Androgen Treatment of Abdominally Obese Men

Middle-aged men with abdominal obesity were treated in a double-blind study with moderate doses of transdermal preparations of testosterone (T), dihydrotestosterone (DHT), or placebo. This resulted in moderately elevated T concentrations and marked decreases in follicle stimulating and luteinizing hormones in the group treated with T, while the DHT group showed elevated DHT, markedly lower T values, and less diminution of gonadotropin concentrations. In the group treated with T visceral fat mass decreased (measured by computerized tomography) without significant changes in other depot fat regions. Lean body mass did not change. In the group treated with T, glucose disposal rate, measured with the euglycemic hyperinsulinemic clamp method, was markedly augmented. Plasma triglycerides, cholesterol, and fasting blood glucose concentrations as well as diastolic blood pressure decreased. There were no such changes in the DHT or placebo treatment groups. The men treated with T reported increased well-being and energy. In none of the groups did prostate volume, specific prostate antigen concentration, genito-urinary history, or urinary flow measurement change. It is suggested that supplementation of abdominal obese men with moderate doses of T might have several beneficial effects.

A policy framework for accelerating adoption of new vaccines

Rapid uptake of new vaccines can improve health and wealth and contribute to meeting Millennium Development Goals. In the past, however, the introduction and use of new vaccines has been characterized by delayed uptake in the countries where the need is greatest. Based on experience with accelerating the adoption of Hib, pneumococcal and rotavirus vaccines, we propose here a framework for new vaccine adoption that may be useful for future efforts. The framework organizes the major steps in the process into a continuum from evidence to policy, implementation and finally access. It highlights the important roles of different actors at various times in the process and may allow new vaccine initiatives to save time and improve their efficiency by anticipating key steps and actions.

Digital mammography using storage phosphor plate technique--optimizing image processing parameters for the visibility of lesions and anatomy

Digital mammograms from a storage phosphor plate system for general radiography were compared to conventional mammograms by means of visual grading analysis (VGA). For the digital images, image processing parameters were optimized and evaluated through observer preference analysis (OPA). The results of the VGA showed significantly better gradings for the conventional mammograms for parenchyma, linear structures, and cysts, and significantly better gradings for the digital mammograms for the skin surface. For calcifications, no significant difference was seen. For the OPA, contrast enhanced mammograms graded significantly best. Using standard image processing, the digital mammograms were considered as adequate for diagnosis in 49% of the cases, as uncertain in 20%, and as inadequate in 31%. However, the observers differed considerably in their gradings both in the VGA and in the OPA.

Comparison of different body composition models in acromegaly

The aberrant body composition of 10 patients with active acromegaly was used to evaluate the validity and limitations of several models and methods to assess body composition. Body composition was determined using either a two-compartment model, dividing the body in a body fat (BF) compartment and a fat-free mass (FFM) compartment, or a four-compartment model in which the FFM compartment comprises the three following components: body cell mass, extracellular water and the fat-free extracellular solids. The measurement techniques consisted of anthropometry, bioelectrical impedance analysis (BIA)-applying various established regression equations-tritiated water dilution, whole body 40K-counting, and whole body computed tomography (CT). This latter method was used as the reference technique. Assessment of total body water using BIA - applying the RJL or Kushner equation-correlated significantly with the assessment using tritiated water dilution (P < 0.01). Body fat assessment using the two-compartment model based on either tritiated water dilution or BIA-applying the RJL or Lukaski equation-as well as body fat assessment using the four-compartment model based on tritiated water dilution and whole body 40K-counting were significantly correlated with body fat assessment using CT (P < 0.01) and resulted in good agreement with each other with respect to the absolute values of the body fat determination. BIA using other regression equations overestimated body fat by 7.2-13.7 kg. Whole body 40K-counting was significantly correlated with CT-determined muscle plus skin volume (P < 0.001). CT-calibrated anthropometric predictions significantly overestimated body fat. It is concluded that in patients with active acromegaly, the determination of body composition using either certain two-compartment models based on measurement of total body water or bioelectrical impedance, or a four-compartment model based on total body water and total body potassium measurements show good agreement with CT-determined body composition.

Reduction in thigh muscle cross-sectional area and strength in a 4-year follow-up in late polio

OBJECTIVE

To study changes in cross-sectional thigh muscle area and muscle strength in late polio subjects over a 4-year period.

DESIGN

Longitudinal study of a cohort of polio survivors, comparing subjects who acknowledge (unstable) with those who do not acknowledge (stable) new muscle weakness.

SETTING

University hospital.

SUBJECTS

Eighteen subjects (6 men, 12 women) with polio-myelitis sequelae (39 to 46 years of age) were studied on two occasions 4 years apart; the first examination was 37 to 44 years after onset of polio. Subjects were recruited through hospital registers, newspaper advertisement, and a patient organization.

OUTCOME MEASUREMENTS

Thigh muscle and intermuscular and intramuscular adipose tissue (AT) cross-sectional areas were measured by computed tomography. Isometric muscle strength for knee extension and flexion was measured using a Kin-Com dynamometer.

