A Randomized Trial of Broad Area ALA-PDT for Field Cancerization Mitigation in High-Risk Patients

BACKGROUND

The relationship between actinic keratoses (AKs) and nonmelanoma skin cancers (NMSCs) is well established. Patients with field cancerization are at high risk of developing new lesions. A treatment to interrupt new lesion formation or progression is required.

OBJECTIVE

To evaluate occurrence of AKs in high-risk patients after field aminolevulinic acid–photodynamic therapy (ALA–PDT).

METHODS

In this randomized, parallel-group, evaluator-blinded, 52-week study, patients with 4–15 facial AKs (N = 166) were random-ized (ALA 2x vs ALA 3x vs vehicle [VEH]-pooled [VEH 2x+VEH 3x], 1:1:1) to receive 2 or 3 PDT treatments (1-hour incubation) following cryotherapy at screening.

RESULTS

More ALA-treated patients than VEH-treated patients had no AKs at week 52 (ALA 2x, 36.0%, P=0.0102; ALA 3x, 37.5%, P=0.0089; VEH, 18.9%). Week 52 lesion recurrence rates were 7.7% (P=0.0004) and 6.1% (P<0.0001) for ALA 2x and ALA 3x, respec-tively, versus 15.5% for VEH. Therapy was well tolerated; no patient requested early termination of light treatment. ALA 3x reduced NMSC development versus VEH (5 vs 12 lesions, P=0.0014).

CONCLUSION

2 or 3 ALA–PDT treatments with 1-hour incubation can significantly reduce occurrence of AKs after 1 year in patients at high risk of NMSC versus VEH–PDT (NCT02239679). J Drugs Dermatol. 2020;19(5):452-458. doi:10.36849/JDD.2020.4930.

Validation of the CNS emotional lability scale for pseudobulbar affect (pathological laughing and crying) in multiple sclerosis patients

Pseudobulbar affect (PBA) or pathological laughing and crying (PLC) is a disorder of affect that occurs in about 10% of multiple sclerosis (MS) patients. The objective of this study was to validate the CNS Emotional Lability Scale (CNS-LS) in MS patients and to correlate the results with the frequency and intensity of episodes of PLC. Physicians at seven private practice referral centers in the United States made a diagnosis concerning PLC based on patient interviews. Clinical coordinators separately administered the CNS-LS, a self-report measure of PLC with seven questions, to MS patients, including patients known to exhibit PLC, patients thought to be free of PLC, and newly diagnosed patients where PLC status was unknown, and the physician was blinded as to the results. A receiver operating characteristic (ROC) curve analysis was performed to define a cut-off best correlating with the physician’s diagnosis. Of 90 MS patients selected to complete the survey, 50 were physician diagnosed with PLC; 40 were without PLC, and 15 of these 90 patients were newly diagnosed with MS (B-6 months). Scores of 17 or higher corresponded to a sensitivity of 0.94 and a specificity of 0.83 (LR -/5.5, LR -/0.07); 89% of patients were correctly diagnosed. The area under the ROC curve was 0.95. Symptoms were greater in patients diagnosed as PLC than in non-PLC patients as evidenced by mean number of episodes/week, number of days/week with episodes, duration of an episode and total time in an episode. Similar results were observed if patients were classified as PLC or non-PLC according to CNS-LS score]-17, suggesting that the CNS-LS is a valid measure for the assessment of PLC in MS patients and could be a useful instrument for clinical and research purposes.

Clinical differences between immigrants voluntarily and involuntarily admitted to acute psychiatric units: a 3-year prospective study

Involuntary psychiatric admissions are widespread among patients with an immigrant background. According to a study in Norway, involuntary admissions are about 75% of admissions among immigrants compared to roughly 50% among ethnic Norwegians. The aim of the present study was to compare clinical and demographic characteristics of immigrant patients with involuntary or voluntary admissions to two acute psychiatric units. A 3-year prospective study of 94 immigrant patients involuntarily and voluntarily admitted to acute psychiatric units was carried out. Sixty-two patients (66.0%) were voluntarily and 30 (31.9%) involuntarily admitted. Involuntary admissions were significantly higher among men (22, 73.3%) compared to women (8, 26.7%; χ(2) = 4.507, d.f. = 1, P= 0.03). The mean length of stay for voluntary and involuntary patients were 7.8 (SD = 6.6) and 21.6 (SD = 27.3; t=-2.7, d.f. = 88, P= 0.01). Patients diagnosed with schizophrenia and psychotic disorder were more often admitted involuntarily (63.0%; χ(2) = 17.83, P= 0.001). This study confirms that immigrant patients diagnosed with psychotic disorders are more often involuntarily than voluntarily admitted. Comparing the clinical and demographic characteristics of immigrants helps identify the reasons behind involuntary admissions and might improve efforts towards reducing such admissions in the future.

Variation in phlebotomy techniques in emergency medicine and the incidence of haemolysed samples

Background

Phlebotomy is a potential cause of preanalytical errors. We have observed phlebotomy in routine practice in a busy Emergency Department, to see how current practice compares with optimal blood sampling.

Methods

Phlebotomy episodes were audited and compared with standard procedures. A computer-based search of the number of haemolysed samples from Emergency Medicine and hospital inpatients was reviewed.

Results

Four different ways of taking blood were observed: cannulation and a syringe (38%), cannula with evacuated tube and adaptor (42%), syringe and needle into vein (14%) and evacuated tube system used conventionally (6%). Where a syringe was used, two methods of transfer into the sample tube were observed; needle kept on with cap piercing (77%) and needle and evacuated cap both removed (23%). On 20 out of 50 phlebotomy episodes (40%), the potassium-EDTA tube was filled prior to the biochemistry serum gel tube. A search of the laboratory computer records for ward-based phlebotomy found 30 of 1034 samples were haemolysed (2.9%). In the 50 phlebotomy episodes in the Majors area of the Emergency Department, 24% produced a haemolysed sample ( P < 0.0001). For samples taken from all areas of Emergency Medicine over a seven-day period, 52 of 485 were haemolysed (10.7%; P < 0.0001).

