Corticosteroid receptor function is decreased in depressed patients

Decreased feedback control of the hypothalamic-pituitary-adrenocortical (HPA) system as revealed by the combined dexamethasone and corticotropin-releasing hormone (DEX-CRH) test has been documented in the vast majority of patients with affective disorders. This finding was interpreted as a failure at the level of the glucocorticoid receptor (GR)-mediated feedback action, which apparently fails to restrain HPA activity in the presence of elevated plasma corticosteroid levels. To test this hypothesis we conducted the DEX/CRH test using increasing doses of DEX in order to establish a dose-response relationship. We used three different DEX doses (0.75, 1.5, 3.0 mg) in three groups of depressed patients and controls. As expected, increasing DEX doses were associated with decreasing amounts of adrenocorticotropin (ACTH) and cortisol being released after CRH injection. However, dose-response curves for both plasma ACTH and cortisol concentrations were shifted to higher area under the curve (AUC) values among patients compared to controls. Pretreatment with 0.75 and 1.5 mg DEX produced significantly higher AUC values for both plasma ACTH and cortisol values among patients. These differences became less obvious with the higher DEX doses, indicating that the dose of 1.5 mg used in the majority of clinical studies so far is well suited to differentiate between healthy controls and patients. The reported data here are consistent with the hypothesis that an altered GR capacity or function underlies the exaggerated HPA activity in depression.

[Comparative tribological studies of Chirulen, Hylamer and Enduron combined with A1203]

The creep and wear behaviour of Chirulen, Hylamer and Enduron, materials which differ only in their manufacturing procedures, was examined and compared. Chirulen is manufactured by being pressed into form by plates, whereas Hylamer and Enduron are shaped by tubes. Hylamer differs from Enduron in that intermediate material processing is undertaken with the goal of improving the initial material. The wear and deformation rate was determined by means of the ring-on-disc testing device after 360,000 cycles and after 1.0 x 10(6) cycles, respectively. The static tests for the determination of wear were carried out at a contact stress of 5.62 MPa and a testing time of 100 h in analogy to the ring-on-disc tests. Chirulen and Hylamer demonstrated comparable wear with a tendency toward a lower wear rate in Hylamer, while Enduron presented a clearly higher wear rate.

[Experimental studies of metal-metal slide combinations and their value in relation to expected in-vivo behavior]

A simulator test was carried out in the hip joint simulator on a metal-on-metal coupling of a modified CoCrMo alloy. The test was run up to 1.9 million cycles and the tribological behaviour of the coupling was documented by means of roundness measurements and scanning electron microscopy. It is seen that the tribological system metal on metal is characterized by mixed friction in the artificial hip joint, thus generating material contacts that are documented by the roundness variation and by the SEM contact zone analysis, showing "three-body" wear of this system. The roundness variations indicate that running-in wear is to be noticed at first with a decreasing tendency over the 1.9 million cycles. Nevertheless, this observation does not allow any prognosis as to the wear rates in the case of a higher number of cycles. It must be taken into consideration that aqua destillata had to be used as a lubricant for technical reasons; the use of serum/Ringer solution might have produced different results. Further investigations in the hip joint simulator and on revised metal-on-metal couplings will be carried out in this respect.

Menopause-associated differences in female fat patterning estimated by dual-energy X-ray absorptiometry

The aim of the present study was to describe and quantify the typical changes in fat patterning from premenopause to postmenopause. The absolute and relative fat and lean body mass were estimated using dual-energy X-ray absorptiometry in 461 healthy non-obese females between the ages of 18 and 64 years (x = 43.2). Significant differences (p < 0.001) in absolute and relative fat mass, body weight and body mass index between pre-, peri- and postmenopausal females were observed. Postmenopausal women were significantly heavier (BMI, x = 26.8) than perimenopausal (BMI, x = 24.4) and younger and older premenopausal women (BMI, x = 22.8) and showed significantly higher fat percentages (fat% x = 38.1) in comparison to perimenopausal (x = 36.8) and premenopausal females (x = 31.4). Three indices, upper body composition index, lower body composition index and fat distribution index were calculated. Typical differences in fat distribution patterns between females of differential menopausal status were found. During the premenopausal phase a more gynoid type of fat distribution prevailed, during the postmenopausal phase a more android kind of fat distribution occurred predominantly. The fat distribution during the perimenopause can be interpreted as less gynoid than during the premenopause.

