Preclinical Characterization of AZD9574, a Blood-Brain Barrier Penetrant Inhibitor of PARP1

PURPOSE

We evaluated the properties and activity of AZD9574, a blood-brain barrier (BBB) penetrant selective inhibitor of PARP1, and assessed its efficacy and safety alone and in combination with temozolomide (TMZ) in preclinical models.

EXPERIMENTAL DESIGN

AZD9574 was interrogated in vitro for selectivity, PARylation inhibition, PARP-DNA trapping, the ability to cross the BBB, and the potential to inhibit cancer cell proliferation. In vivo efficacy was determined using subcutaneous as well as intracranial mouse xenograft models. Mouse, rat, and monkey were used to assess AZD9574 BBB penetration and rat models were used to evaluate potential hematotoxicity for AZD9574 monotherapy and the TMZ combination.

RESULTS

AZD9574 demonstrated PARP1-selectivity in fluorescence anisotropy, PARylation, and PARP-DNA trapping assays and in vivo experiments demonstrated BBB penetration. AZD9574 showed potent single agent efficacy in preclinical models with homologous recombination repair deficiency in vitro and in vivo. In an O6-methylguanine-DNA methyltransferase (MGMT)-methylated orthotopic glioma model, AZD9574 in combination with TMZ was superior in extending the survival of tumor-bearing mice compared with TMZ alone.

CONCLUSIONS

The combination of three key features-PARP1 selectivity, PARP1 trapping profile, and high central nervous system penetration in a single molecule-supports the development of AZD9574 as the best-in-class PARP inhibitor for the treatment of primary and secondary brain tumors. As documented by in vitro and in vivo studies, AZD9574 shows robust anticancer efficacy as a single agent as well as in combination with TMZ. AZD9574 is currently in a phase I trial (NCT05417594). See related commentary by Lynce and Lin, p. 1217.

Preclinical Characterization of AZD5305, A Next-Generation, Highly Selective PARP1 Inhibitor and Trapper

PURPOSE

We hypothesized that inhibition and trapping of PARP1 alone would be sufficient to achieve antitumor activity. In particular, we aimed to achieve selectivity over PARP2, which has been shown to play a role in the survival of hematopoietic/stem progenitor cells in animal models. We developed AZD5305 with the aim of achieving improved clinical efficacy and wider therapeutic window. This next-generation PARP inhibitor (PARPi) could provide a paradigm shift in clinical outcomes achieved by first-generation PARPi, particularly in combination.

EXPERIMENTAL DESIGN

AZD5305 was tested in vitro for PARylation inhibition, PARP-DNA trapping, and antiproliferative abilities. In vivo efficacy was determined in mouse xenograft and PDX models. The potential for hematologic toxicity was evaluated in rat models, as monotherapy and combination.

RESULTS

AZD5305 is a highly potent and selective inhibitor of PARP1 with 500-fold selectivity for PARP1 over PARP2. AZD5305 inhibits growth in cells with deficiencies in DNA repair, with minimal/no effects in other cells. Unlike first-generation PARPi, AZD5305 has minimal effects on hematologic parameters in a rat pre-clinical model at predicted clinically efficacious exposures. Animal models treated with AZD5305 at doses ≥0.1 mg/kg once daily achieved greater depth of tumor regression compared to olaparib 100 mg/kg once daily, and longer duration of response.

CONCLUSIONS

AZD5305 potently and selectively inhibits PARP1 resulting in excellent antiproliferative activity and unprecedented selectivity for DNA repair deficient versus proficient cells. These data confirm the hypothesis that targeting only PARP1 can retain the therapeutic benefit of nonselective PARPi, while reducing potential for hematotoxicity. AZD5305 is currently in phase I trials (NCT04644068).

Abstract 1374: The novel PARP1-selective inhibitor AZD5305 has reduced hematological toxicity when compared to PARP1/2 inhibitors in pre-clinical models

Current clinical poly (ADP-ribose) polymerase (PARP) inhibitors target both PARP1 and PARP2 and they all cause clinical cytopenias with varying severity. Understanding the mechanism underlying the hematological toxicity of these agents is key for the rational design of a best-in-class molecule with greater therapeutic potential, both as monotherapy and in combination with chemotherapy.