Conclusions

This study has shown that phlebotomy techniques in the Emergency Department deviate from standard practice significantly. This may well be a reason for the much higher frequency of haemolysed samples and with the wrong order of collection the possibility of potassium-EDTA-contaminated samples.

Miglustat therapy in juvenile Sandhoff disease

GM(2)-gangliosidosis is a rare and heterogeneous inherited metabolic disorder caused by autosomal recessive mutations in genes encoding the lysosomal enzyme β-hexosaminidase, resulting in the accumulation of ganglioside GM(2) in various tissues, particularly the central nervous system. It is characterized by progressive neurological deterioration that mainly affects motor and spinocerebellar function. Several forms of GM(2)-gangliosidosis exist, including the Sandhoff variant. Currently there is no treatment for these conditions, except for palliative care. Miglustat (Zavesca) is a reversible inhibitor of glucosylceramide synthase, which catalyses the first committed step in the synthesis of glucose-based glycolipids. Miglustat has pharmacokinetic properties that allow it to cross the blood-brain barrier, and preclinical data suggest that it may benefit neuronopathic lysosomal storage diseases. Here we present a case report of a Norwegian patient with Sandhoff disease treated with miglustat at our centre in Norway. The patient initially presented with ataxia and dysarthria at 2-3 years of age, which progressed slowly during childhood. At age 14, he experienced episodes of depression and apathy, leading to weight loss. He was diagnosed with Sandhoff disease at age 16. Following 2.5 years of treatment with miglustat, his body weight was stabilized and disease progression appeared to have slowed, as evidenced by the lack of progressive brain atrophy. His depressive symptoms were managed using electroconvulsive treatment (ECT), which improved general functioning. These findings suggest that miglustat may provide beneficial effects in patients with juvenile Sandhoff disease, and that ECT may alleviate depressive symptoms.

Dextromethorphan and quinidine in adult patients with uncontrolled painful diabetic peripheral neuropathy: a 29-day, multicenter, open-label, dose-escalation study

BACKGROUND

Pain associated with diabetic peripheral neuropathy (DPN) has a substantial negative impact on patients' quality of life.

OBJECTIVES

The primary objective of this study was to evaluate the tolerability of capsules containing dextromethorphan (DM) and quinidine (Q) in patients with painful DPN. A secondary objective was to perform a preliminary assessment of the efficacy of DM/Q in this patient population.

METHODS

This was a multicenter, open-label, dose-escalation study. Eligible patients were aged between 18 and 80 years, had a confirmed diagnosis of diabetes with acceptable glycemic control, had been receiving established diabetic therapy for at least 3 months, and had a clinical diagnosis of distal symmetric sensory neuropathy with daily DPN-associated pain for the previous 3 months. On study entry, patient-rated diabetic pain had to be moderate or greater. Patients who met the inclusion criteria underwent a 2-week washout period during which all analgesics were discontinued, followed by 29 days of treatment with capsules containing DM 30 mg and Q 30 mg (DM30/Q30), beginning with 1 capsule/d and escalating at approximately 1-week intervals, as tolerated, to a maximum dose of 4 capsules/d (DM120/Q120). Tolerability was assessed based on adverse events and changes in clinical and laboratory parameters and nerve conduction velocity. Preliminary efficacy assessments included changes from baseline in scores on the pain intensity rating scale (PIRS), pain relief rating scale (PRRS), peripheral neuropathy quality-of-life instrument, and patients' diary assessments of sleep, present pain intensity, pain, and activity.

RESULTS

The study included 36 men and women (mean age, 58 years; mean body mass index, 32.8 kg/m(2)). Of the 33 subjects who completed the study, 23 (69.7%) did so at the highest permitted dose (DM120/Q120). The most commonly reported adverse events (occurring in > or =5% of subjects) were nausea (27.8%), dizziness (25.0%), and headache (25.0%). Three patients experienced 5 serious adverse events, only 1 of which was considered possibly related to study drug. The most commonly occurring laboratory abnormalities (involving glycosylated hemoglobin, serum glucose, triglycerides, and cholesterol) were considered typical of a population with diabetes. Improvements from baseline in scores on the PIRS, PRRS, and other exploratory efficacy measures were noted (P < 0.001).

CONCLUSIONS

The results of this open-label study indicated that the combination of DMIQ (dose range, DM30/Q30-DM120/Q120) was well tolerated in patients with pain associated with DPN. Based on the preliminary efficacy results, a randomized, controlled, double-blind trial is warranted to assess the tolerability and efficacy of this combination in patients with DPN.

Randomized, controlled trial of dextromethorphan/quinidine for pseudobulbar affect in multiple sclerosis

OBJECTIVE

To evaluate the efficacy and safety of DM/Q (capsules containing dextromethorphan [DM] and quinidine [Q]) compared with placebo, taken twice daily, for the treatment of pseudobulbar affect over a 12-week period in multiple sclerosis patients.

METHODS

A total of 150 patients were randomized in a double-blind, placebo-controlled study to assess pseudobulbar affect with the validated Center for Neurologic Study-Lability Scale. Each patient also recorded the number of episodes experienced between visits, estimated quality of life and quality of relationships on visual analog scales, and completed a pain rating scale.

RESULTS

Patients receiving DM/Q had greater reductions in Center for Neurologic Study-Lability Scale scores than those receiving placebo (p < 0.0001) at all clinic visits (days 15, 29, 57, and 85). All secondary end points also favored DM/Q, including the number of crying or laughing episodes (p <or= 0.0077), quality of life (p < 0.0001), quality of relationships (p = 0.0001), and pain intensity score (p = 0.0271). DM/Q was well tolerated; only dizziness occurred with greater frequency than with placebo.

INTERPRETATION

Results in multiple sclerosis patients were similar to those of a previous study in amyotrophic lateral sclerosis, demonstrating that DM/Q may be beneficial in treating potentially disabling pseudobulbar affect in a variety of neurological disorders.