MRI of microadenomas in patients with hyperprolactinaemia

MRI is a sensitive tool for the investigation of pituitary microadenomas but cannot be used as a screening investigation. To establish a strategy for the use of MRI in patients with hyperprolactinaemia we investigated 74 women with serum prolactin levels above 52 ng/ml for the presence of microadenomas. We examined 55 premenopausal and 19 postmenopausal women, using a 1.5 T unit. We used T1-weighted spin-echo sequences, with coronal and sagittal images before and after intravenous gadolinium. We found microadenomas in 38 patients (51.3%), macroadenomas in 6 (8.1%) and an infundibular glioma in 1;29 patients had a normal pituitary gland (39.2%). The size of the adenomas was related to the prolactin level, and the mean level in patients with MRI evidence of adenomas was higher than in patients without microadenomas (155.72 +/- 131.01 ng/ml versus 110.14 +/- 80.86 ng/ml). The probability of the presence of an adenoma increased with rising serum prolactin levels. We suggest MRI in patients with prolactin levels more than 100 ng/ml. In patients on oestrogen therapy MRI should be performed with only slightly elevated prolactin levels. Evidence of a microadenoma should be considered in planning further therapy, especially concerning the use of hormone replacement therapy or of bromocriptine.

Increased levels of activated factor VII and decreased plasma protein S activity and circulating thrombomodulin during use of oral contraceptives

In the present study the effect of oral contraceptive (OC) treatment on selected factors involved in the activation, i.e. circulating activated factor VII (cFVIIa), and in the inhibition of blood coagulation, i.e. plasma protein S activity and circulating thrombomodulin (cTM), were for the first time measured in OC users in a prospective study. Beside other coagulation variables, these parameters were measured during treatment with three low estrogen formulations containing different gestagen components (norgestimate, gestodene). During OC treatment increases in the activation markers prothrombin fragment F1 + 2 and D-Dimer were found, suggesting an increased activation of blood coagulation and fibrinolysis. Along with elevated plasma levels of FVII antigen, cFVIIa was also found increased in all three treatment groups, while inhibitory components of blood coagulation, plasma protein S activity and cTM, significantly and similarly decreased during treatment in all three treatment groups. We conclude that low dose estrogen pills induce similar changes in the plasma levels of main regulatory components of blood coagulation, despite differences in their gestagen components. Increased levels of activators and decreased activities of inhibitors may contribute to arterial and venous thrombotic complications seen in predisposed OC users.

Serum levels of sex hormones, thyroid hormones, growth hormone, IGF I, and cortisol and their relations to body fat distribution in healthy women dependent on their menopausal status

The relations between 10 anthropometric variables describing the amount of adipose tissue and the serum levels of thyroxine, triiodothyronin, thyroid stimulating hormone, estradiol, progesterone, 17-hydroxyprogesterone, prolactin, luteinizing hormone, follicle stimulating hormone, DHEA-S, androstendion, testosterone, sex hormone binding globulin, growth hormone, IGF I as well as cortisol were investigated in 39 premenopausal and 38 postmenopausal women. Several statistically significant correlations between hormonal parameters and the amount and the distribution of subcutaneous fat tissue were found for the premenopausal group. The postmenopausal probands, however, showed fewer statistically significant connections between the two trait systems. The correlation patterns in both proband groups resembled each other. Only with regard to the gonadotropines (LH and FSH) a difference in the algebraic sign of the correlation coefficients can be observed for pre- and postmenopausal probands. The multiple regression analysis corroborated the hypothesis that hormonal parameters are responsible for somatic changes after menopause.

