The development of pharmacological treatment of obesity in children. A European regulatory perspective.

Childhood obesity is recognized by the World Health Organization as one of the most serious public health challenges of the 21st century. Current treatment recommendations consider the role of pharmacotherapy in the treatment of childhood obesity, as an adjunct to lifestyle modifications. This article focuses on key requirements for paediatric development of medicines for obesity in Europe with reference to the European Medicines Agency guideline and a review of Paediatric Investigation Plans (PIP) submitted for this condition, under Regulation (EC) No. 1901/2006 on medicines for paediatric use. To date the European Medicines Agency (EMA) received four paediatric investigation plans for childhood obesity. Issues encountered during the assessment of paediatric investigation plans were all related to the characteristics of the patient population, trial design, choice of endpoints, and safety aspects. Although the number of paediatric investigation plans submitted to the European Medicines Agency thus far is limited, current experience highlights the need for clinical trial protocols that are in line with the specific European guideline. Divergent approaches should be discussed with regulatory authorities before paediatric trials are initiated and included in paediatric investigation plans.

An inhibition of the hypothalamic somatostatinergic tone is not the cause of the enhanced growth hormone response to growth hormone-releasing hormone in patients with liver cirrhosis.

Animal models of liver cirrhosis (LC) display a reduced hypothalamic somatostatinergic tone. To test whether a similar mechanism could explain the enhanced Growth Hormone (GH) secretory response to GH-Releasing Hormone (GHRH), which is seen in human LC, we studied the effect of the cholinesterase inhibitor pyridostigmine (PD), which is able to reduce the release of hypothalamic somatostatin (SS), on the GHRH-stimulated GH secretion. We considered that if PD were unable to increase GH secretion, this would constitute evidence of an already inhibited endogenous somatostatinergic tone. If proved, this in turn could explain the enhanced GH response to GHRH seen in LC. Ten LC patients and nine controls were given GHRH (100 microg, intravenously), or PD (120 mg, orally) plus GHRH. After GHRH alone, the GH peak was four times higher in LC than in controls (40.85+/-15.7 ng/ml in LC and 9.35+/-2.5 ng/ml in controls). In LC, PD administration markedly increased the GH response to GHRH (GH peak: 98.0+/-19.7 ng/ml; +240% vs. GHRH alone). The ability of PD to increase the GH response in patients with LC suggests that in this condition the enhanced GH response to GHRH is not due to a completely inhibited endogenous somatostatinergic tone. SS appears instead to maintain its modulator role on GH secretion in human LC, in contrast with what observed in animal models.

Successful treatment of retrograde ejaculation with the alpha1-adrenergic agonist methoxamine: case study.

We treated two patients affected by retrograde ejaculation (RE) with the pure alpha1-adrenergic agonist methoxamine; the drug was self-administered intramuscularly by the patients 30 min prior to intercourse or masturbation. A previous trial with oral imipramine had been ineffective in both patients. Sperm count increased substantially, particularly in the first patient who had insulin-dependent diabetes and was seeking fertility. In this patient, total ejaculated sperm increased from 22 millions to 488 and 419.5 millions on two different occasions, with good motility; two clinical pregnancies were obtained in the partner of this patient after 3 and 4 months of treatment, respectively. The second patient did not desire fertility. In both patients, no side effects were seen except for slight piloerection; blood pressure values increased slightly, and heart rate was unchanged. We conclude that self-administered methoxamine can be a useful, noninvasive and inexpensive treatment of RE, when oral agents are ineffective.

Acute promyelocytic leukemia: morphological aspects.