We validated the rat as a physiologically competent translational model to investigate PARP inhibitor-driven hematological toxicity. Here we demonstrate that in comparison with a representative PARP1/2 inhibitor, olaparib, the novel highly potent PARP1-selective inhibitor and trapper, AZD5305, does not cause hematological toxicity as a monotherapy in pre-clinical rat models at predicted clinically efficacious exposures. Thus, monotherapy toxicity of PARP1/2 inhibitors likely depends on PARP2 inhibition.

Next, we proceeded to investigate whether PARP1-selective inhibition would be better tolerated in chemotherapy combinations than PARP1/2 inhibition. We performed a rat in vivo study comparing daily olaparib or daily AZD5305 at matched exposures in combination with one cycle of intravenous carboplatin for 14 days. We show that olaparib and PARP1-selective AZD5305 cause comparable exacerbation of carboplatin-induced peripheral blood effects implicating PARP1 inhibition in combination-driven hematological toxicity. Importantly however, AZD5305+carboplatin showed improved hematological tolerability over olaparib+carboplatin because peripheral reticulocytes and bone marrow erythroid precursor cells recover in the presence of continuous AZD5305 but not in the presence of continuous olaparib. Importantly, this differentiation was maintained in a subsequent rat in vivo study, where daily olaparib or daily AZD5305 were combined with two three-weekly cycles of a higher dose of carboplatin to more closely mimic clinical protocol. AZD5305+carboplatin was associated with a more rapid recovery of reticulocytes, red blood cells and hemoglobin following both cycles of carboplatin. In contrast, olaparib+carboplatin was associated with a slower recovery resulting in a more sustained reduction in red cells and hemoglobin during both the first and second cycle of carboplatin.

Thus, in rodents the novel potent PARP1-selective inhibitor AZD5305 has improved hematological tolerability over dual PARP1/2 inhibitors, both as a monotherapy and in carboplatin combinations.

Citation Format: Sonja J. Gill, Ruth Macdonald, Carmen Pin, Rob Collins, Emilyanne Leonard, Gareth Maglennon, Andy Pike, Peter Cotton, Glen Hawthorne, Jordan Pugh, Rebecca Sargeant, Daniel Sutton, James Atkinson, Stewart Jones, Sarah Chinery, Mark Anderton. The novel PARP1-selective inhibitor AZD5305 has reduced hematological toxicity when compared to PARP1/2 inhibitors in pre-clinical models [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 1374.

Undiagnosed diabetes in the over-60s: performance of the Association of Public Health Observatories (APHO) Diabetes Prevalence Model in a general practice

AIM

The Association of Public Health Observatories (APHO) Diabetes Prevalence Model has been interpreted to suggest that a substantial number of people with diabetes are 'missed'. An affluent suburb of Newcastle upon Tyne has a low known diabetes prevalence. We aimed to determine the true prevalence of diabetes in the practice population aged over 60 years and compare our prevalence estimate with that of the Association of Public Health Observatories Diabetes Prevalence Model (18.0%; uncertainty limit 10.7-27.7%). At baseline, the known prevalence of diabetes in this group was 7.4%.

METHODS

All individuals aged 60 years and over registered with one general practice in Newcastle-upon-Tyne, not known to have diabetes (n = 1375), were invited for a standard oral glucose tolerance test and measurement of HbA(1c). Standard World Health Organization cut points for fasting and post-challenge glucose on oral glucose tolerance test or HbA(1c) ≥ 48 mmol/mol (6.5%) were used to identify diabetes.

RESULTS

Five hundred and eighty-four individuals (42.5%) attended for screening. Using oral glucose tolerance test criteria, 4.5% were identified with undiagnosed diabetes. Using HbA(1c), 3.1% had undiagnosed diabetes. The estimated prevalence of total diabetes for the practice population aged 60 years and older is 11.8 (10.5-13.2%) and 10.3 (9.3-11.6) for oral glucose tolerance test and HbA(1c) criteria, respectively.

CONCLUSIONS

The prevalence of diabetes in those aged 60 years and older registered with this practice is lower than the point estimate of the Association of Public Health Observatories Diabetes Prevalence Model, but within its uncertainty limits. Application of the Association of Public Health Observatories model must take into account its uncertainty limits.

Health-related quality-of-life outcomes from adult cochlear implantation: a cross-sectional survey

PURPOSE

The purpose of this study was to examine the extent to which cochlear implants and related rehabilitation improve health-related quality-of-life (HRQoL) and social participation for deafened adults and their partners.

