Impact of monitoring approaches on data quality in clinical trials

AIMS

Source data verification (SDV) has been reported to account for up to 25% of the budget in clinical trials (CT) and cost-benefit of SDV has been questioned. Guidelines for risk-based monitoring (RBM) were published in 2013 by agencies and in 2016, ICH-GCP-E6-(R2) added a requirement for risk-based approaches. This report will perform a comparison of the impact of RBM vs classic monitoring (CM) on data quality (defined as accuracy of data reporting from source data to final trial data) and expected impact on costs of CTs.

METHODS

Data on residual errors from four, large comparable randomised CTs were examined by post-trial SDV. Observed discrepancies were analysed in the categories of "overall" data, "major efficacy" and "major safety". In each category, the residual error rate was calculated as the number of discrepancies divided by the number of data-fields verified.

RESULTS

A total of 1 716 087 data points were verified using CM and 323 174 using RBM. The overall error rate was 0.40% for RBM and 0.37% for CM (P < 0.01). For major efficacy, defined by risk assessment, the error rate was 0.15% and 0.28% (P < 0.0001); in major safety, defined by risk assessment, the error rate was 0.49% and 0.67% (P = 0.15), both in favour of the RBM approach.

CONCLUSION

These empirical data, directly comparing RBM with CM, suggest that RBM improves data quality regarding data-points of major importance to trial outcomes, efficacy and major safety. Overall, the RBM approach showed a correlation to reduced amount of data collection errors with major relevance for interpretation of study results and subject safety as well as reducing on-site monitoring and data cleaning resources.

Symptomatic and structural benefit of cathepsin K inhibition by MIV-711 in a subgroup with unilateral pain: post-hoc analysis of a randomised phase 2a clinical trial

OBJECTIVES

Osteoarthritis (OA) development programmes face challenges due to discordance between structural changes and symptoms. A novel cathepsin-K inhibitor, MIV-711, recently reported structural benefits, but did not demonstrate a significant difference from placebo in symptoms. Previous work suggests that pain from non-target joints may confound OA pain outcomes. We therefore conducted an exploratory analysis in participants with predominantly unilateral knee pain from the MIV-711-201 trial.

METHOSD

Participants scoring below median contralateral knee NRS pain at baseline from the MIV-711-201 phase 2a clinical trial (n=119) were analysed by treatment group for differences in change from baseline in WOMAC pain, quantitative magnetic resonance imaging bone area and cartilage thickness with a repeated-measures mixed model adjusting for relevant co-variates.

RESULTS

In the subgroup with unilateral knee pain, treatment with MIV-711 100 mg led to greater reduction in WOMAC pain compared to placebo (-5.0, 95% CI: -8.69 to -1.3, p=0.008), while 200 mg did not (-2.5, 95% CI: -6.5 to 1.6, p=0.23). MIV-711 treatment was associated with a reduced change in bone area compared to placebo (200 mg; -19.6 mm2 , 95% CI: -36.2 to -3.0, p=0.02, and 100 mg; -12.5 mm2 , 95% CI: -27.8 to 2.8, p=0.11,). No observed differences between treatment groups in cartilage thickness were found in this subgroup.

CONCLUSIONS

In a subgroup with predominantly unilateral knee pain, significant reduction in OA pain by MIV-711 100 mg treatment was found, with concurrent beneficial structural effects, highlighting the importance of appropriate pain inclusion criteria in OA trials.

The Efficacy and Safety of Multiple Dose Regimens of Kudzu (Pueraria lobata) Root Extract on Bone and Cartilage Turnover and Menopausal Symptoms

Background: Menopause is associated with detrimental changes in turnover of bone and cartilage and a variety of symptoms with negative impact on the quality of life. Naturally occurring isoflavones from Radix Pueraria lobata, Kudzu root, may possess chondroprotective and symptom-relieving properties, but efficacy and safety of dosing and dose frequencies required for pharmacological action is unclear.

Purpose: This clinical trial evaluates the efficacy on bone and cartilage turnover, menopausal symptoms, and safety of five dose regimens of Kudzu root extract administered either once, twice or three times daily in women with at least mild menopausal symptoms.

Materials and Methods: Fifty postmenopausal women were randomized equally into five different dose regimen groups of Kudzu root extract in a four-week, parallel group, open-label, single-center, exploratory study design. Biomarkers CTX-I and CTX-II reflecting bone and cartilage degradation, respectively, were assessed in blood samples and 24-h urine samples. Change from baseline in the Menopause Rating Scale (MRS) and subscales was evaluated. Safety endpoints were frequency of adverse events, changes in hematology and safety chemistry data, vital signs and electrocardiogram.

Results: Fifty women (Age 54.2 years, SD: 2.9) were randomized. After 4 weeks of treatment, biomarkers of bone resorption and cartilage degradation were statistically significantly reduced from baseline levels in the group receiving two capsules three times a day, serum/urine CTX-I (−18.4%, 95% CI: −8.1 to −27.5, p = 0.001/−34.2%, 95% CI: −21.6 to −44.7, p < 0.0001), urine CTX-II (−17.4% 95% CI: −2.5 to −30.0, p = 0.02). The observed effects were consistent across study groups but appeared to favour three times daily dosing. Four weeks of treatment led to statistically significant reductions in the MRS Total Score (p < 0.0001–0.03) in four out of five treatment groups. Kudzu root extract was well tolerated in all dose regimens, and no serious adverse events were reported.

Conclusion: The results indicate that Kudzu extract may possess beneficial effects on bone and cartilage health and may be a promising natural alternative to existing treatments for menopausal symptoms. Kudzu root extract was well tolerated for short-term treatment of mild to severe menopausal symptoms in women in all tested doses and dose frequencies.

Quality of life and fear of COVID-19 in 2600 baccalaureate nursing students at five universities: a cross-sectional study

Background

The COVID-19 pandemic has caused significant disruptions in the implementation of programs across educational institutions. Nursing students, being both young adults and by practical training, part of the health care system, may be particularly vulnerable during the COVID-19 pandemic. The purpose of this study was to explore the associations between self-reported fear of COVID-19, general health, psychological distress and overall quality of life (QoL) in a sample of Norwegian baccalaureate nursing students compared to reference data.

Methods

The survey targeted baccalaureate nursing students from five universities in February 2021. An electronic questionnaire consisted of the Fear of COVID-19 Scale (FCV-19S), the Hopkins Symptom Checklist 5 (SCL-5), one general health and one overall QoL question. The respondents’ mean scores were compared to reference data. Hierarchical regression analyses were conducted, and effect sizes (Cohen’s d) were evaluated.

Results

In total, 2605 out of 6088 (43%) students responded. Their FCV-19S scores (mean 2.45, CI 2.42, 2.48) were significantly higher than those of the reference population (mean 1.8, P < 0.001). Nursing students scores showed significantly lower general health (mean 3.50 ± 0.93 SD, population mean = 3.57, Cohen’s d = 0.07), higher levels of psychological distress (mean 2.68 ± 1.03 SD, population mean = 2.12, Cohen’s d = 0.55) and lower overall QoL (mean 5.50 ± 2.16 SD, population mean = 8.00, Cohen’s d = 1.16) compared to pre-pandemic reference data. FCV-19S scores were significantly associated with levels of general health (Cohen’s d = 0.26), psychological distress (Cohen’s d = 0.76) and overall QoL (Cohen’s d = 0.18).

Conclusions

Baccalaureate nursing students reported worse outcomes during the Covid-19 pandemic on general health, psychological distress and overall QoL compared to the reference population. Level of fear of Covid-19, however, accounted for few of these differences. Other factors related to the pandemic may have reduced nursing students’ overall QoL.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12955-021-01837-2.

Does moderate intensity impact exercise and non-impact exercise induce acute changes in collagen biochemical markers related to osteoarthritis? - An exploratory randomized cross-over trial

OBJECTIVE

To investigate acute changes in biochemical markers of cartilage turnover in response to moderate intensity exercise with and without joint impact in humans with knee osteoarthritis.

