Safety and efficacy of an α1 -blocker plus mirabegron compared with an α1 -blocker plus antimuscarinic in men with lower urinary tract symptoms secondary to benign prostatic hyperplasia and overactive bladder: A systematic review and network meta-analysis

AIM

Antimuscarinics and the β3-adrenoreceptor agonist, mirabegron, are commonly used for treating patients with overactive bladder (OAB) and α1 -adrenoreceptor antagonists (α1 -blockers) are the main pharmacological agents used for treating lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH). As these conditions commonly occur together, the aim of this systematic review was to identify publications that compared the use of an α1 -blocker plus mirabegron with an α1 -blocker plus antimuscarinic in men with LUTS secondary to BPH and OAB. A meta-analysis was subsequently conducted to explore the safety and efficacy of these combinations.

METHODS

Included records had to be from a parallel-group, randomized clinical trial that was ≥8 weeks in duration. Participants were male with LUTS secondary to BPH and OAB. The indirect analyses that were identified compared an α1 -blocker plus OAB agent with an α1 -blocker plus placebo. The PubMed/Medical Literature Analysis and Retrieval System Online, the Excerpta Medica Database, the Cochrane Central Register of Controlled Trials, and the ClinicalTrials.gov registry were searched for relevant records up until March 5, 2020. Safety outcomes included incidences of overall treatment-emergent adverse events (TEAEs) and urinary retention, postvoid residual volume, and maximum urinary flow (Qmax ). Primary efficacy outcomes were micturitions/day, incontinence episodes/day, and urgency episodes/day, and secondary outcomes were Overactive Bladder Symptom Score and International Prostate Symptom Score. A Bayesian network meta-analysis approach was used for the meta-analysis.

RESULTS

Out of a total of 1039 records identified, 24 were eligible for inclusion in the meta-analysis. There were no statistically significant differences between the α1 -blocker plus mirabegron and α1 -blocker plus antimuscarinic groups in terms of the comparisons identified for all the safety and efficacy analyses conducted. Numerically superior results were frequently observed for the α1 -blocker plus mirabegron group compared with the α1 -blocker plus antimuscarinic group for the safety parameters, including TEAEs, urinary retention, and Qmax . For some of the efficacy parameters, most notably micturitions/day, numerically superior results were noted for the α1 -blocker plus antimuscarinic group. Inconsistency in reporting and study variability were noted in the included records, which hindered data interpretation.

CONCLUSION

This systematic review and meta-analysis showed that an α1 -blocker plus mirabegron and an α1 -blocker plus antimuscarinic have similar safety and efficacy profiles in male patients with LUTS secondary to BPH and OAB. Patients may, therefore, benefit from the use of either combination within the clinical setting.

Predicting Mirabegron Treatment Response in Patients with Overactive Bladder: A Post Hoc Analysis of Data from Clinical Trials

BACKGROUND

Many patients discontinue overactive bladder (OAB) treatment because of unmet treatment expectations and/or tolerability issues.

OBJECTIVE

To develop a model for predicting the individual treatment response to mirabegron using patient baseline characteristics.

DESIGN, SETTING, AND PARTICIPANTS

This was a post hoc analysis of data from eight global phase 2/3, double-blind, randomized, placebo- or active-controlled trials of mirabegron in adult patients with OAB.

INTERVENTION

Mirabegron 50 mg once-daily monotherapy for ≥12 wk.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Primary efficacy outcomes were the change in the mean number of micturitions and the number of incontinence episodes/24 h after 12 wk of treatment. Secondary efficacy outcomes were the change in the mean number of urgency episodes/24 h and the change in Symptom Bother score after 12 wk of treatment. Baseline demographic characteristics, OAB-related characteristics, and intrinsic and extrinsic factor variables were used to create multivariable linear regression models to predict the primary and secondary outcomes.

RESULTS AND LIMITATIONS

Data for 3627 patients were included. The predicted effect of mirabegron 50 mg was an average of 2.5 fewer micturition episodes/24 h (95% confidence interval -2.85 to -2.14) and 0.81 fewer incontinence episodes/24 h (95% confidence interval -1.15 to -0.46) from baseline to week 12. A higher number of urgency episodes was predictive of a larger reduction in micturition episodes; body mass index (BMI) ≥30 kg/m2, OAB symptoms for ≥12 mo, and incontinence at baseline were predictive of a smaller reduction. Mixed stress/urgency incontinence and more than five urgency episodes per day were predictive of greater reductions in incontinence episodes. Reductions in urgency episodes and Symptom Bother score were also predicted with mirabegron. Limitations include the exclusion of placebo groups from the analysis and the use of clinical trial rather than real-world data.