Pharmacokinetics of dextromethorphan after single or multiple dosing in combination with quinidine in extensive and poor metabolizers

Dextromethorphan (DM) pharmacological properties predict that the widely used cough suppressant could be used to treat several neuronal disorders, but it is rapidly metabolized after oral dosing. To find out whether quinidine (Q), a CYP2D6 inhibitor, could elevate and prolong DM plasma profiles, 2 multiple-dose studies identified the lowest oral dose of Q that could be used in a fixed combination with 3 doses of DM. A multiple-dose study in healthy subjects with an extensive or a poor enzyme metabolizer phenotype evaluated the safety and pharmacokinetic profile of a selected fixed-dose combination (AVP-923). Study 1 randomized 46 healthy subjects, who were extensive CYP2D6 metabolizers, to receive 0, 2.5, 10, 25, 50, or 75 mg Q twice daily in combination with 30 mg DM for 7 days. Plasma and urine samples were collected after the first and last doses for the assay of DM, dextrorphan (DX), and Q. Study 2 randomized 65 healthy extensive CYP2D6 metabolizers to 8 groups given twice-daily 45- or 60-mg DM doses combined with 0, 30, 45, or 60 mg Q for 7 days. The effects of increasing Q were not different with doses greater than 25 mg, whereas lower doses showed a dose-related increase in plasma DM concentrations. Urinary ratios of DM/DX showed a Q dose- and time-related increase in the number of subjects converted to the poor metabolizer phenotype that reached 100% on day 3 of dosing with 25 mg Q. Results from both studies indicated that 25 to 30 mg Q is adequate to maximally suppress O-demethylation of DM. Study 3 evaluated 7 extensive metabolizers and 2 poor metabolizers given an oral capsule every 12 hours containing 30 mg Q combined with 30 mg DM. DM plasma AUC values increased in both groups of subjects during the 8-day study. The mean urinary metabolic ratio (DM/DX) increased at least 27-fold in extensive metabolizers by day 8. There was no effect of Q on urinary metabolic ratios in poor metabolizers. Safety evaluations, including electrocardiograms, indicated that the combination was well tolerated, with no difference between extensive and poor metabolizer phenotypes.

Treatment of pseudobulbar affect in ALS with dextromethorphan/quinidine: A randomized trial

BACKGROUND

Patients with ALS commonly exhibit pseudobulbar affect.

METHODS

The authors conducted a multicenter, randomized, double-blind, controlled, parallel, three-arm study to test a defined combination of dextromethorphan hydrobromide (DM) and quinidine sulfate (Q) (AVP-923) for the treatment of pseudobulbar affect in ALS. Q inhibits the rapid first-pass metabolism of DM. The effects of AVP-923 (30 mg of DM plus 30 mg of Q) given twice daily for 28 days were compared with those of its components. Patients were evaluated on days 1, 15, and 29. The primary efficacy variable was the change from baseline in the Center for Neurologic Study Lability Scale (CNS-LS) score. Secondary efficacy variables were laughing/crying episode rates and changes in Visual Analog Scales for Quality of Life (QOL) and Relationships (QOR). Efficacy was evaluated in intention-to-treat subjects who were not poor metabolizers of DM (n = 65 for AVP-923, n = 30 for DM, and n = 34 for Q). Safety was assessed in all randomized subjects (n = 140).

RESULTS

AVP-923 patients experienced 3.3-point greater improvements in CNS-LS than DM patients (p = 0.001) and 3.7-point greater improvements than Q patients (p < 0.001). AVP-923 patients exhibited lower overall episode rates, improved QOL scores, and improved QOR scores (p < 0.01 for all endpoints). Adverse effects were mostly mild or moderate; treatment-related discontinuation was 24% for AVP-923, 6% for DM, and 8% for Q.

CONCLUSIONS

AVP-923 palliates pseudobulbar affect in ALS. Overall benefits of treatment are reflected in fewer episodes of crying and laughing and improvements in overall quality of life and quality of relationships.

Influence of concomitant quinidine administration on dextromethorphan disposition in rats

High doses of dextromethorphan (DM) have been clinically investigated for the treatment of multiple neuronal disorders including neuropathic pain. Several authors have suggested the concomitant administration of DM and a CYP2D6 reversible inhibitor in order to enhance the exposure of DM and limit the exposure to total dextrorphan (DX). The present study proposes to determine whether or not a single dose of quinidine is sufficient to enhance the plasma concentrations of DM in rats and keep those of DX at a minimal level. Oral doses of DM (50 mg/kg) were administered with increasing dose levels of quinidine (0, 2, 20, and 50 mg/kg) to male Sprague-Dawley rats and blood samples were collected over 24 h. Plasma concentrations of DM and total DX were determined using ESI-LC/MS/MS. Quinidine coadministration resulted in a more than twofold increase in the area under the curve of DM with an ED(50) of approximately 2 mg/kg whereas those of total DX were only increased by 21%. These results support the working hypothesis that a single dose of quinidine may enhance the plasma concentrations of DM relative to those of total DX and may therefore improve the treatment of neuropathic pain.

Cardiovascular risk factors in young drug addicts

Since the type of life-style often encountered in drug addicts is purported to influence their risk of cardiovascular disease, it seemed of interest to carry out a descriptive study on risk factors in young addicts. Twenty-four young intravenous drug addicts, mean age 29 years and mean body mass index (BMI) 22.5 (kg/m(-2)), were compared with 24 healthy people matched for age, gender and BMI. Both groups responded to a questionnaire on life-style risk factors. In addition, fasting blood samples were investigated for several coronary risk factors. Drug addicts had smoked more cigarettes (17 vs. 3 cigarettes/day) for a longer time period (15 vs. 5 years) than control subjects. They also had higher serum activities of liver enzymes related to alcohol abuse than controls. Level of physical activity and indicators of dietary intake of fruit, vegetables and salt were not significantly different between the groups. Blood lipid values, total cholesterol (5.1 vs. 5.6 mmol/l), and HDL-cholesterol (1.2 mmol/l), apolipoproteins, and an atherogenic index reflecting the balance between the atherogenic low density lipoproteins (LDL) and the antiatherogenic fraction (HDL), as well as the smoking-related factors fibrinogen and TBARS, were all similar in both groups. The study indicates that the prevalence of many known cardiovascular risk factors was similar in drug addicts and matched controls.