DESIGN

We conducted a randomized, cross-over, exploratory clinical study. Twenty subjects with knee osteoarthritis (OA) were randomized, of which twenty completed 30 min of cycling and 15 completed 30 min of running on days 1 week apart. Fasting blood samples were taken before, immediately after and 1, 2, 3, and 24 h after activity was initiated. Midstream spot urine was sampled before and after activity. Serum samples were analyzed for concentrations of fragment of type II collagen degradation, C2M, fragment of type VI collagen degradation, C6M, cartilage oligomeric matrix protein, COMP, marker of type II collagen formation, PRO-C2, and urine for marker of crosslinked type II collagen degradation, CTX-II. To establish a reference, all subjects had similar samples taken during rest on a separate day. Data was analyzed in a restricted maximum likelihood based random effects linear mixed model.

RESULTS

C2M trended to increase after cycling compared running (13.49%, 95%CI: -0.36-27.34%) and resting (12.88%, 95%CI: 0.2-25.6%) and the type II collagen formation/degradation ratio switched towards degradation after cycling, but not running. C6M trended to decrease after cycling (-8.1%, 95%CI: -14.8 to -1.4%) and running (-6.8%, 95%CI: -14.16-0.55%).

CONCLUSION

In persons with knee OA moderate intensity exercise without joint impact may induce acute changes in circulating levels of biochemical markers reflecting type II and VI collagen degradation.

Long-term structural and symptomatic effects of intra-articular sprifermin in patients with knee osteoarthritis: 5-year results from the FORWARD study

OBJECTIVE

The FORWARD (FGF-18 Osteoarthritis Randomized Trial with Administration of Repeated Doses) trial assessed efficacy and safety of the potential disease-modifying osteoarthritis drug (DMOAD) sprifermin in patients with knee osteoarthritis. Here, we report 5-year efficacy and safety results.

METHODS

Patients were randomised to intra-articular sprifermin 100 µg or 30 µg every 6 months (q6mo) or 12 months, or placebo, for 18 months. The primary analysis was at year 2, with follow-up at years 3, 4 and 5. Additional post hoc exploratory analyses were conducted in patients with baseline minimum radiographic joint space width 1.5-3.5 mm and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain 40-90, a subgroup at risk (SAR) of progression.

RESULTS

378 (69%) patients completed the 5-year follow-up. A significant dose-response in total femorotibial joint cartilage thickness with sprifermin (trend test, p<0.001) and a 0.05 mm mean difference with sprifermin 100 µg q6mo versus placebo (95% CI 0.00 to 0.10; p=0.015) were sustained to year 5. WOMAC pain scores improved ~50% from baseline in all groups. No patient in the 100 µg q6mo group had replacement of the treated knee. 96%-98% of patients receiving sprifermin and 98% placebo reported adverse events, most were mild or moderate and deemed unrelated to treatment. Adverse event-related study withdrawals were <10%. Differentiation in WOMAC pain between sprifermin 100 µg q6mo and placebo in the SAR (n=161) at year 3 was maintained to year 5 (-10.08; 95% CI -25.68 to 5.53).

CONCLUSION

In the longest DMOAD trial reported to date, sprifermin maintained long-term structural modification of articular cartilage over 3.5 years post-treatment. Potential translation to clinical benefit was observed in the SAR.

TRIAL REGISTRATION NUMBER

NCT01919164.

Can adenosine triphosphate be a proxy measure in evaluation of hand disinfection effect?

Contaminated hands may contribute to the transmission of pathogens. In the prevention of healthcare-associated infections the effect of disinfection methods should ideally be possible to measure in a simple way. Microbial cultivation is the reference standard, but it is a rather complicated and time-consuming procedure, and the use of swabs for measuring adenosine triphosphate (ATP) has become a much-used proxy measurement (bioluminescence). We evaluated the effect of three hand-disinfection methods on eradication of Escherichia coli from artificially contaminated hands, using cultivation and ATP measurements in parallel. ATP measurement was found to be an unsuitable method as this reflects the total amount of cellular material left on the hands, not only the viable bacteria.

Effect of Intra-Articular Sprifermin vs Placebo on Femorotibial Joint Cartilage Thickness in Patients With Osteoarthritis: The FORWARD Randomized Clinical Trial

IMPORTANCE

Sprifermin is under investigation as a disease-modifying osteoarthritis drug.

OBJECTIVE

To evaluate the effects of sprifermin on changes in total femorotibial joint cartilage thickness in the more symptomatic knee of patients with osteoarthritis.

DESIGN, SETTING, AND PARTICIPANTS

FORWARD (FGF-18 Osteoarthritis Randomized Trial with Administration of Repeated Doses) was a 5-year, dose-finding, multicenter randomized clinical trial conducted at 10 sites. Eligible participants were aged 40 to 85 years with symptomatic, radiographic knee osteoarthritis and Kellgren-Lawrence grade 2 or 3. Enrollment began in July 2013 and ended in May 2014; the last participant visit occurred on May 8, 2017. The primary outcome at 2 years and a follow-up analysis at 3 years are reported.

INTERVENTIONS

Participants were randomized to 1 of 5 groups: intra-articular injections of 100 μg of sprifermin administered every 6 months (n = 110) or every 12 months (n = 110), 30 μg of sprifermin every 6 months (n = 111) or every 12 months (n = 110), or placebo every 6 months (n = 108). Each treatment consisted of weekly injections over 3 weeks.

MAIN OUTCOMES AND MEASURES

The primary end point was change in total femorotibial joint cartilage thickness measured by quantitative magnetic resonance imaging at 2 years. The secondary end points (of 15 total) included 2-year change from baseline in total Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores. The minimal clinically important difference (MCID) is unknown for the primary outcome; for total WOMAC score in patients with hip and knee osteoarthritis, the absolute MCID is 7 U (95% CI, 4 to 10 U) and the percentage MCID is 14% (95% CI, 9% to 18%).

RESULTS

Among 549 participants (median age, 65.0 years; 379 female [69.0%]), 474 (86.3%) completed 2-year follow-up. Compared with placebo, the changes from baseline to 2 years in total femorotibial joint cartilage thickness were 0.05 mm (95% CI, 0.03 to 0.07 mm) for 100 μg of sprifermin administered every 6 months; 0.04 mm (95% CI, 0.02 to 0.06 mm) for 100 μg of sprifermin every 12 months; 0.02 mm (95% CI, -0.01 to 0.04 mm) for 30 μg of sprifermin every 6 months; and 0.01 mm (95% CI, -0.01 to 0.03 mm) for 30 μg of sprifermin every 12 months. Compared with placebo, there were no statistically significant differences in mean absolute change from baseline in total WOMAC scores for 100 μg of sprifermin administered every 6 months or every 12 months, or for 30 μg of sprifermin every 6 months or every 12 months. The most frequently reported treatment-emergent adverse event was arthralgia (placebo: n = 46 [43.0%]; 100 μg of sprifermin administered every 6 months: n = 45 [41.3%]; 100 μg of sprifermin every 12 months: n = 50 [45.0%]; 30 μg of sprifermin every 6 months: n = 40 [36.0%]; and 30 μg of sprifermin every 12 months: n = 48 [44.0%]).

CONCLUSIONS AND RELEVANCE

Among participants with symptomatic radiographic knee osteoarthritis, the intra-articular administration of 100 μg of sprifermin every 6 or 12 months vs placebo resulted in an improvement in total femorotibial joint cartilage thickness after 2 years that was statistically significant, but of uncertain clinical importance; there was no significant difference for 30 μg of sprifermin every 6 or 12 months vs placebo. Durability of response also was uncertain.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01919164.

Associations between biomarkers of bone and cartilage turnover, gender, pain categories and radiographic severity in knee osteoarthritis

Background

Excessive cartilage degradation is a known characteristic of osteoarthritis (OA). Biochemical markers, such as uCTX-II, have been shown to be associated with disease severity, yet the tissue origin of CTX-II has been disputed. This analysis investigates the association between OA knee joints at different radiographic stages and pain categories with levels of uCTX-II and biomarkers of bone resorption and formation.