CONCLUSIONS

Data from the predictive models provide new insights into the effects of modifiable factors (such as BMI) and nonmodifiable factors on treatment outcomes with mirabegron 50 mg.

PATIENT SUMMARY

This study aimed to identify factors that could predict how patients with overactive bladder respond to mirabegron treatment to help doctors effectively treat this condition. Mirabegron treatment was associated with a lower number of urinations and occurrences of urinary incontinence per day. Factors associated with worse responses to the medication included being obese.

Efficacy and safety of mirabegron in children and adolescents with neurogenic detrusor overactivity: An open-label, phase 3, dose-titration study

Aims

To evaluate the efficacy and safety of mirabegron in children and adolescents (aged 3 to <18 years) with neurogenic detrusor overactivity (NDO) using clean intermittent catheterization.

Methods

In this open‐label, multicenter, baseline‐controlled, Phase III study (NCT02751931), participants received once‐daily mirabegron at an adult dose equivalent of 25 mg. Dose was increased to 50 mg equivalent unless there were safety/tolerability concerns. The primary efficacy endpoint was change from baseline to Week 24 in maximum cystometric capacity (MCC). Secondary urodynamic assessments, Pediatric Incontinence Questionnaire (PIN‐Q), Patient Global Impression of Severity (PGI‐S), Clinician Global Impression of Change (CGI‐C), and Acceptability questionnaires were included.

Results

Overall, 86 participants (55 aged 3 to <12 years, 31 aged 12 to <18 years) received treatment; 68 were included in efficacy assessments. A statistically significant increase in MCC from baseline to Week 24 was observed (87.20 ml, 95% confidence interval: 66.07, 108.33; p < .001); this increase was apparent from Week 4. Significant increases in bladder compliance, bladder volume until first detrusor contraction, average volume per catheterization, maximum daytime catheterized volume and number of dry days per week. Significant decreases in detrusor pressure and number of leakage episodes per day were also observed. Significant improvement in PGI‐S but not PIN‐Q was observed. Most participants reported their condition had either much or very much improved using the CGI‐C. Mirabegron was well tolerated in this population with a profile aligned with that in adults.

Conclusions

Mirabegron was effective and well‐tolerated in the treatment of pediatric patients with NDO.

What are the additional signs and symptoms in patients with detrusor underactivity and coexisting detrusor overactivity?

AIMS

This study aimed to determine what difference the inclusion of patients with coexisting detrusor overactivity (DO) makes to the signs and symptoms of patients with detrusor underactivity (DU).

METHODS

A total of 250 male and 435 female urodynamic tests were analyzed retrospectively. Signs and symptoms which showed a statistically significant difference between DU without DO and DU with DO were identified.

RESULTS

Males with DO in addition to DU had higher age and number of daily micturitions, and were more likely to report urgency with or without urgency incontinence than males with DU without DO. They also had lower volumes for first desire to void, volume voided, and post void residual urine, lower abdominal pressure at Q_max and were less likely to report a history of retention or reduced bladder filling sensation than males with DU without DO. Females with DO in addition to DU had higher age and BMI, and were more likely to report urgency incontinence, higher day and night pad usage, constipation and have reduced anal tone than females with DU without DO. They also had lower volumes for first desire to void, volume voided, and post void residual urine, and lower abdominal pressure at Q_max than females who had DU without DO.

CONCLUSIONS

There are differences in signs and symptoms between patients who have DU without DO, compared to patients having DU with DO. This understanding will help future studies investigating treatment options for DU patients.

Signs and symptoms that distinguish detrusor underactivity from mixed detrusor underactivity and bladder outlet obstruction in male patients

AIMS

This study aimed to identify signs and symptoms which show differences between men with detrusor underactivity (DU) compared to those with both DU and bladder outlet obstruction (BOO).

METHODS

One thousand six hundred and twelve urodynamic tests on male patients were analyzed retrospectively. Signs and symptoms which showed a statistically significant difference between patients with DU alone and patients with both DU+BOO were identified.