METHOD

A cross-sectional survey was used to examine HRQoL and social participation experiences of 202 deafened adults (148 with implants and 54 without) and 136 partners associated with cochlear implant clinics in Australia and New Zealand. Respondents completed a mailed survey consisting of the Assessment of Quality of Life instrument (a utility instrument), the Participation Scale and questions concerning their socioeconomic status. Both univariate and multivariate analyses were performed.

RESULTS

Controlling for socioeconomic factors, people with cochlear implants reported improved HRQoL and social participation when compared with non-implantees. Implantees reported a relative gain in health utility of 50%, and a relative improvement in social participation of 31%. Such differences were not reported by partners, although patient and partner HRQoL were weakly correlated.

CONCLUSION

The results of this cross-sectional study suggest that cochlear implantation contributes significantly to improvements for deafened adults in everyday communication settings and makes a major contribution to their HRQoL. Nonetheless, when compared with population-based studies, this population continues to report considerably reduced quality of life. Partners also report significantly reduced quality of life when compared to population norms.

Laparoscopic versus open Burch colposuspension: a randomised controlled trial

OBJECTIVE

To compare perioperative characteristics, short-term, and long-term outcomes for laparoscopic Burch colposuspension (LBC) and open Burch colposuspension (OBC) for the treatment of urinary stress incontinence.

DESIGN

Randomised surgical trial with single blinding.

SETTING

Three tertiary level teaching hospitals involving seven surgeons of varying skill levels.

POPULATION

Two hundred women with urodynamic stress incontinence (USI).

METHODS

The two groups were treated in identical fashion, except for the laparoscopic or open approach to surgery. Attempts were made to blind the subjects and the observers obtaining outcome data to treatment group. Analyses were adjusted for surgeon experience.

MAIN OUTCOME MEASURES

Absence of USI 6 months following surgery, postoperative pain, time spent in hospital, and time to return to activities of normal daily living.

RESULTS

There were no significant differences in objective and subjective measures of cure and in patient satisfaction at 6 months, 24 months, or 3-5 years of follow up between laparoscopic and open colposuspension groups. Laparoscopic colposuspension took longer time to perform (87 versus 42 minutes, P< 0.0001) but was associated with less blood loss (P = 0.03), less pain (P = 0.02), and quicker return to normal activities (P = 0.01).

CONCLUSION

LBC has significant advantages over traditional OBC, without any apparent compromise in short-term and long-term outcomes. To compare perioperative characteristics, short-term, and long-term outcomes for laparoscopic Burch colposuspension (LBC) and open Burch colposuspension (OBC) for the treatment of urinary stress incontinence. Randomised surgical trial with single blinding. Three tertiary level teaching hospitals involving seven surgeons of varying skill levels. Two hundred women with urodynamic stress incontinence (USI). The two groups were treated in identical fashion, except for the laparoscopic or open approach to surgery. Attempts were made to blind the subjects and the observers obtaining outcome data to treatment group. Analyses were adjusted for surgeon experience. Absence of USI 6 months following surgery, postoperative pain, time spent in hospital, and time to return to activities of normal daily living. There were no significant differences in objective and subjective measures of cure and in patient satisfaction at 6 months, 24 months, or 3-5 years of follow up between laparoscopic and open colposuspension groups. Laparoscopic colposuspension took longer time to perform (87 versus 42 minutes, P < 0.0001) but was associated with less blood loss (P= 0.03), less pain (P= 0.02), and quicker return to normal activities (P= 0.01). LBC has significant advantages over traditional OBC, without any apparent compromise in short-term and long-term outcomes.

Metformin use and diabetic pregnancy-has its time come?

The prevalence of Type 2 diabetes in women of childbearing age continues to grow as the incidence of Type 2 diabetes increases. Recent evidence shows that treatment of gestational diabetes ensures the best possible outcome for pregnancy complicated by gestational diabetes. Metformin is a logical treatment in these circumstances but there has always been concern about its safety for the fetus, particularly as it crosses the placenta and it may increase the risk of teratogenesis. Although evidence is accumulating that metformin is useful and has a role in polycystic ovary syndrome, a condition of insulin resistance, it is not yet accepted as treatment for Type 2 diabetes in pregnancy and gestational diabetes. Observational data supports the use of metformin in Type 2 diabetes in pregnancy and its role in gestational diabetes is currently under investigation. Metformin may become an important treatment for women with either gestational or Type 2 diabetes in pregnancy and indeed may have additional important benefits for women, including reducing insulin resistance, body weight and long-term risk of diabetes. There is a need for a randomized controlled trial in women with Type 2 diabetes in pregnancy with long-term follow-up of both mothers and children. Until then the best advice remains that optimized glycaemic control prior to conception and during pregnancy is the most important intervention for best possible pregnancy outcome.

