Protective Responses in Tuberculosis: Induction of Genes for Interferon-gamma and Cytotoxicity by Mycobacterium tuberculosis and During Human Tuberculosis

The host effector mechanisms against Mycobacterium tuberculosis infection are not well understood, and this remains a problem in the development of new vaccines and immunotherapies in tuberculosis (TB). Here, we studied the expression of genes for interferon gamma (IFN-gamma) and molecules involved in lymphocyte-mediated cytotoxicity [granzyme B (grzB), perforin, granulysin and Fas ligand (FasL)] against M. tuberculosis-infected macrophages. The kinetics of expression of these molecules were first established in peripheral blood mononuclear cells (PBMC) of healthy donors, and then investigated in TB patients with and without HIV-1 coinfection and appropriate control groups. We found that only IFN-gamma and grzB were induced by M. tuberculosis in PBMC from healthy purified protein derivative skin test reactive subjects. However, expression of neither gene nor IFN-gamma protein correlated with intracellular M. tuberculosis growth containment by macrophages. Mycobacterium tuberculosis induction of IFN-gamma, but not grzB, mRNA expression was significantly lower (P < 0.03) in TB patients as compared with healthy subjects.

Effect of extracellular hypertonicity and alkalosis on endothelial-derived EA.hy 926 cells in vitro

Endothelial and local metabolic mechanisms contribute in concert to the regulation of blood flow. In vivo extracellular alkalosis induces a vasoconstriction, hyperosmolarity a vasodilatation. The interaction between local metabolic and endothelial mechanisms is poorly understood. Therefore we investigated in endothelial-derived EA.hy926 cells the secretion of endothelial modulators of vascular tone under hypertonic stress with and without alkalosis: hyperosmolality was generated by either the addition of NaHCO subset 3 (25, 50, 100 mM, pH up to > 8) or mannitol (50, 100, 200 mM) to the cell culture media. The cells were studied using automated cell counting, measurement of the activity of the lactate dehydrogenase (LDH) and a bromo-deoxyuridine (BrdU) cell proliferation assay. Endothelin and cGMP, a surrogate marker for nitric oxide (NO), were measured with specific ELISAs. EA.hy 926 cells formed stable monolayers in vitro. The secretion of endothelin, but not of cGMP was inversely correlated with the osmolality of the incubation media: the endothelin concentration in the supernatants decreased in both mannitol- and NaHCO subset 3 -treated cells in a concentration-dependent manner (152.4 +/- 6.2 pg/ml (control) to 24.4 +/- 2.4 pg/ml (200 mM mannitol), res. to 18.2 +/- 2.7 pg/ml (100 mM NaHCO subset 3). Neither hypertonic bicarbonate nor mannitol solutions decreased the monolayer cell density or cell viability during the 6 hour incubation period. In conclusion, EA.hy926 cells are quite resistant against a 6-hour hypertonic/alkaline stress. Hypertonicity decreases the secretion of endothelin and has no effect on cGMP. At each level of hypertonicity the endothelin concentration was similar in the NaHCO subset 3 and mannitol media arguing against a direct role of endothelin in alkalosis-induced vasoconstriction in vivo. The decreased secretion of endothelin during hypertonicity could contribute to the hyperosmolal vasodilation seen in vivo.

Identification of two nogo/rtn4 genes and analysis of Nogo-A expression in Xenopus laevis

Myelin-associated axon growth inhibitors such as Nogo-A/RTN4-A impair axon regeneration in the adult mammalian central nervous system (CNS). Here, we describe the cloning and expression of two independent Xenopus laevis rtn4 orthologs. As in mammals, alternative transcripts are generated both through differential splicing and promoter usage, giving rise to Xenopus nogo-A, -B, -C and to a new isoform, nogo-N/rtn4-N. Xenopus is therefore the 'lowest' vertebrate where Nogo-A was identified. Xenopus Nogo-A/RTN4-A is predominantly expressed in the nervous system, whereas the other isoforms mainly occur in nonneuronal tissues. Nogo-A/RTN4-A specific antisera detect the protein in myelinated fiber tracts of the spinal cord, hindbrain, optic nerve, tectum opticum and in isolated oligodendrocytes. In addition, subpopulations of CNS neurons are Nogo-A/RTN4-A positive. This expression pattern is consistent with that observed for rat Nogo-A and suggests similar functions. Nogo-A in Xenopus myelin might therefore contribute to the failure of spinal cord regeneration in frogs-a feature that may have evolved during the transition from fish to land vertebrates.

