Sensory motor cortex: correlation of presurgical mapping with functional MR imaging and invasive cortical mapping

PURPOSE

To describe a clinically useful application of functional magnetic resonance (MR) imaging--presurgical mapping of the sensory motor cortex--and to validate the results with established physiologic techniques.

MATERIALS AND METHODS

Functional MR mapping of the sensory motor cortex was performed in two women, aged 24 and 38 years. Both had intractable, simple partial motor seizures due to tumors located in or near the sensory motor cortex. They subsequently underwent invasive cortical mapping--direct cortical stimulation and/or sensory-evoked-potential recording--to localize the affected sensory motor area prior to tumor resection.

RESULTS

In both patients, the functional MR study demonstrated task activation of the sensory motor cortex. In both cases, results of cortical functional mapping with invasive techniques matched those obtained with functional MR imaging.

CONCLUSION

Presurgical mapping of the sensory motor cortex is a potentially useful clinical application of functional MR imaging.

Three-dimensional display in the evaluation and performance of neurosurgery without a stereotactic frame: more than a pretty picture?

Display of three-dimensionally rendered images derived from radiological data sets is often suggested to be useful for surgical and radiation treatment planning in neurosurgery. Nevertheless, physicians will often note (off the record) that these rendered images are 'just a pretty picture' and are not clinically useful. This paper will discuss our three-dimensional rendering and quantitative analysis software and its primary use in evaluating and utilizing frameless stereotactic methodologies. A variety of concepts and techniques will be discussed. Specifically, a computer graphic and statistical-based technique will be presented that enables timely and measurable image registration between radiological image space and the coordinate system of computer-driven surgical devices in the operating room. This technique may be utilized to maintain a surgeon's orientation and to quantitatively and graphically monitor the position of probes and instruments in the surgical field. Three-dimensional quantitative results of phantom testing will be presented. Correlation to and validation against stereotactic imaging calculations using the compass stereotactic system will also be discussed. These computer graphic/statistical-based techniques are applicable for evaluating the accuracy of any frameless stereotactic device including, but not limited to robotic arms, spark gap, LED and magnetic field digitizers.

The limited value of cytoreductive surgery in elderly patients with malignant gliomas

In this retrospective, consecutive series of 128 elderly patients (over 65 years of age) with histologically proven Grade 4 astrocytomas, 88 patients underwent stereotactic biopsy and 40 patients underwent stereotactic volumetric resection of the mass lesion defined by contrast enhancement on computed tomography. There were no significant differences in age (average age in the biopsy group, 71.6 yr; resection group, 70.15 yr) or Karnofsky Performance Scores (biopsy group, 84.33; resection group, 83.88) between the two groups. Four of the biopsy patients and one of the resection patients died within 30 days of surgery. The overall mean survival was 126 days; 108 days (15.4 wk) in the patients who had biopsies and 189 days (27 wk) in the patients who had resections. Radiation therapy was completed in 62 of the patients who had biopsies (mean survival, 118 d or 16.9 wk) and 34 of the patients undergoing resection (mean survival, 210 d or 30 wk) (log rank P = 0.0215; Smirnov P = 0.006). Although some prolongation of survival is noted after resection (more than after a biopsy) in selected patients over 65 years of age, that benefit is modest.

Bone loss after heart transplantation: a prospective study

Osteoporotic fractures result in substantial morbidity after heart transplantation. To measure the acute effects of corticosteroids on bone after heart transplantation, we measured bone mineral density by dual energy x-ray absorptiometry and biochemical indexes of bone turnover in 25 patients (21 male, 4 female) at baseline, 6 months, and 12 months after transplantation. Two patients sustained vertebral fractures. Bone loss was rapid in the first 6 months, occurred in 24 of 25 (96%) patients, and was most marked from the lumbar spine (mean +/- SD, -7.4% +/- 4.5%). In the second 6 months little further bone loss was evident (lumbar spine, -7.8% total over 12 months) despite continuing moderate maintenance doses of corticosteroids. Serum osteocalcin and testosterone levels rose and urinary hydroxyproline:creatinine level ratio fell significantly by 6 months. Bone loss from the lumbar spine correlated inversely with serum osteocalcin level at 6 months. Serum osteocalcin level was the only significant predictor of lumbar spine bone loss by multiple regression analysis that included age, corticosteroid dose, cyclosporine dose, lean body mass, and body mass index. These data suggest that prophylactic therapy to prevent bone loss may only be necessary in the first 6 to 12 months after heart transplantation.