Methods

Baseline data of two randomised clinical trials (NCT00486434 and NCT00704847) in patients with radiographic OA and presence of pain were analysed post hoc. A subgroup with available urine samples and evaluable radiographs for both knees (N = 1241) was analysed. Urine CTX-I, urine CTX-II and serum osteocalcin were analysed for associations with combined Kellgren-Lawrence (KL) scores, gender and pain for both knees to assess the contribution of joints at different stages.

Results

Pain, BMI, age, gender and KL grade were all significantly associated with uCTX-II. The association between pain and CTX-II appeared to be driven by weight-bearing pain. The level of uCTX-II incrementally increased with higher radiographic severity of each knee. Levels of bone markers CTX-I and osteocalcin were both significantly associated with BMI and gender, but neither were associated with radiographic severity. Biomarker levels between male or female groups of identical KL scores were found to be higher in females compared to males in some but not all KL score groups.

Conclusions

These results indicate that levels of uCTX-II are independently associated with radiographic severity of OA and pain intensity. CTX-II was associated with weight-bearing pain, but not non-weight-bearing pain, independent of co-variates. Bilateral OA knee joints appear to contribute to uCTX-II levels in an incremental manner according to radiographic severity of single joints. The data suggest that biomarker differences between genders should be taken into account when evaluating these markers in the context of structural features of OA.

Ozonized water as an alternative to alcohol-based hand disinfection

BACKGROUND

Hand hygiene plays a vital role in the prevention of transmission of micro-organisms. Ozone (O₃) is a highly reactive gas with a broad spectrum of antimicrobial effects on bacteria, viruses, and protozoa. It can easily be produced locally in small generators, and dissolved in tap water, and quickly transmits into ordinary O₂ in the surrounding air.

AIM

To compare ozonized tap water and alcohol rub in decontamination of bacterially contaminated hands.

METHODS

A cross-over study among 30 nursing students. Hands were artificially contaminated with Escherichia coli (ATCC 25922), then sanitized with ozonized tap water (0.8 or 4 ppm) or 3 mL standard alcohol-based rub (Antibac 85%). The transient microbes from fingers were cultivated and colony-forming units (cfu)/mL were counted. The test procedure was modified from European Standard EN 1500:2013.

FINDINGS

All contaminated hands before disinfection showed cfu >30,000/mL. The mean (SD) bacterial counts in (cfu/mL) on both hands combined were 1017 (1391) after using ozonized water, and 2337 (4664) after alcohol hand disinfection. The median (range) values were 500 (0-6700) and 250 (0-16,000) respectively (non-significant difference). Twenty per cent of participants reported adverse skin effects (burning/dryness) from alcohol disinfection compared with no adverse sensations with ozone.

CONCLUSION

Ozonized tap water is an effective decontaminant of E. coli, and it could be an alternative to traditional alcohol-fluid hand disinfectants both in healthcare institutions and public places. Ozonized water may be especially valuable for individuals with skin problems.

Physical activity preferences of 10-year-old children and identified activities with positive and negative associations to cardiorespiratory fitness

AIM

This study investigated children's physical activity (PA) preferences, as these can aid the design of school-based interventions.

METHODS

Data were collected in 2014 as a part of the Active Smarter Kids study and 1026 students (52% boys) from 57 Norwegian primary schools completed a questionnaire about their favourite physical activities at a mean age of 10.2 ± 0.3 years. We identified five patterns of PA and studied whether gender, cardiorespiratory fitness and abdominal adiposity were associated with these patterns.

RESULTS

Soccer and slalom skiing were the favourite activities, and the most pronounced gender differences were for activities favoured by girls, which included dancing, gymnastics, exercising to music and jumping rope (p < 0.001). When the five component patterns were analysed using linear mixed-effect models, this showed a strong female preference for dancing, gymnastics, exercising to music and climbing. Cardiovascular fitness was negatively associated with frisbee, dodgeball, baseball and floorball, and positively associated with team handball, volleyball and basketball and with slalom skiing and cross-country skiing. It was interesting that the children's preferences were not related to their abdominal adiposity.

CONCLUSION

The results showed different gender-based PA preferences and positive and negative associations with cardiovascular fitness, but no relationship with abdominal adiposity.

A review of systematic reviews on the effects of patient-reported outcome monitoring with clinical feedback systems on health-related quality of life-implications for a novel technology in obesity treatment

Patient-reported outcome monitoring with clinical feedback systems (PRO/CFS) has been employed in many disease states to measure and improve health-related quality of life (HRQOL). Exploring the role of PRO/CFS in treatment for obesity may prove valuable. Systematic reviews were summarized to determine the effectiveness of PRO/CFS on HRQOL in any disease area. Primary studies evaluating the effect of PRO/CFS on HRQOL in treatment for obesity were also considered for inclusion. Systematic searches were performed in The Cochrane Library, PROSPERO, Epistemonikos, HTA, DARE, CINAHL, Medline, Embase, PsycINFO, BMJ Clinical Evidence, PDQ-Evidence and PubPsych. Two reviewers independently screened references until final inclusion and critically appraised included reviews using PRISMA checklist. Five systematic reviews and no primary studies met inclusion criteria. Although results were inconsistent, effectiveness of PRO/CFS on HRQOL was demonstrated in some diseases/treatments (e.g. psychiatric treatment; symptom burden in cancer treatment). No trials using PRO/CFS in treatment for obesity were identified. In some trials, PRO/CFS was not fully integrated into consultations, thereby PRO/CFS was not extensively studied. General effectiveness of PRO/CFS on HRQOL is inconclusive due to heterogeneous and statistically insignificant findings, and lack of stringency in conceptualization and execution of PRO/CFS. There are no data relevant to treatment for obesity. Future studies should use rigorous methodology to examine the effectiveness of PRO/CFS in treatment for obesity.

Identification of pain categories associated with change in pain in patients receiving placebo: data from two phase 3 randomized clinical trials in symptomatic knee osteoarthritis

Background

Pain is the principal clinical symptom of osteoarthritis (OA), and development of safe and effective analgesics for OA pain is needed. Drug development of new analgesics for OA pain is impaired by substantial change in pain in patients receiving placebo, and more data describing clinical characteristics and pain categories particularly associated with this phenomenon is needed.

The purpose of this post-hoc analysis was to investigate clinical characteristics and pain categories and their association with radiographic progression and placebo pain reduction (PPR) in OA patients as measured the Western Ontario and McMasters Arthritis (WOMAC).

Methods

Pooled data from the placebo groups of two phase III randomized clinical trials in patients with knee OA followed for 2 years were analyzed. Differences between individual sub-scores and pain categories of weight-bearing and non-weight bearing pain over time were assessed. Selected patient baseline characteristics were assessed for association with PPR. Association between pain categories and radiographic progression was analyzed.

Results

The reduction of pain in placebo-treated patients was significantly higher in the composite of questions related to weight-bearing pain compared to non-weight-bearing pain of the target knee. Baseline BMI, age and JSW were not associated with pain change. Pain reduction was higher in the Target knee, compared to the Non-Target knee at all corresponding time-points. A very weak correlation was found between weight-bearing pain and progression in the non-target knee.

Conclusions

These results indicate that the reduction in pain in patients treated with placebo is significantly different between pain categories, as weight-bearing pain was significantly more reduced compared to non-weight-bearing pain. Further research in pain categories in OA is warranted.

Trial Registration

NCT00486434 (trial 1) and NCT00704847 (trial 2)

Disease-modifying treatments for osteoarthritis (DMOADs) of the knee and hip: lessons learned from failures and opportunities for the future

Osteoarthritis (OA) is the biggest unmet medical need among the many musculoskeletal conditions and the most common form of arthritis. It is a major cause of disability and impaired quality of life in the elderly. We review several ambitious but failed attempts to develop joint structure-modifying treatments for OA. Insights gleaned from these attempts suggest that these failures arose from unrealistic hypotheses, sub-optimal selection of patient populations or drug dose, and/or inadequate sensitivity of the trial endpoints. The long list of failures has prompted a paradigm shift in OA drug development with redirection of attention to: (1) consideration of the benefits of localized vs systemic pharmacological agents, as indicated by the increasing number of intra-articularly administered compounds entering clinical development; (2) recognition of OA as a complex disease with multiple phenotypes, that may each require somewhat different approaches for optimizing treatment; and (3) trial enhancements based on guidance regarding biomarkers provided by regulatory agencies, such as the Food and Drug Administration (FDA), that could be harnessed to help turn failures into successes.

