Iodine supplementation in Austria: methods and results

Until 1963 Austria was an extremely iodine-deficient area with low iodine intake and high goiter prevalence. Therefore, for the first time in 1963, salt iodination with 10 mg of potassium iodide per kilogram of salt was introduced by federal law. Twenty years after this salt iodination, however, investigations in schoolchildren demonstrated iodine deficiency grade I to II according to the World Health Organization (WHO) (urinary iodine excretion, 42-75 microg/g Crea) and goiter prevalence of far more than 10%. In 1990, salt iodination was increased to 20 mg of potassium iodide per kilogram of salt. In 1994, further investigations in schoolchildren demonstrated an increase of urinary iodine excretion (121 microg/g Crea) and a reduction of goiter prevalence below 5%, with the exception of pupils ages 14-19 (12%). In the year 2000, 10 years after the increase of salt iodination in Austria, 430 nonselected adult inhabitants of three communities in Carinthia (a county of Austria) were investigated for iodine excretion, goiter prevalence, and prevalence of thyroid autoantibodies. This study demonstrated that although iodine supply is sufficient now in Austria (males, 163.7 microg of Crea; females, 183.3 microg of iodine per gram of Crea), goiter prevalence is still high in the elderly, who lived for a longer period of iodine deficiency (34.3% in women and 21.3% in men), whereas goiter prevalence in younger people up to age 40 years is below 5%. It could also be shown that the percentage of thyroid autoantibodies is now as high as in other countries with sufficient iodine supply (3.19% in males, 5.17% in females). In addition to the changes of urinary iodine excretion and goiter prevalence because of salt iodination, changes of incidence in hyperthyroidism and histologic types of thyroid cancer are discussed in this paper. In conclusion, the introduction of salt iodination led to an improvement in iodine supply with a marked reduction of goiter prevalence in people who were born after 1963, but also to an increase in hyperthyroidism and autoimmune thyroid diseases as well as changes in histologic types of thyroid cancer.

18F-FDG positron emission tomography in the early diagnosis of enterocolitis: preliminary results

Collagenous and eosinophilic colitis are rare diseases characterised by chronic watery diarrhoea. Radiographic evaluation of the gastrointestinal tract and colonoscopy are usually non-diagnostic since as many as one-third of patients will have minor abnormalities. To date a few investigators have reported increased fluorine-18 fluorodeoxyglucose ((18)F-FDG) uptake on positron emission tomography (PET) in patients with acute enterocolitis, but there have been no reports on the use of (18)F-FDG PET for the diagnosis of collagenous or eosinophilic colitis in an early clinical stage. The aim of this preliminary study was to evaluate the usefulness of (18)F-FDG PET in the early diagnosis of patients with colitis. We investigated five women (mean age 61.2+/-12.1 years) who had been diagnosed as having colitis in an early clinical stage. In all but one of the patients, the diagnosis of colitis was based on biopsy. Magnetic resonance colonography, ultrasonography and colonoscopy were performed in all but one of the patients. Two women were identified as having collagenous colitis in an early clinical stage. Another two patients had eosinophilic colitis. The morphological imaging methods, magnetic resonance colonography and ultrasonography, yielded no suspicious findings, and the results of colonoscopy similarly showed no abnormalities. One patient had colitis due to bacterial infection. In all patients (18)F-FDG PET showed a pathological increase in tracer uptake in the large bowel, suggestive of colitis. In four of the five patients, colitis was confirmed by histology, and in one, by bacterial analysis. (18)F-FDG PET was able to detect colitis in an early clinical stage, when morphological imaging methods and colonoscopy were non-diagnostic. The early performance of (18)F-FDG PET imaging in patients with possible colitis is encouraging.