RESULTS

In the DU only group, considering only patients without a history of bladder outlet surgery, the number of daytime micturitions was lower, maximum voided volume on the bladder diary was higher, and slow stream was reported less often, whereas urinary tract infections were reported more often than for DU+BOO males. The average urine flow rate and abdominal pressure at maximum flow were greater in the DU males, compared to the DU+BOO males.

CONCLUSIONS

These data suggest that by combining symptoms, medical history and signs, that could be measured without the need for invasive urodynamics, it may be possible to identify men with DU in a non-invasive way. By doing so, men with DU could be separated from men with both DU+BOO, with sufficient specificity to allow the use of any new non-surgical treatment modalities, such as new and effective medical therapy.

Tapentadol prolonged-release for moderate-to-severe chronic osteoarthritis knee pain: a double-blind, randomized, placebo- and oxycodone controlled release-controlled study

OBJECTIVE

To assess efficacy and safety of tapentadol prolonged release (PR) for moderate-to-severe chronic osteoarthritis knee pain.

METHODS

Patients (n = 990) were randomized (1:1:1) to tapentadol PR, oxycodone controlled release (CR; reference compound for assay sensitivity), or placebo for a double-blind 3-week titration and 12-week maintenance period. Primary efficacy end-points were change from baseline in average pain intensity at week 12 of maintenance (US end-point) and over the entire maintenance period (non-US end-point) with "last observation carried forward" as imputation method for missing scores.

RESULTS

Both primary end-points were not significantly different for tapentadol PR nor for oxycodone CR vs placebo at week 12 (least squares [LS] mean difference = -0.3 [95% CI = -0.61-0.09]; p = 0.152 and 0.2 [95% CI = -0.16-0.54]; p = 0.279, respectively) and over the maintenance period (LS mean difference = -0.2 [95% CI = -0.55-0.07]; p = 0.135 and 0.1 [95% CI = -0.18-0.44]; p = 0.421, respectively). Considerably more patients receiving tapentadol PR than oxycodone CR completed the trial (58.3% vs 36.6%). This is consistent with better results with tapentadol PR on the overall health status (PGIC) compared to oxycodone CR. Indeed, respectively, 56% and 42.5% rated at least "much improved" at the end of treatment. Incidences of gastrointestinal adverse events were higher for both active treatments compared to placebo. Tapentadol PR was associated with a better gastrointestinal tolerability profile with incidences of constipation (17.9% vs 35%) and of the composite of nausea and/or vomiting (23.8% vs 46.8%) significantly lower vs oxycodone CR (p < 0.001).

CONCLUSIONS

The study did not demonstrate assay sensitivity. The finding that both primary end-points for tapentadol PR were not met can, thus, not be interpreted. Tapentadol PR was better tolerated than oxycodone CR, largely due to fewer gastrointestinal side-effects.

Direct conversion from tramadol to tapentadol prolonged release for moderate to severe, chronic malignant tumour-related pain

Background

A recent randomized‐withdrawal, active‐ and placebo‐controlled, double‐blind phase 3 study showed that tapentadol prolonged release (PR) was effective and well tolerated for managing moderate to severe, chronic malignant tumour‐related pain in patients who were opioid naive or dissatisfied with current treatment (Pain Physician, 2014, 17, 329–343). This post hoc, subgroup analysis evaluated the efficacy and tolerability of tapentadol PR in patients who previously received and were dissatisfied with tramadol for any reason and who had a pain intensity ≥5 (11‐point numerical rating scale) before converting directly to tapentadol PR.

Methods

In the original study, eligible patients had been randomized (2:1) and titrated to their optimal dose of tapentadol PR (100–250 mg bid) or morphine sulphate‐controlled release (40–100 mg bid) over 2 weeks. The present report focuses on results during the titration period for a subgroup of patients randomized to tapentadol PR after having been on tramadol treatment prior to randomization in the study (n = 129). Results for this subgroup are compared with results for all 338 patients who received tapentadol PR during titration (overall tapentadol PR group).

Results

Responder rates (responders: completed titration, mean pain intensity <5 [0–10 scale] and ≤20 mg/day rescue medication during last 3 days) were slightly better for the tramadol/tapentadol PR subgroup (69.8% [90/129]) vs. the overall tapentadol PR group (63.9% [214/335]). Tolerability profiles were comparable for both groups.