The toxicity of behenyl alcohol. II. Reproduction studies in rats and rabbits

Behenyl alcohol is a saturated 22-carbon, long-chain aliphatic alcohol, which has potential for use in foods as an oil-structuring and -solidifying agent in fats. Previously completed studies with behenyl alcohol indicated an absence of mutagenic or genotoxic potential. In addition, subchronic toxicity studies in rats and dogs reported no adverse effects following gross and histopathological examinations. Compound-related effects were limited to the observation of pale feces in dogs treated with high doses of behenyl alcohol, and were attributable to unabsorbed behenyl alcohol. The reproductive effects of behenyl alcohol were investigated in a fertility and reproduction study, and an embryonic development study in rats and rabbits, respectively. No evidence of maternal or fetal toxicity was observed in either study. Behenyl alcohol demonstrated no effects on the fertility or reproduction of rats dosed up to 1000 mg/kg body weight. Similarly, behenyl alcohol had no reproductive effects on rabbits treated with doses up to 2000 mg/kg body weight. The observation of pale feces was the only compound-related effect reported, limited to rabbits treated with 2000 mg behenyl alcohol/kg body weight. Based on these findings, there is no evidence to suggest that behenyl alcohol is teratogenic or embryotoxic.

The toxicity of behenyl alcohol. I. Genotoxicity and subchronic toxicity in rats and dogs

The genotoxic potential of behenyl alcohol, a saturated long-chain (C22:0) fatty alcohol, was examined in the Ames Salmonella typhimurium reverse mutation assay, the gene mutation, and chromosome aberrations assays in Chinese hamster V79 cells, and the micronucleus assay in NMRI mice. Behenyl alcohol did not increase the number of revertants per plate compared to controls in the S. typhimurium assay, with or without metabolic activation. No significant increases in the number of mutant colonies or in structural chromosome aberrations were observed in Chinese hamster V79 cells. In addition, behenyl alcohol did not increase the frequency of bone marrow polychromatic erythrocyte (PCE) micronuclei in mice in vivo. In two subchronic toxicity studies, CD rats and beagle dogs were administered behenyl alcohol by oral gavage for at least 26 weeks at doses of 0, 10, 100, or 1000 mg behenyl alcohol/kg body weight/day for rats and 0, 20, 200, or 2000 mg behenyl alcohol/kg body weight/day for dogs. Adverse effects were not observed following gross and histopathological evaluations of dosed rats. Compound-related effects in dogs were limited to observations of pale feces, indicative of unabsorbed behenyl alcohol, at doses of 2000 mg/kg body weight/day. There were no histopathological changes observed in dogs dosed with behenyl alcohol. The no-observed-adverse-effect-level (NOAEL) for behenyl alcohol was 1000 mg/kg body weight/day for rats, and 2000 mg/kg body weight/day for dogs, the highest doses used in these studies.

Clinical efficacy of topical docosanol 10% cream for herpes simplex labialis: A multicenter, randomized, placebo-controlled trial

BACKGROUND

Recurrent herpes simplex labialis (HSL) occurs in 20% to 40% of the US population. Although the disease is self-limiting in persons with a healthy immune response, patients seek treatment because of the discomfort and visibility of a recurrent lesion.

OBJECTIVE

Our purpose was to determine whether docosanol 10% cream (docosanol) is efficacious compared with placebo for the topical treatment of episodes of acute HSL.

METHODS

Two identical double-blind, placebo-controlled studies were conducted at a total of 21 sites. Otherwise healthy adults, with documented histories of HSL, were randomized to receive either docosanol or polyethylene glycol placebo and initiated therapy in the prodrome or erythema stage of an episode. Treatment was administered 5 times daily until healing occurred (ie, the crust fell off spontaneously or there was no longer evidence of an active lesion) with twice-daily visits.

RESULTS

The median time to healing in the 370 docosanol-treated patients was 4.1 days, 18 hours shorter than observed in the 367 placebo-treated patients (P =.008; 95% confidence interval [CI]: 2, 22). The docosanol group also exhibited reduced times from treatment initiation to (1) cessation of pain and all other symptoms (itching, burning, and/or tingling; P =.002; 95% CI: 3, 16.5); (2) complete healing of classic lesions (P =.023; 95% CI: 1, 24.5); and (3) cessation of the ulcer or soft crust stage of classic lesions (P <.001; 95% CI: 8, 25). Aborted episodes were experienced by 40% of the docosanol recipients versus 34% of placebo recipients (P =.109; 95% CI for odds ratio: 0.95, 1.73). Adverse experiences with docosanol were mild and similar to those with placebo.

CONCLUSION

Docosanol applied 5 times daily is safe and effective in the treatment of recurrent HSL. Differences in healing time compared favorably with those reported for the only treatment of HSL that has been approved by the Food and Drug Administration.

The antiviral drug docosanol as a treatment for Kaposi's sarcoma lesions in HIV type 1-infected patients: a pilot clinical study

Docosanol inhibits a broad spectrum of lipid-enveloped viruses in vitro including HSV-1, HSV-2, VZV, CMV, HHV-6, and HIV-1. These observations led us to conduct a pilot clinical study with docosanol 10% cream as a topical treatment for Kaposi's sarcoma (KS) in HIV-1-infected patients. In this open-label study 28 cutaneous KS lesions in 10 HIV-1-infected patients were treated topically five times daily for 4 weeks with evaluation of lesion characteristics of area, edema, and color. All patients elected to enroll in an extended treatment protocol and continued to treat for up to 35 weeks. Within 28 days, 2 of 10 patients exhibited a partial response based on standardized criteria exhibiting 74 to 83% reductions in total target lesion areas. With extended treatment, a partial response was exhibited in two additional patients where total target lesion area was reduced by 52% in one patient and target lesions in another patient that had been large, swollen, and painful at study initiation were no longer visible. No patient experienced disease progression or signs of visceral disease. The average percent decrease in lesion area for all target lesions was 20% (p < 0.01). A patient's response to therapy appeared to be independent of anti-HIV regimen, HIV viral load, or previous KS treatments. These results suggest that docosanol merits further investigation as a potential topical therapy in the treatment of AIDS-associated Kaposi's sarcoma lesions.