Effects of hormonal replacement therapy on plasma sex hormone-binding globulin, androgen and insulin-like growth factor-1 levels in postmenopausal women

Plasma sex hormone-binding globulin (SHBG) levels are important in the regulation of plasma free and albumin-bound androgens and estrogens. In postmenopausal women associated to the decrease of estrogen production, a decrease of plasma SHBG levels occurs. Hormone replacement therapy (HRT) in postmenopausal women modulates plasma SHBG levels, in relationship with the different regimens and routes of administration. The present study aimed to compare the effect of different HRT on plasma SHBG levels in relationship with the changes of plasma androgen [dehydroepiandrosterone sulphate (DHEAS), testosterone (T), androstenedione (A)] and insulin-like growth factor-1 (IGF-1) levels. In a retrospective study 443 postmenopausal women were studied and divided into 2 groups. The group 1 (n = 170) was subdivided in 4 groups of women as follows: A) treated with transdermal 17-beta estradiol + medroxyprogesterone acetate, B) treated with oral conjugated estrogens, C) treated with sequential HRT (estradiol valerate (EV) + norgestrel), and D) treated with a combined HRT (micronized estradiol (E2) + noretisterone acetate). Women of group 2 (n = 273) did not receive HRT and served as controls. All groups of women treated with different HRT showed plasma estradiol levels significantly higher than controls (p < 0.01), showing the highest values in women treated with oral HRT. Plasma SHBG levels were not significantly different between patients treated with transdermal 17-beta estradiol + medroxyprogesterone acetate and controls. On the other hand, all the groups of patients treated with oral conjugated estrogen with or without progestagens showed plasma SHBG levels significantly higher than controls (p < 0.01). Plasma SHBG levels were higher in the group treated with estrogen alone than in groups of women treated with sequential or combined HRT. Plasma DHEAS, T and A levels in patients treated with different HRT regimens were in the same range of levels as control women. Plasma IGF-1 levels were not significantly affected by the various HRT regimens and remained in the same range as controls. In conclusion, plasma SHBG levels increase following oral HRT while are not affected by transdermal HRT. Plasma IGF-1 and androgen levels are not influenced from oral or transdermal HRT.

Poststroke rehabilitation in older Americans. The Medicare experience

OBJECTIVES

This study examines the poststroke rehabilitation experience for a 20% sample of Medicare patients age 65 years and older admitted to an acute-care hospital with a stroke diagnosis during the 6-month interval, January 1, 1991 to June 30, 1991. Their Medicare claims data are used for two purposes: to identify current poststroke rehabilitation practice in the US population age 65 years and older, and to evaluate the importance of practice variation within this population.

METHODS

Regarding the first objective, the authors develop estimates for many poststroke rehabilitation use and cost parameters that formerly were unmeasured. With respect to the second objective, the authors construct and compare average service use rates across all stroke patients in a census division and across all stroke patients residing in the 30 largest metropolitan statistical areas.

RESULTS

The authors' Medicare claims analysis indicates that 73% of stroke survivors received either postacute institutional or ambulatory rehabilitation care during the first 6 months poststroke. The published stroke literature, on the other hand, focuses on the minority of stroke survivors, 16.5% in the Medicare data, who were admitted to an inpatient rehabilitation hospital. Regarding the second study objective, the Medicare analysis provides graphic evidence that poststroke rehabilitation practice varies substantially from one geographic area to another and that practice differences translate into large geographic-related differences in the cost of poststroke rehabilitation.

CONCLUSIONS

The authors believe the findings demonstrate a problem with inconsistent poststroke rehabilitation practice.

Measurement of amniochorionic membrane thickness using high-frequency ultrasound

Premature rupture of the membranes (PROM) accounts for approximately 30 per cent of all preterm deliveries. PROM is thought to be mainly due to a decrease in membrane integrity. The aim of our investigation was to determine, post-partum after 28 normal deliveries, the thickness of the amniochorionic membrane using a 20 MHz high-frequency ultrasound. The data obtained were compared with histological sections for measurement accuracy using a linear regression analysis method. The membrane thickness of the total study group was 0.83 +/- 0.11 mm (0.72-1.08 mm). Based on a statistical comparison with the histological sections, the high-frequency ultrasound examination was shown to be highly reliable, with a correlation coefficient of r = 0.96 (P < 0.0001). High-frequency ultrasonographic examinations of membrane thickness are an objective and reliable method and may be a gain to prenatal diagnostics once this method can be used in vivo.