Conclusions

Results of this subgroup analysis indicate that patients with cancer pain could safely switch from prior treatment with the weak centrally acting analgesic tramadol directly to the strong centrally acting analgesic tapentadol PR, for an improved analgesic therapy for severe pain.

What does this study add?

Results of this post hoc analysis show that patients who had received prior tramadol therapy could switch directly to tapentadol PR, with the majority (˜70%) experiencing improved efficacy.

Tapentadol prolonged release for managing moderate to severe, chronic malignant tumor-related pain

BACKGROUND

Tapentadol prolonged release (PR) is effective and well tolerated for chronic osteoarthritis, low back, and diabetic peripheral neuropathic pain.

OBJECTIVES

To evaluate the efficacy and tolerability of tapentadol PR compared with placebo and morphine controlled release (CR) for managing moderate to severe chronic malignant tumor-related pain.

STUDY DESIGN

Randomized-withdrawal, parallel group, active- and placebo-controlled, double-blind phase 3 study (NCT00472303).

SETTING

Primary, secondary, and tertiary care settings in 16 countries.

METHODS

Eligible patients (pain intensity ≥ 5 [11-point numerical rating scale] on prior analgesics) were randomized (2:1) and titrated to their optimal dose of tapentadol PR (100-250 mg bid) or morphine sulfate CR (40-100 mg bid) over 2 weeks. Morphine sulfate immediate release 10 mg was permitted as needed for rescue medication (no maximum dose). Patients who completed titration and, during the last 3 days of titration, had mean pain intensity < 5 (based on twice-daily ratings) and mean rescue medication use = 20 mg/day continued into a 4-week maintenance period; patients who received morphine CR during titration continued taking morphine CR, and those who received tapentadol PR were re-randomized (1:1) to tapentadol PR or placebo bid. Response during maintenance (primary efficacy endpoint) was defined as having: (1) completed the maintenance period, (2) a mean pain intensity < 5 during maintenance, and (3) used an average of = 20 mg/day of rescue medication during maintenance. Response at the end of titration was defined similarly, with pain intensity and rescue medication averages based on the last 3 days of titration.

RESULTS

Of 622 patients screened, 496 were randomized, treated during titration, and evaluable for safety; 327 were re-randomized, treated during maintenance, and evaluable for safety; and 325 were evaluable for efficacy. The adjusted responder rate estimate during maintenance (logistic regression adjusting for treatment group, pooled center, and pain intensity at start of maintenance) was significantly higher with tapentadol PR (64.3%) than with placebo (47.1%; odds ratio (OR), 2.02 [95% confidence interval (CI), 1.12 - 3.65]; P = 0.02). Based on responder rates at the end of titration, tapentadol PR (76.0% [174/229]) was non-inferior to morphine CR (83.0% [83/100]). The lower limit of the 95% CI for the between-groups difference (-15.5%) was within the pre-specified 20% non-inferiority margin. During titration, incidences of treatment-emergent adverse events (TEAEs) were 50.0% (169/338) with tapentadol PR and 63.9% (101/158) with morphine CR; incidences of nausea, vomiting, and dry mouth were lower with tapentadol PR than with morphine CR. During maintenance, incidences of TEAEs were 56.3% (63/112), 62.3% (66/106), and 62.4% (68/109) with placebo, tapentadol PR, and morphine CR, respectively.

LIMITATIONS

Statistical comparisons between tapentadol PR and morphine CR were limited to descriptive statistics during the maintenance period because of the pre-selection of responders to tapentadol PR or morphine CR during titration.

CONCLUSIONS

Results obtained during maintenance indicate that tapentadol PR (100-250 mg bid) is effective compared with placebo for managing moderate to severe chronic malignant tumor-related pain. Based on results obtained during titration, tapentadol PR provides comparable efficacy to that of morphine sulfate CR (40-100 mg bid), but is associated with better gastrointestinal tolerability.

A pooled analysis of patient-specific factors and efficacy and tolerability of tapentadol extended release treatment for moderate to severe chronic pain

OBJECTIVE

To evaluate via retrospective analysis the efficacy and tolerability of tapentadol extended release (ER; 100-250 mg bid) based on patient-specific factors, including baseline pain intensity, prior opioid experience, gender, and body mass index (BMI).