Overbite and overjet are not related to self-report of temporomandibular disorder symptoms

Overbite and overjet, especially high or low values, have been found in some studies to be associated with temporomandibular disorders (TMD). This study evaluates the relationship between overbite/overjet and three TMD self-report measures (pain, joint noises, limited mouth-opening). Subjects were from two population-based cross-sectional studies (3033 subjects). After adjustment for age and gender, high or low values of overbite were not associated with an increased risk of self-reported TMD pain as compared with a reference category of a normal overbite of 2 to 3 mm (-8 to -1 mm, odds ratio = 0.36, 95% confidence interval = 0.05-2.76; 6 to 15 mm, odds ratio = 1.08, 95% confidence interval = 0.68-1.72). Similar non-significant results were found for overjet and TMD pain, and for the association of overjet/overbite and joint noises or limited mouth-opening. This study provides the strongest evidence to date that there is no association between overbite or overjet and self-reported TMD.

Ubiquitination is essential for human cytomegalovirus US11-mediated dislocation of MHC class I molecules from the endoplasmic reticulum to the cytosol

Human cytomegalovirus encodes two glycoproteins, US2 and US11, which cause rapid degradation of MHC class I molecules, thus preventing recognition of virus-infected cells by the immune system. This degradation process involves retrograde transport or 'dislocation' of MHC class I molecules from the endoplasmic reticulum (ER) to the cytosol, where they are deglycosylated by an N-glycanase and degraded by the proteasome. At present it is unknown whether ubiquitination is required for US2- and US11-mediated dislocation and degradation of MHC class I molecules. Here, we show that in E36ts20 hamster cells, which contain a temperature-sensitive mutation in the E1 ubiquitin-activating enzyme, US11-mediated degradation of MHC class I molecules is strongly impaired at the non-permissive temperature, indicating the necessity for ubiquitination in this process. We next addressed the question of whether ubiquitination is a condition for the retrograde movement of MHC class I molecules from the ER to the cytosol, or whether ubiquitination is merely required for recognition of dislocated MHC class I molecules by the proteasome. In the absence of a functional ubiquitin system, complexes of US11 and MHC class I molecules accumulate in the ER. In this state the membrane topology of MHC class I molecules does not significantly change, as judged from proteinase K digestions. Thus the results indicate that a functional ubiquitin system is essential for dislocation of MHC class I molecules from the ER to the cytosol.

Evaluation of suspected tuberculous pleurisy: clinical and diagnostic findings in HIV-1-positive and HIV-negative adults in Uganda

SETTING

National Tuberculosis Treatment Centre, Mulago Hospital, Kampala, Uganda.

OBJECTIVES

To compare clinical and radiographic presentation, and diagnostic methods, in adults with tuberculous pleurisy who are negative and positive for the human immunodeficiency virus (HIV).

DESIGN

Adults with suspected pleural tuberculosis were screened by clinical examination, thoracocentesis and closed pleural biopsy. Biopsy material was cultured on Middlebrook 7H-10 solid medium and in BACTEC 12B radiometric vials. Pleural fluid was cultured using Löwenstein-Jensen slants, BACTEC and Kirchner liquid medium.

RESULTS

Of 156 individuals enrolled, 142 had tuberculosis, of whom 80% were HIV-positive. Among those with tuberculosis, HIV-positive patients bad a more severe and longer illness. The size of effusions was similar in HIV-positive and HIV-negative patients. A higher proportion of HIV-positive patients had parenchymal infiltrates but this difference was not statistically significant. Pleural fluid lymphocytosis was present in all HIV-negative and 97% of the HIV-positive patients. HIV-positive patients had lower pleural fluid lymphocyte counts. Pleural fluid cultures were more often positive in HIV-positive patients. BACTEC and Kirchner liquid media gave higher yields than solid media.

CONCLUSION

HIV-positive patients with tuberculous pleurisy had a more severe illness than HIV-negative patients. Mycobacterial cultures from HIV-positive patients were more often positive, suggesting more mycobacterial extension from the lungs into the pleural space. Liquid culture media were superior to solid media with regard to diagnostic yield and time until diagnosis.