The effects of estradiol valerate plus medroxyprogesterone acetate and conjugated estrogens plus medrogestone on climacteric symptoms and metabolic variables in perimenopausal women

BACKGROUND

Two sequential hormone replacement regimens, containing either estradiol valerate plus medroxyprogesterone acetate (E2V/MPA) or conjugated estrogens plus medrogestone (CE/MED), were compared with respect to effects on climacteric symptoms, lipid metabolism, and hemostasis.

METHODS

In an open, multicenter study, 51 perimenopausal women were randomized to E2V/MPA and 50 to CE/MED. Assessment of climacteric complaints was performed at baseline and at months 1, 3, and 6. The effects on lipid and hemostatic variables were measured at baseline and at month 6. Quantitative data were analyzed using analysis of variance, the paired t-test or the chi2 Mantel-Hanszel test, where appropriate. RESILTS: Efficacy regarding treatment of climacteric symptoms was with E2V/MPA as good as with CE/MED, with a statistically significant reduction of most symptoms in both groups. After 6 months, total cholesterol and triglycerides had remained unchanged in both groups. High-density lipoprotein cholesterol showed no significant change with E2V/MPA, whereas an increase was noted in the CE/MED group (p<0.05). Low-density lipoprotein cholesterol was decreased with E2V/MPA (p<0.01) and was unchanged in the CE/MED group. Hemostatic parameters showed no significant changes after 6 months, with the exception of a decreased prothrombin time with E2V/MPA (p<0.05). Acceptability was excellent, expressed by the low incidence of treatment-related drop-outs in both groups.

CONCLUSIONS

E2V/MPA is a one tablet per day sequential HRT regimen, which is as effective and acceptable as hormone replacement therapy with CE/MED regarding treatment of climacteric symptoms. Neither preparation had negative effects on lipid metabolism and hemostatic variables.

Hormonal, syndromal and EEG mapping studies in menopausal syndrome patients with and without depression as compared with controls

The aim of the study was to investigate brain function in menopausal depression by EEG mapping, as compared with menopausal syndrome patients without depression and normal controls, and to correlate neurophysiological with clinical and hormonal findings in order to elucidate the pathogenesis of depression in the menopause.

METHODS

One hundred and twenty-nine menopausal women, aged 45-60 years, with no previous hormonal replacement therapy were investigated in regard to hormones (estradiol [E2], follicle stimulating hormone [FSH]), clinical symptomatology (Kupperman Index [KI], Hamilton depression score [HAMD]) and brain function (EEG mapping). Based on KI and DSM-III-R research criteria for major depression, 3 groups were available for statistics (after removal of protocol violators): group A had a KI of <15 and no depression (n = 29); group B had a KI of > or = 15 and no depression (n = 29) and group C had a KI of > or = 15 and fulfilled the criteria for major depression (n = 60).

RESULTS

EEG maps of depressed patients demonstrated less total power and absolute power in the delta, theta and beta band, more relative delta and less alpha power as well as a slower delta/theta and faster alpha and beta centroid than controls, suggesting a vigilance decrement. Group B did not differ from group A. Correlation maps showed significant relationships between estradiol levels and EEG measures (the lower the E2, the worse the vigilance) and between the EEG measures and the Hamilton depression (HAMD) score (the worse the vigilance, the higher the depression score). There were no correlations between the hormones E2 and FSH and the syndromes KI and HAMD. In the target variable, the asymmetry index, depressed patients showed less alpha power over the right than left frontal lobe, whereas normal controls exhibited the opposite. Group B did not differ from group A. The frontal asymmetry index was significantly correlated with the Hamilton depression score and suggests right frontal hyper- and left frontal hypoactivation in depression.