Among AML with maturation, acute promyelocytic leukemia (APL) represents a distinct subtype which accounts for 5-10% of all the FAB variants. APL may be recognized by different cytological pictures: (i) Hypergranular APL, the most typical form, showing promyelocytes with cytoplasm packed with purple granules. Most of the primary granules may be incorporated into Auer rods, sometimes stacked in bundles of faggots. (ii) Microgranular APL, characterized by fine dust-like granulation in the cytoplasm; some promyelocytes may even appear agranular by light microscopy. Most of the cells show bilobed or folded nuclei, a picture which may simulate that of acute myelomonocytic leukemia. (iii) Hyperbasophilic form, characterized by cells with high N/C ratio, and strongly basophilic cytoplasm with either sparse or no granules. Conspicuous cytoplasmatic budding is usually present, recalling the feature of micromegakaryocytes. Strong positivity for myeloperoxidase, Sudan black B and chloroacetate esterase represents the typical cytochemical pattern of M3; usually a weaker reactivity may be observed in M3v. However, sometimes a degree of cytochemical heterogeneity of APL cells may be observed, as suggested by cases displaying a strong sodium fluoride-sensitive nonspecific esterase reaction. Recently a distinct entity associated with basophilic differentiation has been described. Differential diagnosis of this form with M2-baso subtype and with cases of MDS or AML with basophilia (M2, M4 with t(6;9) translocation) may be obtained by the use of cytochemistry, cytogenetic investigations, and electron microscopy.

Acute promyelocytic leukemia: morphological aspects.

Among AML with maturation, acute promyelocytic leukemia (APL) represents a distinct subtype which accounts for 5-10% of all the FAB variants. APL may be recognized by different cytological pictures: (i) Hypergranular APL, the most typical form, showing promyelocytes with cytoplasm packed with purple granules. Most of the primary granules may be incorporated into Auer rods, sometimes stacked in bundles of faggots. (ii) Microgranular APL, characterized by fine dustlike granulation in the cytoplasm; some promyelocytes may even appear agranular by light microscopy. Most of the cells show bilobed or folded nuclei, a picture which may simulate that of acute myelomonocytic leukemia. (iii) Hyperbasophilic form, characterized by cells with high N/C ratio, and strongly basophilic cytoplasm with either sparse or no granules. Conspicuous cytoplasmatic budding is usually present, recalling the feature of micromegakaryocytes. Strong positivity for myeloperoxidase, Sudan black B and chloroacetate esterase represents the typical cytochemical pattern of M3; usually a weaker reactivity may be observed in M3v. However, sometimes a degree of cytochemical heterogeneity of APL cells may be observed, as suggested by cases displaying a strong sodium fluoride-sensitive non-specific esterase reaction. Recently a distinct entity associated with basophilic differentiation has been described. Differential diagnosis of this form with M2-baso subtype and with cases of MDS or AML with basophilia (M2, M4 with t(6;9) translocation) may be obtained by the use of cytochemistry, cytogenetic investigations, and electron microscopy.

Opioids stimulate growth hormone (GH) release in man independently of GH-releasing hormone.

The Met-enkephalin analog DAMME [D-Ala2,MePhe4-Met-enkephalin-(o)-o1, FK 33-824] can stimulate GH secretion in man. In this study we investigated the effects of the guanyl derivative of DAMME (G-DAMME) on the serum GH response to an analog of GHRH in normal men. GHRH-(1-29)NH2 and G-DAMME each induced a rise in serum GH, and the increase was greater when both were given together. Since the GHRH-(1-29)NH2 dose (100 micrograms) used was a maximally stimulatory one, these results suggest that the enhancing effect of G-DAMME on GHRH-induced GH release may be mediated through inhibition of somatostatin release.

Spontaneous nocturnal growth hormone secretion in anorexia nervosa.