A stereotactic magnetic field digitizer

A three-dimensional magnetic field digitizer has been interfaced the COMPASS Stereotactic System to act as a measuring device aiding in computer-assisted volumetric procedures. Reference points on the stereotactic headholder are used to create a transformation matrix to convert the digitizer coordinates to stereotactic coordinates, allowing the location of the stylus to be displayed on CT and reconstructed tumor volume images to maintain the surgeon's orientation. This technology is an adjunct to and employs treatment planning software of the system to calculate a target and determine a safe trajectory to a lesion. Environmental effects of the magnetic field have been studied to determine overall accuracy and reliability of the system. A device was developed to map the magnetic field in efforts to compensate for environmental effects. The device has been utilized on five procedures. We have found it to be a useful tool in aiding the surgeon in locating the surgical field preoperatively and maintaining orientation intraoperatively.

An assessment of the reproducibility of combined glottography in a clinical setting

Although combined glottography has potential as a clinical tool, it has had limited use in the monitoring of laryngeal function before and after treatment. There is no data about the standardization nor reproducibility of the procedure. An indication of the reproducibility of combined glottography is paramount if changes in laryngeal function are to be measured accurately. Using a standardized technique, two complimentary studies examined the reproducibility of combined glottography within one sitting (Study 1) and over time (Study 2). The components of variance were analysed (ANOVA). In Study 1 the variance under controlled conditions for Open Quotient (OQ) and Speed Quotient (SQ) was only 13% and 18% respectively of the total, whilst in Study 2 the variance over time for OQ and SQ was 55% and 58% respectively. Under controlled conditions combined glottography is a reproducible technique.

MRI assessments of hippocampal pathology in extratemporal lesional epilepsy

We performed a prospective study in 18 patients to determine the extent of MRI-identified hippocampal pathology in patients with intractable partial epilepsy of extratemporal origin. A mesial temporal signal-intensity alteration or hippocampal formation (HF) atrophy, or both, have been shown to be reliable markers of the temporal lobe of seizure origin in patients with mesial temporal sclerosis. All patients subsequently received surgical ablative therapy between 1988 and 1992. During shortterm follow-up, 14 of the 18 patients experienced a significant reduction in seizure tendency, and 12 patients were rendered seizure-free. Qualitative and quantitative (HF volumetry) assessments of HF pathology were performed retrospectively by a blinded investigator. No hippocampal imaging alteration was present in 17 patients. Left HF atrophy was confirmed in one patient with post-traumatic epilepsy who underwent a successful right frontal lobectomy. Morphometric MRI studies rarely identify hippocampal pathology in patients with extratemporal epilepsy.

Infections with Babesia canis and Ehrlichia canis in dogs in Zimbabwe

Of 105 dogs examined at a veterinary hospital in Harare, Zimbabwe, 52 per cent had antibodies reactive with Ehrlichia canis in indirect fluorescent antibody tests, 26 per cent had Babesia canis parasites in peripheral blood smears and 17 per cent had both infections. None of the dogs with serological evidence of ehrlichiosis had typical E canis morulae detectable in blood smears. The infections were regarded as incidental findings not readily related to the reasons for examination in 46 per cent of the dogs with antibodies to E canis and 17 per cent of the dogs with both infections. The most common laboratory abnormalities were anaemia and thrombocytopenia and the prevalence and severity of these in concurrent infections were intermediate to those found in individual infections. There were no pathognomonic clinical signs or laboratory abnormalities which could be used to distinguish between individual and concurrent infections. However, there was a significantly higher prevalence of non-regenerative anaemia in dogs with antibodies to E canis than in dogs with both infections. The prevalence of thrombocytopenia was significantly higher in dogs with babesiosis than in dogs with antibodies to E canis and the prevalence of hyperglobulinaemia was significantly higher in dogs with both infections than in dogs with antibodies to E canis.

p53 protein overexpression identifies a group of central primitive neuroectodermal tumours with poor prognosis

