Effect of 12-months testosterone replacement therapy on bone mineral density and markers of bone turnover in testicular cancer survivors - results from a randomized double-blind trial

BACKGROUND

Testicular cancer survivors (TCS) are at risk of Leydig cell insufficiency, which is a condition characterized by elevated luteinising hormone (LH) in combination with low levels of testosterone. It has been suggested that this condition is associated with impaired metabolic profile and low bone mineral density (BMD). The primary aim of the randomized double-blind trial NCT02991209 was to evaluate metabolic profile after 12-months testosterone replacement therapy (TRT) in TCS with mild Leydig cell insufficiency. Here we present the secondary outcomes of changes in BMD and markers of bone turnover.

METHODOLOGY

In total, 69 TCS with mild Leydig cell insufficiency were randomized 1:1 to 12 months TRT (n = 35) (Tostran, gel, 2%, applied transdermally, with a maximum daily dose of 40 mg) or placebo (n = 34). BMD and markers of bone turnover were evaluated at baseline, after 6- and 12-months TRT, and 3-months post-treatment. Linear mixed effects models were used to analyse changes in BMD, N-terminal propeptide of type 1 procollagen (P1NP) and C-terminal telopeptide of type I collagen (CTX).

RESULTS

After 12 months treatment, TRT was not associated with a statistically significant difference in BMD compared to placebo; total body BMD: 0.01 g/cm2 (95% confidence interval (CI): -0.01 - 0.02), BMD of the lumbar spine: 0.01 g/cm2, (95% CI: -0.01-0.03), BMD of the left femoral neck: 0.00, (95% CI: -0.01-0.02). TRT was associated with a small but statistically significant increase in P1NP: 11.65 µg/L (95% CI: 3.96, 19.35), while there was no difference in CTX.

CONCLUSION

12 months of TRT did not change BMD, while there was as small and clinically irrelevant increase in P1NP compared to placebo in TCS with mild Leydig cell insufficiency. The findings need validation in a larger cohort.

Baseline bone turnover marker levels can predict change in bone mineral density during antiresorptive treatment in osteoporotic patients: the Copenhagen bone turnover marker study

Anti-resorptive osteoporosis treatment might be more effective in patients with high bone turnover. In this registry study including clinical data, high pre-treatment bone turnover measured with biochemical markers was correlated with higher bone mineral density increases. Bone turnover markers may be useful tools to identify patients benefitting most from anti-resorptive treatment.

INTRODUCTION

In randomized, controlled trials of bisphosphonates, high pre-treatment levels of bone turnover markers (BTM) were associated with a larger increase in bone mineral density (BMD). The purpose of this study was to examine this correlation in a real-world setting.

METHODS

In this registry-based cohort study of osteoporosis patients (n = 158) receiving antiresorptive therapy, the association between pre-treatment levels of plasma C-telopeptide of type I Collagen (CTX) and/or N-terminal propeptide of type I procollagen (PINP) and change in bone mineral density (BMD) at lumbar spine, total hip, and femoral neck upon treatment was examined. Patients were grouped according to their pre-treatment BTM levels, defined as values above and below the geometric mean for premenopausal women.

RESULTS

Pre-treatment CTX correlated with annual increase in total hip BMD, where patients with CTX above the geometric mean experienced a larger annual increase in BMD (p = 0.008) than patients with CTX below the geometric mean. The numerical pre-treatment level of CTX showed a similar correlation at all three skeletal sites (total hip (p = 0.03), femoral neck (p = 0.04), and lumbar spine (p = 0.0003)). A similar association was found for PINP where pre-treatment levels of PINP above the geometric mean correlated with a larger annual increase in BMD for total hip (p = 0.02) and lumbar spine (p = 0.006).

CONCLUSION

Measurement of pre-treatment BTM levels predicts osteoporosis patients' response to antiresorptive treatment. Patients with high pre-treatment levels of CTX and/or PINP benefit more from antiresorptive treatment with larger increases in BMD than patients with lower pre-treatment levels.

Effect of Liraglutide Treatment on Prediabetes and Overweight or Obesity in Clozapine- or Olanzapine-Treated Patients With Schizophrenia Spectrum Disorder: A Randomized Clinical Trial

IMPORTANCE

Compared with the general population, patients with schizophrenia have a 2- to 3-fold higher mortality rate primarily caused by cardiovascular disease. Previous interventions designed to counteract antipsychotic-induced weight gain and cardiometabolic disturbances reported limited effects.

OBJECTIVES

To determine the effects of the glucagon-like peptide-1 receptor agonist liraglutide added to clozapine or olanzapine treatment of schizophrenia spectrum disorders.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical double-blind trial enrolled participants at 2 clinical sites in Denmark. Of 214 eligible participants with a schizophrenia spectrum disorder, 103 were randomized to liraglutide or placebo. Participants received stable treatment with clozapine or olanzapine, were overweight or obese, and had prediabetes. Data were collected from May 1, 2013, through February 25, 2016.