RESULTS

Cross-sectional muscle area decreased on average 1.3 +/- 3.6 cm2 (1.4%, p < .05); the intermuscular and intramuscular AT area increased 1.8 +/- 3.4 cm2 (12.1%, p < .05). When divided by legs in which subjects reported (unstable) or did not report (unstable) or did not report (stable) increased muscle weakness, unstable legs showed significant reduction (p < .05) in muscle area, whereas stable legs did not. Estimated total thigh muscle strength decreased 7.8% +/- 2.9% (p < .01), with a significant (p < .001) reduction in unstable legs (13.4% +/- 4.3%) but not in stable legs. The reduction in strength appears to be greater than the reduction in cross-sectional muscle area, but there is still a significant correlation (r = .44, p < .05).

CONCLUSION

The present results demonstrate not only progress of muscle weakness, but also of muscle atrophy in postpolio subjects.

Endurance training effect on individuals with postpoliomyelitis

OBJECTIVE

To determine the effects of an endurance training program on the exercise capacity and muscle structure and function in individuals with postpolio syndrome.

DESIGN

Preexercise and postexercise testing was performed with muscle strength evaluations using isokinetic testing as well as hand-held Myometer. Muscle fatigue was determined by use of isokinetic testing, and endurance was determined by exercise testing. Enzymatic evaluation was performed with muscle biopsies taken at the same site; preexercise and postexercise muscle cross-sectional area was measured by computed tomography. Disability and psychosocial evaluation was performed by a Functional Status Questionnaire.

SETTING

A university.

SUBJECTS

Seventeen postpolio subjects ranging in age from 39 to 49 years volunteered for a 6-month combined endurance and strength training program. They had a history of acute poliomyelitis at least 25 years earlier and were able to walk with or without aid.

INTERVENTION

Twelve of the subjects (mean age 42 years) completed the program, attending an average of 29 sessions, which were offered for 60 minutes twice a week.

MAIN OUTCOME MEASURES

Strength, endurance, enzymatic activity, and cross-sectional area were measured 3 months before the beginning of training, just before training, and at the completion of the exercise program.

RESULTS

Knee extension was reduced to an average of 60% of control values and did not change with training. Strength measured with a hand-held Myometer increased significantly for elbow flexion, wrist extension, and hip abduction. Exercise test on a bicycle-ergometer showed significant reduction (6beats/min) in heart rate at 70W and increase (12beats/min) in maximal heart rate with training. The training program could be performed without major complications and resulted in an increase in muscle strength in some muscle groups and in work performance with respect to heart rate at submaximal work load.

Body composition and tissue distributions in growth hormone deficient adults before and after growth hormone treatment

This study examines short and long-term effects of recombinant human growth hormone (rhGH) on body composition and regional tissue distributions by using a multicompartment technique based on computed tomography. Part I includes nine subjects aged 46 +/- 9 years with adult onset GH deficiency who were examined before and in the end of 6 months treatment with rhGH (0.4 U.kg-1.week-1) in a double-blind crossover trial. Part II is an ongoing open trial including seven of the males in part I. They were treated with rhGH (0.25 U.kg-1.week-1) over an additional period of 24 months. Adipose tissue (AT) was reduced by 4.7 kg (p < 0.01) while the muscle plus skin compartment (M) and visceral organs (V) were increased by 2.4 (p < 0.05) and 0.7 kg (p < 0.01), respectively, over 6 months of treatment with a high rhGH dose. A preferential lipid mobilization occurred in the visceral and subcutaneous trunk depots resulting in a changed AT distribution. Muscles of legs and arms increased while the increase of trunk muscles did not reach significance. The body composition changes were maintained over 2 years additional treatment. The preferential loss in visceral AT was further pronounced while other changes in tissue distributions observed during the first 6 months tended to be reversed on the lower rhGH dosage. It is concluded that growth hormone has profound and discordant effects on AT, M and V and with associated changes in tissue distributions. The beneficial effects on body composition seen in short-term treatment is preserved throughout an additional 24 months period of treatment.

Hormones, body composition and cardiovascular risk

Some 20 compartments of the body may be measured by CT and organ areas determined in 28 CT scans. Advantages of CT are described. While there have been extensive studies of hormones in pre- and postnatal growth, apart from evidence from disease, the role of hormones in adults has been less known. Data on growth hormone and sex hormones, from organ-oriented body composition studies, are summarized, together with implications for the relation between body composition and cardiovascular risk. Sex-specific anthropometric equations allow estimation of LBM, visceral and sc AT with <20% error. In the obese such estimates show visceral AT to be a stronger risk predictor than other compartments or W/HR.

Effects of recombinant human growth hormone on basal metabolic rate in adults with pituitary deficiency

The effect of recombinant human growth hormone (rhGH) on basal metabolic rate (BMR) was studied in a placebo-controlled, double-blind, crossover trial. Ten patients with a history of complete pituitary insufficiency were randomized for 26 weeks in each period. Three patients were excluded due to withdrawal, fever, and claustrophobia, respectively. All patients had received adrenal, thyroid, and gonadal substitution therapy for at least 1 year before the study. The dose of rhGH was 0.25 to 0.5 U/kg/wk, administered subcutaneously once a day in the evening. BMR was determined by indirect calorimetry in a computerized ventilated open-hood system. Body composition was examined using four different methods--computed tomography (CT), tritium dilution, 40K determinations, and total body nitrogen (TBN) measured with neutron activation. The body composition data have previously been reported. Fat-free mass (FFM) increased and body fat (BF) decreased during the first 6 weeks of rhGH treatment, but no further changes in body composition occurred between 6 and 26 weeks. Baseline BMRs in GH-deficient (GHD) patients were in the lower part of the reference range, but BMR and the ratio between BMR and FFM (BMR/FFM) were not significantly lower than in a carefully selected control group. BMR increased between 0 and 6 weeks (mean +/- SD: from 6.68 +/- 1.55 to 7.75 +/- 1.35 MJ/24 h, P < .001) and then remained unchanged between 6 and 26 weeks. The increase in BMR was closely related to the increase in FFM (r = .91, P < .01).(ABSTRACT TRUNCATED AT 250 WORDS)