TRANSDERMAL POSTERIOR TIBIAL NERVE LASER THERAPY IS NOT EFFECTIVE IN WOMEN WITH INTERSTITIAL CYSTITIS

PURPOSE

Interstitial cystitis (IC) is a debilitating condition which causes irritative bladder symptoms, pain and a decrease in health status. The pathophysiology is poorly understood so therapeutic options are diverse. Percutaneous posterior tibial nerve stimulation is an effective treatment and pulsed transdermal laser stimulation is an established technique for pain management. We evaluated the efficacy of transdermal laser stimulation of the posterior tibial nerve for patients with IC.

MATERIALS AND METHODS

Women meeting the National Institutes of Health National Institute for Diabetes and Digestive and Kidney Diseases criteria for IC were prospectively recruited and randomized to treatment (29) or placebo (27) cohorts in a double-blind trial. At home the patient performed laser therapy daily for 30 seconds over the SP6 acupuncture point for 12 weeks. Measures at baseline and at 84-day followup included the 7-day voiding diary, the Interstitial Cystitis Problem Index, Interstitial Cystitis Symptom Index and RAND 36-Item Health Survey questionnaires.

RESULTS

There were no significant differences between the treatment and control cohorts on any of the measures. However, there was a significant decrease between baseline and 12-week followup in the amount voided, symptom problems and severity, and on all 8 SF-36 scales. There was no significant effect of fluid intake.

CONCLUSIONS

This study demonstrated no difference between the active and sham device. However, it is interesting that treatment and control cohorts experienced similar improvements, suggesting that the control cohort improvements may have been due to participants' belief that they were receiving active treatment from the stimulator. These findings provide support for investigating placebo effects in randomized trials.

Cardiovascular malformations in infants of diabetic mothers

OBJECTIVE

To compare the prevalence at live birth and the spectrum of cardiovascular malformations in infants born to diabetic mothers with pre-existing diabetes with that in infants of non-diabetic mothers.

DESIGN

Prospective study of all live births in the resident population of one health region, with recording of details of the outcome of all pregnancies of women with pre-existing diabetes and of all live born babies with cardiovascular malformations.

RESULTS

In the six years 1995-2000 there were 192 618 live births in the study population. Cardiovascular malformations were confirmed in 22 of 609 (3.6%) babies with diabetic mothers and in 1417 of 192 009 (0.74%) babies with non-diabetic mothers. The odds ratio for a cardiovascular malformation with maternal diabetes was 5.0 (95% confidence interval 3.3 to 7.8). Combination of these results with previous reports and comparison with the spectrum of cardiovascular malformations in infants of non-diabetic mothers shows a greater than threefold excess of transposition of the great arteries, truncus arteriosus, and tricuspid atresia.

CONCLUSIONS

Pre-existing maternal diabetes is associated with a fivefold increase in risk of cardiovascular malformations. Transposition of the great arteries, truncus arteriosus, and tricuspid atresia are overrepresented to produce a substantial excess of these malformations.

Maternity services for women with diabetes in the UK

Diabetic pregnancy is high risk in those regions within the UK that have reported on such an outcome. There is a paucity of information about diabetic pregnancy outcome in the rest of the UK but it seems appropriate to assume that poor outcome is widespread. Previously reports have highlighted problems with the delivery of preconception care and the lack of agreement about the screening and diagnosis of gestational diabetes. The provision of maternity services for women with diabetes in the UK is reviewed. Service development is traced from the 1980s to more recent surveys from Scotland and the former Northern region of England. Service provision has improved over the years in those regions that have agreed and audited standards for provision of care. There is a lack of information about current services within the UK but this will be partly addressed by the forthcoming survey of organization of services co-ordinated by the Confidential Enquiry into Stillbirths and deaths in Infancy (CESDI), which will survey England, Wales and Northern Ireland. In Scotland the Scottish Intercollegiate Guidelines 'Management of diabetes in pregnancy' has been implemented and audited. A similar guideline of agreed standards of care is needed for the rest of the UK.