Intensive lifestyle intervention provides rapid reduction of serum fatty acid levels in women with severe obesity without lowering omega-3 to unhealthy levels

Serum fatty acid (FA) levels were monitored in women with severe obesity during intensive lifestyle intervention. At baseline, total FA levels and most individual FAs were elevated compared to a matching cohort of normal and overweight women (healthy controls). After 3 weeks of intensive lifestyle intervention, total level was only 11-12% higher than in the healthy controls and with almost all FAs being significantly lower than at baseline, but with levels of omega-3 being similar to the healthy controls. This is contrary to observations for patients subjected to bariatric surgery where omega-3 levels dropped to levels significantly lower than in the lifestyle patients and healthy controls. During the next 3 weeks of treatment, the FA levels in lifestyle patients were unchanged, while the weight loss continued at almost the same rate as in the first 3 weeks. Multivariate analysis revealed that weight loss and change of serum FA patterns were unrelated outcomes of the intervention for lifestyle patients. For bariatric patients, these processes were associated probably due to reduced dietary input and increased input from the patients' own fat deposits, causing a higher rate of weight loss and simultaneous reduction of the ratio of serum eicosapentaenoic to arachidonic acid.

The impact of clinical trial monitoring approaches on data integrity and cost--a review of current literature

PURPOSE

Monitoring is a costly requirement when conducting clinical trials. New regulatory guidance encourages the industry to consider alternative monitoring methods to the traditional 100 % source data verification (SDV) approach. The purpose of this literature review is to provide an overview of publications on different monitoring methods and their impact on subject safety data, data integrity, and monitoring cost.

METHODS

The literature search was performed by keyword searches in MEDLINE and hand search of key journals. All publications were reviewed for details on how a monitoring approach impacted subject safety data, data integrity, or monitoring costs.

RESULTS

Twenty-two publications were identified. Three publications showed that SDV has some value for detection of not initially reported adverse events and centralized statistical monitoring (CSM) captures atypical trends. Fourteen publications showed little objective evidence of improved data integrity with traditional monitoring such as 100 % SDV and sponsor queries as compared to reduced SDV, CSM, and remote monitoring. Eight publications proposed a potential for significant cost reductions of monitoring by reducing SDV without compromising the validity of the trial results.

CONCLUSIONS

One hundred percent SDV is not a rational method of ensuring data integrity and subject safety based on the high cost, and this literature review indicates that reduced SDV is a viable monitoring method. Alternative methods of monitoring such as centralized monitoring utilizing statistical tests are promising alternatives but have limitations as stand-alone tools. Reduced SDV combined with a centralized, risk-based approach may be the ideal solution to reduce monitoring costs while improving essential data quality.

Impact of source data verification on data quality in clinical trials: an empirical post hoc analysis of three phase 3 randomized clinical trials

AIM

The aim of this project was to perform an empirical evaluation of the impact of on site source data verification (SDV) on the data quality in a clinical trial database to guide an informed decision on selection of the monitoring approach.

METHODS

We used data from three randomized phase III trials monitored with a combination of complete SDV or partial SDV. After database lock, individual subject data were extracted from the clinical database and subjected to post hoc complete SDV. Error rates were calculated with focus on the degree of on study monitoring and relevance and analyzed for potential impact on end points.

RESULTS

Data from a total of 2566 subjects including more than 3 million data fields were 100% source data verified post hoc. An overall error rate of 0.45% was found. No sites had 0% errors. 100% SDV yielded an error rate of 0.27% as compared with partial SDV having an error rate of 0.53% (P < 0.0001). Comparing partly and fully monitored subjects, minor differences were identified between variables of major importance to efficacy or safety.

CONCLUSIONS

The findings challenge the notion that a 0% error rate is obtainable with on site monitoring. Data indicate consistently low error rates across the three trials analyzed. The use of complete vs. partial SDV offers a marginal absolute error rate reduction of 0.26%, i.e. a need to perform complete SDV of about 370 data points to avoid one unspecified error and does not support complete SDV as a means of providing meaningful improvements in data accuracy.

OA phenotypes, rather than disease stage, drive structural progression--identification of structural progressors from 2 phase III randomized clinical studies with symptomatic knee OA

BACKGROUND/PURPOSE

The aim of this study was to identify key characteristics of disease progression through investigation of the association of radiographic progression over two years with baseline Joint Space Width (JSW), Kellgren-Lawrence (KL) grade, Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain, Joint Space Narrowing (JSN), and BMI.

METHODS

Data from 2206 subjects (4390 knees) were combined for this post-hoc analysis of two randomized, double-blind, multi-center, placebo-controlled phase III trials (NCT00486434 and NCT00704847) that evaluated the efficacy and safety of 2-years treatment with oral salmon calcitonin of subjects with painful knee osteoarthritis (OA).

RESULTS

There was a clear positive and significant correlation between KL grade and WOMAC pain and total WOMAC, albeit the variance in pain measures was from min-to-max for all KL categories, emphasizing the heterogeneity of this patient population and pain perception. 32% of target knees did not progress, and only 51% had changes over minimum significant change (MSC). BMI, KL-Score and WOMAC pain was diagnostic, but only KL-score and pain had prognostic value, albeit pain in a non-linear manner.

CONCLUSION

These data clearly describe significant associations between KL grade, JSW, pain and BMI in patients with symptomatic knee OA. KL grade, BMI and WOMAC pain were diagnostically associated with OA based on JSW but only KL-score and pain in a non-linier fashion was prognostic. 50% of patients did not progress more than MSC, highlighting the importance for identification of structural progressors and the phenotypes associated with these. These results suggest that disease phenotypes, rather than disease status, are responsible for disease progression.

Impact of physical activity and diet on lipoprotein particle concentrations in severely obese women participating in a 1-year lifestyle intervention

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT

Physical activity and high aerobic fitness protects against cardiovascular disease and early death, besides having a very modest impact on lipoprotein-cholesterol in obese subjects. Physical activity has been shown to favourably alter lipoprotein particle concentrations and apolipoprotein B with minimal weight loss in overweight to moderately obese subjects.

WHAT THIS STUDY ADDS

We studied the impact of physical activity on lipoprotein subclass particle concentrations in women with severe obesity. Increased physical activity duration was associated with favourable changes, whereas increased PA intensity was associated with adverse changes in some lipoprotein particle subclasses in severely obese women. Severely obese women that manage to increase their physical activity level can improve their lipoprotein profile, whether or not they lose fat mass Physical activity (PA) and high aerobic fitness protects against cardiovascular disease and early death possibly among others because of an anti-atherogenic impact on lipoprotein particle concentrations. The objective of this study was to determine the impact of PA and diet on lipoprotein particle concentrations. Thirty-one severely obese women (age 43.6 ± 10.2 years; body mass index 43.0 ± 6.3 kg m(-2) ) participated in a 1-year lifestyle intervention with repeated measurements of lipoprotein particle subclass concentrations and size of very low density lipoprotein (VLDL), low density lipoprotein (LDL) and high density lipoprotein (HDL), as well as fat mass, PA and diet. Multiple regression was used to determine associations with change (Δ) in two principal components (PCs) describing lipoprotein distributions: ΔPC 1 LIPO (dominated by VLDL and LDL) and ΔPC 2 LIPO (dominated by large HDL and mean HDL particle size). ΔPA duration was the only variable that was significantly related to ΔPC 1 LIPO (partial r = -0.40, P = 0.008), while ΔPA intensity was the only variable that was significantly related to ΔPC 2 LIPO (partial r = -0.43, P = 0.003) in adjusted models. Increased PA duration was associated with favourable changes, whereas increased PA intensity was associated with adverse changes in some lipoprotein particle subclasses in severely obese women.

