Jaw Complications Associated with Bisphosphonate Use in Patients with Plasma Cell Dyscrasias

Osteonecrosis of the jaw has been linked with bisphosphonate use in breast cancer and multiple myeloma patients. We report 17 cases of patients with plasma cell dyscrasia being treated with bisphosphonate who developed osteonecrosis/osteomyelitis of the jaw. Seventeen patients evaluated at our institution between 1998 and 2005 are reported. All were being treated with bisphosphonates for a median of 5 mo prior to the onset of jaw symptoms. Sixteen of the 17 patients are 51 yr or older. None of the patients had been irradiated in the jaw nor had obvious osseous manifestation of multiple myeloma in the jaw. Thirteen patients were receiving zoledronic acid and four patients were receiving pamidronate at the onset of jaw symptoms. Six of the 17 did receive both agents at some time and all of these individuals were receiving zoledronic acid at diagnosis. Microorganisms were isolated in 7/17 patients with the most common organism being actinomycosis. We have initiated the following guidelines in an effort to ameliorate the incidence of this complication. Patients should have a full dental examination at the time of diagnosis of the plasma cell dyscrasia especially if bisphosphonates are to be considered as part of the therapy. In addition, bisphosphonates are held for a period of 3 mo prior to invasive dental procedures to allow for the osteoclastic recovery, therefore enhanced debris removal and lessening the chance of creating a fertile bacterial medium. Following the dental procedure we would re-introduce bisphosphonates only after the healing process is complete. Finally, multiple myeloma patients diagnosed with jaw osteonecrosis probably have a concurrent infection and should be aggressively treated with antibiotics.

mRNA-expression of often used house-keeping genes and the relation between RNA and DNA are sex steroid-dependent parameters in human myometrium and fibroids

The content of RNA and DNA in human myometrium and fibroids obtained at different endocrine conditions varied, with the highest RNA/DNA ratio in tissues from pregnant patients, intermediate ratios in women during the menstrual cycle and the lowest in tissues from postmenopausal and GnRHa-treated patients. mRNA expression of two house-keeping genes, gamma-actin and GAPDH, was highest in myometrium from pregnant women, intermediate in untreated women of fertile age and lowest in tissues from GnRHa-treated and postmenopausal women. To control for degradation of nucleic acids when measuring mRNA expression, we suggest additional analysis of gene(s), where the expression pattern is known, and that expression, whenever possible, is related to DNA, which is a more stable parameter than RNA and total nucleic acids, when there are differences in proliferation between tissues and/or groups of patients.

Expression of progesterone receptors A and B and insulin-like growth factor-I in human myometrium and fibroids after treatment with a gonadotropin-releasing hormone analogue

OBJECTIVE

To determine mRNA and protein expression of the progesterone receptor (PR) and insulin-like growth factor-I (IGF-I) in myometrium and fibroids.

DESIGN

Retrospective clinical study.

SETTING

Hospital-based and university-affiliated research laboratories.

PATIENT(S)

Twelve women in the proliferative phase and six women treated with GnRH analogue (GnRH-a).

INTERVENTION(S)

Blood sampling and collection of myometrium and fibroids.

MAIN OUTCOME MEASURE(S)

PR and IGF-I mRNA levels in fibroids and myometrium were analyzed by solution hybridization and in situ hybridization whereas the proteins were localized by immunohistochemistry.

RESULT(S)

Fibroids and myometrium from women in the proliferative phase showed significantly higher PR mRNA than the corresponding tissues from GnRH-a-treated women. The amount of cells positively stained for PR-AB and PR-B in fibroids and myometrium decreased after GnRH-a treatment compared with in the proliferative phase. The IGF-I mRNA in both fibroids and myometrium in the proliferative phase was significantly higher than those after GnRH-a treatment. The immunostaining of IGF-I showed no difference between the two tissues. There was weaker immunostaining in the GnRH-a-treated group compared with in the proliferative phase group.

CONCLUSION(S)

The shrinkage of fibroids after steroid deprivation is associated with alterations in PR and IGF-I expression.

Different expression of estrogen receptors alpha and beta in human myometrium and leiomyoma during the proliferative phase of the menstrual cycle and after GnRHa treatment

Uterine leiomyomas (uterine fibroids) are sex-steroid dependent benign tumors. Limited knowledge is available regarding the role of estrogen and their receptors in the regulation of fibroids in premenopausal women, and in their shrinkage after treatment with a gonadotropin-releasing hormone analogue (GnRHa). The expression of the two subtypes of the estrogen receptor (ER), ER alpha and ER beta, was studied in leiomyoma and homologous myometrium from women in the proliferative phase of the menstrual cycle and from women treated with GnRHa. The mRNA levels of ER alpha and ER beta were monitored by solution hybridization and in situ hybridization, and receptor proteins were detected and localized by immunohistochemistry. Both ER alpha and ER beta were present in the leiomyomas and homologous myometrium. The ER alpha mRNA level in the leiomyomas was higher than in the surrounding myometrium. The ER beta mRNA level was lower than that of ER alpha in both groups. ER beta immunoreactivity was lower in leiomyomas when compared with the myometrium after GnRHa treatment, while ER alpha was higher in the leiomyomas. The present results imply that the increased ratio of ER alpha/ER beta observed in the fibroids after GnRHa treatment could reflect or be the cause of the shrinkage of the leiomyoma, which is the clinical outcome of this treatment.