Changes in body composition and adipose tissue distribution after treatment of women with Cushing's syndrome

Longitudinal studies on changes in body composition and adipose tissue (AT) distribution in response to altered cortisol exposure have not yet been undertaken. Therefore, we determined body composition in seven women aged 34 +/- 9 years (mean +/- SD) with Cushing's disease/syndrome before and 8 +/- 2 (SD) months after surgical treatment for pituitary (n = 5) or cortical adrenal (n = 2) adenomas. The treatment resulted in a reduction of plasma and urinary cortisol by 78% and 97% (P < .01), respectively, and body weight (BW) reductions of 10.2 +/- 8.1 (SD) kg. The volumes of AT, skeletal muscle plus skin, and visceral organs were determined using a multiscan computed tomography (CT) technique. Organ and tissue volumes were converted to weight by multiplying with organ densities. After treatment, AT was reduced by 8.2 +/- 6.1 kg (P = .012), skeletal muscle plus skin by 1.3 +/- 1.7 kg (NS), and visceral organs by 0.6 +/- 1.0 kg (NS). The net change of AT, skeletal muscle plus skin, and visceral organs (delta AMV) was thus -10.1 +/- 7.8 kg, which was in good agreement with the change in BW (delta BW, -10.2 +/- 8.1 kg). The standard error of a single determination calculated on the differences between delta BW and delta AMV was 2.8%. Although total skeletal muscle plus skin was not changed, muscle of arms was reduced by 0.3 +/- 0.2 L (P = .014). Except for leg AT (P = .088), the reductions of all regional AT depots (arms, head+neck, subcutaneous trunk, viscera) were significant when expressed in liters. The total AT was reduced by 23% +/- 11%.(ABSTRACT TRUNCATED AT 250 WORDS)

A multicompartment body composition technique based on computerized tomography

The objective of this study was to develop a body composition method based on computerized tomography (CT) which would make it possible to divide the body into multiple compartments at the tissue and organ level. Eight healthy males (21-42 years old) with BMIs ranging from 18.6 to 25.3 kg/m2 were used for the methodological development. Areas of tissues, organs and air/gas were measured in 28 cross-sectional scans having defined and identical positions in all examined subjects. The area determinations were performed with the following attenuation intervals (given in Hounsfield units, HU): air, gas and lungs: -1001 to -191 HU; adipose tissue (AT): -190 to -30 HU; all other soft tissues and organs: -29 to +151 HU; skeleton: 152 to 2500 HU. Various tissue and organ areas in the -29 to +151 HU interval were obtained by means of cursor circumscriptions, while area determinations in other intervals were based on the number of pixels fulfilling given attenuation criteria. Volumes of tissues, organs and gas were obtained from corresponding areas and the distances between the scans. The body was divided into 12 main volumes of tissues, organs and gas that could be further subdivided by region. The main volumes observed (in litres; mean +/- s.d.) were: skeleton (subdivisible into dense skeleton, red and yellow bone marrow): 8.7 +/- 0.9; skeletal muscle: 31.9 +/- 5.1; visceral AT (subdivisible into intra- and retroperitoneal, cardiac, other thoracic AT): 3.0 +/- 1.7; intra- and retroperitoneal organs other than AT: 4.6 +/- 0.8; gastrointestinal gas: 0.25 +/- 0.09; heart: 0.61 +/- 0.12; lungs and bronchial air: 5.1 +/- 1.1; other thoracic organs: 0.32 +/- 0.08; mammary glands: 0.001 +/- 0.004; CNS (subdivisible into brain and contents of spinal channel): 1.6 +/- 0.15; air in sinuses and trachea: 0.19 +/- 0.05; subcutaneous AT: 11.6 +/- 2.8; skin: 2.4 +/- 0.39. Precision errors as determined from double analyses of different tissue volumes ranged from 0.01 to 0.3 litres. For validation purposes, CT-estimated organ weights were obtained by multiplying organ volumes by their assumed densities. The sums of all organ weights were then compared with the measured body weights. The error calculated from the individual differences between these weights was 0.6 kg (0.85%). The multicompartmentation technique described has a high validity and reproducibility and is applicable over a wide range of medical fields which require body composition measurements at the tissue and organ level.