Cryptosporidium andersoni from a Danish cattle herd: identification and preliminary characterisation

In November 1997, Cryptosporidium andersoni, for the first time, was isolated from a Danish heifer. The isolate was characterised morphologically, molecularly, and furthermore inoculated into mice and one calf. Data on the distribution of cryptosporidia in the herd of origin were obtained at two separate visits in December 1997 and April 1998. C. andersoni was detected in 27 (19.0%) of 142 cattle examined at the first visit, whereas C. parvum was found in six (4.2%). At the following visit 42 (28.0%) of 150 cattle excreted C. andersoni, while 25 (16.7%) were positive for C. parvum. Oocysts of the Danish C. andersoni isolate were ovoid, 7.3(6.5-8.0) x 5.7(5.0-7.0) microm(2) (n=25), with smooth, colourless, single layer oocyst wall and distinct oocyst residuum. The length to width ratio was 1.27 (1.14-1.40, n=25). The identification was verified by sequencing of a 246bp fragment of the rDNA, which was identical to Cryptosporidium muris, the calf genotype (AF093496). The Danish C. andersoni isolate was not transmissible to mice, whereas oocysts were detected in the faeces of one experimentally infected calf from 25 days post-infection (DPI) and shed intermittently at low numbers until 165 DPI, the day of euthanasia. No macroscopic or microscopic changes that could be attributed to infection with C. andersoni were seen in the gastro-intestinal tract of the experimentally infected calf following necropsy and histological examination. This is to our knowledge the first report of C. andersoni in Scandinavia.

Clinical outcome of radiosynoviorthesis: a meta-analysis including 2190 treated joints

A variety of indications for radiosynoviorthesis have been reported in literature, but the clinical outcome differs and depends on the primary disease and the pre-existing degenerative changes. This metaanalysis was carried out to establish groups for radiosynoviorthesis based on clinical outcome with respect to primary disease, clinical stage and the pre-existing degenerative changes. The literature search was carried out using the MEDLINE search term 'radionuclide synovectomy'. Based on reports in the literature we determined groups for radiosynoviorthesis for clinical use. Our literature list comprised 2190 joints that were treated with radiosynoviorthesis. The overall response rate for all treated joints was 72.5+/-17%. The mean improvement rate for the treated joints in rheumatoid arthritis was 66.7+/-15.4%. For osteoarthritis the success rate was 56+/-11%, with better results in case of minimal radiological changes. Radiosynoviorthesis in patients with changes according to Steinbrocker I and II was successful in 72.8+/-12.3%, and in 64+/-17.3%, respectively. Steinbrocker III and IV had a mean success rate of 52.4+/-23.6%. In the case of haemophilia and Willebrand's disease a reduction of joint bleedings and factor usages after radiosynoviorthesis was evident in 91+/-4.3%. In patients with pigmented villonodular synovitis radiosynoviorthesis was successful in 77.3+/-25.3%. It is concluded that radiosynoviorthesis provides better results in rheumatoid arthritis than in osteoarthritis. Minimal or moderate changes according to Steinbrocker stages I and II respond better to radionuclide therapy than do stages III and IV. Deformed or unstable joints might fail treatment and therefore surgical interventions should be considered. Close cooperation with orthopaedists and rheumatologists is necessary to consider radiosynoviorthesis in each patient to ensure optimal medical care.

Effects of cholesterol and inflammation-sensitive plasma proteins on incidence of myocardial infarction and stroke in men

BACKGROUND

Although cholesterol is a major cardiovascular risk factor, its association with stroke remains controversial. This study explored whether the cholesterol-related incidence of stroke and myocardial infarction is modified by plasma markers of inflammation in a large, population-based cohort with a long follow-up.

