter.

The effects of skin temperature and testing site on blood glucose measurements taken by a modern blood glucose monitoring device

BACKGROUND

Modern blood glucose (BG) monitoring devices (e.g., InDuo [LifeScan, Inc., Milpitas, CA]) require very low blood volumes, allowing for testing at sites other than the traditional fingertip, but the reliability of such testing has not been fully elucidated. The aim of this randomized study was to compare the effects of cold/warm skin temperature combined with alternative site (forearm) testing versus conventional fingertip measurements on fasting and postprandial conditions.

MATERIALS AND METHODS

The study population consisted of 19 patients who had previously used InDuo for 6 weeks. Four simultaneous (within 1 min) BG readings (left and right forearm and fingertips) were obtained from each patient 15, 10, and 5 min before eating. Ten minutes before eating, the patient immersed one arm in cold water (15.5 degrees C) and the other in warm water (35 degrees C). At time 0 min arms were removed from water baths, and the patient was offered a standard meal (duration 15 min). Arms were again immersed in water baths, and BG was measured from the same locations 20 min after eating and at subsequent 15-min intervals for 185 min. The effects of site testing and temperature were assessed in this period by identifying maximum BG concentrations (C (max)) and time to C (max) (T (max)).

RESULTS

Significantly lower Cmax values were observed for (1) cold forearm versus cold fingertip (mean Delta 28.6 mg/dL, P < 0.001), (2) warm forearm versus warm fingertip (mean Delta 12 mg/dL, P = 0.028), (3) cold fingertip versus warm fingertip (mean Delta 17.2 mg/dL, P = 0.002), and (4) cold forearm versus warm forearm (mean Delta 33.7 mg/dL, P < 0.001). Significantly longer Tmax values were reported for cold forearm versus warm forearm (mean Delta 22.4 min, P < 0.001) and cold forearm versus cold fingertip (mean Delta 20 min, P < 0.001).

CONCLUSIONS

These results demonstrate that cold skin and forearm conditions significantly underestimate BG concentrations and delay T(max) compared with warm skin and fingertip measurements.

Endoscopic lithotripsy with a new device combining ultrasound and lithoclast

BACKGROUND AND PURPOSE

Endoscopic lithotripsy is still the method of choice for a number of stones, especially large stones. Various disintegration techniques exist. We investigated the combination of two of these techniques: ultrasound and pneumatic lithotripsy.

PATIENTS AND METHODS

Fourteen consecutive patients with renal and one patient with bladder stones were treated with this new device. Ultrasound and pneumatic lithotripsy could be used independently or simultaneously.

RESULTS

Disintegration and stone removal was fast. The use of forceps or other instruments could generally be avoided. No complications attributable to the lithotripsy device were observed.

CONCLUSION

The combined ultrasound/pneumatic lithotripsy device is safe and highly effective. It reduces treatment time and enhances surgeon's comfort.

The KID Study VI: diabetic complications and associated diseases in younger type 2 diabetics still performing a profession. Prevalence and correlation with duration of diabetic state, BMI and C-peptide

A sub-study evaluated 698 younger (54.5 +/- 6.9 years) type 2 diabetics of the KID Study participants to establish the prevalence of diabetic complications and associated diseases and their correlation with body mass index (BMI), duration of disease and to C-peptide levels. Only 19.8% of the type 2 diabetics had a normal weight. In all weight subgroups, the average age of diabetes manifestation were around age 45. In 46.6% of all type 2 diabetics we could already demonstrate microangiopathic complications. Strikingly, 15.9% of the patients already had proliferative retinopathies and 12.6% had albuminuria of more than 1000 mg/dl. 74.7% of our type 2 diabetics presented with the well-known risk cluster of the metabolic syndrome: In every other patient, we found hypertension and/or hyperlipoproteinaemia. Accordingly, the prevalence of the macroangiopathic diabetic complications, coronary artery disease and peripheral vascular disease was 17.8%, which is high for a relatively young population with a mean age of 53.9 years and goes conform with recent literature (Lowel et al., 1999). An increase in BMI correlated significantly with deterioration of HbA1, a decrease in HDL cholesterol, an increase in triglycerides and with a higher prevalence of hypertension. The frequency of nephropathy increase significantly up to a BMI of 30-35 kg/m2. Retinopathies and polyneuropathies were associated with BMI but increased significantly with the duration of the diabetic state. In contrast to microangiopathic diabetic complications, there was already a high prevalence of nephropathy after a comparatively short duration of disease. The prevalence of hyperlipoproteinaemia and hypertension did not depend from the duration of diabetes. These concomitant diseases already were frequent early in the disease and did not increase with the duration of disease. However, there was a strong correlation between increasing hyperlipoproteinaemia and hypertension and higher C-peptide levels. We found no coincidence between C-peptide levels and microangiopathic diabetic complications.