Functional diagnosis as a tool in rehabilitation: a comparison of teachers and other employees

Work-related stress and burnout has been observed in primary school teachers in many countries. Functional deficits have been related to certain psychosomatic diagnoses and the work environment. We have compared 100 teachers with a matched group of non-teachers according to diagnostic differences, all attending a 4 week resident stay at a vocational rehabilitation centre in 1993-5. Seventy-five percent were women. The use of ICD-9 diagnoses and a five-dimensional functional diagnostic tool were compared. The five dimensions were defined along the following axes: work environment, family relations, health, personal economy and leisure time activity. There were no significant differences between ICD-9 diagnostic groups between teachers and non-teachers. Indefinite diagnostic entities (fatigue, chronic myalgia, fibromyalgia, etc.) were used in more than half of residents in both groups. Definite musculo-skeletal disorders were the second most prominent diagnosis. On the five-dimensional functional diagnostic tool teachers scored significantly worse than non-teachers on the family relations axis, and on a sum score of all axes. The difference was mainly present in women. The study suggests that work-related stress and signs of burnout in teachers may be higher than in other employees, but the factors contributing to this may be found outside the work environment.

Complaints that predict drop-out from a detoxification and counselling unit

Sixty-one consecutive clients in a multidrug addiction detoxification and counselling unit were interviewed by their medical counsellor about bodily pain, distress, and coherence in their life. Clients who did not complete the 3-week postdetoxification program reported a higher level of fatigue and difficulties with concentration compared with completers. Antonovsky's Sense of Coherence test showed less favourable values in noncompleters than in completers. No significant difference was found on the Hopkins Symptom checklist. Factor analysis showed that both pain and emotional distress belonged to one dimension. Fatigue was the symptom that predicted drop-out when adjusting for other complaints and background factors.

Effects of acupuncture on smoking cessation or reduction for motivated smokers

BACKGROUND

This study was undertaken to examine the effects of acupuncture on smoking reduction and possibly also cessation and to examine whether some acupoints are more effective than others for smoking cessation.

METHODS

A total of 46 healthy men and women, 39 +/- 9 years of age (mean +/- SD), who smoked 20 +/- 6 cigarettes per day and had smoked for 23 +/- 8 years, and who wanted to quit smoking, volunteered to participate. The subjects were randomly assigned to two groups. One group was given acupuncture treatment at points previously used for anti-smoking (test group, TG). The other group was given acupuncture treatment at points assumed to have no effect for smoking cessation (control group, CG). Before each treatment and after the last treatment each subject answered questionnaires about his or her smoking habits and attitudes. In addition the concentrations of serum cotinine, serum thiocyanate, serum peroxides, and plasma fibrinogen were measured before the first and after the last acupuncture treatment.

RESULTS

The daily cigarette consumption fell during the treatment period in both groups, but the reduction was larger for TG than for CG (P < 0.002). Altogether 31% of subjects in TG had quit smoking completely at the end of the treatment, compared with none in CG. For TG the concentrations of cotinine and thiocyanate were reduced significantly after the treatment period (P < 0.001), but no significant reductions were observed for CG. For both groups the taste of tobacco worsened during the treatment period, but the effect was more pronounced for TG than for CG (P < 0.05). The desire to smoke fell significantly in both groups after treatment, and the reduction was larger for TG than for CG (P < 0.001). No significant changes in serum peroxides and plasma fibrinogen concentrations were observed during the treatment period for either group.

CONCLUSIONS

This study suggests that acupuncture may help motivated smokers to reduce their smoking or even quit smoking completely. Different acupoints appear to have different effects for smoking cessation and reduction.

[Mortality among Norwegian addicts after admission to different types of institutions. A 10-year follow-up study 1985-94]

Ten years after enrollment in six different treatment and rehabilitation facilities in 1984-85, 482 drug addicts (158 women) were followed-up by means of official death records. 97 drug addicts (20%) had died, i.e. an incidence rate of 2.3 per 100 observation years. The incidence rate among those enrolled in psychiatry-oriented institutions was 2.8 for men and 2.0 for women. Among those enrolled in rehabilitation-oriented institutions the corresponding incidence rate was 2.0 and 0.6. The ratio between the incidence rates for the two types of institutions was 1.6 (95% CI 1.0-2.6). Excluding those who were 21 to 25 years of age in 1984-85, the death rate was significantly higher among the drug addicts in psychiatry-oriented institutions than among the addicts at institutions focusing on rehabilitation(relative risk 2.1, 95% CI 1.1-4.1).

A comparison of cardiovascular risk as measured by compound blood lipid indices and two indices including lifestyle factors in occupational health service

Healthy employees in a non-manufacturing firm (n = 252) were divided into low and high cardiovascular risk subjects in order to compare different indices of cardiovascular risk for use in occupational health service. The levels of total cholesterol (TC), a compound index of blood lipid components, the 'atherogenic index' (ATH-index) defined as ([TC-HDLc] x [apoB])/([HDLc] x [apoA]), and two other compound indices, one Norwegian (Westlund) and one Scottish (Dundee score) were compared. Information on smoking habits and blood pressure were part of the two last indices. Cut-off values to separate between low and high risk subjects were defined with TC = 6.5 mmol/l, HDLc = 0.9 mmol/l, apoA = 1.8 g/l and apoB = 1.3 g/l, all values based on clinical guidelines in Norway. No smoking and a systolic blood pressure < 150 mmHg was included as cut-off of the combined indices. According to the three indices (ATH, Westlund and Dundee) 102, 25 and 116 employees were allocated to the increased risk group. Persons allocated to the increased risk group by the combined indices and not by the compound index were practically all smokers. Systolic blood pressure differed between indices only for persons with extreme pressures. A compound blood lipid index of CV risk, which may be drawn easily in an occupational health setting in an unfasting state and sent by post to a laboratory, mimics the allocation of persons to an increased risk group using combined indices. Smokers with normal lipid values would be allocated to increased risk by the combined indices, but not necessarily by the compound index. The use of the compound index together with advice to stop smoking is suggested as a time-saving strategy.