DESIGN

Data were pooled from three randomized, double-blind phase III studies of similar design that evaluated the efficacy and tolerability of tapentadol ER for the management of moderate to severe, chronic osteoarthritis knee pain (NCT00421928, NCT00486811) or low back pain (NCT00449176).

SETTING

In the original trials, patients were recruited at primary, secondary, and tertiary care centers, institutional settings, and private practices in North America, Europe, Australia, and New Zealand.

PATIENTS

Data were analyzed separately for groups of patients divided by baseline pain intensity, prior opioid experience, gender, and BMI.

INTERVENTIONS

Patients received twice-daily placebo, tapentadol ER (100-250 mg), or oxycodone HCl controlled release (CR; 20-50 mg) for a 3-week titration and 12-week maintenance period.

MAIN OUTCOME MEASURES

Changes from baseline in average pain intensity (11-point numerical rating scale) at week 12 of the maintenance period and for the overall maintenance period.

RESULTS

Efficacy and tolerability were evaluated in 2,968 and 2,974 patients, respectively. The efficacy of tapentadol ER was shown in subpopulations divided by baseline pain intensity, prior opioid experience, gender, and BMI. Tapentadol ER was also shown to be well tolerated and associated with better gastrointestinal tolerability than oxycodone CR in the evaluated subpopulations (divided by prior opioid experience and gender).

CONCLUSIONS

Results suggest that tapentadol ER (100-250 mg bid) provides similar pain relief and tolerability, regardless of baseline pain intensity, prior opioid experience, gender, or BMI.

Efficacy and safety of tapentadol extended release for the management of chronic low back pain: results of a prospective, randomized, double-blind, placebo- and active-controlled Phase III study

OBJECTIVE

To evaluate the efficacy and safety of tapentadol extended release (ER) for the management of moderate to severe chronic low back pain.

RESEARCH DESIGN

Patients (N = 981) were randomized 1:1:1 to receive tapentadol ER 100 - 250 mg b.i.d., oxycodone HCl controlled release (CR) 20 - 50 mg b.i.d., or placebo over 15 weeks (3-week titration period, 12-week maintenance period).

MAIN OUTCOME MEASURES

Efficacy was assessed as change from baseline in average pain intensity (11-point NRS) at week 12 of the maintenance period and throughout the maintenance period; last observation carried forward was used to impute missing pain scores. Adverse events (AEs) were monitored throughout the study.

RESULTS

Tapentadol ER significantly reduced average pain intensity versus placebo at week 12 (least squares mean difference vs placebo [95% confidence interval], -0.8 [-1.22, -0.47]; p < 0.001) and throughout the maintenance period (-0.7 [-1.06,-0.35]; p < 0.001). Oxycodone CR significantly reduced average pain intensity versus placebo at week 12 (-0.9 [-1.24,-0.49]; p < 0.001) and throughout the maintenance period (-0.8 [-1.16,-0.46]; p < 0.001). Tapentadol ER was associated with a lower incidence of treatment-emergent AEs (TEAEs) than oxycodone CR. Gastrointestinal TEAEs, including constipation, nausea, and vomiting, were among the most commonly reported TEAEs (placebo, 26.3%; tapentadol ER, 43.7%; oxycodone CR, 61.9%). The odds of experiencing constipation or the composite of nausea and/or vomiting were significantly lower with tapentadol ER than with oxycodone CR (both p < 0.001).

CONCLUSIONS

Tapentadol ER (100 - 250 mg b.i.d.) effectively relieved moderate to severe chronic low back pain over 15 weeks and had better gastrointestinal tolerability than oxycodone HCl CR (20 - 50 mg b.i.d.).

The efficacy and tolerability of multiple-dose tapentadol immediate release for the relief of acute pain following orthopedic (bunionectomy) surgery

OBJECTIVE

Tapentadol is a new, centrally acting analgesic with two mechanisms of action, combining μ-opioid agonism and norepinephrine reuptake inhibition in a single molecule. This study assessed tapentadol immediate release (IR) in patients with postsurgical orthopedic pain.