Evaluation of the efficacy, safety and pharmacokinetic profile of oral recombinant human parathyroid hormone [rhPTH(1-31)NH(2)] in postmenopausal women with osteoporosis

CONTEXT

Treatment of osteoporosis with subcutaneous (SC) injections of rhPTH(1-34) or rhPTH(1-84) is associated with significant improvements in BMD and reductions in osteoporotic fractures. However, subcutaneous injections can be associated with discomfort and thus deteriorating compliance.

OBJECTIVE

The UGL-OR1001 trial aimed to establish the efficacy and safety parameters of a novel oral tablet formulation of rhPTH(1-31)NH(2) and matching placebo tablets and open-label teriparatide positive control in postmenopausal women with osteoporosis.

DESIGN

24 weeks of randomized, double-blind treatment with once daily doses of 5mg oral treatment or corresponding placebo, or open-label subcutaneous teriparatide.

PATIENTS OR OTHER PARTICIPANTS

Women diagnosed with postmenopausal osteoporosis as detected by lumbar spine DXA, with an exclusion of those with prior treatment with bone active agents.

INTERVENTION(S)

Orally formulated recombinant human PTH(1-31)NH(2) and placebo, or open-label subcutaneous teriparatide as a positive control.

MAIN OUTCOME MEASURE(S)

The primary endpoint was to characterize the percent change from baseline in bone mineral density (BMD) at L1-L4 axial lumbar spine after 24 weeks in the rhPTH(1-31)NH(2) arm. Secondary and exploratory endpoints included safety and tolerability of the oral formulation, measurement of biochemical markers of bone turnover, and evaluation of the PK profile at first and last dose. The study was registered at ClinicalTrials.gov with the identifier: NCT01321723.

RESULTS

The oral tablet formulation of rhPTH(1-31)NH(2) resulted in similar PK profiles at both timepoints with mean C(max) values similar to subcutaneous administration. In the rhPTH(1-31)NH(2) arm, a 2.2% increase in lumbar spine BMD was observed compared to baseline (p<0.001), while no change was observed in the placebo arm. Open-label teriparatide resulted in a 5.1% increase in LS BMD (p<0.001). In the oral PTH study arm, the bone formation marker osteocalcin was increased by 32%, 21% and 23% at Weeks 4, 12 and 24, respectively. There was no significant increase in the level of the bone resorption marker CTx-1.

CONCLUSIONS

In summary, these data demonstrate that enteric-coated oral tablet formulation technology consistently generated robust levels of exposure of rhPTH(1-31)NH(2) leading to induction of bone formation without inducing bone resorption resulting in significantly increased levels of LS BMD. Few adverse events were observed, recommending this orally delivered drug candidate for further development.

Development of technology for the early post mortem prediction of water holding capacity and drip loss in fresh pork

Two different technologies were tested on the slaughterline for their ability to predict drip loss at 24 h, namely near infrared reflectance (NIR) and impedance measurements using a tetra polar measuring geometry at a frequency of 1000 Hz. The results demonstrate that NIR measurements (900-1800 nm) acquired during a 6 min period starting only 30 min post exsanguination through a fibre optic probe in combination with multivariate data analysis can be used for predicting drip loss 24 h after slaughter. A correlation higher than 0.8 was observed for a trial on 99 carcasses measured at a commercial slaughterhouse. The tetrapolar impedance measurements did not perform as well as NIR yielding a correlation of 0.5 with 24 h drip loss.

Erythrocyte mean cell volume--correlation to drinking pattern in heavy alcoholics

Erythrocyte mean cell volume (MCV) correlates well to alcohol intake in moderate alcoholism, but only about 50% of heavy drinkers have increased MCV. To evaluate the influence of the duration and extent of a drinking episode on MCV, 64 addictive alcoholics were investigated prospectively within two weeks after a drinking period. Their daily alcohol intake was 120-480 g and the actual drinking period has lasted for 1-104 weeks. For comparison, 21 non-active alcoholics were investigated. There was no correlation between MCV of active alcoholics and daily alcohol consumption or smoking habits, whereas a significant positive correlation was found between MCV and both duration of actual drinking episode and total alcohol intake in this period. We conclude that MCV is probably of greater value in estimating the duration and extent of actual drinking episodes in heavy alcoholics than in screening for alcoholism.

Surface-catalysed reactions on pollutant-removing building products for indoor use

In order to evaluate the potential for emission of secondary reaction products from building materials designed to remove pollutants from indoor air, four samples of ceiling tiles--three commercially available and one custom-made--were investigated in chamber experiments. The chambers were irradiated with artificial light simulating indoor conditions and formaldehyde as well as several VOCs (2-butanone, n-butanol, toluene, hexanal, n- butylacetate, 2-butoxyethanol, alpha-pinene, benzaldehyde, n-decane, limonene and 1,2-dichlorobenzene) were added. Depending on the individual substrate-substance combination, it was possible to identify secondary emissions, e.g. formaldehyde, furfural, acetophenone, n-butylbutyrate, n-butyl-i-butyrate, n-butylpropionate, 4-heptanone, acetic acid, i-butyraldehyde and crotonaldehyde. These were generated by cleavage, hydrolysis, rearrangement or radical reactions. Some of these reactions also occurred with samples not containing photocatalysts. All these secondary emissions have to be taken seriously into account when evaluating the performance of materials designed to remove pollutants from indoor air, as they can prove detrimental to human health.

Cigarette smoking accelerates progression of alcoholic chronic pancreatitis

BACKGROUND

Smoking is a recognised risk factor for pancreatic cancer and has been associated with chronic pancreatitis and also with type II diabetes.

AIMS

The aim of this study was to investigate the effect of tobacco on the age of diagnosis of pancreatitis and progression of disease, as measured by the appearance of calcification and diabetes.

PATIENTS

We used data from a retrospective cohort of 934 patients with chronic alcoholic pancreatitis where information on smoking was available, who were diagnosed and followed in clinical centres in five countries.

METHODS

We compared age at diagnosis of pancreatitis in smokers versus non-smokers, and used the Cox proportional hazards model to evaluate the effects of tobacco on the development of calcification and diabetes, after adjustment for age, sex, centre, and alcohol consumption.

RESULTS

The diagnosis of pancreatitis was made, on average, 4.7 years earlier in smokers than in non-smokers (p = 0.001). Tobacco smoking increased significantly the risk of pancreatic calcifications (hazard ratio (HR) 4.9 (95% confidence interval (CI) 2.3-10.5) for smokers v non-smokers) and to a lesser extent the risk of diabetes (HR 2.3 (95% CI 1.2-4.2)) during the course of pancreatitis.

CONCLUSIONS

In this study, tobacco smoking was associated with earlier diagnosis of chronic alcoholic pancreatitis and with the appearance of calcifications and diabetes, independent of alcohol consumption.

Incidence of nutritional risk and causes of inadequate nutritional care in hospitals

BACKGROUND AND AIMS

Many patients in hospitals are undernourished and nutritional care is inadequate in most hospitals. The aim of this investigation was to gain insight into how this situation could be improved.

METHODS

Seven hundred and fifty randomly selected patients were screened at admission in three hospitals and surveyed during their entire hospitalization. Each time a patient was not treated according to a clearly defined nutritional standard, the nurse responsible for the patient was interviewed about possible reasons according to preformed questionnaires.

RESULTS

The investigators found that 22% of the patients were nutritionally at-risk, and that only 25% of these patients received an adequate amount of energy and protein. The departments had only screened for nutritional problems in 60% of the cases. Only 47% of the patients, who the departments judged to be at-risk patients, had a nutrition plan worked out, and only about 30% of the at-risk patients were monitored by the departments by recording of dietary intake and/or body weight. The main causes for inadequate nutritional care were lack of instructions to deal with these problems, and lack of basic knowledge with respect to dietary requirements and practical aspects of the hospital's food provision. Patient-related aspects and the system of food provision also contributed, but only to a small degree.