Normal cholesterol measurements in white collar workers still at cardiovascular risk?

Low serum total cholesterol (TC) in workers has been taken to indicate absence of cardiovascular (CV) risk. In angiographically confirmed coronary artery disease TC has been shown to be less poignant than compound indices of cardiovascular risk in separating patients from controls. The implications for prevention in an industrial medical setting of relying on TC measurements are discussed. Employees (n = 229) tested by an occupational health service in a non-manufacturing firm were dichotomized as low and high cardiovascular risk subjects either by the level of total cholesterol, or by two compound indices of blood lipid components. The compound indices were: the TC/HDLc-ratio, and an 'atherogenic index' (ATH-index) defined as ([TC-HDLc] x [apo B]) + ([HDLc] x [apo A]). (apo A = apolipoprotein A-I, apo B = apolipoprotein B). Cut-off values to separate between low- and high-risk subjects were defined as TC = 6.0 mmol/l, HDLc = 0.9 mmol/l, apo A = 1.8 milligrams and apo B = 1.3 milligrams, based on clinical guidelines in Norway. These individual cut-off values gave TC/HDLc and ATH-index cut-off values of 6.7 and 4.1, respectively. Assuming a more correct discrimination between persons at low- and high-risk, using compound lipid indices, both the number of persons given unnecessary advice on lifestyle changes or urged to take TC reducing medication, and the number of persons not treated on the basis of normal TC levels, would be reduced. Percentages of persons classified as TC-level-low risk, were adjusted using empirical data on sensitivity and specificity of the compound indices. Among employees with TC < 6.0mmol/l, 15% and 23% of women, and 12% and 19% of men would be classified as high-risk persons using the TC/HDLc-ratio or the ATH-index, respectively. Lack of prospective data on compound indices suggests cautious interpretation. TC values in spurious testing, as often applied in occupational health service without due regard to other lipid fractions, would increase the probability of unnecessarily treating persons not at CV risk and withholding people at probable CV risk from treatment. Although prospective studies are needed to confirm findings, the changes observed suggest avoiding measurements of some single lipid factors.

Screening for cardiovascular risk: cost-benefit considerations in a comparison of total cholesterol measurements and two compound blood lipid indices

BACKGROUND

Serum total cholesterol measurements have been shown to differentiate between patients with angiographically confirmed coronary artery disease and controls less well than compound indices of cardiovascular risk. Details of employees (n = 229) nominated by an occupational health service in a non-manufacturing firm were used as a starting point for calculations to compare the costs and benefits of using compound indices of cardiovascular risk with those of total cholesterol measurements alone.

METHODS

Healthy employees were defined as having a low or a high risk of cardiovascular disease according to either total cholesterol level or two compound indices of blood lipid components. The compound indices were the ratio of total to high-density lipoprotein (HDL) cholesterol (the TC: HDLC ratio) and an 'atherogenic index' defined as ([total cholesterol-HDL cholesterol] x [apolipoprotein B])/([HDL cholesterol] x [apolipoprotein A]). If compound indices discriminate better between people at low and high risk, both the number of people given unnecessary advice on lifestyle changes or urged to take cholesterol-reducing medication and the number of people not treated because of their 'normal' cholesterol levels would be reduced. In our calculations, we assumed as 'gains' that (1) the disclosure that a total cholesterol test result is false-positive is equal to treatment costs, consultation fee and consumption foregone (i.e. resources already used on medication, services etc.) (8909 Nkr [US $1 = 7 Nkr]), and (2) the disclosure that a test result is false-negative is equal to consultation fee plus loss of 2 h wages (288 Nkr).

RESULTS

The screening of 100,000 men and 100,000 women would incur a cost of 99 and 710 Nkr, respectively, per person assumed to benefit from extended screening using two different compound indices. Net gain would be 438 and 192 million Nkr, respectively, for the two compound indices. However, the lack of prospective data on compound indices suggests the need for cautious interpretation.

CONCLUSION

Although prospective studies are needed to confirm our findings, the changes in number of false-positive and false-negative values achievable using different indices suggests a need for greater caution when using single lipid measurements as predictors of risk. The calculations of this non-prospective study indicated an increased benefit-cost ratio in assessing cardiovascular risk by using compound indices of cardiovascular risk compared with total cholesterol measurements alone.

[Alcohol--no universal drug against heart disease]

Alcohol is part of the normal culture for a majority of the population in western countries. Few investigators or clinicians disagree with the contention that there is a positive relationship between cardiovascular disease and mortality in the upper part of the alcohol consumption curve. No such general agreement exists when infrequent users and non-users are studied. Epidemiological evidence of the relationship between cardiovascular mortality and levels of alcohol consumption is scrutinized, with emphasis on how alcohol anamnestic data are collected, the characterization of non-users, and the authors' definition of moderate consumers. The results indicate that there is hardly any evidence to advocate moderate consumption of alcohol as a health-promoting activity. On the other hand there seems to be a positive relationship between moderation in many aspects of lifestyle and some health gain.

Cardiovascular risk determination: discrepancy between total cholesterol evaluation and two compound laboratory indices in Norway

OBJECTIVE

To compare group classification of cardiovascular risk by two compound laboratory indices with classification according to the serum total cholesterol concentration alone.