Primitive neuroectodermal tumours (PNET's) or medulloblastomas are common primary brain tumours of childhood. Current treatment protocols achieve 50-60% cures. However, it has proved difficult to develop better treatment for the remaining patients because prognostic factors are not established. We have investigated the prognostic value of p53 protein expression in 87 PNET's using immunohistochemistry with DO-7 and CM-1 antibodies on biopsy paraffin sections. Eight patients (9%) had intensely reactive tumour cell nuclei, and a significantly reduced survival (P = 0.002); only one survives and this with a recurrent tumour 50 months following diagnosis. Sixty eight per cent of patients had faintly reactive tumour cell nuclei, a reduced survival up to 4 years but a long term survival not significantly different (P = 0.41) from 23% of patients with p53 negative PNET's; the 10 year survival rates were 37% and 40%, respectively. Males had a reduced survival (P = 0.04) with a 2-fold relative risk of death compared to females. Multivariate analysis showed that intense overexpression of p53 protein identifies a group of PNET patients with a 7-fold relative risk of death compared to all other cases, irrespective of sex. This marked difference suggests the involvement of p53 in the pathogenesis of PNET's which have a particularly poor response to treatment, and should help to develop new therapies for this group of patients.

Dairy cows as reservoirs of Coxiella burnetii in Zimbabwe

Sera obtained from 274 dairy cows in commercial dairies around Zimbabwe examined by indirect immunofluorescence for antibodies reactive with phase II Coxiella burnetii antigens. Overall, 41 pc of the cows were reactive at a titre of 1/40 or greater with the seroprevalence in dairies varying from 33-75 pc. The implications for human and animal health are discussed.

Stereotactic procedures for lesions of the pineal region

During the 7-year period between June 1985 and May 1992, 34 patients with pineal lesions underwent 66 stereotactic procedures (37 biopsies, 19 third ventriculostomies, 6 cyst aspirations, 3 instillations of 32P into cysts, and 1 insertion of an Ommaya reservoir into a cyst) at the Mayo Clinic. Nine patients subsequently also underwent 10 open resections of lesions of the pineal region. In the 34 study patients, the pathologic entities were 9 gliomas (5 astrocytomas, 2 ependymomas, and 2 oligodendrogliomas), 9 germ cell tumors (7 germinomas, 1 entodermal sinus tumor, and 1 malignant teratoma), 8 pineal parenchymal tumors (3 pinealomas, 3 pinealoblastomas, 1 mixed pinealoma-pinealoblastoma, and 1 intermediate differentiation pineal tumor), 4 other malignant tumors (2 undifferentiated carcinomas, 1 malignant melanoma, and 1 non-Hodgkin's lymphoma), 2 meningiomas, and 2 nonneoplastic lesions (1 glial cyst and 1 inflammatory lesion). No mortality or permanent morbidity was associated with the 66 stereotactic procedures; 2 patients had temporary complications--1 neurologic (transient diplopia) and 1 nonneurologic (pulmonary embolism). Diagnostic tissue was obtained in 33 of the 34 patients. An algorithm for the diagnosis and management of patients with lesions of the pineal region is presented. We conclude that stereotactic biopsy of pineal lesions can be performed safely, has a high diagnostic yield, and facilitates rational planning of treatment.

An immunoblotting diagnostic assay for heartwater based on the immunodominant 32-kilodalton protein of Cowdria ruminantium detects false positives in field sera

Heartwater, a major constraint to improved livestock production in Zimbabwe, threatens to invade areas which have been previously unaffected. To monitor its spread in Zimbabwe, an immunoblotting diagnostic assay based on the responses of animals to the immunodominant, conserved 32-kDa protein of Cowdria ruminantium was evaluated. In this assay, no false reactions were detected with sera known to be positive and negative, but sera from some cattle, sheep, and goats from heartwater-free areas of Zimbabwe reacted strongly with the 32-kDa protein, suggesting that either these animals had previous exposure to heartwater or they were false positives. To investigate the possibility of previous exposure to heartwater, 11 immunoblot-positive and 6 immunoblot-negative sheep from heartwater-free areas of Zimbabwe were compared regarding their susceptibilities to challenge with C. ruminantium. Prior to challenge, C. ruminantium could not be detected in any sheep by transmission to Amblyomma hebraeum ticks or by the polymerase chain reaction (PCR) conducted with plasma samples. All sheep were equally susceptible to the challenge, and infection was confirmed by brain biopsy, necropsy, PCR, and transmission of C. ruminantium to ticks. Our data suggest that the immunoblot-positive reactions of sera from heartwater-free areas were due not to previous C. ruminantium infection but rather to antigenic cross-reactivity between C. ruminantium and another agent(s) such as Ehrlichia species. In conclusion, the immunodominant 32-kDa protein is not antigenically specific to C. ruminantium and its use in serological diagnosis of heartwater requires reevaluation.