Involvement in caregiving and adjustment to death of a spouse: findings from the caregiver health effects study

CONTEXT

Most deaths in the United States occur among older persons who have 1 or more disabling conditions. As a result, many deaths are preceded by an extended period during which family members provide care to their disabled relative.

OBJECTIVE

To better understand the effect of bereavement on family caregivers by examining predeath vs postdeath changes in self-reported and objective health outcomes among elderly persons providing varying levels of care prior to their spouse's death.

DESIGN AND SETTING

Prospective, population-based cohort study conducted in 4 US communities between 1993 and 1998.

PARTICIPANTS

One hundred twenty-nine individuals aged 66 to 96 years whose spouse died during an average 4-year follow-up. Individuals were classified as noncaregivers (n = 40), caregivers who reported no strain (n = 37), or strained caregivers (n = 52).

MAIN OUTCOME MEASURES

Changes in depression symptoms (assessed by the 10-item Center for Epidemiological Studies-Depression [CES-D] scale), antidepressant medication use, 6 health risk behaviors, and weight among the 3 groups of participants.

RESULTS

Controlling for age, sex, race, education, prevalent cardiovascular disease at baseline, and interval between predeath and postdeath assessments, CES-D scores remained high but did not change among strained caregivers (9.44 vs 9.19; P =.76), while these scores increased for both noncaregivers (4.74 vs 8.25; F(1,116) = 14.33; P<.001) and nonstrained caregivers (4.94 vs 7.13; F(1,116) = 4.35; P =.04). Noncaregivers were significantly more likely to be using nontricyclic antidepressant medications following the death than the nonstrained caregiver group (odds ratio [OR], 12.85; 95% confidence interval [CI], 1.02-162.13; P =.05). The strained caregiver group experienced significant improvement in health risk behaviors following the death of their spouse (1.47 vs 0.66 behaviors; F(1,118) = 20.23; P<.001), while the noncaregiver and nonstrained caregiver groups showed little change (0.27 vs 0.27 [P =.99] and 0.46 vs 0.27 [P =.39] behaviors, respectively). Noncaregivers experienced significant weight loss following the death (149.1 vs 145.3 lb [67.1 vs 65.4 kg]; F(1,101) = 8.12; P =.005), while the strained and nonstrained caregiving groups did not show significant weight change (156.2 vs 155.2 lb [70.3 vs 69.8 kg] [P =.41] and 156.2 vs 154.0 lb [70.3 vs 69.3 kg] [P =.12], respectively).

CONCLUSIONS

These data indicate that the impact of losing one's spouse among older persons varies as a function of the caregiving experiences that precede the death. Among individuals who are already strained prior to the death of their spouse, the death itself does not increase their level of distress. Instead, they show reductions in health risk behaviors. Among noncaregivers, losing one's spouse results in increased depression and weight loss.

Activation of β‐Chemokines and CCR5 in Persons Infected with Human Immunodeficiency Virus Type 1 and Tuberculosis

Tuberculosis (TB) in human immunodeficiency virus type 1 (HIV-1)-infected persons is associated with progression of HIV-1 disease. The expression of macrophage inflammatory protein (MIP)-1alpha and CCR5 was assessed in HIV-1-infected patients with pulmonary TB (HIV-1/PTB) and without PTB (HIV-1/C), PTB patients not infected with HIV-1 (PTB), and control subjects. Mycobacterium tuberculosis (MTB)-induced MIP-1alpha production was lower in peripheral blood mononuclear cells (PBMC) of HIV-1/PTB patients than in those of PTB patients (P< .05) and was lower in PBMC of HIV-1/C patients than in those of control subjects (P< .005). However, MIP-1alpha production was higher in PBMC of HIV/PTB patients than in those of HIV-1/C patients (P< .01). The pattern of MTB-induced RANTES production was similar to that of MIP-1alpha. However, MTB induced greater expression of mRNA for CCR5 in PBMC of HIV-1/PTB patients than in those of HIV-1/C patients (P< .04). Furthermore, the MTB-induced HIV p24 antigen level in PBMC of HIV-1/PTB patients with a CD4 cell count <500 cells/microL was higher (P< .05) than that in HIV-1/C patients. Thus, perturbations in chemokine pathways in HIV-1/PTB patients may accelerate HIV-1 disease.