Quality management and the Emergency Services Enhancement Program

Since the introduction of the Emergency Services Enhancement Program (ESEP) in Victoria in 1995, improvements have been demonstrated in the indicators relating to Emergency waiting times, ambulance bypass rates and inpatient bed access block. This study focuses on staff perceptions of changes in these indicators, factors perceived to influence performance improvements and the extent to which ESEP is perceived to have contributed to overall patient care. A questionnaire was directed at four focus groups within each of the hospitals participating in ESEP. These were Chief Executive Officers, Emergency Department Directors and Nurse Unit Managers, bed coordinators and personnel from the Emergency Department floor. A total of 101 staff responded. Emergency Department staff were generally accurate in their perceptions of performance changes. The most important factors effecting the changes were perceived to be changes in staff profile, management of patient flow through the department, changes in administrative policies and changes in work practices. Staff perceived that patient care has improved by 10% since 1995 and that ESEP has contributed 8% of this improvement. Staff have perceived improvements in ESEP performance indicators consistent with actual changes. The possible mechanisms by which these changes have occurred are presented and discussed. Factor analysis indicated that changes perceived to be most likely to result in improvements were: changes in staff profile (seniority), managing the flow of patients through emergency departments, changing administrative policies, changes in work practices and changes in staff numbers. Improvements in patient care were considered partly due to ESEP. In addition, ESEP has raised awareness of quality management issues.

A comparison of the Assessment of Quality of Life (AQoL) with four other generic utility instruments

As part of the validation of the Assessment of Quality of Life (AQoL) instrument comparisons were made between five multiattribute utility (MAU) instruments, each purporting to measure health-related quality of life (HRQoL). These were the AQoL, the Canadian Health Utilities Index (HUI) 3, the Finnish 15D, the EQ-5D (formerly the EuroQoL) and the SF6D (derived from the SF-36). The paper compares absolute utility scores, instrument sensitivity, and incremental differences in measured utility between different instruments predicted by different individuals. The AQoL predicted utilities are similar to those from the HUI3 and EQ-5D. By contrast the 15D and SF6D predict systematically higher utilities, and the differences between individuals are significantly smaller. There is some evidence that the AQoL has greater sensitivity to health states than other instruments. It is concluded that at present no single MAU instrument can claim to be the 'gold standard', and that researchers should select an instrument sensitive to the health states they are investigating. Caution should be exercised in treating any of the instrument scores as representing a trade-off between length of life and HRQoL.

The role of economic evaluation in mental health care

OBJECTIVE

A consequence of the integration of psychiatry into acute and public health medicine is that psychiatrists are being asked to evaluate their services. There is pressure on mental health-care systems because it is recognized that funds should be directed where they can provide the best health outcomes, and also because there are resource constraints which limit our capacity to meet all demands for health care. This pressure can be responded to by evaluation which demonstrates the effectiveness and efficiency of psychiatric treatment. This paper seeks to remind psychiatrists of the fundamental principles of economic evaluation in the hope that these will enable psychiatrists to understand the methods used in evaluation and to work comfortably with evaluators.

METHOD

The paper reviews the basic principles behind economic evaluation, illustrating these with reference to case studies. It describes: (i) the cost of the burden of illness and treatment, and how these costs are measured; (ii) the measurement of treatment outcomes, both as changes in health status and as resources saved; and (iii) the various types of economic evaluation, including cost-minimization, cost-effectiveness, cost-utility and cost-benefit analysis.

RESULTS

The advice in the paper provides psychiatrists with the necessary background to work closely with evaluators. A checklist of the critical questions to be addressed is provided as a guide for those undertaking economic evaluations.

CONCLUSIONS

If psychiatrists are willing to learn the basic principles of economic evaluation and to apply these, they can respond to the challenges of evaluation.

Pay for performance: what trustees should be applauding

The responsibilities of the board's compensation committee go beyond just determining annual pay. The committee must develop a plan that outlines organizational goals and identifies the CEO's accountabilities. Then trustees can fulfill their fiduciary and stewardship roles by providing continuous feedback to their CEO.