Tussometry: an objective assessment of vocal cord function

A number of techniques have recently been developed for altering laryngeal function, including structural framework surgery, reinnervation procedures, augmentation of the vocal cords, electrical stimulation, and pharmacologic intervention. The application of such procedures to appropriate disorders would be facilitated by better objective measures of the outcome. This study describes the new technique of tussometry, which investigates the airflow pattern produced during coughing. The value of 1 parameter, peak value time, is shown by a study of 35 vocal cord palsies versus a control, and of 17 vocal cord palsies before and after augmentation, to be an accurate assessment of vocal cord position. The technique is independent of lung function parameters and intraoral pressures. It is truly objective, having an interobserver variation of 0%, and is eminently reproducible, with an intrasubject coefficient of variation of 3.1% to 5.7%. Tussometry is a rapid, noninvasive technique providing inexpensive objective assessment of vocal cord function in the office setting.

A new concept in fracture immobilization. The application of a pressurized brace

Sixteen dogs and 14 anatomic tibiae were studied to determine the effect of a pressurized brace on a canine tibial fracture model. Bilateral tibial fractures were treated with an external fixator for 48 days. At 48 days, the pressurized brace was applied to one tibia, and a conventional cast was applied to the opposite tibia. The dogs were allowed unrestricted weight bearing until 88 days. Postmortem biomechanical studies indicated that tibiae were stronger on the side treated by the pressurized brace. This was reflected in torque values, energy, and degrees of rotation. The histomorphometry of the periosteal bone of the fracture sites disclosed a more dense periosteal callus on the side treated with a pressurized brace. In vitro mechanical studies in cadaveric tibias at 30 degrees rotation indicated that the pressurized brace provided significantly more stability.

Reactions of sera from laboratory, domestic and wild animals in Africa with protein A and a recombinant chimeric protein AG

An ELISA was developed to determine the reactivity of peroxidase labelled Protein A and a recombinant Protein A + Protein G construct, to sera from a variety of laboratory, domestic and wild animals from Africa. There was variability in the binding capacity of sera from individuals of the same species, but four groups could be recognized. Sera from birds and crocodiles were at most weakly reactive with either Protein A or the chimeric construct. Sera from some domestic animals such as horse, goat and cat, and sera from some wild ungulates including buffalo, wildebeest, waterbuck and impala were reactive with Protein A, but reacted to a much greater degree with the chimeric construct. Sera from larger wild animals such as elephant, rhinoceros and giraffe were strongly reactive with the chimeric protein and moderately reactive with Protein A. Sera from primates and dog, pig, guinea pig and rabbit reacted strongly with both proteins. Chimeric proteins that combine the IgG binding capacities of Protein A and Protein G can be used to detect immunoglobulin from a wide variety of African wild animal species. They may thus be of great value in seroepidemiological investigations of these animal populations.

Linkage of rheumatoid arthritis with HLA

OBJECTIVE

To determine whether HLA exerts a variable influence on the predisposition of siblings of probands with clinically mild and severe rheumatoid arthritis (RA).

METHOD

Calculation of crude and adjusted odds ratios for concordance rates in sibships sharing two, one and no HLA haplotypes with a proband with clinically mild and severe RA, and HLA haplotype sharing in multiply affected sibships in the same clinical groups.

RESULTS

Compared with a reference value of 1.0 in siblings sharing no HLA haplotypes with a proband with mild RA, siblings sharing two HLA haplotypes with a severely affected proband had a sibship concordance rate odds ratio of 9.7 (95% confidence interval 2.5 to 38.2). When adjusted for age, sex, and disease duration, the odds ratio was 7.6 (1.8 to 32.4). No other sibships showed concordance rates which were significantly higher than the reference group. HLA haplotype sharing in multiply affected sibships in which the proband had severe RA deviated significantly from random (two, one, and no HLA haplotypes shared: 53.3, 40, and 6.7%, respectively; expected 25, 50, and 25%), whereas in sibships of probands with mild RA they did not (14.6, 70.8, and 14.6%).