CT-determined changes in adipose tissue distribution during a small weight reduction in obese males

Nine obese males of Scandinavian origin were examined with a multiscan (n = 22) computerized tomography (CT) technique before and after a small weight reduction (4.4 kg). The total adipose tissue (AT) volume was reduced by 2.6 litres. Expressed as a percentage of initial depot volume, there were significant reductions (P < 0.02) in the AT depots of viscera (9.6%), upper limbs (7.0%), subcutaneous trunk (6.0%) and lower limbs (4.9%), while the AT of head and neck (1.9%) did not decrease significantly (P = 0.08). These results indicated a changed fat patterning and evidence for this was obtained by expressing the AT volume of each depot as a percentage of the total AT volume both before and after the weight reduction. Visceral AT constituted 21.7% of the total AT before and 20.9% after weight reduction. Thus, the fraction of AT in viscera was changed by -0.8 +/- 0.9% units which was significantly different from the change in leg AT (+0.5 +/- 1.1% units) (P < 0.02) and tended to be different from the change of subcutaneous AT (+0.2 +/- 1.0% units) (P < 0.07). Thus, the AT distribution was changed in a favourable direction by weight reduction. Changes in visceral/total AT area ratios of different trunk scans were not consistent and, in a stricter sense, fat patterning cannot be studied with area determinations since AT areas cannot be expressed as fractions of the total AT volume.

Distribution of adipose tissue and muscle mass in alcoholic men

An elevated waist to hip ratio (WHR) has been found to be a predictor for several prevalent diseases. To examine the potential role of alcohol in the elevation of WHR, established alcoholic men without severe liver damage who were in adequate nutritional condition were compared with organized teetotalers matched for age, height, and body weight; the groups had similar total body fat content and lean body mass. Computed tomographic (CT) measurements at thigh and trunk levels showed a significant increase in the visceral adipose tissue (AT) areas and a slight decrease of muscle areas in the gluteal and femoral regions of the alcoholics. The alcoholic men had 48% of their AT areas of trunk scans localized retroperitoneally and intraperitoneally compared with 38% for the teetotalers (P < .01). The difference seemed to be more marked for retroperitoneal than for intraperitoneal AT (97 v 60 cm2, P < .01). The elevated visceral AT areas seemed to be independent of smoking. It was concluded that the increased WHR of alcoholics may include not only changes in AT, but also in muscle tissue distribution.

Adipose tissue and muscle volume determination by computed tomography in acromegaly, before and 1 year after adenomectomy

The adipose tissue volume, skeletal muscle and skin volume and visceral organ volume were determined using the multiscan CT (computed tomography) technique in 15 patients with acromegaly. The examinations were performed before treatment and 1 year after transsphenoidal adenectomy. The mean body weight did not change significantly after treatment; 91.3 kg and 92.3 kg pre and postoperatively in men and 66.7 kg and 65.9 kg in women respectively. The total adipose tissue volume increased by 7.11 (59.2%, P < 0.01) in the male group and 3.9 1 (20.3%, P < 0.05) in the female group. Muscle and skin mass and visceral organ mass decreased significantly after treatment. The muscle and skin mass decreased by 3.6 1 (-7.4%, P < 0.01) in males and by 3.2 1 in females (-11.5%, P < 0.02). The corresponding decrease in visceral organ mass was 1.5 1 (-17.0%, P < 0.01) in males and 1.0 1 (15.4%, P < 0.05) in females respectively. On average, the fractions of adipose tissue in the subcutaneous trunk and the intra-abdominal depots increased after treatment, while the fractions of adipose tissue in the limbs and the head and neck region decreased. The change in adipose tissue distribution pattern reached significance (P < 0.005) in men only.

Treatment of adults with growth hormone (GH) deficiency with recombinant human GH

In a double blind, cross-over placebo-controlled trial, we studied the effects of 26 weeks of replacement therapy with recombinant human GH on body composition, metabolic parameters, and well-being in 10 patients with adult-onset GH deficiency (GHD). All patients received appropriate thyroid, adrenal, and gonadal replacement therapy. The dose of recombinant human GH was 0.25-0.5 U/kg.week (0.013-0.026 mg/kg.day) and was administered sc daily at bedtime. One patient was withdrawn from the study because of edema and atrial fibrillation. Body composition was estimated with three independent methods: computed tomography, bioelectric impedance, and total body potassium combined with total body water assessments. The Comprehensive Psychological Rating Scale and the Symptom Check List-90 were used to assess any change in psychopathology. After 26 weeks of treatment, adipose tissue (AT) mass decreased 4.7 kg (P < 0.001). Subcutaneous AT decreased by an average of 13%, whereas visceral AT was reduced by 30%. Muscle volume increased by 2.5 kg (5%; P < 0.05). According to the four-compartment model derived from assessments of total body potassium and total body water, body cell mass and extracellular fluid volume increased significantly by 1.6 and 3.0 kg, whereas body fat decreased by 6.1 kg. Results obtained by the bioelectric impedance technique were similar. The mean (+/- SD) concentrations of insulin-like growth factor-I increased from 0.26 (0.06) at baseline to 2.56 (1.55) and 2.09 (1.03) kU/L after 6 and 26 weeks of treatment. Calcium and serum phosphate, osteocalcin, and procollagen-III concentrations were significantly higher, and intact PTH concentrations were reduced after 6 and 26 weeks of treatment, respectively. Total and free T3 concentrations were significantly increased after 6 and 26 weeks of treatment, whereas free T4 concentrations were reduced at 6 weeks, but after 26 weeks, free T4 concentrations had returned to pretreatment values. Finally, after 26 weeks of treatment, there was a decrease in the Comprehensive Psychological Rating Scale score (P < 0.05). The results show that GH replacement in GHD adults results in marked alterations in body composition, fat distribution, and bone and mineral metabolism and reduces psychiatric symptoms. Finally, we conclude that the observed beneficial effects of replacement therapy with GH are of sufficient magnitude to consider treatment of GHD adults.