METHODS

This randomized, double-blind, phase II study involved patients with moderate-to-severe pain after bunionectomy surgery (first metatarsal with osteotomy). Patients (N = 269) were randomly assigned to receive tapentadol IR 50 or 100 mg, oxycodone HCl IR 10 mg, or placebo; the study drug was taken every 4-6 h, over a 72-h period starting 1 day after surgery (Evaluation Day 2). The primary endpoint was the sum of pain intensity over 24 h (SPI-24) on the second day after randomization (Evaluation Day 3). Potential limitations of this study included the use of rescue medication and the fact that it was not powered to statistically compare between-group differences in tolerability measures.

RESULTS

Mean (standard deviation [SD]) SPI-24 values on Evaluation Day 3 were significantly lower for tapentadol IR (50 mg: 33.6 [19.7], p = 0.0133; 100 mg: 29.2 [15.2], p = 0.0001) and oxycodone HCl IR 10 mg (35.7 [17.2]; nominal p = 0.0365) compared with placebo (41.9 [17.7]). The most common treatment-emergent adverse events for all treatment groups were characteristic of drugs with μ-opioid agonist activity. While providing similar analgesic efficacy, tapentadol IR 50 mg was associated with lower rates of nausea (46.3% vs. 71.6% for oxycodone HCl IR 10 mg), dizziness (32.8% vs. 56.7%), vomiting (16.4% vs. 38.8%), and constipation (6.0% vs. 17.9%), and a similar rate of somnolence (28.4% vs. 26.9%) compared with oxycodone HCl IR 10 mg.

CONCLUSIONS

Tapentadol IR 50 and 100 mg and oxycodone HCl IR 10 mg were effective in this study for the relief of acute postoperative pain following bunionectomy. The study results suggest improved gastrointestinal tolerability of tapentadol IR 50 mg compared with oxycodone at a dose showing comparable efficacy.

Implant-supported anterior tooth restoration

Various options are available for restoring anterior teeth. Their choice is dictated by the severity of infection of the teeth to be extracted and the pocket depth. Immediate single-stage implant placement proved to be the least traumatic option, which best preserved the soft tissue. A differential use of surgical and prosthodontic techniques is indispensable to account for conditions in the individual case. Given an adequate amount of hard tissue, soft tissue contours can be expected to return to normal. Immediate implants combined with a soft tissue support have been found to ensure that the depth of even larger pockets is stable for years.

Indoor environment and respiratory symptoms in children living in the Dutch-German borderland

OBJECTIVE

To investigate the relation between indoor environmental risk factors and respiratory symptoms in 7-8-year-old children living in the Dutch-German borderland.

METHODS

A nested case-control study was conducted among children participating in a large longitudinal study on respiratory health. Parents of all 781 children with respiratory complaints and an equal number of randomly selected controls were asked to complete a questionnaire, including questions on indoor environment.

RESULTS

The parents of 1191 children (76.2%) participated. Past exposure to environmental (OR = 2.73, 95% CI 1.14-6.67) as well as in utero exposure (OR = 2.28, 95% CI 1.15-4.53) to tobacco smoke, use of an unvented geyser for water heating (OR = 3.01, 95% CI 1.21-7.56), long-term exposure to dampness (OR = 2.98, 95% CI 1.10-8.28) or pets (OR = 2.18, 95% CI 1.39-3.42) increased the risk of asthmatic symptoms in 7-8-year-old children. A middle or low socio-economic status also increased the risk of asthmatic symptoms. An inverse association with asthmatic symptoms was seen for wall-to-wall carpeting (OR = 0.57, 95% CI 0.33-0.95) and insulation measures (OR = 0.46, 95% CI 0.25-0.83). Except for the presence of an unvented geyser, these environmental risk factors also presented a risk for coughing symptoms in children.

CONCLUSION

This study showed an increased risk of respiratory symptoms in children exposed to several indoor environmental risk factors.

Nasal function in self-reported chemically intolerant individuals

Nasal function has not yet been investigated under controlled exposures in individuals with self-reported Multiple Chemical Sensitivity (sMCS). Therefore, anterior rhinomanometry and acoustic rhinometry were applied in 12 individuals with sMCS, and 12 age-matched controls. The sMCS individuals and controls were selected on the basis of a standardized questionnaire. Controlled 4-hr exposures to ethylbenzene and 2-butanone were performed during 4 sessions. Exposures were close to the current German threshold limit values, and they approximated odor thresholds. Subjects with sMCS had a significant decrease in the flow value in anterior rhinomanometry, independent of substance and doses, compared with controls. This result suggests somatic reactions to the exposure. The result must be confirmed in additional studies, and pathophysiological examinations must be performed. For these investigations, anterior rhinomanometry was usable, but acoustic rhinometry can be recommended only after sufficient standardization has occurred. Furthermore, biochemical parameters of nasal mucosa must be considered.