INTERVENTIONS

Treatment for 16 weeks with once-daily subcutaneous injection of liraglutide or placebo. Trial drug therapy was titrated during the first 2 weeks of the study.

MAIN OUTCOMES AND MEASURES

The primary end point was change in glucose tolerance estimated by a 75-g oral glucose tolerance test result. Secondary end points included change in body weight and cardiometabolic parameters.

RESULTS

Of the 103 patients undergoing randomization (60 men [58.3%] and 43 women [41.7%]), 97 were included in the efficacy analysis, with a mean (SD) age of 42.5 (10.5) years and mean (SD) body mass index (calculated as weight in kilograms divided by height in meters squared) of 33.8 (5.9). The liraglutide and placebo groups had comparable characteristics (mean [SD] age, 42.1 [10.7] vs 43.0 [10.5] years; 30 men in each group; mean [SD] body mass index, 33.7 [5.1] vs 33.9 [6.6]). A total of 96 randomized participants (93.2%) completed the trial. Glucose tolerance improved in the liraglutide group compared with the placebo group (P < .001). Altogether, 30 liraglutide-treated participants (63.8%) developed normal glucose tolerance compared with 8 placebo-treated participants (16.0%) (P < .001; number needed to treat, 2). Body weight decreased with liraglutide compared with placebo (-5.3 kg; 95% CI, -7.0 to -3.7 kg). Reductions in waist circumference (-4.1 cm; 95% CI, -6.0 to -2.3 cm), systolic blood pressure (-4.9 mm Hg; 95% CI, -9.5 to -0.3 mm Hg), visceral fat (-250.19 g; 95% CI, -459.9 to -40.5 g), and low-density lipoprotein levels (-15.4 mg/dL; 95% CI, -23.2 to -7.7 mg/dL) occurred with liraglutide compared with placebo. Adverse events with liraglutide affected mainly the gastrointestinal tract.

CONCLUSIONS AND RELEVANCE

Liraglutide significantly improved glucose tolerance, body weight, and cardiometabolic disturbances in patients with schizophrenia spectrum disorders treated with clozapine or olanzapine.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01845259.

Reproductive hormones and metabolic syndrome in 24 testicular cancer survivors and their biological brothers

Testicular cancer survivors have impaired gonadal function and increased risk of metabolic syndrome when compared to healthy controls. However, because of the fetal etiology of testicular cancer, familial unrelated healthy men might not be an optimal control group. The objective of this study was to clarify if testicular cancer survivors have impaired gonadal function and increased risk of metabolic syndrome when compared to their biological brothers. A cross-sectional study of testicular cancer survivors (ClinicalTrials.gov number, NCT02240966) was conducted between 2014 and 2016. Of 158 testicular cancer survivors included, 24 had a biological brother who accepted to participate in the study. Serum levels of reproductive hormones and prevalence of metabolic syndrome according to International Diabetes Federation Criteria and National Cholesterol Education Program (Adult Treatment Panel III) criteria comprised the main outcome measures of the study. Median age was similar in testicular cancer survivors and their biological brothers [44 years (IQR 39-50) vs. 46 (40-53) years respectively (p = 0.1)]. In testicular cancer survivors, follow-up since treatment was 12 years (7-19). Serum levels of luteinizing hormone and follicle-stimulating hormone were elevated (p ≤ 0.001), while total testosterone, free testosterone, inhibin B and anti-Müllerian hormone were lower (p ≤ 0.001) in testicular cancer survivors than in their biological brothers. The prevalence of metabolic syndrome was similar and apart from HDL-cholesterol, which was lower in testicular cancer survivors (p = 0.01); there were no differences in the individual components of the metabolic syndrome between testicular cancer survivors and their brothers. In conclusion, gonadal function was impaired in testicular cancer survivors, while we did not detect any difference in the prevalence of metabolic syndrome between testicular cancer survivors and their biological brothers.

Renal deterioration after spinal cord injury is associated with length of detrusor contractions during cystometry-A study with a median of 41 years follow-up

AIMS

To investigate which urodynamic parameters are associated with renal deterioration over a median of 41 years follow-up after traumatic spinal cord injury.

METHODS

Medical records of patients with a traumatic spinal cord injury sustained 1944-1975 were reviewed from time of injury until 2012. Patients who attended regular renography and/or renal clearance examinations and had minimum one cystometry and pressure-flow study were included. Renal deterioration was diagnosed as split renal function ≤30% in one kidney or relative glomerular filtration rate ≤51% of expected according to age and gender. Detrusor function, presence of detrusor sphincter dyssynergia, maximum detrusor pressure, post-void residual volume, and cystometric bladder capacity were obtained. In patients with detrusor overactivity, a detrusor overactivity/cystometry ratio was calculated using duration of detrusor contraction(s) during filling cystometry divided by total duration of filling cystometry.