Low concentrations of insulin-like growth factor-I in abdominal obesity

Growth hormone secretion is blunted in obesity. Recent studies have shown that the sub-group of obesity with preponderance of accumulation of fat in visceral depots is associated with endocrine abnormalities. We therefore measured IGF-I concentrations in serum in 27 men who also underwent computerized tomography measurements of regional and total body fat mass. Furthermore, euglycemic-hyperinsulinemic glucose clamps were used to determine insulin resistance, and established 'risk factors' for cardiovascular disease and non-insulin dependent diabetes mellitus were measured, i.e. blood pressure, plasma lipids, and blood glucose, as well as sex steroid hormones. Visceral fat mass systolic blood pressure and triglycerides were higher (P < 0.05) in the group with low (87 +/- 4 micrograms/l) IGF-I values, compared to those with high (126 +/- 6 micrograms/l) IGF-I values, divided after the median value. IGF-I was negatively correlated with visceral fat mass (r = 0.40), independently of subcutaneous and total fat mass. As described before visceral fat mass was directly associated to a majority of the measured 'risk factors', as well as indirectly to testosterone and sex hormone binding globulin (SHBG) concentrations. The latter were also strongly related statistically to the 'risk factors'. IGF-I concentrations showed, however, weaker correlations with the metabolic factors, blood pressure or sex steroid hormones. Multivariate analyses revealed that the correlations of visceral fat with the risk factors were not influenced by IGF-I, while testosterone or SHBG totally abolished these associations. The results indicate that low serum IGF-I concentrations, suggesting deficient growth hormone secretion, are associated with visceral but not with subcutaneous or total fat masses.(ABSTRACT TRUNCATED AT 250 WORDS)

The effects of testosterone treatment on body composition and metabolism in middle-aged obese men

Twenty-three middle-aged abdominally obese men were treated for eight months with testosterone or with placebo. Testosterone treatment was followed by a decrease of visceral fat mass, measured by computerized tomography, without a change in body mass, subcutaneous fat mass or lean body mass. Insulin resistance, measured by the euglycemic/hyperinsulinemic glucose clamp method, improved and blood glucose, diastolic blood pressure and serum cholesterol decreased with testosterone treatment. A small increase in prostate volume was noted, but serum prostate specific antigen concentrations were unchanged and no adverse functional side-effects were found. Insulin sensitivity improved more in men with relatively low testosterone values at the outset. The mechanisms involved in these changes might act either via effects on visceral fat accumulation, followed by metabolic improvements, and/or via direct effects on muscle insulin sensitivity, as suggested by results of other recent studies. It is concluded that testosterone treatment of middle-aged abdominally obese men gives beneficial effects on well-being and the cardiovascular and diabetes risk profile, results similar to those observed after hormonal replacement therapy in postmenopausal women.

Training can improve muscle strength and endurance in 78- to 84-yr-old men

Nine men, 78-84 yr of age, participated in a dynamometer training program 2-3 times/wk, totaling 25 sessions, using voluntary maximal isometric, concentric, and eccentric right knee-extension actions (30 and 180 degrees/s). Measurements of muscle strength with a Kin-Com dynamometer and simultaneous electromyograms (EMG) were performed of both sides before and after the training period. Muscle biopsies were taken from the right vastus lateralis muscle. The total quadriceps cross-sectional area was measured with computerized tomography. Training led to an increase in maximal torque for concentric (10% at 30 degrees/s) and eccentric (13-19%) actions in the trained leg. The EMG activity increased at maximal eccentric activities. The total cross-sectional quadriceps area of the trained leg increased by 3%, but no changes were recorded in muscle fiber areas in these subjects, who already had large mean fiber areas (5.15 microns 2 x 10(3)). The fatigue index measured from 50 consecutive concentric contractions at 180 degrees/s decreased and the citrate synthase activity increased in all but one subject. The results demonstrate that increased neural activation accompanies an increase in muscle strength at least during eccentric action in already rather active elderly men and that muscle endurance may also be improved with training.

The morphology and metabolism of intraabdominal adipose tissue in men

Mass, morphology, and metabolism of total adipose tissue and its subcutaneous, visceral, and retroperitoneal subcompartments were examined in 16 men with a wide variation of total body fat. Computerized tomography (CT) scans showed that the intraabdominal fat mass comprised approximately 20% of total fat mass. Visceral and retroperitoneal fat masses were approximately 80% and 20% of total intraabdominal fat mass, respectively. Enlargement of intraabdominal fat depots was due to a parallel adipocyte enlargement only. Direct significant correlations were found between these adipose tissue masses and blood glucose and plasma insulin levels, blood pressure, and liver function tests, while glucose disposal rate during euglycemic glucose clamp measurements at submaximal insulin concentrations (GDR), plasma testosterone, and sex hormone-binding globulin concentrations correlated negatively. The correlations for glucose, insulin, and GDR were strongest with visceral fat mass. Adipose tissue lipid uptake, measured after oral administration of labeled oleic acid in triglyceride, was approximately 50% higher in omental than in subcutaneous adipose tissues. Adipocytes from omental fat also showed a higher lipolytic sensitivity and responsiveness to catecholamines. Furthermore, these adipocytes were less sensitive to the antilipolytic effects of insulin. Both lipid uptake and lipolytic sensitivity and responsiveness showed strong correlations (r = 0.8 to 0.9) to blood glucose and plasma insulin concentrations and also to the GDR (negative), while no such correlations were found with lipid uptake in subcutaneous or retroperitoneal abdominal adipose tissues. Taken together, these results suggest a higher turnover of lipids in visceral than in the other fat depots, which is closely correlated to systemic insulin resistance and glucose metabolism in men.