The KID Study V: the natural history of type 2 diabetes in younger patients still practising a profession. Heterogeneity of basal and reactive C-peptide levels in relation to BMI, duration of disease, age and HbA1

In a detailed evaluation of the data accumulated for 493 type 2 diabetics who participated in the KID Study, pre- and postprandial C-peptide was correlated with blood glucose level, HbA1, body mass index (BMI), duration of disease and age. As described earlier the KID-Study examined a younger cohort of type 2 diabetics predominately practising a profession. Our investigations demonstrate a significant increase of pre- as well as postprandial C-peptide levels with increasing obesity. However, delta C-peptide, as an indicator at the reaction capacity of pancreatic secretion, decreases significantly and continuously. Pre- as well as postprandial C-peptide levels decrease significantly with up to 15-20 years duration of disease. The preprandial pancreatic secretion is usually even at a high normal level at such a late stage whereas the secretory reserve of normal or mildly overweight as well as of obese type 2 diabetics is more impaired. In contrast to patients with a BMI < 30, obese patients with a BMI > 30 will also develop impairment of basal insulin secretion over decades. The patient's age did not influence the pre- or postprandial insulin secretion. The quality of metabolic control as measured by the HbA1 has nearly exclusive impact on the secretory reserve capacity. Correlation with increasing HbA1 concentrations, the postprandial but not the preprandial C-peptide levels decreased significantly and continuously. Predictive factors for a deterioration in pancreatic function are in order of importance: the extent of obesity, the quality of metabolic control and only last the duration of diabetes. Fortunately, consistent diabetic care can have an impact on the first two.

Synthesis and cytostatic activities of didemnin derivatives

The highly cytostatic didemnins contain a 23-membered cyclopeptolide with a side chain attached to the backbone through the amine group of threonine. Thirty-six derivatives varying the side chain were prepared, but only compounds with D-MeLeu attached to threonine show remarkable biological activities. To protect the macrocycle from degradation by lipases the two ester bonds were replaced successively by amide bonds. Although these variations have a major effect on the conformation and rigidity of the ring, the compound which contains exclusively amide bonds is highly active, equivalent to acetyl-didemnin A.

Polymorphisms in the PMP-22 gene region (17p11.2-12) are crucial for simplified diagnosis of duplications/deletions

DNA duplications and deletions of a 1.5-Mb region in chromosome 17p11.2-12 comprising the gene encoding peripheral myelin protein 22 (PMP-22) are the common mutations in Charcot-Marie-Tooth disease type 1 (CMT1) and hereditary neuropathy with liability to pressure palsies (HNPP). A 1.7-kb recombination hotspot region has been identified within misaligned flanking repeats (CMT1-REP elements) by detection of CMT- and HNPP-specific junction fragments in Southern blot analyses. In order to simplify routine diagnosis we introduce a polymerase chain reaction-based method to identify directly specific REP junction fragments. Using this test, specific fragments were detected in approximately 67% of both CMT duplication and HNPP deletion cases. Polymorphism within a specific restriction enzyme recognition site is crucial for both Southern blot and PCR analyses of junction fragments.

Treatment of brain metastases in patients with testicular cancer

PURPOSE

Despite improved cure rates for patients with metastatic testicular cancer with cisplatin-based combination chemotherapy, patients who develop brain metastases are generally considered to possess a poor prognosis. This report summarizes the long-term results in 44 patients with brain metastases from testicular cancer treated between 1978 and 1995 at Hannover University Medical School.

PATIENTS AND METHODS

Histologically, 42 patients (95%) had a nonseminomatous germ cell cancer and two patients (5%) a seminoma. Thirty-nine patients (89%) had lung metastases and 37 (84%) fulfilled the criteria for advanced disease according to the Indiana University classification even without considering the brain metastases. Eighteen patients (41%) presented with brain metastases at primary diagnosis (group 1), four (9%) developed brain metastases at relapse after a previous favorable response to combination chemotherapy (group 2), and 22 (50%) developed brain metastases during or directly after cisplatin-based chemotherapy. Chemotherapy consisted of cisplatin-based combination treatment and radiotherapy was given as whole-brain irradiation of 30 to 40 Gy and in single cases combined with a boost of 10 Gy to single lesions.