The association of bone mineral density and depression in an older population

OBJECTIVE

To evaluate the association between bone mineral density (BMD) and measurements of depression in an older population.

DESIGN

Population-based, cross-sectional study.

SETTING

Study subjects were participants in the Cardiovascular Health Study (CHS), a longitudinal, long-term, follow-up study, at the University of California Davis (Sacramento, California) and the University of Pittsburgh (Pittsburgh, Pennsylvania) clinical centers.

PARTICIPANTS

A random sample of 1,566 Medicare enrollees age 65 and older enrolled in the CHS.

MEASUREMENTS

Total hip BMD, measured using dual energy x-ray absorptiometry (DEXA), after adjustment for multiple covariates, was compared with depression evaluated with the Center for Epidemiological Studies 10-item Depression Scale (CES-Dm). Risk factors for osteoporosis were compared in depressed and nondepressed participants. Potential correlates were entered into a regression model. Depression scores were compared in normal, osteopenic, and osteoporotic individuals.

RESULTS

Sixteen percent of participants were clinically depressed; 9% had BMDs in the osteoporotic range. Mean BMD was 40 mg/cm2 lower in those with clinical depression. High CES-Dm scores were associated with lower BMD (P < .001) when adjusted for body mass index (BMI), age, kilocalories of activity, estrogen use, gender, race, smoking and drinking. When stratified by race, this remained true for all Caucasians (P < .01), all African Americans (P < .05), and when stratified by race and gender the association remained only for all Caucasian women (P < .001). In women and Caucasian men there was an increase in depression scores among individuals with osteoporotic-range BMDs.

CONCLUSIONS

A significant association was found between BMD and depressive symptoms after adjustment for osteoporosis risk factors. In Caucasians, depressive symptoms were associated with both osteoporotic and osteopenic levels of BMD. Causality cannot be ascribed, with only one measurement of BMD. We postulate that there may be an unmeasured third factor, such as an endogenous steroid, that is responsible for both low BMD and depression.

Carbohydrate metabolism in sickle cell patients using a subdermal implant containing nomegestrol acetate (Uniplant)

Uniplant, a second-generation contraceptive implant, has been demonstrated to promote a significant improvement in the overall well-being of women with sickle cell anemia. It has been suggested that the discrete increase in blood glucose levels observed in Uniplant users could be a contributory factor for clinical improvement. Ten healthy sickle cell patients were enrolled in the study. An oral glucose tolerance test was performed prior to implant insertion and at 1, 6, and 12 months of therapy. Blood glucose and insulin were measured before and at 30, 60, 120, and 180 min after a 75-g glucose load. The glucose and insulin areas under the curves were calculated. Fasting glycosylated hemoglobin was also measured. No significant changes were observed in glycosylated hemoglobin, glucose or insulin. We conclude that Uniplant is a safe contraceptive for sickle cell patients.

Frailty in older adults: evidence for a phenotype

BACKGROUND

Frailty is considered highly prevalent in old age and to confer high risk for falls, disability, hospitalization, and mortality. Frailty has been considered synonymous with disability, comorbidity, and other characteristics, but it is recognized that it may have a biologic basis and be a distinct clinical syndrome. A standardized definition has not yet been established.

METHODS

To develop and operationalize a phenotype of frailty in older adults and assess concurrent and predictive validity, the study used data from the Cardiovascular Health Study. Participants were 5,317 men and women 65 years and older (4,735 from an original cohort recruited in 1989-90 and 582 from an African American cohort recruited in 1992-93). Both cohorts received almost identical baseline evaluations and 7 and 4 years of follow-up, respectively, with annual examinations and surveillance for outcomes including incident disease, hospitalization, falls, disability, and mortality.