CONCLUSIONS

Although hormonal findings are not directly linked to psychic changes, low estradiol levels do contribute to a decreased vigilance at the neurophysiological level , which is in turn correlated with higher depressive and menopausal symptomatology at the behavioural level. Depression is further correlated to a right frontal hyper- and left frontal hypoactivation.

Decreased sexual interest and its relationship to body build in postmenopausal women

OBJECTIVES

The relationship between body build, androgen levels and changes in sexual interest after menopause was investigated in 171 postmenopausal women from Vienna, Austria.

METHODS

All women were interviewed using a structured questionnaire. Body build was determined by employing five absolute body dimensions and four anthropometric indices.

RESULTS

Body weight, as well as the amount of subcutaneous centripetal fat (such as in the chest, waist and hip region), were statistically significantly related to the degree of reduced sexual interest. Corpulent and heavy women suffered far more frequently from a severe decrease in sexual interest after menopause. Statistically significant associations between androgen levels and decrease in sexual interest could not be demonstrated.

CONCLUSIONS

Reduced sexual interest is associated with a kind of body type not corresponding to the culture-specific beauty ideals of our society, first of all evident in women whose menopause occurred relatively early.

Tibolone versus conjugated estrogens and sequential progestogen in the treatment of climacteric complaints

OBJECTIVE

Tibolone has been shown to alleviate climacteric symptoms. This study was designed to compare the effect of tibolone (Livial, 2.5 mg daily) on different climacteric complaints and its impact on the endometrium, determined by vaginal ultrasound, with that of conjugated estrogens (Premarin, 0.625 mg daily) continuously for 6 months in combination with the progestogen medrogestone (Colpron, 2 x 5 mg daily for 12 days each month).

METHODS

One hundred and twenty-nine postmenopausal women were recruited and the severity of climacteric symptoms as well as endometrial thickness were recorded at the pre-trial examination and after 1, 3, and 6 months.

RESULTS

With the exception of vertigo, mood depression, mood disorder, loss of libido, and dryness of skin, where tibolone was found to be more effective than conjugated estrogens/medrogestone, climacteric symptoms improved significantly in both groups over the 6-month study period. Endometrial thickness did not increase significantly in the tibolone group, whereas in the conjugated estrogens/medrogestone group there was a highly significant increase after 1 month and still a trend towards significance after 6 months. Recurrence of vaginal bleeding occurred significantly less frequently in the tibolone group than in the comparison group.

CONCLUSION

Tibolone seems to offer a complete treatment of the climacteric complaints whilst avoiding some of the problems associated with classical hormone replacement therapy.

Systematic strength training as a model of therapeutic intervention. A controlled trial in postmenopausal women with osteopenia

Physical exercise is often recommended as a therapeutic tool to combat pre- and postmenopausal loss of bone density. However, the relationship between training dosage (intensity, duration, frequency) and the effect on bone density still is undergoing discussion. Furthermore, the exercise quantification programs are often described so inadequately that they are neither quantitatively nor qualitatively reproducible. The aim of this investigation was to determine whether a clearly defined training of muscle strength, under defined safety aspects, performed only twice weekly, can counteract bone density loss in women with postmenopausal osteopenia. Data from 16 women in the training group (age, 63.6 +/- 6.2 yr) and 15 women in the control group (age, 67.4 +/-9.7 yr), of comparable height and weight, were evaluated. Strength training was performed for 6 mo as continually adapted strength training, providing an intensity of about 70% of each test person's one repetition maximum. Bone mineral density of lumbar vertebrae 2 to 4 and the femoral neck was measured by dual-energy x-ray absorptiometry. Maximum performance in watts and parameters of hemodynamics were controlled with a bicycle ergometer test to maximal effort. In addition, metabolic data were assessed. In the lumbar spine and femoral neck, the training group showed no significant changes, whereas the control group demonstrated a significant loss of bone mineral density, especially in the femoral neck (P<0.05). The strength increase was highly significant in all exercised muscle groups, rising to about 70% above the pretraining status (P<0.001). Heart rate and blood pressure data indicated a slight economization, metabolism was not significantly influenced. Based on these findings, we conclude that continually adapted strength training is an effective, safe, reproducible, and adaptable method of therapeutic strength training, following only two exercise sessions per week.