Gene expression and tissue concentrations of IGF-I in human myometrium and fibroids under different hormonal conditions

The expression of insulin-like growth factor-I (IGF-I) was measured at the mRNA and protein level in myometrium and fibroids from women with and without preoperative treatment with a gonadotrophin-releasing hormone (GnRH) agonist for 3 months, from post-menopausal women, from pregnant women and in myometrium from women without fibroid disease. Women with menstrual periods were classified according to the phase of the cycle. In tissues from non-treated premenopausal women, IGF-I mRNA expression was significantly higher in fibroids than in myometrium, with no differences related to phase of the menstrual cycle. In post-menopausal women and in GnRH agonist-treated women responding to treatment, similar mRNA expression was seen in myometrium and fibroids but the concentrations were lower than in untreated premenopausal women. The IGF-I mRNA value in fibroids from pregnant women was higher than in any other group and myometrium from pregnant women exhibited higher mRNA expression than myometrium from non-treated premenopausal women. The IGF-I protein was more abundant in fibroids than in myometrium of non-treated premenopausal and of pregnant women and in both tissues the concentration was significantly higher in the group of pregnant women. The IGF-I protein concentrations in fibroids and myometrium from GnRH agonist-treated and post-menopausal women were similar to those from premenopausal non-treated women. High sex steroid concentrations in pregnant and non-pregnant women of fertile age seem to be associated with a higher expression of IGF-I in fibroids than in myometrium, suggesting that IGF-I contributes to the selective growth advantage of these tumours.

Tissue differences but limited sex steroid responsiveness of c-fos and c-jun in human fibroids and myometrium

Sex steroids influence the growth of mammalian uterine tissues and the proto-oncogenes c-fos and c-jun have been implicated in the cascade of cellular events induced by the cyclic influence of oestrogen and progesterone. To investigate the role of these proto-oncogenes for fibroid growth their mRNA expression was measured in myometrium and fibroids under different hormonal conditions, using a solution hybridization method. Fibroids and myometrium were collected at surgery from premenopausal, postmenopausal and pregnant women as well as women treated with a gonadotrophin releasing hormone agonist (GnRHa; Goserelin). The phase of the menstrual cycle was determined in all the untreated, premenopausal, non-pregnant women. The mRNA expression of c-fos and c-jun in fibroids was significantly lower than in homologous myometrium. No significant differences in c-fos expression were observed in myometrium, or fibroids, due to menstrual cycle phase, GnRHa treatment, pregnancy or the menopause. The c-jun expression in myometrium from pregnant women without fibroid disease was significantly higher than the corresponding control myometrium from premenopausal, non-pregnant women. These results demonstrate a tissue difference in the expression of c-fos and c-jun between myometrium and fibroids.

Laboratory studies on the effects of temperature variations on drowsiness

20 subjects were analysed in a laboratory study investigating the inhibition of drowsiness by altering air temperature. The EEGs of the subjects were used to measure the effect of sequences of temperature lowerings of 10 degrees for 2- and 4-min. periods. The effect upon wakefulness was analysed through EEG recordings and subjective ratings. Results indicated that reductions of the air temperature of 10 degrees during repeated 2- and 4-min. periods significantly increased wakefulness.

Sound exposure as a measure against driver drowsiness

Twelve lorry drivers participated in a field study, including in total 110 tests of a waking sound system. The system was based on a time and frequency varied sound, generated at intervals between 1 and 15 min for periods of 3-7 s. The waking effect of the sound was analysed through subjective ratings. Exposure to the sounds was correlated to improvements of the immediate as well as the long-term self-reported changes in wakefulness. The results of the study show consistently positive assessments concerning the applied waking system, both regarding the system as a measure for raised wakefulness, increased road safety and the interest in having the system installed in the vehicle. The waking sounds were in no case felt to be annoying. Analyses of the wakefulness and other factors and the interaction related to fatigue and driving are included in the investigation.