[Interreg II--European regional study of chronic respiratory tract diseases in children in the Germany-Netherlands border zone]

AIM OF THE STUDY

In Westelijke Mijnstreek (WM), Midden-Limburg (ML), both The Netherlands, and Kreis Heinsberg (HS), Germany, the relationship between quality of the indoor environment and respiratory symptoms in children was studied, finally resulting in proposals for prevention of respiratory symptoms in the three regions. This paper presents the results of the first part of the study, investigating prevalences of respiratory complaints.

METHODS AND RESULTS

A brief questionnaire was used to document prevalences of respiratory complaints, physicians diagnoses and treatment in about 7,000 children 5-6 resp. 7-8 years of age from HS, ML and WM, in 1995 and 1997. Prevalences of respiratory symptoms differed slightly between the regions, but there were differences in physician-diagnosed asthma and bronchitis and treatment of the children.

PERSPECTIVES

The brief questionnaire is a useful instrument to get an overview on respiratory symptoms. Since 1995, it is used by several German Municipal Health Services for Public Health Reports.

Value of acoustic rhinometry in environmental medicine

It is a weak point of environmental medicine that health disturbances, e.g. functional affections of the upper respiratory tract, cannot be objectively judged by physicians resp. researchers. In this study, the validity of acoustic rhinometry, a method giving information on cross-sectional areas of the upper airways by means of ultrasound probing, was tested in 40 volunteers seven times during one year. Furthermore, using a simplified model of the nose the accuracy of this method to measure the minimal cross-sectional area (MCA) in the nose was tested. The measurements were extremely confounded by the mode of connection to the nose (e.g. selected adapter, direction of application) and by the MCA in the nasal cavity. Statistical analyses showed a good reproducibility of measurements repeated within minutes, but suggested an intrapersonal variability over the analyzed examination phases due to apparatus independent factors. However, this variability could not be explained by influencing and confounding factors obtained by questionnaire, medical history, and physical examination. The test model showed little to great errors (1.5 to 568.5%) between the actual and the measured MCA, depending on the diameter. It is concluded that the method of acoustic rhinometry has to be standardized before it's value for environmental medicine can finally be judged. Further studies are necessary that should focus among others on factors influencing the variability of MCA and the effect of MCA on the measurement of the area behind the MCA. So far, the use of acoustic rhinometry for the evaluation of nasal function cannot be recommended.

Sema3C and netrin-1 differentially affect axon growth in the hippocampal formation

The interaction between outgrowing neurons and their targets is a central element in the development of the afferent and efferent connections of the hippocampal system. This requires that axonal growth cones recognize specific guidance cues in the appropriate target area. At present, little is known about the mechanisms that determine the lamina-specific termination of hippocampal afferents. In order to understand the role of different guidance factors, we analyzed the effects of Sema3C and Netrin-1 on explants from the entorhinal cortex, dentate gyrus, cornu ammonis regions CA1 and CA3 and medial septum in a collagen coculture assay. Our observations suggest that both semaphorins and netrin play important roles in the neuron-target interactions in the hippocampal system. Sema3C is involved in the control of the ingrowth of the septohippocampal projection. We also show that netrin-1 is involved in attracting commissural neurons from dentate gyrus/hilus and CA3 to their target area in the contralateral hippocampus.