[Effect of surface energy on wear characteristics of material combinations for the artificial hip joint]

One of the factors determining the wear of UHMWPE used as acetabular cup material is the lubricating properties of the head materials. In order to determine the lubricating properties, the wettability of Al2O3, ZrO2, CoCrMo and N-coated TiAl6V4 was established. Wettability is determined by the surface energy of the head material (solid-state material), which was measured via the contact angle of drops of fluid. As head material, appropriate rings from the Ring-on-Disc Test as per International Standard 6474 were used. The poorest wettability was associated with CoCrMo. The wettability of Al2O3 and ZrO2 was comparable. Worthy of note is the tendentially good wettability of N-coated TiAl6V4.

Double-blind, placebo-controlled, hormonal, syndromal and EEG mapping studies with transdermal oestradiol therapy in menopausal depression

In a double-blind, placebo-controlled study, the antidepressant and vigilance-promoting properties of transdermal oestrogen in post-menopausal depression were investigated utilizing hormonal, syndromal and EEG mapping evaluations. Sixty-nine menopausal women, aged 45-60 years without previous hormonal replacement therapy, diagnosed as major depression without psychotic or suicidal symptoms (DSM-III-R criteria), were randomly assigned to a 3-month treatment with transdermal oestradiol [Estraderm TTS (ETTS) 50 micrograms, applied twice weekly] or placebo. No other psychoactive medication was allowed. After removal of protocol violators, 32 patients were evaluable in each group, which did not differ in age, height or weight. As five patients discontinued prematurely in both groups and in one placebo patient a post-drug EEG could not be obtained, 27 patients remained in the ETTS and 26 in the placebo group for efficacy analysis. While in the placebo group, oestradiol (E2) and follicle stimulating hormone (FSH) remained unchanged, E2 increased and FSH decreased significantly in the ETTS group. Syndromal evaluation showed a significant improvement in the Kupperman Index (KI) as well as Hamilton Depression Rating Scale (HAMD) in both groups, with no inter-group difference. However, EEG mapping demonstrated significant inter-drug differences in brain function, mostly over the left temporal region. While ETTS patients showed an increase of alpha and alpha-adjacent theta activity and a decrease of beta activity, as well as an acceleration of the delta/theta centroid and a slowing of the alpha, beta and total power centroid, no changes occurred in the placebo-treated patients. These neurophysiological findings suggest improvement of vigilance by oestrogen, previously referred to as "mental tonic" effect. There were no changes, however, in the frontal alpha asymmetry index, reflecting left frontal hypo- and right frontal hyperactivation. Thus, this neurophysiological variable represents a state-independent marker for depression. The tolerability of ETTS was very good.

Effects of hormone replacement therapy on growth hormone secretion patterns in correlation to somatometric parameters in healthy postmenopausal women

OBJECTIVES

The aim of the present study was to investigate the influence of a continuous estrogen, cyclic progesterone replacement therapy on the secretion of growth hormone (GH) and IGF I as well as of somatometric-GH correlation patterns.

METHODS

The study included 23 healthy postmenopausal women. Of the proband group 13 randomly selected women were treated with orally applicated 2 mg estradiol-valerat (E2V) and 10 mg dydrogesterone for 10 months. Ten women did not receive any hormonal treatment during this time. After 10 months all probands were reexamined and their GH and IGF I secretion, as well as their somatometric-hormonal correlation patterns, compared with those of a fertile control group.

RESULTS

It could be shown, that in postmenopausal women a 10-month oral hormone replacement therapy led to a significant increase of GH- and IGF I levels, however, the treated postmenopausal women did not reach the levels of the fertile controls. Those women who did not receive any hormonal treatment and the postmenopausal women before HRT showed nearly identical GH- and IGF I levels as well as somatometric-GH correlation patterns.

CONCLUSIONS

The results of the present paper indicate a marked influence of estrogens on GH and IGF I secretion. Furthermore, hormonal replacement therapy (HRT) may influence somatometric GH correlation patterns too.