METHODS AND RESULTS

Plasma cholesterol and 5 inflammation-sensitive plasma proteins (ISP) (fibrinogen, alpha1-antitrypsin, haptoglobin, ceruloplasmin, and orosomucoid) were determined in 6063 healthy men, 28 to 61 years of age. The incidence of stroke, cardiac events (fatal and nonfatal), and cardiovascular deaths was compared between groups defined by levels of cholesterol and ISP. Mean follow-up was 18.7 years. High ISP level was defined as 2 to 5 ISP in the top quartile. High cholesterol was associated with higher levels of ISP. Hypercholesterolemia (> or =6.5 mmol/L, 251 mg/dL) was associated with an increased incidence of ischemic stroke and cardiac events and with a reduced incidence of intracerebral hemorrhage. The ISP levels modified these associations. After risk factor adjustment, men with hypercholesterolemia and high ISP levels had a significantly higher risk of cardiovascular death (relative risk [RR]=2.4; CI, 1.8 to 3.3), cardiac events (RR=2.3; CI, 1.8 to 3.0), and ischemic stroke (RR=2.1; CI, 1.4 to 3.3) than men with normal cholesterol and low ISP levels. In the absence of high ISP levels, hypercholesterolemia was associated with a moderately higher risk of cardiovascular death (RR=1.4; CI, 1.0 to 2.0) and cardiac events (RR=1.5; CI, 1.2 to 1.9) but not significantly with ischemic stroke (RR=1.25; CI, 0.8 to 2.0).

CONCLUSIONS

Hypercholesterolemia is associated with high plasma levels of ISP. These proteins increase the cholesterol-related incidence of cardiovascular diseases. In the absence of elevated ISP levels, no statistically confirmed association was found between hypercholesterolemia and ischemic stroke.

Non-lethal infection parameters in mice separate sheep Type II Toxoplasma gondii isolates by virulence

The zoonotic protozoan parasite Toxoplasma gondii can infect all warm-blooded animals, but virulence of isolates has previously been characterised mainly by the ability to kill mice after experimental infections. In the present study, 15 Type II strains of T. gondii, isolated from five adult sheep, six sheep abortions, two pigs, one cat and one fox were examined for their virulence to young mice by less dramatic parameters. Clinical disease of inoculated mice, directly evidenced by reduced weight gain, was correlated to increase in serum level of haptoglobin and level of specific antibodies. Although Type II T. gondii strains are non-virulent to mice by lethality studies, significant differences in mouse virulence were observed between the strains of T. gondii isolated either from adult sheep or from sheep abortions. It was not possible to characterise strains isolated from sheep abortions as being more or less virulent than strains isolated from adult slaughter sheep.

Interpretation of the gamma interferon test for diagnosis of subclinical paratuberculosis in cattle

A group of 252 cattle without clinical signs of paratuberculosis (paraTB) in 10 herds infected with paraTB and a group of 117 cattle in 5 herds without paraTB were selected. Whole-blood samples were stimulated with bovine, avian, and johnin purified protein derivative (PPD) and examined for gamma interferon (IFN-gamma) release. For diagnosis of paraTB, satisfactory estimated specificities (95 to 99%) could be obtained by johnin PPD stimulation irrespective of interpretation relative to bovine PPD or no-antigen stimulation alone, but numbers of test positives in the infected herds varied from 64 to 112 with different interpretation criteria. For a limited number of test-positive animals, no change in the test results could be observed with increasing antigen concentrations but IFN-gamma responses were significantly reduced (P < 0.0001) and four out of seven reactors tested negative when stimulation was performed on day-old samples. Denmark is free of bovine tuberculosis, but cross-reactivity with paraTB could be documented for cattle more than 14 months old in paraTB-infected herds compared with those in non-paraTB-infected herds. In both paraTB-free and paraTB-infected herds, false positives were observed when the test was applied to calves less than 15 months of age. Until novel antigen formulations more specific for these diseases are available, interpretation of the IFN-gamma test must be individually adjusted to fit specific needs and the context within which the test is applied and, for paraTB, the test seems most appropriate for use as a supportive tool for evaluation of disease-preventive measures in young stock.

[Tc-99m ciprofloxacin in clinically selected patients for peripheral osteomyelitis, spondylodiscitis and fever of unknown origin--preliminary results]

AIM

Retrospective evaluation of Tc-99m ciprofloxacin (infection) scintigraphy consecutively performed in a series of patients clinically suspected for peripheral osteomyelitis (OM), spondylodiscitis (SD) and fever of unknown origin (FUO).