RESULTS

Overall, 10 patients achieved long-term survival (23%; 95% confidence interval [CI], 10.1% to 35.4%). The prognosis was significantly better for patients in groups 1 and 2, with six of 18 (33%) and three of four (75%) patients alive, compared with only one of 22 (5%) in group 3 (P < .01). Patients treated with either chemotherapy or radiotherapy alone did not achieve long-term survival, while nine of 28 (32%) who received treatment with both modalities with or without surgery achieved sustained long-term survival. During univariate analysis, patients with the diagnosis of brain metastases at first presentation (P < .01), patients with a single brain lesion (P < .02), and patients who received combined chemotherapy and radiotherapy (P < .03) had a significantly improved outcome.

CONCLUSIONS

Long-term survival can be achieved in approximately 25% of patients with brain metastases from testicular cancer by combined treatment with brain irradiation and aggressive cisplatin-based chemotherapy. Patients who develop brain metastases during systemic treatment should receive only palliative radiation therapy, since sustained survival will not be reached.

The KID study IV: effects of inpatient rehabilitation on the frequency of glucose self-monitoring, quality of further primary care, on time being unable to work and on everyday psychic strain of type I and type II diabetics--a one-year follow-up. Kissingen Diabetes Intervention Study

The Kissingen Diabetes Intervention Study (KID) evaluated 1,050 diabetic patients of the German Federal Insurance Institution for Salaried Employees (BfA) admitted for inpatient rehabilitation in a single-center, prospective, longitudinal study which was carried out to collect data concerning the structure of the patient cohort, socioeconomic factors, psychological data and state of medical care by consecutively registered random tests. These results have already been published. We will now report on the outcome 6 and 12 months after inpatient treatment. Consisting of rather young diabetics in higher professional standing, our patient cohort is especially interesting for health policy. The numbers of type I diabetics and of insulin-treated type II diabetics who self-monitor blood glucose levels several times daily significantly increased after inpatient rehabilitation. This situation is maintained 6 and 12 months after discharge. The number of type II diabetics on diet or oral hypoglycemics who do not monitor urinary glucose levels at all, is significantly reduced. The frequency of daily or weekly checks is significantly raised even after 12 months. Due to inpatient diabetic education, self-monitoring of glucose levels plays a more important role in primary care of these patients. 68.5% of all type I and about 60% of all type II diabetics receive test material without problems and are encouraged to continue monitoring. However, about 30% of type I and type II diabetics under primary-care management are still supplied with test material only when especially demanding it. The frequency of consultations in primary care diabetic management remains unchanged after inpatient treatment. The quality of diabetic management in primary care is improved by patient education. Monitoring of HbA1 is significantly increased in type I diabetics and significantly increased in type II diabetics. A similar development is seen in monitoring urinary albumin excretion but here are still deficits. For type II diabetics, the body weight and serum lipids are increasingly controlled main parameters. But in many places and especially in the case of type II diabetics the fasting glucose level is still used as main parameter. Compared with the 6 months prior to inpatient treatment, times when type I and type II diabetics are unable to work are significantly reduced in the 6 months and 12 months after-wards. Evaluating individual profiles of psychosocial strain shows that the more intense confrontation with problems of the disease and demands of the treatment can lead to a poorer quality of life in several categories. This was seen in the categories anxiety, depression, fear of hypoglycemias in the case of type I diabetics, restriction of leisure time activities, relationship with the partner and acceptance of disease. Only in the categories patient-physician relationship and professional strain was an improvement found. These alterations are still demonstrable after 6 and 12 months.

A randomized trial of cisplatin, etoposide and bleomycin (PEB) versus carboplatin, etoposide and bleomycin (CEB) for patients with 'good-risk' metastatic non-seminomatous germ cell tumors

BACKGROUND

Cisplatin-based combination chemotherapy will cure 70% to 80% of patients with metastatic non-seminomatous germ cell tumors but is associated with the possibility of severe neuro-, oto- and nephro-toxicities. Carboplatin, a cisplatin analogue, is an active drug in testicular cancer with a more favourable spectrum of side effects. In a randomized trial, the German Testicular Cancer Study Group compared a combination regimen of carboplatin, etoposide and bleomycin (CEB) to standard cisplatin, etoposide and bleomycin (PEB) chemotherapy for patients with 'minimal-' and moderate-disease' non-seminomatous germ cell tumors, according to the Indiana University classification.