Sex steroid receptors in human myometrium and fibroids: changes during the menstrual cycle and gonadotropin-releasing hormone treatment

The content of estrogen and progesterone receptors (ER, PR) is higher in fibroid tissue than in homologous myometrium, and both receptors seem to be regulated by the levels of circulating sex steroids. Myometrial and fibroid tissues were recovered from women undergoing gynecological operations during different phases of the menstrual cycle and during treatment with an analogue of GnRH (GnRHa). Contents of ER and PR in the tissue cytosol were determined by enzyme immunoassay. The ER levels were significantly higher in fibroid tissue than in homologous myometrium in all the endocrine conditions. During the secretory phase, when luteal progesterone production is prominent, the ER levels in the myometrium and fibroids were lower than during the proliferative phase. During GnRHa treatment, the ER levels in both tissues were similar to those in the proliferative phase but significantly higher than in the secretory phase. The PR levels were also significantly higher in fibroids than in myometrium in all the different endocrine conditions. In both tissues, the PR levels were lower in the secretory phase and during GnRHa treatment, compared with the proliferative phase. Our data suggest that, in these categories of women, both ER and PR are overexpressed in fibroid tissue. Apparently, high progesterone levels down-regulate the ER in both fibroids and myometrium, whereas estrogen mediates the up-regulation of the PR during the proliferative phase. Increased knowledge about the mechanisms by which sex steroids regulate their own receptors in uterine tissues might provide a basis for development of new treatment strategies for women with fibroid disease.

Thirteen-year evolution of azole resistance in yeast isolates and prevalence of resistant strains carried by cancer patients at a large medical center

Drug resistance is emerging in many important microbial pathogens, including Candida albicans. We performed fungal susceptibility tests with archived isolates obtained from 1984 through 1993 and fresh clinical isolates obtained from 1994 through 1997 by testing their susceptibilities to fluconazole, ketoconazole, and miconazole and compared the results to the rate of fluconazole use. All isolates recovered prior to 1993 were susceptible to fluconazole. Within 3 years of widespread azole use, we detected resistance to all agents in this class. In order to assess the current prevalence of resistant isolates in our hematologic malignancy and transplant patients, we obtained rectal swabs from hospitalized, non-AIDS, immunocompromised patients between June 1995 and January 1996. The swabs were inoculated onto sheep's blood agar plates containing 10 microg of vancomycin and 20 microg of gentamicin/ml of agar. One hundred one yeasts were recovered from 97 patients and were tested for their susceptibilities to amphotericin B, fluconazole, flucytosine, ketoconazole, and miconazole. The susceptibility pattern was then compared to those for all clinical isolates obtained throughout the medical center. The antifungal drug histories for each patient were also assessed. The yeasts from this surveillance study were at least as susceptible as the overall hospital strains. There did not appear to be a direct linkage between prior receipt of antifungal agent therapy and carriage of a new, drug-resistant isolate. Increased resistance to newer antifungal agents has occurred at our medical center, but it is not focal to any high-risk patient population that we studied. Monitoring of susceptibility to antifungal agents appears to be necessary for optimizing clinical therapeutic decision making.

Laboratory studies of a sound system that maintains wakefulness

Two studies investigated the effects of a waking sound that enhances wakefulness. Study I investigated the effect of the sound level and Study 2 the effect of time and frequency variability of the sound. The recordings of EEG and subjective ratings were analysed to study the effect upon wakefulness. The waking effect increased when sound varied in duration and frequency. A number of specific conditions necessary for the waking effect are described. The exposure should be based on high frequency sounds and several tones chosen to produce disharmony. The exposure should be loud enough to be heard over the masking background noise. The duration and tonal quality should be variable from one presentation to another.

Serum levels of endometrial proteins during transcervical resection of the endometrium

OBJECTIVE

To study the potential for dissemination of endometrial tissue substances during transcervical resection of the endometrium (TCRE).

DESIGN

Prospective study.

SETTING

One university and two county hospitals.

PARTICIPANTS

Forty-eight women with dysfunctional bleeding.

INTERVENTIONS

The serum levels of two endometrial proteins, insulin-like growth factor binding protein-1 (IGFBP-1) and placental protein 14 (PP14), were measured before and every 10 min during the operations. Blood loss was also measured by a photometer together with absorption of the irrigating fluid containing glycine 1.5% and ethanol 1% by expired-breath tests, and serum sodium and volumetric fluid balances.

MAIN OUTCOME MEASURES

Linear correlations between changes in IGFBP-1 and PP14 during TCRE and operating parameters such as operating time, blood loss and fluid absorption.

RESULTS

The baseline levels of IGFBP-1 were normal but PP14 could only be detected in one third of the patients, which was due, in part, to pre-operative treatment with danazol. The highest levels of IGFBP-1 and PP14 during surgery correlated positively with the baseline concentrations. Fluid absorption (median 405 ml, range 0-2177) was the only surgical factor associated with increasing serum levels of endometrial proteins.

CONCLUSION

Absorption of the solution used to irrigate the uterus is associated with dissemination of endometrial products in the bloodstream during TCRE.