Inner room-questionnaire for the German-speaking area

The sick building syndrome (SBS) is well known in Germany, too. Because reliable objective data are missing questionnaires are essential in investigations of SBS. Internationally, different questionnaires are used which often lack thorough validation. Therefore, aim of this study was to combine the development of a questionnaire and the analysis of its sensitivity and reliability. For proofing sensitivity, 40 volunteers kept a Symptom Diary for one week and, for comparison, answered the questionnaire in the following week seven times during one year. For testing reliability, 60 volunteers filled in the questionnaire on Monday and on Friday of the same week. Agreement was tested by statistical measure kappa (kappa). The sensitivity test showed that details obtained by diary occurred less pronounced but similarly distributed in the questionnaire. The reliability test showed stable socio-demographic and work-related variables. Among the symptoms, eye troubles (kappa = 0.88), skin troubles in the face (kappa = 0.77) and on the hands (kappa = 0.75) were stable. Among the indoor complaints unpleasant odors (kappa = 0.68), sounds (kappa = 0.72), bright lighting (kappa = 0.85), and dust (kappa = 0.86) were stable. Our questionnaire recorded principally plausibly indoor complaints and well-being disturbances. A definite judgement of the questionnaire can only be made after its application to a SBS-affected group. Nevertheless, our questionnaire can be introduced into the process of developing a standardised international SBS-questionnaire. Moreover, our results indicate that events asked by questionnaire over a retrospective period of more than one week should be interpreted with caution.

Semaphorin D acts as a repulsive factor for entorhinal and hippocampal neurons

We analysed the effects of semaphorin D on axons from the developing rat entorhinal-hippocampal formation. Explants from superficial layers of the entorhinal cortex and of the hippocampus anlage were obtained from various developmental stages and co-cultured with cell aggregates expressing semaphorin D. Neurites extending from entorhinal explants that had been isolated from early embryonic stages (E16 and E17) were not affected by semaphorin D, but were repelled at later stages (E20 and E21). Axons from hippocampal neurons explanted at E21 were also repelled by semaphorin D. In situ hybridization studies revealed expression of the semaphorin D receptor neuropilin-1 in the entorhinal cortex from stage E17 to stage P7, and in the dentate gyrus and CA1-3 regions between E17 and adulthood. These data suggest that semaphorin D is involved in the formation of the perforant pathway and acts, via the neuropilin-1 receptor, as a repulsive signal that prevents entorhinal fibres from growing into the granular layer of the dentate gyrus. These data also suggest a role for semaphorin D in the development of intrahippocampal connections.

Toe agnosia in Gerstmann syndrome

The following case report presents a patient exhibiting Gerstmann syndrome accompanied by toe agnosia. A 72 year old right handed woman had a focal lesion in the angular gyrus of the left hemisphere which was caused by a glioblastoma multiforme. The first symptom she had complained of was severe headache. Standardised neuropsychological tests of intelligence, memory, attention, fluency, apraxia, and language functions as well as tests for the assessment of agraphia, acalculia, right-left disorientation, and digit agnosia were performed. The patient displayed all four symptoms of the Gerstmann syndrome--namely, agraphia, acalculia, right-left disorientation, and finger agnosia. The patient did not display aphasia, constructional apraxia, or any other neuropsychological impairment. In addition to the four symptoms of the Gerstmann syndrome an agnosia of the toes was found. Further studies should determine whether finger agnosia in Gerstmann syndrome is usually accompanied by toe agnosia. Finger agnosia in the context of this syndrome may be better named digit agnosia.

[The effect of indomethacin and dexamethasone on the excretion of epinephrine, levarterenol and dopamine in the urine of rats with adjuvant arthritis]

The repeated application of indometacine or dexamethasone on rats with adjuvant arthritis results in a most cases significant inhibition of the arthritis in the primary and secondary phase as well as in a normalisation of the increased urinary excretion of epinephrine and norepinephrine of untreated arthritis rats. The dopamine excretion of adjuvant arthritis rats was also higher then the prepared rats. We suppose, that the results show the regulative endogenous excretion of epinephrine and norepinephrine in inflammatory processes. Consequently these drugs have essentially antiinflammatory activities. The inhibition of the inflammation is than connected with the normalisation of the excretion of catecholamines.

[Fluorometric determination of levarterenol, epinephrine and dopamine in the urine of rats with carrageenan edema and adjuvant arthritis]

After adsorption-chromatographic separation (using aluminium oxide) and chemical conversion to the corresponding trihydroxyindole derivatives, epinephrine, levarterenol and dopamine were determined fluorometrically in urine from rats. In case of carrageenin oedema, as well as during the secondary phase of adjuvant arthritis, the excretion of epinephrine and levarterenol was increased as compared to that in control animals. This difference was statistically significant. These findings can possibly be connected with an inhibitory activity of the catecholamines in inflammatory processes; as to dopamine, it seems to be of minor importance.