PATIENTS AND METHODS

PEB was given for three cycles at standard doses (given days 1-5), and the CEB regimen consisted of carboplatin (target AUC of 5 mg/ml x min) on day 1, etoposide 120 mg/m2 on days 1 to 3 and bleomycin 30 mg on days 1, 8 and 15. Four cycles of CEB were given, with the omission of bleomycin in the fourth cycle. Thus, the cumulative doses of etoposide and bleomycin applied in the two treatment arms were comparable. Fifty-four patients were entered on the trial, 29 were treated with PEB and 25 with CEB chemotherapy. Patients were stratified according to disease extent (minimal versus moderate) and the degree of tumor marker elevation. Thirty-two patients (59%) belonged to the group with minimal disease and low markers.

RESULTS

No significant difference in response to chemotherapy was seen between the two arms, with CR rates of 81% for the PEB arm and 76% for CEB treatment. However, more patients treated with CEB (32% versus 13%) have relapsed after therapy, and 4 patients (16%) have died of disease progression after CEP in contrast to 1 (3%) after PEB therapy. The first interim analysis of negative events (relapse, vital tumor at secondary resection, death from disease and therapy-associated death) showed a significantly higher rate after CEB than after PEB therapy, and the trial was terminated early. After a median follow-up of 33 months for all patients, the calculation of negative events is still significantly in favour of PEB-treated patient, particularly since three late relapses > 2 years have been observed in the CEB arm (P = 0.03).

CONCLUSION

This randomized trial demonstrates that even with the use of adequate doses of etoposide and full-dose bleomycin, carboplatin cannot altogether replace cisplatin in patients with testicular cancer. Treatment with the PEB regimen remains the standard approach in patients with 'good-risk' non-seminomatous germ cell tumors.

The KID Study. III: Impact of inpatient rehabilitation on the metabolic control of type I and type II diabetics--a one-year follow-up

The Kissingen Diabetes Intervention Study (KID) evaluated 1050 diabetic patients of the German Federal Insurance Institution for Salaried Employees (BfA) admitted for inpatient rehabilitation. The data for the prospective longitudinal study (which was collected in a single center) relate to the structure of the patient cohort, socio-economic and psychological factors and the mode of medical management at the time of admission and discharge. Data regarding the same variables was checked by random testing six and twelve months after discharge and used in this part of the study. This cohort of patients is especially interesting for aspects of health policy because it comprises rather young diabetics engaged in highly qualified professional work. Therapy modifications entailing a more intensive insulin regimen were necessary in 20.7% of all type I diabetics. Most of these alterations were maintained over the following 12 months of management by the general practitioner. Improvement of HbA1 levels was related to the number of daily insulin administrations. The results obtained during inpatient treatment in patients on ICT are maintained even one year after their discharge. For type I diabetics, the first training measure especially results in a long-term improvement of the metabolic situation, whereas patients who have already received training several times previously benefit continuously less with increasing repetition of training. After twelve months the intensified insulin therapy of type I diabetics had no further effect on the BMI or the already previously normal serum lipids. In 55.5% of all type II diabetics, the therapy had to be modified. Inpatient rehabilitation resulted in raising the low number of type II diabetics treated just with diet by 5.3%. This proportion was again slightly reduced 12 months later. During inpatient residence the number of overweight type II diabetics treated with drugs was reduced both in the group on oral hypoglycemics and in the group on pre-mixed insulin, according to the weight loss achieved. On the other hand, it was often necessary to intensify the usual insulin regimen twice daily in the group of younger patients with normal body weight. These modifications were maintained twelve months after the stay in hospital for most of these patients. Virtually all type II diabetics on oral hypoglycemics are overweight as a reflection of too early prescriptions of oral hypoglycemics which often neglects the chance of a dietary management only. In this group, therapy modifications were directed towards treatment with diet only and with oral hypoglycemics having an extra-pancreatic action. On metformin, the HbA1 was reduced by 0.3% and the BMI by 0.9 kg/m2 even 12 months later. In the 90% of type II diabetics previously treated with sulphonylureas (almost exclusively glibenclamide), re-modification of therapy from metformin back to the old regimen (16:9%) was especially high. This is probably due to the uncertainty with and general restrictions in the prescription of metformin in the relevant period 1991 to 1995. The results 12 months after inpatient treatment show the small improvement of HbA1 and serum lipids as already seen in other larger interventional studies. The BMI does not change significantly within the relatively short follow-up period. The best long-term results are achieved by a combined therapy with sulphonylurea compounds and metformin. The KID study demonstrates major deficits in intensifying the insulin regimen of type I diabetics and in the individual adaptation to therapy of type II diabetes in Germany, even when younger patients of higher professional status are considered. Interventional inpatient rehabilitation improves their metabolic situation with lasting effect and can compensate deficits in outpatient management by the general practitioner. However, future concepts have to be improved at all levels of diabetic management, with a view to achieving an optimum interaction.