Inhibitors of the arachidonic acid metabolism attenuate the thyroliberin (TRH) stimulated prolactin production without modifying the production of inositolphosphates in GH4C1 pituitary cells

Some arachidonic acid metabolites might be among the intracellular signalling substances that regulate hormone release. We report that the phospholipase A2 and diacylglycerol lipase inhibitor quinacrine (1-10 mumol l-1) inhibited the thyroliberin stimulated prolactin (rPRL) production in a dose-dependent way in a rat pituitary tumour cell line (GH4Cl cells). The lipoxygenase inhibitor nafazatrom (5-50 mumol-1) also dose-dependently inhibited the thyroliberin stimulated rPRL production, while the cyclo-oxygenase inhibitor indomethacin had no such effect on rPRL production. The inhibitors of the arachidonic acid metabolism (quinacrine, ETYA and nafazatrom) had no effect on the accumulation of inositolpolyphosphates indicating that the arachidonic acid metabolites are not involved in the regulation of the phospholipase C activity.

The lipoxygenase inhibitor nafazatrom inhibits stimulated prolactin secretion in cultured rat lactotrophs (GH4C1 cells)

Arachidonic acid metabolites are involved in the regulation of prolactin (PRL) secretion from rat lactotrophs (GH4C1 cells). Phospholipase A2 (PLA2) stimulated PRL secretion, while the PLA2 inhibitor quinacrine reduced both thyrotropin-releasing hormone (TRH) and vasoactive intestinal peptide (VIP) stimulated PRL release. Hormonally stimulated PRL release was further increased in the presence of the cyclo-oxygenase inhibitor indomethacin. Nafazatrom, a lipoxygenase inhibitor, reduced stimulated PRL secretion regardless of the mechanism of stimulation [hormonally (VIP and TRH) or by increasing intracellular Ca2+ concentration by KCl or Bay-K and cAMP by forskolin]. None of the inhibitors used in this study had any effect either on the basal PRL secretion or on the production of cAMP. Lipoxygenase products seem to be involved in the regulation of PRL secretion, probably by affecting a late step in the signal transduction.

Could bacterial vaginosis be due to the competitive suppression of lactobacilli by aerobic microorganisms?

Bacterial vaginosis (BV) is characterized by lack of lactobacilli and predominance of anaerobic species. Ciprofloxacin is active against a great number of aerobic bacteria. The effect of ciprofloxacin on the vaginal microbial flora was studied both in healthy subjects and in patients with BV in order to test if BV may be due to competitive suppression of lactobacilli by aerobic species. About half of the patients were relieved of their symptoms. No adverse effects on the microbial profile or colonization by lactobacilli were produced by the drug. Lactobacilli known to be able to produce hydrogen peroxide were found to be significantly more common in healthy women than in women with BV. The species most frequently related to vaginal health were Lactobacillus jensenii and Lactobacillus rogosae.

Peripheral nerve block with use of nerve stimulator

The authors describe use of the nerve stimulator in conjunction with a percutaneous exploring needle to achieve peripheral blocks accurately and without injuring the nerve. The nerve stimulator allows accurate nerve blocks without causing paresthesiae and the need for additional anesthetic. This technique decreases the possibility of nerve injury.

Bacterial vaginosis is not a simple ecological disorder

Eighty-four patients with bacterial vaginosis were examined in an open randomized trial, the aim of which was to define clinical results and the microbiological panorama after topical treatment for 1 week with either an acetic acid jelly (A), an estrogen cream (B), a fermented milk product (C) or metronidazole (D). After exclusion because of chlamydia infection (15 cases) or for other reasons, 61 cases remained for complete evaluation 4 weeks after the start of treatment. Clinical cure was obtained in 3 cases out of 17 on regimen A, in 1 out of 16 on regimen B, in 1 of 14 on regimen C, and in 13 out of 14 on regimen D. The patients were conclusively either symptomless or symptomatic when examined on 113 occasions. Statistically significant reduction after treatment resulting in relief of symptoms was observed in the numbers of corynebacteria and anaerobic cocci, whereas lactobacilli increased in numbers. The instillation of high numbers of Lactobacillus acidophilus (C) into the vagina cured only 1 patient and did not influence the predominance of lactobacilli in the vagina at the follow-up examination. The difference in microbiological profile of women in symptomatic and asymptomatic conditions becomes still more apparent when the results of the present and previously published studies on the subject by the present group of investigators are combined. The symptomatic woman is significantly more often harboring corynebacteria, Gardnerella vaginalis, peptostreptococci, peptococci, eubacteria and Bacteroides species. Lactobacilli are significantly reduced in numbers. However, only 51% of our previously symptomatic, but now symptomless women show predominant growth of lactobacilli, which is less than expected for healthy women.(ABSTRACT TRUNCATED AT 250 WORDS)