DESIGN

Healthy employees were defined as low and high cardiovascular risk subjects according to their total cholesterol concentration or two compound indices of blood lipid components-the total cholesterol: high density lipoprotein (HDL) cholesterol ratio and an atherogenic index defined as ([total cholesterol-HDL cholesterol]*[apolipoprotein B])/([HDL cholesterol]*[apolipoprotein A-I]). Cut off values to distinguish between low and high risk subjects were as follows: total cholesterol 6.5 mmol/l, HDL cholesterol 0.9 mmol/l, apolipoprotein A = 1.8 g/l, and apolipoprotein B = 1.3 g/l. These gave total: HDL cholesterol ratio and atherogenic index cut off values of 7.2 and 4.5 respectively.

SETTING

An occupational health service in a non-manufacturing company in Norway.

PARTICIPANTS

A total of 112 male and 117 female employees. The mean body mass index values were 25.6 and 23.6 kg/m2 and the mean ages 39.8 and 40.1 years in men and women respectively. Those with cardiovascular, diabetic, or renal diseases were excluded.

MEAN OUTCOME MEASURES

Serum total cholesterol, HDL cholesterol, apolipoproteins A-I and B, lipid peroxidation, blood pressure, smoking, physical activity, and fruit, vegetables, and salt in the diet were determined.

RESULTS

The cut off values allocated 19%, 7%, and 40% as high risk subjects according to total cholesterol, total: HDL cholesterol, and the atherogenic index respectively. The mean age was two to four years higher in the high risk groups. Cardiovascular risk in siblings and no reported physical activity were more prevalent in those high risk groups defined by the compound indices than by total cholesterol alone, as was a high body mass index and a measure of lipid peroxidation. Grouping according to total cholesterol failed to allocate heavy smokers mainly to the high risk group. Diet variables did not demarcate clearly between indices.

CONCLUSIONS

There is considerable variability in classification into high and low risk subjects when using the total cholesterol concentration alone compared with compound risk indices. Smoking was more prevalent in the high risk groups defined by the compound indices than by total cholesterol. These findings call for caution when total cholesterol is used to estimate cardiovascular risk in epidemiological studies, and even more so at individual counselling in occupational or primary health care settings.

Workload and cardiovascular risk factors in executives and non-executives of the same company

The lifestyle of executives purportedly differs from that of their employees who are not in an executive position, with respect to workload, amount of travelling, and eating habits. These aspects of lifestyle and cardiovascular (CV) risk factors in blood were compared in 22 executives and a matched sample of non-executives in an insurance company in Norway. The mean age was 42.8 years in both groups and the mean body mass index was 25.5 and 24.8 kg/m2 in executives and non-executives, respectively. Executives travelled more and worked more hours than non-executives, but smoking habits, levels of physical activity, diet habits and blood pressure were comparable in the two groups. The blood lipoprotein estimates of total cholesterol, high density lipoprotein cholesterol, apolipoproteins and two compound lipoprotein indices of CV risk, as well as liver enzymes, were also of the same magnitude in both groups. The executive lifestyle as such, compared to that of non-executives, does not imply an elevated CV risk in this study, as judged from CV risk factors in blood. The efforts of the occupational health service to improve health, including the opportunity for executives to choose their workload, may have contributed to this 'negative' finding. This may indicate that preventive health programmes in the company could have been acting as intended for all groups of employees. However, somewhat high mean levels of total cholesterol (> 6.0 mmol/l) and of a compound atherogenic index in both groups suggest that continued action by the occupational health service is required.

Street sale of heroin--a profitable way of making a living?

The aim of the study was to give an outline of the financial environment of heroin-sale at street level in Norway and the possibilities of making retail sale of heroin a living. Data were gathered through police records and interviews with informants at street level. Retail sale price has been nominally stable at 300 Nkr (28 pounds, i.e., 1 pound = 11 Nkr) per end-user dose since 1978. This price is coupled to the price of one standard service by street prostitutes. Both the end-users and retailers formally make their living from social welfare payments. The retailer purchases from a wholesaler batches of up to 10 g of heroin at a cost of 50,000 Nkr (4800 pounds). At monthly intervals of delivery this yields 120,000 Nkr (11,500 pounds) as net tax-free income per year, on top of the social welfare payments, even when the retailer and his accomplice consumes a third of the purchased quantity. Crime of gain on the part of the retailer is negligible, due to increased risk of also disclosing his drug trafficking.

Reduced plasma fibrinogen, serum peroxides, lipids, and apolipoproteins after a 3-week vegetarian diet

The influence of a 3-week vegetarian diet and fasting on serum concentration of peroxides, lipids, apolipoproteins, and plasma fibrinogen was studied in ten middle-aged fibromyalgia/fibrositis patients (eight women, two men). Mean serum peroxide concentration (estimated as thiobarbituric acid reacting substances) was reduced from 3.60 +/- 0.14 to 2.82 +/- 0.15 umol/l (p = 0.01) and plasma fibrinogen from 3.33 +/- 0.25 to 2.74 +/- 0.15 g/l (p = 0.02). Serum total cholesterol fell from 6.61 +/- 0.50 to 4.83 +/- 0.35 mmol/l (p < 0.0001), apolipoprotein B from 1.77 +/- 0.14 to 1.31 +/- 0.11 g/l (p < 0.0001), and apolipoprotein A from 1.41 +/- 0.09 to 1.23 +/- 0.05 g/l (p = 0.03). High density lipoprotein cholesterol concentration also decreased somewhat (from 1.26 +/- 0.09 to 1.07 +/- 0.04 mmol/l, p = 0.03) An atherogenic index, reflecting the balance between low and high density lipoproteins, was reduced by 31% (from 5.74 +/- 0.79 to 3.97 +/- 0.60, p = 0.02). The results suggest that vegetarian diet/fasting may have a beneficial influence on the concentration of serum peroxides and plasma fibrinogen concentration, and on the serum level of several lipoprotein-related coronary risk factors.