METHODS

A total of 20 patients clinically suspected for OM (n = 12), SD (n = 3) and FUO (n = 5) were included in our retrospective analysis. The additional criterion was a positive 3-phase bone scan for OM, or a 2-phase bone scan in case of SD. Planar whole body scans and static acquisitions were performed 1 and 4 h after application of 370 MBq Tc-99m ciprofloxacin. In 10 patients with suspected OM, additional immunoscintigraphy using Tc-99m labelled monoclonal antibodies (Mab BW 250/183) was performed and the correlation of infection to bloodpool and antigranulocyte scintigraphy was analysed.

RESULTS

OM: Bacterial infection was confirmed in 8 of 15 lesions. Infection demonstrated true positive (TP) results in 7 of 8, true negative (TN) results in 2 of 7, false positive (FP) results in 5 of 7 patients and one false negative (FN) result. A strong correlation could be demonstrated between T/NT ratios of infection and bloodpool Tc-99m medronate imaging (r = 0.84, 0.88) and between infection and BW 250/183 (r = 0.92, 0.90). Using a threshold of 2.0 for T/NT ratio, only TP results could be observed whereas a T/NT in the range of 1.0-2.0 could not discriminate between septic and aseptic inflammation. Concordant results with Mab BW 250/183 could only be observed in 5 of 10 patients (4 TP, 1 TN) by showing 4 FP and 1 FN lesions with IF.

CONCLUSION

Non-specific uptake of infection can be observed in a variety of clinical situations with moderate uptake, by showing a strong correlation with blood-pool imaging. Nevertheless, intense uptake may be specific for septic inflammation.

[Paget disease or fibrous dysplasia of the radius?--A case report]

A 46 years old man, who showed a painful and progressive deformity of the left radius, is presented. After some months a fracture within the affected bone area occurred. The diagnostic procedures including X-ray, MRI, scintigraphy and histology were controversial. Both fibrous dysplasia and Paget's disease of bone were suspected. The critical analysis of all results concluded that the most likely diagnosis was fibrous dysplasia. Unaware of the diagnostic discrepancies, the patient received a therapy with pamidronate 3 x 60 mg intravenously, which improved symptoms. After 14 months, the patient complained again about pain in the left radius. After a second therapy with pamidronate the patient currently exhibits no symptoms. The controversial diagnostic results and the applied therapeutic procedure are discussed.

[Preoperative assessment of thyroid nodules in an endemic goiter region--possibilities and limitations]

In iodine-sufficient areas any thyroid nodule has to be regarded as potentially malignant, whereas in iodine-deficient areas (endemic goiter areas) thyroid nodules, even multinodular goiter, are frequent. The majority of thyroid nodules in an endemic goiter area can be regarded as being most likely benign and thus not all patients with multinodular goiter have to undergo surgery. The major diagnostic aim and challenge is the selection for surgery of only those patients who suffer from mechanical obstruction due to large goiter and those who present with nodules suspicious of malignancy. Thus, for these cases the question of accurately excluding or verifying malignancy is essential for the patient and the specialist of nuclear medicine or endocrinology. A variety of investigations may be used for the preoperative evaluation of thyroid nodules, although currently sonography and fine-needle biopsy have to be regarded as the key investigations to clarify preoperatively the dignity of thyroid nodules. The article presents the indications and limitations of the different methods in use for the evaluation of thyroid malignancy. The authors present a diagnostic algorithm for the preoperative evaluation of thyroid malignancy with special respect to problems occurring in a(n) (former) endemic goiter area.

[Ablative therapy for immune hyperthyroidism in patients with ophthalmopathy]

The influence of ablative treatment of Graves' disease on the course of endocrine ophthalmopathy is discussed controversially. Data are inhomogeneous, because some studies were performed retrospectively, some prospectively, because of different follow up periods and different patient groups. In principal near total resection seems to influence endocrine ophthalmopathy in a positive way, due to the removal of thyroid antigen. Most studies also demonstrate that treatment using radioiodine has a negative influence on ophthalmopathy, because the course of disease is worsening in up to one third of patients. There is also consensus that treatment of Graves' disease with radioiodine should be performed only by concomitant administration of glucocorticoids. The early administration of L-thyroxine after radio-iodine therapy of Graves' disease seems to have a positive influence on the course of disease, whereas additional treatment with methimazole has no positive influence on endocrine ophthalmopathy.