RESULTS

Frailty was defined as a clinical syndrome in which three or more of the following criteria were present: unintentional weight loss (10 lbs in past year), self-reported exhaustion, weakness (grip strength), slow walking speed, and low physical activity. The overall prevalence of frailty in this community-dwelling population was 6.9%; it increased with age and was greater in women than men. Four-year incidence was 7.2%. Frailty was associated with being African American, having lower education and income, poorer health, and having higher rates of comorbid chronic diseases and disability. There was overlap, but not concordance, in the cooccurrence of frailty, comorbidity, and disability. This frailty phenotype was independently predictive (over 3 years) of incident falls, worsening mobility or ADL disability, hospitalization, and death, with hazard ratios ranging from 1.82 to 4.46, unadjusted, and 1.29-2.24, adjusted for a number of health, disease, and social characteristics predictive of 5-year mortality. Intermediate frailty status, as indicated by the presence of one or two criteria, showed intermediate risk of these outcomes as well as increased risk of becoming frail over 3-4 years of follow-up (odds ratios for incident frailty = 4.51 unadjusted and 2.63 adjusted for covariates, compared to those with no frailty criteria at baseline).

CONCLUSIONS

This study provides a potential standardized definition for frailty in community-dwelling older adults and offers concurrent and predictive validity for the definition. It also finds that there is an intermediate stage identifying those at high risk of frailty. Finally, it provides evidence that frailty is not synonymous with either comorbidity or disability, but comorbidity is an etiologic risk factor for, and disability is an outcome of, frailty. This provides a potential basis for clinical assessment for those who are frail or at risk, and for future research to develop interventions for frailty based on a standardized ascertainment of frailty.

Frailty in older adults: evidence for a phenotype

BACKGROUND

Frailty is considered highly prevalent in old age and to confer high risk for falls, disability, hospitalization, and mortality. Frailty has been considered synonymous with disability, comorbidity, and other characteristics, but it is recognized that it may have a biologic basis and be a distinct clinical syndrome. A standardized definition has not yet been established.

METHODS

To develop and operationalize a phenotype of frailty in older adults and assess concurrent and predictive validity, the study used data from the Cardiovascular Health Study. Participants were 5,317 men and women 65 years and older (4,735 from an original cohort recruited in 1989-90 and 582 from an African American cohort recruited in 1992-93). Both cohorts received almost identical baseline evaluations and 7 and 4 years of follow-up, respectively, with annual examinations and surveillance for outcomes including incident disease, hospitalization, falls, disability, and mortality.

RESULTS

Frailty was defined as a clinical syndrome in which three or more of the following criteria were present: unintentional weight loss (10 lbs in past year), self-reported exhaustion, weakness (grip strength), slow walking speed, and low physical activity. The overall prevalence of frailty in this community-dwelling population was 6.9%; it increased with age and was greater in women than men. Four-year incidence was 7.2%. Frailty was associated with being African American, having lower education and income, poorer health, and having higher rates of comorbid chronic diseases and disability. There was overlap, but not concordance, in the cooccurrence of frailty, comorbidity, and disability. This frailty phenotype was independently predictive (over 3 years) of incident falls, worsening mobility or ADL disability, hospitalization, and death, with hazard ratios ranging from 1.82 to 4.46, unadjusted, and 1.29-2.24, adjusted for a number of health, disease, and social characteristics predictive of 5-year mortality. Intermediate frailty status, as indicated by the presence of one or two criteria, showed intermediate risk of these outcomes as well as increased risk of becoming frail over 3-4 years of follow-up (odds ratios for incident frailty = 4.51 unadjusted and 2.63 adjusted for covariates, compared to those with no frailty criteria at baseline).

CONCLUSIONS

This study provides a potential standardized definition for frailty in community-dwelling older adults and offers concurrent and predictive validity for the definition. It also finds that there is an intermediate stage identifying those at high risk of frailty. Finally, it provides evidence that frailty is not synonymous with either comorbidity or disability, but comorbidity is an etiologic risk factor for, and disability is an outcome of, frailty. This provides a potential basis for clinical assessment for those who are frail or at risk, and for future research to develop interventions for frailty based on a standardized ascertainment of frailty.

T cell activation, apoptosis and cytokine dysregulation in the (co)pathogenesis of HIV and pulmonary tuberculosis (TB)

Immune parameters were compared in four groups of Ugandan subjects: HIV-and HIV+ adult patients with active pulmonary TB (HIV- PTB n = 38; HIV+ PTB n = 28), patients with HIV infection only (n = 26) and PPD+ healthy controls (n = 25). Compared with healthy controls, CD4 and CD8 T cells from patients with HIV and/or PTB expressed more activation markers (HLA-DR, CD38); their CD8 T cells expressed more CD95 (pre-apoptosis) and less CD28 (co-stimulatory receptor). Peripheral blood mononuclear cells (PBMC) of patients with either HIV or PTB were impaired in interferon-gamma (IFN-gamma) production upon antigenic stimulation. PTB (with or without HIV) was characterized by monocytosis, granulocytosis, increased transforming growth factor-beta 1 production and PPD-induced apoptosis. In vivo CD4 T cell depletion, in vitro increased spontaneous CD4 T cell apoptosis and defects in IFN-gamma responses upon mitogenic stimulation were restricted to HIV+ subjects (with or without PTB). Overlapping and distinctive immune alterations, associated with PTB and HIV, might explain mutual unfavourable influences of both diseases.