CONCLUSIONS

These findings form the basis of the strategy to improve nutritional care in these hospitals.

[Vitamin E and coronary heart disease--why the lack of effect in large clinical trials?]

BACKGROUND

Oxidative modification of low-density lipoprotein (LDL) is likely to play a role in the development of atherosclerosis and coronary heart disease. In vitro studies, animal experiments and several observational investigations suggest that vitamin E is an effective preventive agent. Unfortunately, large clinical studies have failed to confirm these findings.

MATERIAL AND METHODS

On the basis of literature studies, I discuss the lack of effect.

RESULTS

The hypothesis that LDL must be oxidised to be really harmful, could be wrong. If oxidised LDL is an important atherogenic factor, vitamin E (alpha-tocopherol) might not be a powerful enough antioxidant, especially in the later stages of atherosclerosis. Maybe one needs to use a mixture of different kinds of vitamin E and co-antioxidants that can regenerate vitamin E to achieve an effect that is powerful enough? The effect of vitamin E might have been masked by n-3 fatty acids in some studies. The most plausible hypothesis is that only people with extraordinarily high oxidative stress will benefit from vitamin E supplementation.

INTERPRETATION

Further research is needed to understand how oxidised LDL and vitamin E affect the development of coronary heart disease. In the meantime it is important to point out that a healthy diet with balanced amounts of antioxidants and enough n-3 fatty acids has been proven effective.

Alpha-fetoprotein in plasma and serum of healthy adults: preanalytical, analytical and biological sources of variation and construction of age-dependent reference intervals

Alpha-fetoprotein (AFP) is a tumor marker for hepatomas and germ cell tumors, and the serum concentration has prognostic significance in other diseases. We examined the normal serum concentration of AFP in adults and sources of variation in the immunochemical variation of AFP. The serum concentration of the tumor marker alpha-fetoprotein (S-AFP) was log-normally distributed in 284 adult blood donors. S-AFP increased with age (p < 10(-7)), whereas no gender-related difference was found. Reference intervals (95-interpercentile) were constructed for persons < or =40 years (0.60-9.30 kIU/L) and >40 years (1.40 12.60 kIU/L). The concentration of AFP was significantly, albeit slightly, higher in serum than in plasma, whereas hemolysis, pretreatment with KCl and food intake did not influence S-AFP. S-AFP only changed 6% when measured twice 2 months apart (p=0.04). Three enzyme immunoassays, using three different anti-AFP monoclonal antibodies for detection, were compared and two assays gave S-AFP values significantly higher, 2.8% (p=0.03) and 19.0% (p<10(-4)), than the other assay. Thus, the choice of antibody may influence the result of immunochemical concentration determination. This can be explained by the existence of conformational variants of AFP with different antibody reactivities, and calls for careful standardization of monoclonal antibodies used in assays for AFP. With broad population reference ranges and slight intra-personal variation, the most effective reference range for S-AFP is previous values obtained in the same person.

Depletion of acyl-coenzyme A-binding protein affects sphingolipid synthesis and causes vesicle accumulation and membrane defects in Saccharomyces cerevisiae

Deletion of the yeast gene ACB1 encoding Acb1p, the yeast homologue of the acyl-CoA-binding protein (ACBP), resulted in a slower growing phenotype that adapted into a faster growing phenotype with a frequency >1:10(5). A conditional knockout strain (Y700pGAL1-ACB1) with the ACB1 gene under control of the GAL1 promoter exhibited an altered acyl-CoA profile with a threefold increase in the relative content of C18:0-CoA, without affecting total acyl-CoA level as previously reported for an adapted acb1Delta strain. Depletion of Acb1p did not affect the general phospholipid pattern, the rate of phospholipid synthesis, or the turnover of individual phospholipid classes, indicating that Acb1p is not required for general glycerolipid synthesis. In contrast, cells depleted for Acb1p showed a dramatically reduced content of C26:0 in total fatty acids and the sphingolipid synthesis was reduced by 50-70%. The reduced incorporation of [(3)H]myo-inositol into sphingolipids was due to a reduced incorporation into inositol-phosphoceramide and mannose-inositol-phosphoceramide only, a pattern that is characteristic for cells with aberrant endoplasmic reticulum to Golgi transport. The plasma membrane of the Acb1p-depleted strain contained increased levels of inositol-phosphoceramide and mannose-inositol-phosphoceramide and lysophospholipids. Acb1p-depleted cells accumulated 50- to 60-nm vesicles and autophagocytotic like bodies and showed strongly perturbed plasma membrane structures. The present results strongly suggest that Acb1p plays an important role in fatty acid elongation and membrane assembly and organization.

Disturbances of ano-rectal function in multiple sclerosis

Thirty patients with multiple sclerosis (MS) [18 men and 12 women, mean age 40 years (range 22-50), disease duration 12 years (range 0.5-34), Kurtzke's Expanded Disability Status Score 6.0 (range 4.0-7.5)] were interviewed about bowel symptoms and studied using ano-rectal manometry. The results were compared with findings in healthy controls. Twenty-eight had bowel symptoms: 8 constipation, 10 constipation and infrequent faecal urgency, 4 infrequent faecal incontinence and 6 frequent faecal incontinence. Anal sphincter pressure at rest was significantly reduced in MS patients 69 (SD 17) cm H2O, compared with 92 (SD 15) cm H2O in controls, and the external sphincter contraction force was also significantly reduced. Rectal sensation and rectal compliance were reduced and the ano-rectal inhibition reflex (defaecation reflex) required a higher rectal pressure to be elicited in the patients. Upon rectal filling, an early external sphincter excitation was seen. The presence of faecal incontinence correlated strongly with reduced rectal sensation. The findings suggest that faecal incontinence can at least partly be explained by low anal sphincter pressure and poor rectal sensation. The findings of early sphincter excitation and increased threshold of ano-rectal inhibition reflex may be an important pathophysiological factor for constipation in MS patients.

Implantation metastasis after laparoscopic biopsy of bladder cancer

We report a case of tumor implantation in the abdominal wall following laparoscopic biopsy of a transitional cell tumor. Tumor seeding is a known risk in patients with transitional cell carcinoma and we recommend that laparoscopic biopsy of urothelial tumors be avoided.

The radiology of bone allografts

Bone allograft surgery provides an attractive and effective solution to many orthopedic problems. Nevertheless, the entire process is technically demanding and associated with many potential complications of which infection is one of the most difficult to treat. Many advances have been made in the procurement and use of bone allografts, and further investigation should expand the applications of allograft surgery and continue to diminish the incidence of complications.

[Cancer morbidity among alcoholics]

Data on the association between alcohol abuse and cancer morbidity are scarce in large cohorts of non-hospitalized alcoholic men an women. Of 18,368 alcohol abusers who entered an out-patient clinic in Copenhagen between 1954-1987, 18,307 were followed. Their cancer incidence was compared to that of the total Danish population. The overall morbidity of cancer was significantly increased among alcohol abusers. The men developed 1441 cancer cases (RR = 1.6), and the women 182 cases (RR = 1.5). Significantly increased incidences were found for cancer of the tongue, mouth, pharynx, oesophagus, liver, larynx, lung, pleura, and secondary cancer. The women had a significantly increased risk of cervical cancer (RR = 2.0). The men developed prostatic cancer significantly more frequently than expected (RR = 1.4). The relative risks of cancer of the stomach, pancreas, kidney and endocrine system were only slightly increased. The risk of breast cancer in women was not significantly increased (RR = 1.3).

Prognosis of chronic pancreatitis: an international multicenter study. International Pancreatitis Study Group

OBJECTIVES

The aim of this study was to determine which factors predict mortality in a cohort of patients with chronic alcoholic and nonalcoholic pancreatitis. Patients with chronic pancreatitis are known to have a reduced life expectancy, but the quantitative relationship between various clinical features and survival is unclear.

METHODS

We evaluated survival among 2015 subjects with chronic pancreatitis treated at seven centers located in six countries.