Results of preoperative ultrasound guided fine needle aspiration biopsy of solitary thyroid nodules as compared with the histology. A retrospective analysis of 538 patients

AIM

The goal of this study was to assess the accuracy and limitations of ultrasound guided fine-needle aspiration biopsy (ug-FNAB) of solitary thyroid nodules.

METHODS

The ug-FNAB results of 538 patients with solitary thyroid nodules, who afterwards underwent thyroid surgery, were compared retrospectively with the histology. Patients with multinodular goiter were excluded from the study. Ug-FNAB was performed on growing and/or hypoechoic and/or hypofunctional nodules. The ug-FNAB results were grouped as follows: group 1: malignant (n = 44); group 2: malignancy cannot be ruled out (n = 173); group 3: non-malignant (n = 296), group 4: inadequate (n = 25).

RESULTS

When the cytological results of group 1 and group 2 were interpreted as being malignant and those of group 3 as being benign, sensitivity, specificity and accuracy of ug-FNAB were 96.7%, 65.8% and 69.5% respectively. The 62 thyroid carcinomas (TC) biopsied presented in 59 cases a suspicious or malignant cytology (95.2%). The smallest TC diagnosed by ug-FNAB had a diameter of 0.5 cm and 36.4% of all papillary TC < or = 1 cm displayed stage pT4. The histology verified a TC in 18 cases out of the 173 ug-FNABs in group 2. Non-malignant ug-FNABs were confirmed by histology in 294 patients (99.3%) in group 3. In 4.65% of the ug-FNABs inadequate material was aspirated.

CONCLUSION

Nodules with non-suspicious ug-FNAB results can be safely followed-up by sonography, as the cytological diagnoses were verified in more than 99% by histology. Papillary TC can be diagnosed with ug-FNAB very accurately. As stage pT4 was present in more than one third of patients with papillary TC < or = 1 cm, ug-FNAB is also recommended for thyroid nodules 0.5-1 cm in diameter located adjacent to the thyroid capsule. However, microfollicular proliferations remain the limitation of ug-FNAB, as the cytology cannot distinguish between benign adenoma and follicular TC.

Relating radiation-induced regional lung injury to changes in pulmonary function tests

PURPOSE

To determine whether the sum of radiotherapy (RT)-induced reductions in regional lung perfusion is quantitatively related to changes in global lung function as assessed by reductions in pulmonary function tests (PFTs).

METHODS AND MATERIALS

Two hundred seven patients (70% with lung cancer) who received incidental partial lung irradiation underwent PFTs (forced expiratory volume in 1 s and diffusion capacity for carbon monoxide) before and repeatedly after RT as part of a prospective clinical study. Regional lung function was serially assessed before and after RT by single photon emission computed tomography perfusion scans. Of these, 53 patients had 105 post-RT evaluations of changes in both regional perfusion and PFTs, were without evidence of intrathoracic disease recurrence that might influence regional perfusion and PFT findings, and were not taking steroids. The summation of the regional functional perfusion changes were compared with changes in PFTs using linear regression analysis.

RESULTS

Follow-up ranged from 3 to 86 months (median 19). Overall, a significant correlation was found between the sum of changes in regional perfusion and the changes in the PFTs (p = 0.002-0.24, depending on the particular PFT index). However, the correlation coefficients were small (r = 0.16-0.41).

CONCLUSIONS

A statistically significant correlation was found between RT-induced changes in regional function (i.e., perfusion) and global function (i.e., PFTs). However, the correlation coefficients are low, making it difficult to relate changes in perfusion to changes in the PFT results. Thus, with our current techniques, the prediction of changes in perfusion alone does not appear to be sufficient to predict the changes in PFTs accurately. Additional studies to clarify the relationship between regional and global lung injury are needed.