CONCLUSIONS

In the predisposition of siblings to RA, sharing HLA haplotypes with a proband is only important if the proband has severe RA. Mild RA is not genetically linked to the HLA region.

MRI hippocampal volumes and memory function before and after temporal lobectomy

We investigated the relationship between preoperative MRI hippocampal volumes and clinical neuropsychological memory test data obtained before and after temporal lobectomy and amygdalohippocampectomy for intractable epilepsy in 44 left (LTL) and 36 right (RTL) temporal lobectomy patients. In LTL patients, the difference (right minus left hippocampal volume) between hippocampal volumes (DHF) was significantly (p < 0.001) correlated (r = 0.61) with postoperative verbal memory change as measured by a delayed memory percent retention score from the Wechsler Memory Scale-Revised, Logical Memory subtest. DHF was also positively associated with postoperative memory for abstract geometric designs in LTL patients (r = 0.49, p < 0.005). Resection of a relatively nonatrophic left hippocampus was associated with poorer verbal and visual memory outcome. In RTL patients, larger right adjusted (for total intracranial volume) hippocampal volume was associated with decline in visual-spatial learning, but not memory, following surgery. MRI hippocampal volume data appear to provide meaningful information in evaluating the risk for memory impairment following temporal lobectomy.

Antibodies bound to nitrocellulose in acidic buffers retain biological activity

This report compares the binding of proteins to nitrocellulose membranes in acidic buffers (pH 2 and 3) with binding in neutral buffer (pH 7). Initially, similar amounts of antibodies and other proteins bound to the nitrocellulose membrane in both acidic and neutral buffers. However, the susceptibility of individual proteins to displacement (stripping) from the membrane by the milk blocking agent depended on the pH of the buffer used to bind the proteins to the membrane. Most proteins that bound to nitrocellulose in acidic buffers were relatively resistant to milk-stripping compared to proteins bound in pH 7 buffer. Acid-binding of proteins to nitrocellulose also decreased the amount of protein that was stripped from the nitrocellulose membrane when Tween 20 was included in the washing buffer. After correcting for the amount of antibody remaining on the membrane after the milk block, it was found that acid-bound antibodies were unchanged in biological activity when compared with the same antibodies bound at neutral pH. These results suggest that acid-binding of proteins could increase the sensitivity of nitrocellulose membrane assays that use milk and/or Tween 20.

Western blot and indirect fluorescent antibody testing for antibodies reactive with Ehrlichia canis in sera from apparently healthy dogs in Zimbabwe

Sera were collected from apparently healthy dogs in 3 major centres in Zimbabwe to establish the prevalence of antibodies reactive with Ehrlichia canis by indirect fluorescent antibody (IFA) testing at titres of 1/20 or greater. The overall seroprevalence was 42% (39/93) with dogs from Mutare (40%) and Harare (33%) having similar rates which were lower than those for Bulawayo (68%). The majority of the IFA positive dogs from Harare (67%) had no haematological or biochemical evidence of canine ehrlichiosis. Total protein, albumin and globulin values were determined in sera from blood collected from Bulawayo and Mutare and all values were within normal reference ranges. Western blot profiles of sera from dogs with IFA titres of greater than 1/160 were similar to those using sera from dogs experimentally infected with E. canis Oklahoma strain. Our results indicate that an organism which is antigenically very similar or identical to E. canis is present in Zimbabwe and that dogs are commonly exposed to this organism.

Intracranial parenchymal schwannoma. A clinicopathological and neuroimaging study of nine cases

The clinical, radiological, and pathological features of nine cases of intracranial parenchymal schwannoma are described. The clinical course in four patients 23 years of age or younger mirrored the indolent nature of this neoplasm. Imaging studies included computerized tomography in eight patients and magnetic resonance imaging in three. The lesions were well demarcated with only mild surrounding edema. Five tumors were deep within the temporoparieto-occipital region, three were in the cerebellum, and one lay peripherally in the parietal lobe. Over two-thirds of the nine tumors were either cystic (five) or contained areas of cystic degeneration (two). One lesion was frankly hemorrhagic. A variety of imaging characteristics and contrast enhancement patterns were observed, including those of a cyst with a mural nodule and peripheral enhancement. Of the four solid neoplasms, two enhanced homogeneously while the other two demonstrated heterogeneous enhancement. Six tumors were resected totally. The follow-up period ranging from 2 months to 2 years has shown no recurrences. Microscopically, immunohistochemically, and ultrastructurally, the tumors were indistinguishable from peripheral schwannomas. A possible mechanism underlying the histogenesis of these rare lesions is discussed. The importance of recognizing this tumor is stressed, particularly in younger patients, given its benign nature, radiological resemblance to other tumors such as pilocytic astrocytoma, and favorable response to resection.