[Who is long-term sick-listed in Norway? From the project Evaluation of the follow-up of long-term sick-listed]

The aim of the study was to analyse the characteristics of persons with long-term sickness certification at the end of 1990 in Norway. The study was based on data registered by the National Insurance Administration: Age, sex, place of residence, diagnoses, and prognosis as registered on Sickness certificate II. At the end of 1990 a total of 57,567 persons had been incapacitated for work for longer than eight weeks and up to 52 weeks. The prevalence was 27.9 per 1,000 employed persons, with a significantly higher prevalence among women than among men. 25% of the women certified as sick were 40-49 years old. The highest prevalence of long-term certification of sickness was found in the counties Finnmark and Troms in Northern Norway, and Hedmark in central Norway. In cases of long-term sickness certification, the most common diagnoses were musculoskeletal/connective tissue diseases and mental disorders, with a prevalence of 9.3 and 3.1 per 1,000 employed persons respectively. The study indicates the possibility of using data from existing administrative population registers to provide information on the epidemiology of long-term sickness certification in Norway. It is necessary to further improve the validity of the data.

Tobacco chemistry. 73. 4,6,8-trihydroxy-11-capnosene-2,10-dione, a new cembrane-derived bicyclic diterpenoid from tobacco

A new diterpenoid containing a rare carbobicyclic cembrane-derived skeleton, the capnosane skeleton, has been isolated from flowers of Greek tobacco. It has been identified as (1S*,3R*,4S*,6R*,7R*,8R*,11Z)-4,6,8-trihydroxy-11-capnosene- 2,10-dione by spectral methods and X-ray analysis of the corresponding benzoate. A full account of the X-ray work is given.

[How is it going with the Sick-listing II patients? From the project Evaluation of Follow-up of Long-term Sick-listed Persons]

The aim of the study was to follow up 712 persons with respect to social insurance and labour market status one year after the start of a period of long-term sickness certificate. The study is based on information from the local National Insurance Offices in five municipalities in Norway. Mean duration of the long-term sickness certificate was 185 calendar days, slightly longer for males than females. 44.9% returned to work during the first year, another 2.9% attended vocational rehabilitation programmes, 11.7% were still receiving medical treatment, 12.2% had qualified for a disability pension, 5.6% were in receipt of an old age pension and 5.6% were unemployed. The remaining 17.1% had either died or had moved from the municipality. The few patients attending vocational rehabilitation programmes, compared with the increasing number of persons granted a disability pension in Norway since 1985 indicate insufficient effort to provide vocational rehabilitation.

[Unemployment among long-term sick-listed persons. From the project Evaluation of Follow-up of Long-term Sick-listed Persons]

The aim of the study was to compare two subgroups of patients with long-term sickness certificate, i.e. a group who were unemployed after eight weeks of incapacity for work and a group who still had a paid job at the end of the eight weeks. 712 patients who received a medical certificate II after eight weeks of incapacity for work in 1988 were followed up for another 12-15 months by means of information collected as a routine at the local National Insurance Offices in five municipalities in Norway. Of our total sample of patients, the sub-group of unemployed persons differed in a number of ways from the group who still had a job. Among the unemployed the duration of sickness certificate was longer and there were higher frequencies of mental disorders and diseases of the nervous system/sense organs. Admission to hospital was less frequent, however, among the unemployed group than among the group who still had a job. The rate of return-to-work observed after one year of sickness certificate was lower among the unemployed.

[Working in basic groups. From the Project Evaluation of Follow-up of Long-term Sick-listed Persons]

By 1988, all Norwegian municipalities were to have established "basic groups", i.e. interprofessional groups to guide patients in their vocational rehabilitation process. The work of these "basic groups" has been evaluated, both in terms of patients admitted for group discussions, type of actions taken and the work status of the patients one year later. The material consists of all patients admitted for basic group discussions in eight municipalities over a three months' period in the autumn 1988 (n = 261). In general the educational level of the patients was found to be low and their most common complaint was musculoskeletal/connective tissue diseases. The most frequent action suggested by the basic groups was continued medical attention. Only 11% of the patients actually attended the meeting where their situation was discussed. After a follow-up period of one year one fifth of the patients were back at their normal job, and one fourth were receiving a disability pension. Good motivation was regarded as the most important factor influencing whether the patients returned to work.

[The sick leave notification II system. From the project Evaluation of follow-up of long-term sick leave patients]

In 1988 the National Insurance Administration in Norway introduced a compulsory sickness certificate to be issued by the doctor after eight weeks of incapacity of work (sickness certificate II). The form contains 25 specified items to be filled in by the doctor. We registered and analysed the sickness certificates received by the local National Insurance offices in five municipalities during the last three months of 1988 (n = 735). The patients included a slight majority of males. 1/3 of the patients were younger than 30 years old and 2/3 younger than 50. 1/4 of the items had not been filled in by the doctors. The most frequent diagnostic groups were musculo-skeletal/connective tissue diseases (46.4%), mental disorders (11.2%), and complications related to pregnancy and birth (9.6%). Sickness certificate II included a five-level prognosis scheme. 68.3% of the patients were allocated to prognosis A, i.e. full recovery as a result of medical treatment only. Few doctors noted that cooperation with other health and social welfare personnel was desirable. The level of unemployment was reported as being higher in patients who were certified sick for greater than or equal to 8 weeks than in the general population of the countries included in the study. The extra costs of introducing sickness certificate II are estimated to equal one day's sickness allowance for each of the 735 patients.

Tobacco chemistry. 65. Two new 7,8-epoxycembranoids from tobacco

Two new diterpenoids have been isolated from tobacco. They have been identified as the (1S,2E,4S,6R,7R,8R,11E)- and (1S,2E,4S,6R,7S,8S,11E)-7,8-epoxy-2,11-cembradiene-4,6-diols 1 and 2 by synthesis and X-ray analysis. The conformation about the 5,6 bond in some 7,8-epoxycembranoids is discussed, as is the biogenesis of the two new compounds.