Effects of thoracic epidural anesthesia on coronary arteries and arterioles in patients with coronary artery disease

The effect of cardiac sympathetic blockade by high thoracic epidural anesthesia (TEA) (T1-T6, bupivacaine) on the luminal diameter of normal and diseased portions of epicardial coronary arteries was determined by quantitative coronary angiography in patients (n = 27) with severe coronary artery disease (CAD). In a separate group of patients (n = 9) with severe CAD, the effects of TEA on coronary arterioles (resistance vessels) were studied, by measuring total and regional myocardial blood flow and metabolism with the retrograde coronary sinus thermodilution technique. At the stenotic segments, TEA induced an increase in luminal diameter from 1.34 +/- 0.11 to 1.56 +/- 0.13 mm (P less than 0.002), but did not change the diameter of the nonstenotic segments (3.07 +/- 0.13 to 2.99 +/- 0.13 mm). In the second group of patients, TEA induced no changes in coronary perfusion pressure, total or regional myocardial blood flow, coronary venous oxygen content, coronary blood flow distribution, regional myocardial oxygen consumption, or lactate extraction or uptake. Two patients had chest pain in the control situation and had regional myocardial lactate production that was attenuated by TEA. We conclude that TEA may increase the diameter of stenotic epicardial coronary artery segments in patients with CAD without causing a dilation of coronary arterioles. These effects may be beneficial when high TEA is used to treat severe ischemic chest pain in patients at rest.

Visceral fat accumulation in men is positively associated with insulin, glucose, and C-peptide levels, but negatively with testosterone levels

Twenty-three healthy men (age 25 to 50 years), covering a wide range of fatness and body fat distribution, were studied. An oral glucose tolerance test was performed and adipose tissue areas were calculated from computed tomography (CT) scans made at the level of L4/L5. Visceral fat area was associated with elevated concentrations of insulin and C-peptide and with glucose intolerance before and after the oral glucose load. Concentrations of sex-hormone-binding globulin (SHBG), as well as total and free testosterone, were negatively correlated with waist/hip circumference ratio and visceral fat area and also negatively associated with increased glucose, insulin, and C-peptide concentrations. In multiple linear regression, adjusting for age, body mass index, and visceral fat area, serum concentrations of free testosterone were still negatively correlated with glucose, insulin, and C-peptide levels. Without claiming any causality in the observed associations, we conclude that, unlike in women, abdominal fat distribution, insulin, glucose, and C-peptide levels are negatively associated with serum testosterone levels in men.

Regional distribution of muscle and fat mass in men--new insight into the risk of abdominal obesity using computed tomography

We studied 24 healthy men (25-50 years old) covering a wide range of fatness (body mass index range: 21-34 kg/m2) and fat distribution (waist/hip range: 0.75-1.06). Computed tomography scans were taken at five levels (thigh, hip, waist, arm, and liver) from which fat, muscle and bone areas were calculated. Both waist/hip and BMI were correlated with fat areas in the thigh, arm and waist scans. BMI showed stronger correlations with peripheral fat areas, whereas waist/hip showed stronger correlations with fat areas in the waist scan (particularly with visceral fat area: r = 0.88, P less than 0.001). BMI was correlated with muscle and bone areas in the thigh scan. In multiple regression BMI was, independently of waist/hip and age, positively correlated with fat areas in the arm, thigh, and waist (not with visceral fat) and muscle and bone areas in the thigh. Waist/hip was independently of BMI and age correlated with fat areas in the arm and waist, including visceral fat area (but not with fat areas in the thigh). Moreover, waist/hip showed an independent negative correlation with muscle area in the thigh, muscle endurance and physical activity. Serum triglycerides, plasma insulin, glucose, uric acid and diastolic and systolic blood pressure were associated with visceral fat area but also to anthropometric indicators of abdominal fat distribution (especially waist/hip ratio). Liver attenuation, but not the liver/spleen attenuation ratio, was associated with some liver enzymes and BMI but not with waist/hip or metabolic parameters. We conclude that a higher BMI is associated with increased central and peripheral fat stores (but not visceral fat) and increased thigh muscle whereas waist/hip is primarily associated with increased central fat stores (noteably with visceral fat), decreased thigh muscle and reduced physical fitness. It is suggested that physical training might be an important element in the treatment of abdominal obesity in men.