In anorexia nervosa, serum GH levels are increased under basal conditions and respond abnormally to provocative stimuli. We report here, for the first time, an analysis of pulsatile GH secretion in these patients performed by Cluster algorithm. Seven anorectic and six normal weight, healthy women underwent serial blood sampling at 20-min intervals form 2030-0830 h for GH estimation. The total area under the curve (AUC; micrograms per L/min) was elevated 4-fold in anorectic patients compared to controls (4743.0 +/- 1520.09 vs. 1148.6 +/- 519.27; P < 0.01), largely due to an increase in the non-pulsatile fraction (3212.5 +/- 990.45 vs. 378.7 +/- 123.27; P < 0.01). Accordingly, the valley mean value was higher in anorectic than in control subjects (5.9 +/- 2.25 vs. 1.0 +/- 1.30 micrograms/L; P < 0.01). Furthermore, pulsatile AUC was also greater in anorectic patients (1530.4 +/- 654.72 vs. 769.8 +/- 404.02; P < 0.01) due to a significant increase in GH peak frequency (5.0 +/- 0.81 vs. 3.0 +/- 0.89; P < 0.01). No correlations were observed in these patients between body mass index and any of the parameters of spontaneous GH release, whereas a positive correlation was found between insulin-like growth factor I levels and pulsatile AUC (r2 = 0.583; P < 0.05), peak height (r2 = 0.743; P = 0.01), peak increment (r2 = 0.801; P < 0.01), and GH valley mean (r2 = 0.576; P < 0.05). In conclusion, it appears that the enhanced GH secretion in anorexia nervosa is the result of an increased frequency of secretory pulses superimposed on enhanced tonic GH secretion. Although this latter is consistent with a reduction of hypothalamic SRIH tone, the former may be accounted for by an increased number of GHRH discharges. Considering that in normal weight and obese subjects parameters of GH release are negatively correlated with adiposity indexes, the lack of such a negative correlation in our patients suggests that the enhancement of spontaneous GH release in anorectic patients is not merely the consequence of malnutrition-dependent impairment of insulin-like growth factor I production, but reflects a more complex hypothalamic dysregulation of GH release.

High prevalence of lactose absorbers in Northern Sardinian patients with type 1 and type 2 diabetes mellitus.

BACKGROUND: Increased intestinal lactase activity has been shown to occur in alloxan and streptozotocin diabetic rats. OBJECTIVE: The objective of this study was to determine whether increased intestinal lactase activity is present in humans with diabetes mellitus. DESIGN: We assessed the capacity to digest lactose by measuring breath-hydrogen production after oral administration of lactose in 50 patients with type 1 diabetes, 50 patients with type 2 diabetes, and 50 healthy control subjects from Sassari, Sardinia, Italy, a population characterized by a low prevalence of lactase persistence (lactose absorbers). RESULTS: Fourteen percent of control subjects were lactose absorbers, compared with 48% of patients with type 1 diabetes and 52% of patients with type 2 diabetes (P < 0.005). The odds ratio of lactase persistence in patients with type 1 diabetes was 5.3 (95% CI: 2.0, 14.0) and in patients with type 2 diabetes was 5.5 (95% CI: 2.1, 14.5). CONCLUSIONS: Diabetes is associated with increased intestinal lactase activity in humans. Consequently, there is a greater exposure to glucose and galactose in diabetic patients with high lactose consumption. This may explain the association between diabetes and the risk of cataract.

Monoclonal origin of B cells producing k, lambda and k lambda immunoglobulin light chains in a patient with chronic lymphocytic leukemia.

Immunoglobulin gene rearrangements can be used as genetic markers of clonality in the study of B-cell populations [4]. We have therefore analysed the structure and expression of heavy and light chain immunoglobulin genes in lymphocytes of a patient with chronic lymphocytic leukemia, where we found both k and lambda producing B cells, but in most of the cells both k and lambda chains were co-expressed on the same surface membrane. Single rearrangements were observed in mu, JH, k and lambda DNA sequences, thus providing strong evidence for the monoclonal origin of the cells bearing different light chains. Moreover, the analysis of Ig sequence RNA showed, in addition to normal mu, k and lambda mRNA molecules, high levels of a small lambda related RNA sequence. These findings are discussed in relation to a model of B-lymphocyte differentiation which could be either an additional or an alternative hypothesis to the current one of isotypic exclusion.

Pulsatile gonadotrophin secretion in hypothyroid women of reproductive age.