Evaluation of head and neck cancer with 18F-FDG PET: a comparison with conventional methods

The aim of this study was to evaluate the usefulness of 18F-FDG PET in the diagnosis and staging of primary and recurrent malignant head and neck tumours in comparison with conventional imaging methods [including ultrasonography, radiography, computed tomography (CT) and magnetic resonance imaging (MRI)], physical examination, panendoscopy and biopsies in clinical routine. A total of 54 patients (13 female, 41 male, age 61.3+/-12 years) were investigated retrospectively. Three groups were formed. In group I, 18F-FDG PET was performed in 15 patients to detect unknown primary cancers. In group II, 24 studies were obtained for preoperative staging of proven head and neck cancer. In group III, 18F-FDG PET was used in 15 patients to monitor tumour recurrence after radiotherapy and/or chemotherapy. In all patients, imaging was obtained at 70 min after the intravenous administration of 180 MBq 18F-FDG. In 11 of the 15 patients in group I, the primary cancer could be found with 18F-FDG, yielding a detection rate of 73.3%. In 4 of the 15 patients, CT findings were also suggestive of the primary cancer but were nonetheless equivocal. In these patients, 18F-FDG showed increased 18F-FDG uptake by the primary tumour, which was confirmed by histology. One patient had recurrence of breast carcinoma that could not be detected with 18F-FDG PET, but was detected by CT. In three cases, the primary cancer could not be found with any imaging method. Among the 24 patients in group II investigated for staging purposes, 18F-FDG PET detected a total of 13 local and three distant lymph node metastases, whereas the conventional imaging methods detected only nine local and one distant lymph node metastases. The results of 18F-FDG PET led to an upstaging in 5/24 (20.8%) patients. The conventional imaging methods were false positive in 5/24 (20.8%). There was one false positive result using 18F-FDG PET. Among the 15 patients of group III with suspected recurrence after radiotherapy and/or chemotherapy, 18F-FDG was true positive in 7/15 (46.6%) and true negative in 4/15 (26.6%). The conventional imaging methods were true positive in 5/15 (33.3%) and true negative in 4/15 (26.6%). One false negative (6.6%) and three false positive findings (20%) on 18F-FDG PET were due to inflamed tissue. The conventional imaging methods were false positive in three (20%) and false negative in three cases (20%). It is concluded that in comparison to conventional diagnostic methods, 18F-FDG PET provides additional and clinically relevant information in the detection of primary and metastatic carcinomas as well as in the early detection of recurrent or persistent head and neck cancer after radiotherapy and/or chemotherapy. 18F-FDG PET should therefore be performed early in clinical routine, usually before CT or MRI.

Study of the infectivity of saline-stored Campylobacter jejuni for day-old chicks

The culturability of three Campylobacter jejuni strains and their infectivity for day-old chicks were assessed following storage of the strains in saline. The potential for colonization of chicks was weakened during the storage period and terminated 3 to 4 weeks before the strains became nonculturable. The results from this study suggest that the role of starved and aged but still culturable campylobacters may be diminutive, but even more, that the role of viable but nonculturable stages in campylobacter epidemiology may be negligible. Even high levels of maternally derived anti-campylobacter outer membrane protein serum antibodies in day-old chicks did not protect the chicks from campylobacter colonization.