Astrocytomas of the cerebellum. A comparative clinicopathologic study of pilocytic and diffuse astrocytomas

BACKGROUND

The majority of patients with astrocytomas of the cerebellum have an excellent prognosis; however, a small percentage of patients continue to do poorly. To clarify the clinical, pathologic, and treatment characteristics that determine prognosis and therapeutic recommendations, a large group of patients with astrocytic tumors of the cerebellum was reviewed and analyzed.

METHODS

A clinicopathologic analysis was performed of all patients undergoing initial operation for astrocytomas in the cerebellum between 1960 and 1984. Of the 132 patients, 105 patients had pilocytic astrocytomas and 27 had diffuse astrocytomas.

RESULTS

Multivariate analysis revealed that the division of pilocytic and diffuse histologic type was the most significant prognostic factor influencing survival. The 5-year, 10-year, and 20-year survival rates were 85%, 81%, and 79%, respectively, for patients with pilocytic astrocytomas and 7%, 7%, and 7%, respectively, for patients with diffuse astrocytomas (P < 0.001). Pilocytic astrocytomas occurred in a younger age group and were more commonly cystic and completely resected.

CONCLUSIONS

Astrocytomas of the cerebellum can be divided into two principal groups, the pilocytic and the diffuse astrocytomas, each of which has distinct clinical, pathologic, and prognostic characteristics.

The relationship of increased capillary filtration and bone formation

The effect of functional activity on bone formation and interstitial fluid space in a standardized tibial defect was measured in 19 dogs with one hind limb elevated and the other weight bearing and in 15 dogs bearing weight on all four legs. The interstitial fluid space (V(isf)) of the woven bone of the weight-bearing defect was larger than that in the elevated legs at seven and 14 days. By 28 days, this difference disappeared. In a third group of six dogs, medullary canal pressure was measured in the immobilized and weight-bearing tibias. The pressures were higher in the weight-bearing tibiae at two, three, four, and five days. Because the increase in V(isf) in the weight-bearing defects coincided with the onset of woven bone formation in the defects and an increase in medullary canal pressure, an increase in venous pressure could increase capillary pressure and capillary filtration. Such an increase in filtration might cause the larger V(isf) in the weight-bearing defects and better capillary perfusion of precursor cells of the osteoblast. A hypothesis is that increased fluid flow from increased capillary filtration might produce streaming potentials, a possible signal for increased cellular activity.

Tamoxifen reduces bone turnover and prevents lumbar spine and proximal femoral bone loss in early postmenopausal women

Although widely used for its anti-estrogen properties tamoxifen has estrogen like effects on a number of tissues including bone and liver. Previous studies suggest a preservation of lumbar spine density in postmenopausal women but the effect on the hip had not been addressed. To determine whether tamoxifen prevents bone loss in the early postmenopausal period bone mineral density at the lumbar spine and femoral neck was measured using dual energy X-ray absorptiometry at presentation and 6 monthly thereafter for 1 year in a prospective controlled study. Also indices of bone turnover, serum osteocalcin and urinary hydroxyproline excretion, were assessed. Fifteen early postmenopausal women with Stage I or II breast cancer treated with tamoxifen and 21 normal postmenopausal women were studied. Sex hormone binding globulin and antithrombin III levels in serum were also measured as indices of the hepatic estrogenic activity. Tamoxifen (20 mg daily) prevented bone loss at the femoral neck and lumbar spine. Median rates of change in bone mineral density (%/year) for the tamoxifen group were +0.09%/year in the lumbar spine and 1.4%/year in the femoral neck compared with -2.3%/year and -1.8%/year for the control group (P = 0.04 and 0.03, respectively). Tamoxifen resulted in a significant decrease in both serum osteocalcin and urinary hydroxyproline by 6 months of treatment and this effect persisted for the 12 months of observation. An increase in sex hormone binding globulin and a decline in antithrombin III levels was also observed. These data indicate that, in recently, postmenopausal women tamoxifen prevented bone loss at both the lumbar spine and femur and reduced bone turnover.