Symptom management in palliative care

Controlling patients' symptoms in palliative care requires good communication skills. Pain, vomiting and nausea are common symptoms, but anorexia and sleep disturbance are also frequently reported. Thorough evaluation and treatment of the underlying cause is imperative. Pain is different for each patient. Pain control therefore may not be achieved with analgesics alone.

Intracellular targeting of the proteasome

Proteasomes are soluble, but can also be found in association with subcellular organelles. Adaptors capable of mediating interactions between proteasomes and intracellular organelles have not yet been identified, although they might exist. Although most proteasomal substrates are soluble, some membrane-bound proteins are also degraded by the proteasome. Processing of such insoluble substrates might cause proteasomes to be organelle-bound by tethering the degradative apparatus to the organelle.

[Radioiodine therapy of functional autonomy of the thyroid gland. Treatment results in view of pretreatment scintigraphic diagnosis and early response of triiodothyronine levels to treatment]

AIM

The goal of this retrospective study was to evaluate the results of radioiodine therapy of thyroid autonomy with respect to the underlying scintigraphic pattern, administered I-131 doses and pretherapeutic Tc-99m and I-131 uptake. Furthermore, early post-therapeutic free triiodothyronine (FT3) levels were measured during the first 6 weeks after radioiodine therapy with respect to a FT3-increase.

PATIENTS AND METHODS

Thyroid autonomy in 632 patients was followed for at least 3 months (mean 10.9 months). The patients were divided into several groups based on scintigraphic pattern of unifocal (UA), a multifocal (MFA), a focal/disseminated (FDA) and a disseminated (DA) autonomy. The early effects of therapy on thyroid function were assessed by evaluation of FT3 values of 786 patients during the 1st, 2nd, 3rd, 4th and 6th week after therapy.

RESULTS

Successful elimination of thyroid autonomy as defined by normalization of FT3 and TSH levels was observed in 92.1% (582/632) of the patients. In 2.2% (14/632) of the patients, immunogenic hyperthyroidism following I-131 therapy was observed. There was no significant difference in the success rates in patients with UA and MFA of 94.9% and 96.1%, respectively, using similar target doses based on the amount of autonomous tissue. The success rate in MFA (96.6%) was similar if target dose was calculated based on the volume of the whole thyroid gland. Compared to MFA (96.6%), however, FDA and DA were associated with significantly lower success rate with 82.7% and 75.5%, respectively, although the target doses were not significantly different. Considering the quantitative Tc-99m uptake prior to therapy, there was no significant difference in the success rate for Tc-99m uptake < or = 3% and > 3%, while the success rate in patients with I-131 uptake of < or = 50% was significantly higher (p = 0.032) than in those with an uptake of > 50%. The determination of FT3 levels during the first 6 weeks after radioiodine therapy revealed a dependence of the FT3 decrease and FT3 increase on the scintigraphic pattern and thyroid function. Patients with FDA and DA with hyperthyroidism showed an increase of FT3 (> 2 to 14.7 pmol/l) in 11 to 18% of the cases, during the first 2 weeks after therapy which occurred significantly more frequently in patients with FDA and DA than in UA and MFA. A similar increase in FT3 level in patients with FDA and DA compared to patients with UA and MFA was observed in 317 patients with euthyroid pretherapeutic hormone levels. A decrease in FT3 level following radioiodine therapy was observed significantly more often and earlier in patients with UA and MFA with hyperthyroid values than in patients with FDA and DA during the first 6 posttherapeutic weeks. Concerning patients with euthyroid FT3 levels, the decrease in FT3 level was observed significantly more frequently in patients with UA and MFA only after 6 weeks following radioiodine therapy.