Regional immune responses with stage-specific antigen recognition profiles develop in lymph nodes of pigs following Ascaris suum larval migration

The early life-cycle of the pig round worm, Ascaris suum, involves well-defined larval development in the liver, lungs and finally the small intestine. Distinct regional immune responses to larval antigens of A. suum were observed in the draining lymph nodes of immunized and challenged pigs during larval migration. This was reflected in a transient enlargement of the stimulated lymph nodes, due to increases in numbers of B cells and CD4 T cells, and the production of A. suum-specific antibody by antibody secreting cell (ASC) cultures. Larval antigen recognition pattern of antibodies in serum, bile and draining lymph node ASC culture supernatant (ASC-probes) was examined by immunoblotting. This revealed distinct organ-specific recognition patterns of larval-specific antigens by the draining lymph nodes at different times after challenge. In particular, an early larval 42 kDa antigen was recognized specifically by ASC-probes of the liver lymph nodes at 7 but not 14 days postchallenge (pc) which was not detected in other lymph nodes, serum or bile of the same pig. Similarly, a late larval antigen of 34 kDa was uniquely detected by lung and jejunal ASC-probes at 14 days pc. These observations demonstrate how development of distinct regional immune responses in tissues with different antigen stimulation can be monitored with ASC-probes and flow cytometry.

Suppressive levothyroxine therapy has no significant influence on bone degradation in women with thyroid carcinoma: a comparison with other disorders affecting bone metabolism

The aim of this study was to examine different influences on bone degradation (estrogen status, thyroid function, parathyroid function, bone metastases) with special interest focusing on the significance of suppressive levothyroxine therapy (LT4) on bone degradation in patients with differentiated thyroid carcinoma (DTC). Two markers of bone degradation (ELItest NTx = U-NTx; Serum CrossLaps = S-CTx) were used (1) to quantify the influence of different metabolic influences on bone degradation and (2) to compare these two markers with each other. One hundred forty samples of 98 female patients ages 23-86 years were analyzed. The correlation between the two assays of bone degradation was high (r = 0.825; p < 0.001). Both assays demonstrated that estrogen deficiency, hyperparathyroidism, and bone metastases caused significant increases of bone degradation. A suppressive LT4 therapy, as used for patients with DTC, led to no significant increases of S-CTx and U-NTx. The study indicates that a well-controlled suppressive LT4 therapy has only a minor effect on the degree of bone degradation and that a possible estrogen deficiency in patients with DTC has a greater impact on bone degradation. Thus, female patients with DTC on suppressive LT4 therapy and estrogen deficiency may benefit from hormone replacement therapy, as patients with DTC and normal estrogen levels presented similar results to euthyroid controls.

Thrombolytic therapy preserves vagal activity early after acute myocardial infarction

OBJECTIVE

The purpose of this study was to evaluate the effects of thrombolytic therapy on vagal tone after acute myocardial infarction (AMI).

DESIGN

Holter monitoring for 24 h was performed at hospital discharge and 6 weeks after AMI in 74 consecutive male survivors of a first AMI, who fulfilled established criteria for thrombolytic therapy. Thirty-five patients received thrombolyses, while the remaining 39 patients did not (controls). In each Holter recording 24-h heart rate variability was calculated as pNN50, which represents the percentage of successive RR interval differences >50 ms. Alterations in pNN50 are known to reflect changes in vagal tone.

RESULTS

The analysis showed that controls early after AMI had low pNN50 values without any diurnal changes. Six weeks after AMI pNN50 values in controls exhibited a circadian rhythm with higher values during night-time. This pattern was similar to the pattern observed in thrombolysed patients early after AMI. In thrombolysed patients pNN50 values, particularly at night, were further improved 6 weeks after AMI (p = 0.037).

CONCLUSION

These observations indicate that thrombolytic therapy, given for a first AMI, preserves vagal activity when compared with patients who are not thrombolysed. The enhanced parasympathetic tone may be a part of the beneficial mechanisms responsible for the reduction in mortality after thrombolysis in AMI.