LU103793 (NSC D-669356): a synthetic peptide that interacts with microtubules and inhibits mitosis

LU103793 (NSC D-669356) is a new synthetic derivative of Dolastatin 15, an antiproliferative compound which was isolated from the mollusk Dolabella auricularia. Like Dolastatin 15, LU103793 is highly cytotoxic in vitro (IC50 = 0.1 nM). To investigate the mechanism of action of LU103793, we used a combination of biochemical and cellular methods. Turbidity assays with bovine brain microtubules demonstrated that LU103793 inhibits microtubule polymerization in a concentration-dependent manner (IC50 = 7 microM). Treatment with this compound also induced depolymerization of preassembled microtubules. Cell cycle analysis of tumor cell lines treated with LU103793 indicated a block in the G2-M phase. At the cellular level, it induced depolymerization of microtubules in interphase cells and development of abnormal spindles and chromosome distribution in mitotic cells. Although these effects are very similar to the cellular alterations caused by vinblastine, LU103793 does not inhibit vinblastine binding to unpolymerized tubulin in vitro. Our results suggest that LU103793 exerts its cytotoxic activity primarily through disruption of microtubule organization.

Influence of shock waves on fracture healing

During the last decades the influence of physical factors on fracture healing has been widely described. With the use of shock waves for the treatment of urolithiasis, a new mechanical medium has been introduced into medicine. For the first time the influence of shock waves on fracture healing was studied in rats. With fractioned shock-wave treatment (5 times 100 shock waves at 14 or 18 kV) an enhancement in healing could be achieved.

[24-hour blood pressure measurement in normal pregnancy in hypertensive pregnant patients]

Noninvasive 24-hour ambulatory blood pressure monitoring was performed in 17 normotensive and 19 preeclamptic pregnant women. The normotensive women showed a significant nightly decline in their systolic and diastolic blood pressure. In contrast, the preeclamptic women demonstrated either an attenuated circadian rhythm or no circadian rhythm at all. This result was even more pronounced in patients with severe hypertension, some of whom had a nocturnal increase in blood pressure in spite of being treated with antihypertensive drugs in an evening dose. The lack of nocturnal blood pressure decrease was also found 24 hours post partum. In summary, these results suggest that preeclamptic women are endangered by hypertensive emergencies mostly during the night. Therefore blood pressure controls should be extended into the night, and antihypertensive drugs should also be given in a sufficient evening dose.

[24-hour blood pressure behavior in patients with untreated and treated hypertension in comparison with normotensive patients]

Blood pressure was continuously monitored over 24 h in 201 patients with mild to moderate essential hypertension using a noninvasive method. Measurements were made both before and after 6 months of antihypertensive treatment and the data were compared to results from 100 normotensive patients. The frequency with which blood pressure values above 140/90 mm Hg occurred during the 24-h period proved to be the most reliable parameter for distinguishing between hypertensive and normotensive profiles. The blood pressures of all patients could be normalized (less than 140/90 mm Hg) on single or combined drug therapy as assessed by casual measurement. However, significant differences were observed between the 24-h profiles of the treated patients and the control group. The mean 24-h blood pressure, the mean day and nighttime blood pressures, the mean hourly pressure, and the frequency of increased blood pressure values were all significantly higher in the patients on medication as compared to the normotensive controls. This would suggest that normotension, as defined by the control group, cannot be attained with antihypertensive medication. In conclusion, 24-h continuous blood pressure monitoring allows a better evaluation of blood pressure profiles and consequently, will be of greater value in assessing cardiovascular risk than occasional random measurements.