Total and visceral adipose-tissue volumes derived from measurements with computed tomography in adult men and women: predictive equations

Total and visceral adipose-tissue (AT) volumes were determined by computed tomography (CT) by a multiscan technique in 17 men and 10 women with a wide range of body weights. In these primary materials, weight, height, and various diameters, circumferences, and subcutaneous AT thicknesses of the trunk were examined for their relationships to CT-determined total and visceral AT volumes. Predictive AT equations from the primary materials were then tested on two cross-validation groups consisting of another 7 men and 9 women. For the prediction of the total AT volume, weight/height was the superior single predictor, with errors less than 11% in primary and cross-validation materials. For the prediction of visceral AT volume, simple equations based entirely on the sagittal diameter of the trunk at the L3-L5 level resulted in errors less than 21% in both sexes.

Adipose tissue volume determination in males by computed tomography and 40K

Seventeen healthy male volunteers with weights ranging from 54 to 145 kg were examined with a Philips Tomoscan 310. The upper attenuation limit of adipose tissue was determined to be -30 HU. The lower attenuation limit was set to -190 HU. Regional and total adipose tissue volumes were calculated from the adipose tissue areas of 22 scans and from the distances between these scans. Three different mathematical formulas were used, which all gave similar results. The adipose tissue area of several trunk scans, as well as the elbow, showed very high correlations (r greater than 0.96) versus the volume determinations based on 22 scans. The visceral adipose tissue area of scan L2-L3 showed a higher correlation (r = 0.986) than any other single scan versus the visceral adipose tissue volume. Total adipose tissue volume determinations with ten selected scans correlated very closely with the results obtained from 22 scans (r = 0.997). The adipose tissue volume of the head and neck region was 1.9 +/- 1.0 per cent of the total volume. Corresponding figures for other regions were: arms 6.8 +/- 1.0 per cent, legs 29.0 +/- 7.3 per cent, subcutaneous part of the trunk 41.4 +/- 7.4 per cent and the visceral region 20.9 +/- 7.0 per cent. With greater total adipose tissue volumes the percentage of the subcutaneous adipose tissue of the trunk increased (r = 0.686; P less than 0.005). There was a very strong negative relationship between the fractional amount of adipose tissue in the legs and in the trunk (r = 0.993, P less than 0.001). The potassium contents of fat-free mass and lean body mass were deduced to be 64.7 and 71.0 mmol/kg, respectively. These calculations were based on adipose tissue volume determinations by computed tomography, on 40K measurements and on the assumption that the volume proportions of fat, water and protein in adipose tissue were 85:13.7:1.3. By using computed tomography (CT) as a standard an optimal weight (W) for height (H) index was constructed by using an iterative correlation technique. The optimal index, i.e. highest correlation and lowest error versus ATCT was found for W/H0.9.

Chronic Achilles paratenonitis in athletes: a histological and histochemical study

Pathological alterations of chronic Achilles paratenonitis were studied histologically and histochemically in tissue samples obtained operatively from 16 athletes with this complaint and from 3 control patients. The activities of 11 different enzymes--lactate, succinate, malate, glucose-6-phosphate and glutamate dehydrogenases, lipoamide dehydrogenase and glutathione reductase (NADH2- and NADPH2-diaphorases), acid and alkaline phosphatases, phosphorylase and leucylaminopeptidase--were studied. Pathological findings were located diffusely around the tendon. A slight inflammatory cell reaction was found in all cases. The fatty areolar tissue was clearly thickened and edematous, and showed fibrinous exudations, widespread fat necrosis, considerable connective tissue proliferation and adhesion formation. The blood vessels showed profound degenerative and necrotizing changes. The thin membranes of the paratenon were clearly hypertrophied. Increased enzyme activities were mainly found in the fibroblasts, inflammatory cells and vascular walls. A moderate activity of lysosomal enzymes, an increased activity of enzymes of electron transport, anaerobic glycolysis, pentose phosphate shunt and decreased activity of those of aerobic energy metabolism were found. Simultaneously an increased amount of both neutral and acid mucopolysaccharides and a locally increased amount of elastic fibres were found in the inflamed paratenon. These results indicate that marked metabolic changes occur in paratenonitis, i.e. an increased catabolism and decreased oxygenation of the inflamed areas. The morphological alterations suggest that the gliding function of the paratenon may be impaired.

Effects of periodic positive airway pressure by mask on postoperative pulmonary function

Postoperative pulmonary complications, alveolar-arteriolar oxygen difference ([A-a]O2-diff), peak expiratory flow (PEF) and forced vital capacity (FVC) were compared in patients using continuous positive airway pressure (CPAP) and positive expiratory pressure (PEP) administered by face mask against those of a control group using a deep-breathing device (Triflo). Forty-three consecutive, randomized patients undergoing elective upper abdominal surgery were included. CPAP, PEP and Triflo were administered for 30 consecutive breaths in every waking hour for three days postoperatively. The (A-a)O2-difference increased equally and significantly in the three groups after surgery, reaching a maximum on the first postoperative day. After this day, however, (A-a)O2-diff decreased in the CPAP and PEP groups, being significantly lower in the PEP group compared to the control group, two days postoperatively (p less than 0.05) and significantly lower in both the PEP and CPAP groups three days postoperatively (p less than 0.001 and p less than 0.05, respectively.) PEF did not differ significantly between the groups before or after surgery, while FVC was significantly higher in the PEP and CPAP groups, compared to control, on the third postoperative day (p less than 0.05). Atelectatic consolidation was observed in six of 15 patients in the control group three days postoperatively, the incidence being significantly lower in both the PEP group (0 of 15, p less than 0.001) and the CPAP group (one of 13, p less than 0.05). We concluded that periodic face mask administration of CPAP and PEP are superior to deep breathing exercises with respect to gas exchange, preservation of lung volumes and development of atelectasis after upper abdominal surgery. We also conclude that the simple and commercially available PEP mask is as effective as the more complicated CPAP system.