Hypothyroid women may have various disturbances of the reproductive system. Although menstrual cycle disturbances and infertility have been reported in hypothyroidism, gonadotrophin levels have usually been found in the normal range. We have investigated whether female hypothyroid patients of reproductive age have any alteration in the pulsatile secretory pattern of gonadotrophin secretion. LH and FSH were assayed on days 2-5 of the menstrual cycle in blood samples taken every 10 min for 8 h from six hypothyroid women and six age-matched control subjects. Pulsatility was analysed using the Cluster and Detect programs. There was no significant difference in the number of peaks identified (3.7 +/- 0.8 vs 3.7 +/- 0.8 for LH, and 3.7 +/- 0.8 vs 4.2 +/- 0.5 for ESH), the mean duration of peaks (LH: 68.0 +/- 6.9 vs 72.7 +/- 5.1 min; FSH: 81.9 +/- 8.1 vs 71.2 +/- 10.3 min), the area under the peaks (LH: 91.5 +/- 20.4 vs 148.2 +/- 55.1 IU/l per min; FSH: 71.5 +/- 4.5 vs 62.7 +/- 15.0 IU/l per min), and the incremental amplitude from baseline (LH: 2.2 +/- 0.4 vs 3.0 +/- 0.8 IU/l; FSH: 1.4 +/- 0.2 vs 2.1 +/- 0.5 IU/ l). However, the absolute pulse amplitude was greater in hypothyroid patients (LH: 14.5 +/- 1.4 vs 8.3 +/- 1.3 IU/l, P < 0.01; FSH: 9.0 +/- 1.5 vs 5.8 +/- 1.2 IU/l, P = 0.04), as were the integrated concentrations (LH: 6.6 +/- 0.7 vs 3.2 +/- 0.4 IU/l per min, P < 0.01; FSH: 4.3 +/- 0.4 vs 2.1 +/- 0.5 IU/l per min, P < 0.01). Oestradiol values were comparable in the two groups (42.7 +/- 0.4 vs 43.5 +/- 9.7 pg/ml). These results indicate that in hypothyroid women there is an increased baseline level with a normal pulsatility of the gonadotrophin secretion. Similar oestrogen levels in both groups, and normal or near-normal cycles in our patients suggest either a decreased biological potency of the gonadotrophins or a mild ovarian resistance.

Effect of exogenous growth hormone administration on endogenous growth hormone secretion induced by a met-enkephalin analog.

Exogenous growth hormone (hGH) administration in humans attenuates the endogenous growth hormone (GH) response to some pharmacological stimuli; in particular, pretreatment with hGH completely blocks the serum GH response to growth hormone-releasing hormone. In order to evaluate the mechanism(s) whereby opiods induce GH secretion in man, we gave the following treatments to six healthy male volunteers: (a) IV saline; (b) a met-enkephalin analog G-DAMME 250 micrograms IV as a bolus at time 0'; (c) hGH 2 IU as an IV bolus at time -180'; (d) G-DAMME as above, preceded by hGH as above. In our study, G-DAMME stimulated GH secretion both basally (peak 17.9 +/- 6.0 ng/ml) and, to a lesser extent, after hGH pretreatment (6.0 +/- 2.7 ng/ml). Since in our study G-DAMME was able to partially overcome the inhibitory effect of hGH administration, it is suggested that opioids act through an inhibition of somatostatin release and not through a GHRH-dependent pathway. However, an additional direct effect of hGH on pituitary somatotrophes cannot be excluded.

Cytogenetic analysis of different cellular populations in chronic myelomonocytic leukemia.

Karyotypes of different cellular populations made after separation of bone marrow cells on a gradient of Percoll were evaluated in seven patients affected by chronic myelomonocytic leukemia diagnosed according to FAB criteria. Megakaryocytes, monocytic cells, and granulocytic and erythroid precursors were preferentially collected after centrifugation between density layers of 1045-1050 mg/ml, 1050-1060 mg/ml, and 1065-1070 mg/ml, respectively. The enriched cell fractions were cultured separately and submitted to cytogenetic investigation after short-term culture. Some chromosome aberrations (5q-,+8) were observed in all cellular fractions in three patients, thus providing cytogenetic evidence of the involvement of a common progenitor stem cell in this myelodysplastic disorder. On the other hand, chromosome abnormalities such as del(3)(q21) and del(11)(q23) appeared to be confined to the megakaryocytic and the monocytic fractions, respectively, in two patients. It is conceivable that lineage-restricted aberrations may develop as a consequence of a multistep clonal evolution and may show a close relationship with the hemopoietic differentiative processes.