RESULTS

Mean age at diagnosis was 46 +/- 13 yr and mean duration of follow-up was 7.4 +/- 6.2 yr. Overall survival at 10 yr was 70% (95% confidence interval (CI), 68-73%) and at 20 yr was 45% (95% CI, 41-49%). Survival was significantly less than in the background population. There were 559 deaths observed among those with chronic pancreatitis compared with an expected number of 157.4, yielding a standardized mortality ratio (SMR) of 3.6 (95% CI, 3.3-3.9). Older subjects and those with alcoholic pancreatitis had a significant reduction in survival. In a multivariate analysis, mortality of middle-aged and older subjects was 2.3 (95% CI, 1.8-2.8) and 6.3 (95% CI, 4.7-8.3) times greater than subjects less than 40 yr at diagnosis. Smoking (hazard ratio, 1.4; 95% CI, 1.0-1.9), drinking (hazard ratio, 1.6; 95% CI, 1.2-2.2), or development of cirrhosis (hazard ratio, 2.5; 95% CI, 2.0-3.2) increased the risk of death during the observation period, but we observed no survival difference in operated vs. nonoperated patients.

CONCLUSIONS

Age at diagnosis, smoking, and drinking are major predictors of mortality in patients with chronic pancreatitis.

Ureteroscopic management of transitional cell tumors

Eighty-nine ureteroscopies, comprising 102 renal units, were performed on 31 patients for diagnosis, treatment or follow-up of transitional cell tumors of the upper urinary tract. The indications were hematuria or filling defect (29 endoscopies), treatment of tumor (19) and follow-up (41), i.e. 33, 21 and 48 renal units. Ureteroscopy (including 2 peroperative) was satisfactorily completed in 93 units. Tumor was suspected or diagnosed in 57 units, but later disproved in 11. Two tumors were overlooked at endoscopy. Surgery was performed in 21 cases (bilateral in 3), with indications based on ureteroscopic findings in 58%. Electroresection, laser photocoagulation or fulguration was done on ten units (average treatment sessions 2.6). Inadequate ureteroscopic treatment led to surgery in two of these units, but in seven open surgery was avoided (follow-up 6-47, mean 25 months). One old patient had no further treatment. Follow-up ureteroscopy was planned for 48 units and completed in 42. Complications occurred after 11 of 89 endoscopies. Ureteroscopic management of upper-tract urothelial tumors can be satisfactory, with long freedom from recurrence.

Serum alpha-fetoprotein and alcohol consumption

Fifty-nine persons, 23 chronic alcoholics and 36 normal healthy persons with a well described alcohol consumption, had the serum concentration of alpha-fetoprotein determined by a sensitive monoclonal immunofluorescent assay. A significant elevation in S-AFP was found in alcoholics, median 4.1 kIU/l as compared to 3.0 kIU/l in near-abstainers (< 12 g ethanol per day) (p < 0.02). This difference was not explained by differences in age. S-AFP correlated positively with age (p = 0.01). In non-alcoholics a borderline significant correlation with S-AFP was found with average daily alcohol consumption (self-reported) (p = 0.09) and a significant correlation with the serum concentration of carbohydrate-deficient transferrin (S-CDT) (p = 0.004). In 11 alcoholics 2 months of abstention from alcohol was accompanied by a median reduction of 21% in S-AFP (p < 10(-5)). In alcoholics, but not in social drinkers, S-AFP correlated with S-ASAT (p = 0.004). The increase of S-AFP with alcohol consumption may reflect reversible alcohol-induced liver affection.

Sex hormone binding globulin phenotypes: their detection and distribution in healthy adults and in different clinical conditions

Human sex hormone binding globulin (SHBG) is encoded by a normal and a variant allele. The resulting SHBG phenotypes (the homozygous normal SHBG, the heterozygous SHBG and the homozygous variant SHBG phenotype) can be distinguished by their electrophoretic patterns. We developed a novel detection system allowing us to distinguish between the different electrophoretic patterns in small amounts of plasma or serum (10 microliters). Small aliquots of Blue Sepharose were added to diluted sera or plasma samples for removal of albumin and the supernatants were subsequently applied to Western blotting. This method of detection was used to determine the distribution of SHBG phenotypes in healthy controls of both sexes and in five different pathological conditions characterized by changes in the SHBG level or endocrine disturbances (malignant and benign ovarian neoplasms, hirsutism, liver cirrhosis and alcoholism). The distribution of SHBG phenotypes was independent of such conditions and in agreement with the expected phenotype distribution of a bi-allelic gene in both healthy controls and patients (Hardy Weinberg law). An allele frequency of 0.13 was found for the SHBG variant allele based on the experimental values. Differences in SHBG phenotypes do not appear to have any clinical significance and no sex difference was found in the SHBG phenotype distribution.

Cancer morbidity in alcohol abusers

Data on the association between alcohol abuse and cancer morbidity are scarce in large cohorts of non-hospitalised alcoholic men and women. Of 18,368 alcohol abusers who entered an outpatient clinic in Copenhagen during 1954-87, 18,307 were followed and their cancer incidence was compared with that of the total Danish population. On average the 15,214 men were observed for 12.9 years and the 3,093 women for 9.4 years. The overall morbidity of cancer was increased significantly. Of the men, 1,441 developed cancer [relative risk (RR) = 1.6; 95% confidence interval (CI) = 1.5-1.7], while 182 women did (RR = 1.5; 95% CI 1.3-1.8). Significantly increased incidences were found of cancer in the tongue, mouth, pharynx, oesophagus, liver, larynx, lung and pleura and secondary cancer. The women had significantly increased risk of cervical cancer (RR = 2.0; 95% CI 1.2-3.0). The men developed prostatic cancer significantly more frequently than expected (RR = 1.4; 95% CI 1.2-1.8). The risk of melanomas (RR = 0.5; 95% CI 0.2-0.8) was significantly lower than expected. The relative risks of cancer of the stomach, pancreas, kidney and endocrine system were only slightly increased. The study group did not develop more colonic (RR = 1.0; 95% CI 0.8-1.3) or rectal cancer (RR = 1.0; CI 0.7-1.3) than expected. The risk of breast cancer in women was slightly increased (RR = 1.3; 95% CI 0.9-1.7), but not statistically significant. Thus, the associations between alcohol and cancer of the upper digestive and respiratory tract and the liver are confirmed. In addition, this study indicates an increased occurrence of cancer of the prostate gland, pleura and uterine cervix in alcohol abusers.

Pancreatitis and the risk of pancreatic cancer. International Pancreatitis Study Group

BACKGROUND

The results of case-control studies and anecdotal reports suggest that pancreatitis may be a risk factor for pancreatic cancer, but there have been no studies of sufficient size and power to assess the magnitude of the relation between these two diseases.

METHODS AND RESULTS

We undertook a multicenter historical cohort study of 2015 subjects with chronic pancreatitis who were recruited from clinical centers in six countries. A total of 56 cancers were identified among these patients during a mean (+/-SD) follow-up of 7.4 +/- 6.2 years. The expected number of cases of cancer calculated from country-specific incidence data and adjusted for age and sex was 2.13, yielding a standardized incidence ratio (the ratio of observed to expected cases) of 26.3 (95 percent confidence interval, 19.9 to 34.2). For subjects with a minimum of two or five years of follow-up, the respective standardized incidence ratios were 16.5 (95 percent confidence interval, 11.1 to 23.7) and 14.4 (95 percent confidence interval, 8.5 to 22.8). The cumulative risk of pancreatic cancer in subjects who were followed for at least 2 years increased steadily, and 10 and 20 years after the diagnosis of pancreatitis, it was 1.8 percent (95 percent confidence interval, 1.0 to 2.6 percent) and 4.0 percent (95 percent confidence interval, 2.0 to 5.9 percent), respectively.

CONCLUSIONS

The risk of pancreatic cancer is significantly elevated in subjects with chronic pancreatitis and appears to be independent of sex, country, and type of pancreatitis.

Collagenous colitis: are bacterial cytotoxins responsible?