Determination of total adipose tissue and body fat in women by computed tomography, 40K, and tritium

The adipose tissue volumes of 12 women were determined by computed tomography (CT). Body weight ranged from 46 to 129 kg. Nine or twenty-two transsectional scans were examined with respect to the adipose tissue area. The total adipose tissue volume (ATCT22 or ATCT9) was calculated by assuming linear changes in the adipose tissue area between adjacent scans. Body fat (BF) was also calculated from total body potassium (BF40K), from total body water (BFTHO), and from both these determinations (BF40K + THO). Body mass index (BMI) was calculated by dividing body weight (BW) by height2 (H2). ATCT22, ATCT9, and BFK were more closely related to BW and BMI than were BFTHO and BF40K + THO. When ATCT was used as a standard, the optimal index of adiposity based on BW and H was in the range BW/H0.8 to BW/H1.2. From the CT and 40K measurements it was possible to deduce that the potassium content is 62 mmol/kg fat free mass and 73-75 mmol/kg lean body mass. The error of ATCT9 was 0.6%, while that of BF40K was at least three to four times larger. It is concluded that the CT-based AT determination is the most reproducible method so far available. The technique might turn out to be of great value in human energy balance experiments.

Adipose tissue volume determinations in women by computed tomography: technical considerations

Eight healthy female volunteers with weights ranging from 46 to 119 kg were examined with a Philips Tomoscan 310 in order to determine the amount of adipose tissue. From analysis of 'attenuation profiles' at the thigh and trunk levels the attenuation interval of adipose tissue was determined to be -190 HU to -30 HU. The adipose tissue volume was calculated from the adipose tissue area of 22 scans and from the distances between these scans. Three different mathematical models were tested which all gave similar results. The adipose tissue surface of the L4-L5 scan showed a higher correlation (r = 0.991) than any other single scan versus the 22-scan-based adipose tissue volume. The adipose tissue volume had to be calculated from nine selected slices in order to agree closely with the results based on 22 scans (r = 0.999) in each individual case. The adipose tissue volume of the head and neck region was 1.7 +/- 0.24 per cent of the total volume, while corresponding figures for other regions were: arms 7.5 +/- 1.2 per cent, legs 31.8 +/- 5.6 per cent, subcutaneous part of the trunk 48.9 +/- 5.1 per cent and visceral region 10.2 +/- 1.7 per cent. The relative amount of subcutaneous trunk adipose tissue increased with increasing adipose tissue volumes while that of legs, and of head and neck tended to decrease. The relative amount of visceral fat was not significantly dependent on the total adipose tissue volume in these eight women.

Fine structural alterations in chronic Achilles paratenonitis in athletes

The fine structural alterations in chronic Achilles paratenonitis were studied in tissue samples obtained from 14 athletes, who were operated on for this complaint and from 3 patients without any history of this disease. In the chronically inflamed paratendineal tissue mainly two types of cells were identified: classic fibroblasts with a smooth and rough endoplasmic reticulum and only a few mitochondria and lysosomes and myofibroblast-like cells with cytoplasmic microfilaments 5-6 nm in diameter, a rough endoplasmic reticulum, some mitochondrias and free ribosomes. These cells represented 19% of 471 studied non-inflammatory cells. In the extracellular space there was an increased amount of fibrils regarded as either type I or type III collagen as sign of tissue repair. Especially around the myofibroblastic cells a fine granular ground substance was found. The amount of ground substance was as a rule increased in pericellular space. Due to the capacity of contraction in healing tissue the myofibroblasts apparently have a role in the clinical symptoms of chronic Achilles paratenonitis.

Total rupture of pectoralis major muscle in athletes

Total rupture of the pectoralis major muscle is rare. It may follow a severe trauma or strenuous athletic exercise or performance. Five cases of total rupture of the pectoralis major muscle treated in athletes are reported. Two of them had made an extremely exerted effort in weight lifting, one was injured during a parachute landing, one was tackled in an ice hockey match, and one injured his pectoralis major muscle while pushing himself up from a swimming pool. In two cases the diagnosis was made early and in three cases 2-4 months after the injury. All of the patients were male and were treated successfully with surgery. Later they were able to exercise their sports. The weight lifters did not go on with competitive sports.

The operative treatment of chronic calcaneal paratenonitis

The conservative management of chronic calcaneal paratenonitis is time-consuming and often unsatisfactory. A new, safe and simple technique is described. The crural fascia on both sides of the tendon is incised and left open, adhesions around the tendon are trimmed away, the strongly hypertrophied portions of the paratenon are removed and mobilisation is begun immediately after operation. Between 1961 and 1978 201 such operations were performed on 182 patients 62 of whom were top-ranking Finnish athletes. Only five patients were not athletes. The results, including early return to full activity, were excellent in 169, good in 25 and poor in seven cases. After operation one of the patients gained an Olympic gold medal; others have attained international prominence.