Alpha interferon in T helper phenotype chronic lymphocytic leukemia: a report of three cases.

Three patients affected by T helper chronic lymphocytic leukemia were treated with low dose interferon alpha-2b (3 MU/m2 3 times weekly). The disease presented different pathologic expressions with diffuse skin lesions in one patient, a mild clinical course and a prolymphocytic variant with aggressive features, respectively, in the other two cases. A consistent response was observed within 3-6 weeks; by that time a reduction of blood and marrow lymphocytosis in the three patients and a regression of the cutaneous lesions were documented. Therefore, it should be emphasized that the use of alpha IFN, whose effectiveness on cutaneous T cell lymphomas has been already demonstrated, may represent an active agent in the treatment of leukemic T helper phenotype chronic lymphocytic proliferations.

Serum beta 2-microglobulin in malignant lymphoproliferative disorders.

Beta 2-microglobulin (B2m) was measured on serum samples in 274 patients with acute and chronic lymphoproliferative disorders (85 non-Hodgkin lymphomas-NHL, 30 Hodgkin lymphomas-HL, 34 B-cell chronic lymphocytic leukemias-B-CLL, 8 Waldenström macroglobulinemias-WM, 76 multiple myelomas-MM, 31 acute lymphoblastic leukemias-ALL, 10 hairy cell leukemias-HCL). Two hundred and four patients were studied at the time of diagnosis, and results were correlated to clinical stage, and histologic subtype in NHL, immunoglobulin type in MM, and immunologic phenotype in ALL. Moreover, B2m was tested during and after chemo- and/or radiotherapy, and results were correlated to response, progression or relapse. Elevated pretreatment B2m values were found in widespread forms of NHL and HL, in patients with B symptoms and in the unfavorable histologic subgroups of NHL. Rapid falls in levels followed therapy institution. In B-CLL and in MM a close relationship between B2m and cell mass was found. A significant B2m level reduction followed treatment, whereas its increase could detect a relapse. In ALL, serum B2m was only slightly above the normal range. B2m seems to reflect the total burden of malignant cells mainly in MM and B-CLL; in other lymphoproliferative disorders it provides less prognostic information.

Giant cell tumor of bone: a model for the in vitro human osteoclast characterization.

The in vitro growth pattern of cells obtained from bioptic material of ten patients with giant cell tumor of bone (GCT) was investigated. Cytochemical reactions and monoclonal antibodies raised against macrophage markers were tested on the two histologically identifiable GCT cell populations. Only monoclonal antibody EBM/11 stained both mononuclear and giant cells. EBM/11 positivity and resistance of acid phosphatase to high doses of tartrate strongly suggest that both mononuclear and giant cells belong to the same lineage.

Calcium ion and pituitary hormones: effect of calcium channel blockers on stimulated secretion of pituitary hormones.

The effects of two calcium channel blockers nifedipine (20 mg sublingual), and verapamil (10 mg i.v.) on growth hormone (GH), thyrotropin (TSH), prolactin (PRL) and gonadotropin (LH and FSH) secretion induced by growth hormone releasing hormone (GHRH), hypoglycemia, thyrotropin releasing hormone (TRH), metoclopramide and gonadotropin releasing hormone (GnRH), were studied in a group of normal volunteers (27 men and 8 women). Neither nifedipine nor verapamil had any effect on PRL, TSH or gonadotropin release. Verapamil did not cause variations in GH secretion following GHRH and insulin-induced hypoglycemia, whereas nifedipine significantly reduced the elevation in GH induced by GHRH; however the GHRH-mediated GH rise still remained within the normal range in all subjects. Our results suggest that neither nifedipine nor verapamil have important effects on stimulated pituitary hormone secretion, at least under conditions of acute administration.