Short-term changes of laboratory values after extracorporeal shock wave lithotripsy: a comparative study

Since the inception of extracorporeal shock wave lithotripsy 9 years ago treatment strategies have changed. Patients currently are receiving larger numbers of higher voltage shock waves. However, upper limits of safety for these treatments have not been established. In an attempt to address this question a comparative study of effects of extracorporeal shock wave lithotripsy on laboratory values between 2 stone centers, Munich and Tucson, using different treatment strategies 3 to 4 years apart was done to identify possible differing effects. Patient stone burdens were similar. However, Tucson patients received almost twice the number of shock waves. Both groups showed a significant decrease in hematocrit (by 8.7 per cent in Munich and 6.4 per cent in Tucson). Both groups had a significant increase in white blood count (14.5 per cent in Munich and 22.7 per cent in Tucson). In addition, both groups had increased serum levels of glutamic oxaloacetic transaminase of 43.3 and 59.7 per cent, respectively. However, only the Tucson group showed increases in serum glutamic pyruvic transaminase, lactic dehydrogenase and total bilirubin in 51.5, 40.8 and 46 per cent of the patients, respectively. Further analysis indicated that extracorporeal shock wave lithotripsy was associated with 2 significant short-term changes of blood or serum laboratory values: 1) those presumed to be dilutional from related infusions, rather than extracorporeal shock wave lithotripsy treatments themselves and 2) those presumed to be related to cellular injury after high energy treatments. Elevated serum glutamic pyruvic transaminase, lactic dehydrogenase and total bilirubin values of Tucson patients clearly were related to higher kilovolts and number of shocks or to treatments on the right side.(ABSTRACT TRUNCATED AT 250 WORDS)

[Absence of nocturnal decrease in blood pressure in 24-hour blood pressure monitoring: an indication of secondary hypertension]

Non invasive 24 hours ambulatory blood pressure monitoring was performed in 81 patients with secondary hypertension (renoparenchymatous nephropathy n = 15, diabetic nephropathy n = 10, Conn's disease n = 4, renal artery stenosis n = 15, pheochromocytoma n = 2, hemodialysis patients n = 15 and patients after kidney transplantation n = 20). The results were compared to 201 patients with essential hypertension. The results showed that 98.5% of patients with essential hypertension have a nightly decline in blood pressure of at least 15 mmHg (systolic + diastolic), whereas 69% of patients with secondary hypertension showed either an attenuated circadian rhythm or no circadian rhythm. Patients with pheochromocytoma who had a night time increase in blood pressure demonstrated the greatest difference to the essential hypertension collective followed by patients with diabetic nephropathy, Conn's disease and the group of patients after kidney transplantation. After successful treatment of the condition leading to hypertension circadian periodicity returned in some patients. In summary these results suggest that the absence of a night time decline in blood pressure during 24-hour-ambulatory monitoring is an indication of secondary hypertension.

Azidobenzamido-008, a new photosensitive substrate for the 'multispecific bile acid transporter' of hepatocytes: evidence for a common transport system for bile acids and cyclosomatostatins in basolateral membranes

Cyclo(-Phe(p-NH[1-14C]Ac)-Thr-Lys-(CO(p-N3)C6H4)-Trp-Phe-DPro++ +), in the following named azidobenzamido-008, was synthesized in order to identify binding sites for c(Phe-Thr-Lys-Trp-Phe-DPro), named 008, (a cyclosomatostatin with retro sequence) in liver cell plasma membranes. In the dark the above photolabel was taken up into isolated hepatocytes, inhibiting the sodium dependent uptake of cholate and taurocholate in a competitive manner (Ki for cholate uptake inhibition = 1 microM; Ki for taurocholate uptake inhibition = 5 microM). When activated by flashed light the inhibition became irreversible (IC50 for cholate uptake inhibition = 2 microM; IC50 for taurocholate uptake inhibition = 9 microM) and the activated cyclopeptide bound chiefly to hepatocellular membrane proteins of 67, 54, 50, 37 kDa. Excess of the initial 008, or of cholate or phalloidin partially protected the above membrane components against labeling with 14C-labeled azidobenzamido-008. In contrast AS 30 D ascites hepatoma cells, known to be deficient in bile acid and cyclosomatostatin transport, could not be specifically labeled by azidobenzamido-008. The membrane proteins preferentially labeled in hepatocytes (50 and 54 kDa) are integral glycoproteins. The 67 kDa protein is a hydrophilic nonglycosylated membrane component. Independent of labeling with 14C-labeled azidobenzamido-008 or with 14C-labeled azidobenzamido-taurocholate, the main radioactive peaks in the pH region of 7, 5.5, 5.25 were identical after solubilization with Nonidet P-40 and subsequent isoelectric focusing. Proteins of 67, 54, 50 and 37 kDa could be enriched by use of 008-containing gels in affinity electrophoresis. Binding sites for 008 were not destroyed by SDS or Nonidet P-40 treatment of plasma membranes.