The Assessment of Quality of Life (AQoL) instrument: a psychometric measure of health-related quality of life

This paper describes constructing the Assessment of Quality of Life (AQoL) instrument; designed to measure health-related quality of life (HRQoL), and to be the descriptive system for a multi-attribute utility instrument. Unlike previous utility instruments' descriptive systems, the AQoL's has been developed using state-of-the-art psychometric procedures. The result is a descriptive system which emphasizes five different facets of HRQoL and which can claim to have construct validity. Based on the WHO's definition of health a model of HRQoL was developed. Items were written by focus groups of doctors and the researchers. These were administered to a construction sample, comprising hospital patients, and community members chosen at random. Final construction was through an iterative process of factor and reliability analyses. The AQoL measures 5 dimensions: illness, independent living, social relationships, physical senses and psychological wellbeing. Each has three items. Exploratory factor analysis showed the dimensions were orthogonal, and each was unidimensional. Internal consistency was alpha = 0.81. Structural equation modeling explored its internal structure; the comparative fit index was 0.90. These preliminary results indicate the AQoL has the prerequisite qualities for a psychometric HRQoL instrument for evaluation; replication with a larger sample is needed to verify these findings. Scaling it for economic evaluation using utilities is being undertaken. Respondents have indicated the AQoL is easy to understand and is quickly completed. Its initial properties suggest it may be widely applicable.

Prospective population based survey of outcome of pregnancy in diabetic women: results of the Northern Diabetic Pregnancy Audit, 1994

OBJECTIVE

To determine whether the St Vincent declaration (1989) target of diabetic pregnancy outcome approximating non-diabetic pregnancy outcome in near to being achieved.

DESIGN

Prospective collection of population based information on pregnancies in women with diabetes from all participating hospitals.

SETTING

District general and teaching hospitals of the former Northern region.

SUBJECTS

111 diabetic women booking with pregnancy during 1 January to 31 December 1994.

MAIN OUTCOME MEASURES

Diabetic control, perinatal mortality rate, fetal abnormality rate.

RESULTS

The perinatal mortality rate was 48/1000 for diabetic pregnancies compared with 8.9/1000 for the background population (odds ratio 5.38; 95% confidence interval 2.27 to 12.70) and the neonatal mortality rate was 59/1000 compared with 3.9/1000 (15.0; 6.77 to 33.10). Two late neonatal deaths were due to congenital heart defects. Six per cent of all fetal losses (6/109 cases) were due to major malformations. The congenital malformation rate was 83/1000 compared with 21.3/1000 (3.76; 2.00 to 7.06) in the background population.

CONCLUSIONS

Diabetic pregnancy remains a high risk state with perinatal mortality and fetal malformation rates much higher than in the background population.

Preteenage drug use in Australia: the key predictors and school-based drug education

PURPOSE

The promise that early intervention school-based drug education is it will have public health benefits. This argument was explored through identifying the key predictors of early adolescent social drug use.

METHODS

A cross-sectional survey involving 3,019 6th year students, aged 11-12 years (participation rate: 99%), enrolled in 86 Melbourne primary schools was carried out to determine students' social drug use. In addition data were collected on known key social, personal, and education predictors. Logistic regression was used to identify significant predictors of drug experimentation and use.

RESULTS

The key predictors of girls' tobacco use were friends' smoking (OR: 6.7), low literacy (OR: 4.4), and alcohol use (OR: 3.9). For boys they were friends' smoking (OR: 8.6), low literacy (OR: 4.2), and alcohol use (OR: 3.1). For alcohol use, the key predictors for girls were smoking (OR: 4.2), parents' drinking (OR: 3.9), and friends' drinking (OR: 3.8). For boys they were friends' drinking (OR: 3.3), smoking (O: 2.8), and poor literacy (OR: 2.6). Regarding analgesic use, for girls the key predictors were alcohol use (OR: 3.3), analgesic self-administration (OR: 2.4), and parents' drinking or working as tradespersons/laborers (OR: 1.7, respectively). For boys they were analgesic self-administration (OR: 2.5), drinking (OR: 1.9), smoking (OR: 1.7).

CONCLUSIONS

The key predictors of social drug use--which suggests multiple recruitment pathways--were all outside the ambit of drug education programs. The impact of education on recruitment to drug use or experimentation among the young is therefore likely to be slight.

Mothers' emotional needs and difficulties after childbirth

OBJECTIVE

To set up and evaluate weekly group sessions for mothers experiencing difficulties after childbirth.

METHOD

These sessions were held at Barwon Region Child Health Centre in Geelong, Victoria, with input from a general practitioner and a clinical psychologist.