[Multichannel cochlear implant: personal experience]. / L'impianto cocleare multicanale. Nostra esperienza.

Cochlear Implantation is a recognized procedure for acoustical rehabilitation of the profoundly or totally deaf unable to effectively use a traditional hearing aid. Since 1989, 30 patients (27 postlingual and 3 perilingual) have been operated on by the senior Author with the implantation of a multichannel device: Med-El (3 cases), Clarion (3 case) and Nucleus Mini-22 (24 cases). The first 24 Nucleus cases, with a multipeak speechcoding strategy, are the object of this retrospective report. Selection of patients was performed according to an international protocol which includes PTA and Speech Audiometry, CT and/or MRI imaging of the ear, the Promontorial Test, an evaluation of lip reading ability, a psychological evaluation, a trial with two recent and currently available aids. The operation was carried out under general anesthesia. An extended endaural approach was adopted. The internal package of the device was firmly seated onto the temporalis squama and the electrode array was introduced into the tympanic cleft via a posterior tympanotomy. The electrode system was inserted into the scala tympani through a cochleotomy drilled out at the anteroinferior border of the round window. The whole system was fixed to the bony walls of the mastoid and squama using an ionomeric bone bonding agent. Starting at the second postoperative month and up to the 24th month of utilization of the device, each patient was evaluated with regard to his or her ability to recognize environmental sounds, to detect prosody transitions and to understand speech with and without visual cues. Selected tests, either close or open set, were used from the MAC and the Iowa Cochlear Implant Battery, as well as the Helen test. Telephone conversation was also evaluated. Results were very encouraging in all cases, showing that the multichannel cochlear device provides the properly selected patient a substantial auditory rehabilitation allowing him or her to understand speech in most instances without any visual cue.

[Single-blind study of the effect of doxazosin mesylate in benign prostatic hypertrophy]. / Etude en simple aveugle de l'efficacité du Mesylate de Doxazosin dans l'hypertrophie bénigne de prostate.

The purpose of this single blind study was to verify the efficiency of Doxazosin Mesylate, an alpha-1 adrenergic blocker, in patients with benign prostatic hyperplasia (BPH). This study involved 20 patients non placebo responders. The duration of treatment was 45 days with administration of Doxazosin Mesylate increased every 15 days from 1 to 2 mg and from 2 to 4 mg respectively. At the end of each dosage cycle the following investigations were performed: a) peak urinary flow, b) residual urinary volume, c) funneling of the prostatic urethra by means of permictional transrectal echography, d) Boyarsky's score. The analysis of these data, applying a two way analysis of variance (ANOVA), showed that Doxazosin Mesylate resulted in improvements in both urodynamic and symptomatic parameters. The statistical analysis proved also that there was a good correlation between the dosage of the drug up until 2 mg and the results from each parameter considered.

[Effect of imipramine hydrochloride on urinary function and serum parameters in enuretic children: preliminary study]. / Action de l'Hydrochloride d'Imipramine sur la fonction urinaire et sur les paramètres sériques chez les enfants énurétiques: étude préliminaire.

We still do not know whether Imipramine works exactly as an antidiuretic. The aim of this study was to investigate any existing urinary or serum factor differences between 9 children with primary nocturnal enuresis and six age and sex matched controls and to see if therapy with Imipramine could modify these parameters. All subjects underwent an evaluation of daily and nightly urinary volume, daily fluid intake, morning plasma and urine osmolality, plasma aldosterone, electrolytes, blood urea nitrogen and plasma glucose. The results, using a one-way ANOVA, would suggest the following: 1) enuretic children have a higher 24 urinary volume with a reduced osmolality compared to controls; 2) Aldosterone does not seem to be involved in the pathogenesis of enuresis; 3) Imipramine HCL therapy does reduce the volume of urine lost in diapers, and its efficiency can be documented objectively; 4) Imipramine HCL's mechanism appears to be related to an increased renal water resorption.