CONCLUSION

In contrast to the multifocal autonomy (MFA), the target dose of 150 to 200 Gy based on total thyroid volume did not result in a comparably high success rate of approximately 95% in disseminated and focal/disseminated types of thyroid autonomy. Therefore, an increase of target dose of 200 to 300 Gy is recommended. The transient FT3 increase particularly observed in FDA and DA in the first weeks following radioiodine therapy makes short-term controls of thyroid function necessary, especially in patients with cardiac risk, in order to initiate necessary therapy.

[Incidence of immunogenic hyperthyroidism after radioiodine therapy of focal thyroid gland autonomy. Results of a multicenter study]

BACKGROUND

There are case reports in the literature that patients occasionally develop immunogenic hyperthyroidism 2 to 14 months following iodine-131-therapy of focal, non-immunogenic, autonomous thyroid nodules with a prevalence between 0.05 and 2.5%. Purpose of this multicenter evaluation was to assess the appearance of this phenomenon in a larger patient population.

PATIENTS AND METHODS

So far 2867 patients out of 4 university hospitals are included in our study focusing on the appearance of pathologically elevated levels of thyrotropin-receptor-antibodies (TRAb) combined with hyperthyroidism following iodine-therapy. Records of the patients were screened for pre- and post-therapeutic biochemical tests, scintigraphic uptake patterns and ultrasound findings of the thyroid.

RESULTS

Nineteen of 2867 patients with pretherapeutically scintigraphic "hot nodules" developed recurrent hyperthyroidism suggestive for immunogenic genesis 2 to 12 months following iodine-131-therapy (elevated TRAb-levels, homogeneous uptake in Tc-99m-pertechnetate scans). Pretherapeutically, 9 of these patients presented with a strictly focal scintigraphic uptake-pattern, 10 cases with a mixed disseminated-focal pattern. Because of missing pretherapeutic TRAb-tests in 8/9 patients presenting with a strictly focal scintigraphic uptake pattern, postradiogenic immunogenic hyperthyroidism could be reliably assessed in 1 case only.

CONCLUSION

One could speculate that iodine-131-therapy may stimulate immunogenic mechanisms finally leading to immunogenic hyperthyroidism. Posttherapeutically observed hyperthyroidism following iodine-treatment might be based on an exacerbation of a preexisting--clinically not relevant/detectable--immunothyropathia. Also pretherapeutic TRAb-negative immunogenic hyperthyroidism could not be definitely excluded. Our multicenter data collected in a large patient population show similar results to the case reports of immunogenic hyperthyroidism following iodine-131-treatment in smaller populations. Therfore, the occurrence of this phenomenon plays a minor role regarding to its prevalence. Therapeutical consequences in treatment of functional thyroid autonomy are not recommended.

Use of a single implant of elcometrine (ST-1435), a nonorally active progestin, as a long acting contraceptive for postpartum nursing women

Because of its unique features, the contraceptive effectiveness and tolerance during breast-feeding of 16-methylene-17 alpha-acetoxy-19-nor-4-pregnene-3,20-dione (elcometrine), delivered within a single subdermal capsule of medical grade polydimethylsiloxane, was investigated. Unlike other progestational steroids, elcometrine has no affinity for androgen and estrogen receptors and is inactive by the oral route. A total of 66 breast-feeding women receiving elcometrine by the subdermal route were enrolled in the study, and 69 women who elected to use Copper-T380 intrauterine devices (IUD) served as control subjects. The women and their infants were observed until the end of the first postpartum year. There were no significant differences in growth and development measurements among the infants in the elcometrine and control groups. The percentage of infants continuing to breast-feed at 3 and 6 months was significantly higher in the elcometrine group. There were no significant differences between the concentration of elcometrine in the mother's blood and milk. At 75 days, blood levels of elcometrine in the infants were near the undetectable and were significantly lower than the levels in maternal blood or milk (p < 0.01). In 15 of 25 infants, blood levels of elcometrine were at the limit of assay sensitivity or undetectable. Two pregnancies occurred in women using IUD, whereas none occurred in those using implants. There were menstrual bleeding irregularities in both groups. A single elcometrine capsule placed subcutaneously at 6-monthly intervals appears to be an effective method of contraception for lactating women and results in blood concentrations of nursing infants at or near undetectable levels.