In a case of collagenous colitis, cholestyramine treatment resulted in symptomatic and histological normalization. After discontinuation of cholestyramine, collagenous colitis relapsed. At this time fecal cytotoxic activity was demonstrated in McCoy cell lines. Symptoms, histologic changes, and cytotoxicity disappeared when cholestyramine treatment was reinstituted. We hypothesize that a bacterial toxin is responsible for the development of collagenous colitis.

A retrospective evaluation of 691 ureteroscopies: indications, procedures, success rate and complications

In the period of 1983-1990, a total of 691 ureteroscopies were performed in 480 patients. The main indications for ureteroscopy were stones, stenoses or making a diagnosis. In one third of the cases, pathology was suspected in the renal pelvis or at the ureteropelvic junction, in one third in the distal third of the ureter, and in the remaining cases, in either the upper or the middle part of the ureter. The most frequent ureteroscopic procedures were diagnostic examination or surveillance and procedures involving treatment of stones. In the 1st attempt, the ureteroscope was introduced to the suspected pathology in 79.9% of all cases, and the main objective was achieved in 76.6%. The success of stone manipulation has increased from 74% in the 1st to 92% in the last part of the period. More than half the procedures involving a ureteral stenosis were not completed satisfactorily. The location of suspected pathology did not influence the results. Complications occurred in 23% of the ureteroscopies, and the relative number of major complications decreased continuously. We conclude that ureteroscopy is appropriate at any location of pathology and that efforts must be made to minimize both major and minor complications.

Disulfiram therapy--adverse drug reactions and interactions

Adverse drug reactions (ADR) to disulfiram treatment have been reported as single cases, but few systematic investigations exist. In this study we analysed the spontaneous ADR reports to the Danish Committee on Adverse Drug Reactions during 1968-1991. In that period 154 ADRs to disulfiram were reported, mainly of hepatic, neurological, skin, and psychiatric reactions, in decreasing order of frequency. The safety of disulfiram, estimated on the amount produced and the number of reactions reported, corresponds to an intermediate rate of adverse reactions (1 per 200-2000 treatment year). Over the 23-year period, 14 deaths were reported in Denmark and this corresponds to a rate of 1 per 25,000 treatment year; the chief cause was liver toxicity. Reports to the WHO collaborating Centre for International Drug Monitoring in Uppsala, Sweden, showed the same ADR profile, although with a higher rate of neurological and psychiatric and a lower rate of hepatic reactions. The latency time from the start of treatment to the manifestation of the ADR differed according to organ. Hepatitis occurred with a distinct peak after 2 months of treatment, skin reactions peaked after 2 weeks, and the rate of neurological ADR increased with duration of therapy. The relation of skin reactions and hepatitis to nickel allergy is discussed, as is the dose-dependency of neuropathy. Concomitant disulfiram treatment affects the metabolism of several drugs and the dynamics of others, leading to a number of clinically important drug interactions. The disulfiram drug interactions are reviewed.

Evaluation of outpatient assessment after transurethral prostatectomy

The need for a three-month visit at the outpatient clinic for assessment including uroflowmetry was retrospectively evaluated in 78 patients who underwent transurethral resection for benign prostatic hypertrophy during 1986. One patient died before discharge and six were lost to follow-up. Eleven patients requested appointments earlier than three months, and 10 of these needed further treatment; four were operated on and six were treated with drugs. The remaining 60 patients attended as arranged. Thirty-nine were discharged, but 21 required further treatment. Eleven were operated on, four were given drugs, one had an external catheter because of incontinence, and five needed further visits to the outpatient clinic for other reasons. It was not possible to predict the necessity for follow-up from preoperative symptoms, cystitis, maximum urinary flow (ml/s), blood loss during operation, or length of stay in hospital after operation. We conclude that 35% (95% c.l. 23-48%) of the arranged outpatient visits three months after transurethral resection for benign prostatic hypertrophy are necessary and that the need is not predictable.

Efficacy of enprofylline in acute airway obstruction

The efficacy and safety of different regimens of intravenously administered enprofylline, an anti-asthma xanthine, were evaluated in a randomized open study, including 155 patients with acute exacerbation of obstructive lung disease. The regimen 2.5 mg/kg i.v. over 10 min was canceled after seven patients had been included, due to two cases of hypotensive/vasovagal reactions. The regimens 2.0 mg/kg/20 min and 2.5 mg/kg/20 min were significantly more effective with regard to bronchodilation than 2.0 mg/kg/10 min (PEF increase +35%, +30% and +17% respectively). Nausea and headache were the most common side effects (16-33% and 23-33% of the patients respectively on different regimens) with the lowest frequency on 2.0 mg/kg/20 min. Four additional hypotensive reactions occurred; one on each 2.0 mg/kg regimen and two on 2.5 mg/kg/20 min. The regimen 2.0 mg/kg20 min was found to be the most favourable with regard to efficacy and side effects. Enprofylline i.v. was found to be an effective bronchodilating treatment of acute airway obstruction but the frequency of side effects has to be considered.

Infrequent voiders syndrome (nurses bladder). Prevalence among nurses and assistant nurses in a surgical ward

We evaluated the prevalence of infrequent voiders syndrome (defined as women with a mean voided volume above 400 ml) and predisposing factors among the female nursing staff in a busy 100 beds department of surgery. One hundred and five nurses and assistant nurses were invited to fill in a questionnaire and a frequency/volume chart for a 24-hour period. The infrequent voiders were further studied using uroflowmetry and medium-fill CO2 cystometry. Seventy-two women completed the study. Six (95% c.l. 3%-17%) were infrequent voiders, although fifty women (57%-80%) suppressed the desire to void during working hours. Main reasons for suppression of desire to void were busy work, poor toilet facilities and indolence. The frequency of micturition was higher during evening and night shifts than in the day shift. In the infrequent voiders the functional bladder capacity ranged from 550-1,100 ml, but none had residual urine exceeding 120 ml.

Pancreatic function in Crohn's disease

We investigated exocrine pancreatic function in a population of patients with Crohn's disease in order to correlate the pancreatic function with clinical and laboratory variables. A total of 143 patients affected by Crohn's disease and 115 control subjects were studied. All had a Lundh meal test. As a group patients with Crohn's disease had significantly decreased activity of both amylase (p less than 0.02) and lipase (p less than 0.001) in duodenal aspirates. In patients with Crohn's disease enzyme activities were not correlated to duration of disease or to extent or localisation of previous bowel resection. The lowest enzyme values were found in patients with the most extensive bowel involvement, and they were significantly lower (p less than 0.05) than in patients with disease confined to the terminal ileum. The differences between enzyme values in other subgroups of patients were not significant. For the patient group as a whole no correlation was found between disease activity and enzyme values, but for the most uniform group of patients, those with terminal ileitis, pancreatic function was significantly lower (p less than 0.05) in patients with moderate and severe disease compared with patients with mild disease. Thus at least two factors seem to be responsible for impaired pancreatic function in Crohn's disease: firstly disease activity and secondly localisation or extent of disease.

Pancreatic insufficiency. Duodenal and jejunal pH, bile acid activity, and micellar lipid solubilization

To investigate the course of postprandial lipid solubilization in nine patients with chronic, alcoholic pancreatitis, luminal contents were aspirated from the proximal part of the jejunum for 180 min after a meal containing 1.5% fat. Six of the patients had pancreatic insufficiency, whereas three patients were without insufficiency. pH was measured continuously at two sites: at the level of the papilla of Vater and the aspiration site. The fraction of bile acids in the micellar phase of the jejunal aspirates correlated positively to both pH in the aspirates (p less than 0.05) and the fraction of fat solubilized (p less than 0.02). pH was below 4.0 for a longer period of time in the patients with insufficiency, compared to the patients without. However, pH fluctuated rapidly, and there was no correlation between the continuously measured values at the aspiration site and values in the aspirates. Lipid solubilization was not correlated to the lipase activity in the aspirates. We conclude that acidic bile acid precipitation most likely plays a dominant role in the pathophysiology of pancreatic steatorrhea although the methods available are too crude to disclose the precise course of events.