RESULTS

Questionnaires confirmed the group sessions were effective in allaying the mothers' concerns about their babies' health, and that the mothers had low self esteem. Records of the meetings indicated that mothers were mainly concerned about their babies' health, anxiety, lifestyle changes, depression, relationship problems, their own health, the birth experience and lack of support. Social factors often predisposed mothers to these problems.

CONCLUSION

There is clearly scope for the general practitioner to be involved in the diagnosis and management of postnatal problems and group sessions are an effective way of achieving this.

The social impact of Life Education: estimating drug use prevalence among Victorian primary school students and the statewide effect of the Life Education programme

Evaluations of drug education programmes focus on the effect on participating students. Although this is appropriate, where programmes are institutionalized the wider population impact should also be considered. This paper examines this argument and provides a practical methodology for examining programme impacts on populations. It illustrates this using the example of the Life Education (LE) programme-a mature early intervention programme operating internationally-on the Victorian (Australia) population of Year 6 schoolchildren. Data from a recent evaluation of Life Education in Victoria, Australia, were re-analysed enabling estimation of adjusted attributable risk percentage (which provide an estimate of programme effect among those who are exposed to it), population prevalence estimates and population attributable risk percentage (which provide estimates of programme impacts on the entire population). In 1992 when the data were collected LE operated in 43% of all Victorian primary schools. The findings showed that within LE-schools 43% of girls' and 35% of boys' recent smoking was attributable to participation in the LE-programme. For drinking within LE-schools, while there was no apparent effect on girls, the programme was associated with 40% of boys' recent drinking. When the data were extrapolated to the state-wide smoking and drinking estimates, these showed that of all smoking among Year 6 schoolchildren, 25% of girls' and 19% of boys' smoking could be attributed to participation in Life Education, as could 22% of all boys' recent drinking. This re-analysis showed there was no preventive effect associated with the programme, at either the school or the population level. The findings suggest that intervention programmes should be thoroughly evaluated prior to widespread implementation, and that such evaluations should include reference to the community-wide impacts of such programmes.

Does Life Education's drug education programme have a public health benefit?

The Life Education organization offers a drug education programme to an estimated one million Australian primary schoolchildren. It is believed the programme delays experimentation with or initiation into smoking, alcohol use and the taking of analgesics. This study examined the short-term public health effects on 3000 11- and 12-year-old students, of whom 1700 were exposed to 5 consecutive years of the programme. The other 1300 students were not exposed to the programme. After controlling for the known predictors of social drug use there was no evidence that Life Education students, when compared with students receiving conventional school-based drug education, were less likely to have smoked, were less likely to have drunk or were less likely to have used analgesics. Indeed, the evidence suggested that Life Education-students were slightly more likely to use these substances, and that the programme had different effects on boys' and girls' drug use. Given that these findings are consistent with previous research evaluating similar drug education programmes, it is hypothesized they are most likely to do with the design of the programme itself.

Outcome of diabetic pregnancy and glucose intolerance in pregnancy: an audit of fetal loss in Newcastle General Hospital 1977-1990

The outcome of pregnancy complicated by established diabetes or gestational glucose intolerance (diabetes mellitus or impaired glucose tolerance) is compared with the outcome of non-diabetic pregnancy. Between 1977 and 1990, 169 pregnancies in women with established diabetes and 61 pregnancies in women with gestational glucose intolerance were referred to the Newcastle General Hospital. The perinatal mortality (PNM) in women with established diabetes was 8.2/1000 and the viable fetal loss (sum of PNM, neonatal and infant loss) was 41/1000. The PNM in women with gestational glucose intolerance was 49.2/1000 and the viable fetal loss was 82/1000. The PNM in the background population was 11.6/1000. The fetal malformation rate was 17.3% for established diabetes, 9.8% in gestational glucose intolerance and 2.2% in the background population. Fetal abnormality remains the major cause of viable fetal loss in both established diabetes and gestational glucose intolerance.

Prolactin responses to thyrotrophin releasing hormone do not distinguish patients with isolated gonadotrophin deficiency from normals

Prolactin secretion in response to TRH has been assessed in six patients with isolated gonadotrophin deficiency (IGD) and in eight normal controls. In all six subjects with IGD, serum oestradiol was below the detection limit of the method. There was no statistical difference between either the basal or maximum increment of serum prolactin between the two groups. Recent claims that prolactin responses to TRH distinguish constitutional delay of puberty from IGD have therefore not been supported.