Influence of plasma fibrinogen levels on the incidence of myocardial infarction and death is modified by other inflammation-sensitive proteins: a long-term cohort study

Inflammation may play an important role in atherosclerotic disease. Plasma fibrinogen is an established predictor of cardiovascular events. The aim of this study was to evaluate whether other inflammation-sensitive plasma proteins modify this prediction. We studied the incidence of cardiac events and death in men in relation to fibrinogen levels alone and in combination with other proteins. The study was based on 6075 men, who were, on average, 46 years old at the time of the screening examination, which included the quantitative assessment of plasma levels of fibrinogen, orosomucoid, alpha(1)-antitrypsin, haptoglobin, and ceruloplasmin. The concentration of each protein was divided into quartiles for each. This classification made it possible to identify 4 groups, ie, men in the first fibrinogen quartile and at the same time either not belonging to the fourth quartile of any of the other proteins (Q1/No group) or also belonging to the fourth quartile of >/=1 of the additional proteins (Q1/Yes group) and corresponding groups in the fourth fibrinogen quartile (Q4/No and Q4/Yes groups). During the follow-up, which occurred at an average of 16 years, 439 (7.2%) men experienced a cardiac event, and 653 (10.7%) died; 278 of these men died of cardiovascular diseases, with 206 deaths attributed to ischemic heart disease. From the lowest to the highest quartile, there was for each protein a stepwise increase in the incidence of cardiac events and mortality. All-cause mortality and cardiovascular mortality were significantly higher in the Q4/Yes group compared with the Q4/No group, but they were similar in the Q4/No and Q1/Yes groups. The incidence of cardiac events was significantly higher in the Q1/Yes and Q4/Yes groups compared with the Q1/No and Q4/No groups, respectively. The increased cardiovascular mortality and cardiac event rates remained after adjustment for several confounders when the Q4/Yes and Q4/No groups were compared. The results suggest that the incidence of cardiac events and death due to cardiovascular diseases in middle-aged men predicted by plasma levels of fibrinogen is modified by other inflammation-sensitive proteins.

Probe-guided surgery for colorectal cancer

Anti-CEA-scintigraphy turned out to be very reliable in detecting primary and recurrent colorectal cancer, its overall accuracy being more than 90%. The intraoperative application of this technology should provide similar results when focussing at extrahepatic tumor deposits, for example in lymph nodes, thus allowing accurate staging of the underlying disease. To test this hypothesis we launched the following feasibility study the results of which are compared to those reported in the recent literature. We investigated 20 patients, six with rectum and 14 with colon cancer. 24 hours before surgery they were intravenously given 1 ml of a fab'-fragment-antibody to CEA, labeled with 25 mCi of 99mTc (CEA-Scan). During surgery the radioactivity in lymph glands regional to the tumors was measured and compared to the much lower activity in healthy nodes. For this we used a scintillation probe (C-Trak, Care Wise, Inc., Morgan Hill, CA). All lymph nodes of interest were then excised and submitted to frozen section pathology. In 7 out of 20 cases scintimetry led to an up-staging of the disease. In addition we found metastatic spread to lymph nodes that were basically not regional to the primary tumor (retroperitoneum, renal hilum etc.). Scintimetry can precisely identify even very small tumor deposits. So it leads to accurate staging while surgery is still ongoing. In a further step the concept of sentinel node diagnosis, which is right now being clinically evaluated, may some day be applied in colorectal surgical oncology.

[Osteoporosis in Turner syndrome with chromosomal mosaicism (45,XO/46,XY). A case report]

We report a rare case of Turner's syndrome (UTS) due to a gonosomal mosaic 45,X0/46,XY with the main clinical feature of several fractures in the course of osteoporosis. The bone mineral density (BMD) of the lumbar spine and the hip measured by DXA showed osteoporosis. The other clinical investigations including laboratory parameters presented beside an estrogen deficiency due to primary amenorrhea, a small thyroid with hypothyroidism, increased renal calciuria and increased markers of bone metabolism. Beside the supplementation of estrogen and thyroid hormone deficits, only a combination of different bone-associated drugs could normalize the bone mineral density and the bone turnover. During a two years' follow-up period no further fractures occurred. Furthermore, theories regarding the occurrence of osteoporosis and other complex pathologies in UTS are discussed with the conclusion that osteopenia in UTS is probably based on a multifactorial genesis. Due to these complex pathologies during adulthood, patients with UTS should get multidisciplinary care in order to reduce morbidity and preserve quality of life.