RESULTS

A total of 73 patients were included in the study, and the median follow-up time was 41 years after injury (range 24-56). Sixty-four patients (88%) used reflex triggering or bladder expression as bladder emptying method for the longest period after injury. During follow-up 60% changed to clean intermittent catheterization. The majority of the patients (68%) had neurogenic detrusor overactivity. In 35 patients, a detrusor-overactivity/cystometry ratio could be calculated and a detrusor overactivity/cystometry ratio > 0.33 was significantly associated with renal deterioration (P < 0.02). No significant association was found between maximum detrusor pressure or other urodynamic parameters and renal deterioration.

CONCLUSIONS

Duration of detrusor overactivity longer than one third of the duration of cystometry is associated with renal deterioration after spinal cord injury.

Vasoactive Intestinal Polypeptide Evokes Only a Minimal Headache in Healthy Volunteers

The role of the parasympathetic nervous system in the pathogenesis of migraine is disputed. The headache-eliciting effect of the parasympathetic neurotransmitter, vasoactive intestinal polypeptide (VIP), and its effect on cerebral arteries and brain haemodynamics has not been systematically studied in man. We hypothesized that infusion of VIP might induce headache in healthy subjects and cause changes in cerebral haemodynamics. VIP (8 pmol/kg per min) or placebo (0.9± saline) was infused for 25 min into 12 healthy young volunteers in a crossover, double-blind design. Headache was scored on a verbal rating scale from 0 to 10, regional cerebral blood flow (rCBF) was measured with single-photon emission computed tomography and 133Xe inhalation and mean flow velocity in the middle cerebral artery (VmeanMCA) was measured with transcranial Doppler ultrasonography. The headache was very mild with a maximum score of 2 and described as a pressing or throbbing sensation. Five participants developed headache during VIP and one during placebo. During the infusion, a significant drop in VmeanMCA was seen for VIP compared with placebo ( P < 0.001), but the effect quickly waned and no difference was found when comparing the time between 30 and 120 min. In addition, no significant difference in the diameter of the MCA could be found during the infusion. No significant differences in rCBF ( P = 0.10) were found between VIP and placebo. A marked dilation of the superficial temporal artery was seen ( P = 0.04) after VIP in the first 30 min but no difference was found when comparing the time between 30 and 120 min. We found no difference in mean arterial blood pressure between VIP and placebo days but the heart rate increased significantly on a VIP day compared with a placebo day (AUC0–30min, P < 0.001). Plasma VIP was significantly higher on a VIP day compared with placebo (AUC0–80min, P < 0.001). These results show that VIP causes a decrease in VmeanMCA without affecting rCBF. In spite of a marked vasodilator effect in the extracranial vessels and increased plasma VIP, healthy subjects developed only a very mild headache.

Automated Bone Scan Index as a quantitative imaging biomarker in metastatic castration-resistant prostate cancer patients being treated with enzalutamide

Background

Having performed analytical validation studies, we are now assessing the clinical utility of the upgraded automated Bone Scan Index (BSI) in metastatic castration-resistant prostate cancer (mCRPC). In the present study, we retrospectively evaluated the discriminatory strength of the automated BSI in predicting overall survival (OS) in mCRPC patients being treated with enzalutamide.

Methods

Retrospectively, we included patients who received enzalutamide as a clinically approved therapy for mCRPC and had undergone bone scan prior to starting therapy. Automated BSI, prostate-specific antigen (PSA), hemoglobin (HgB), and alkaline phosphatase (ALP) were obtained at baseline. Change in automated BSI and PSA were obtained from patients who have had bone scan at week 12 of treatment follow-up. Automated BSI was obtained using the analytically validated EXINI Bone^BSI version 2. Kendall’s tau (τ) was used to assess the correlation of BSI with other blood-based biomarkers. Concordance index (C-index) was used to evaluate the discriminating strength of automated BSI in predicting OS.

Results

Eighty mCRPC patients with baseline bone scans were included in the study. There was a weak correlation of automated BSI with PSA (τ = 0.30), with HgB (τ = −0.17), and with ALP (τ = 0.56). At baseline, the automated BSI was observed to be predictive of OS (C-index 0.72, standard error (SE) 0.03). Adding automated BSI to the blood-based model significantly improved the C-index from 0.67 to 0.72, p = 0.017. Treatment follow-up bone scans were available from 62 patients. Both change in BSI and percent change in PSA were predictive of OS. However, the combined predictive model of percent PSA change and change in automated BSI (C-index 0.77) was significantly higher than that of percent PSA change alone (C-index 0.73), p = 0.041.

Conclusions

The upgraded and analytically validated automated BSI was found to be a strong predictor of OS in mCRPC patients. Additionally, the change in automated BSI demonstrated an additive clinical value to the change in PSA in mCRPC patients being treated with enzalutamide.

Forty-five-year follow-up on the renal function after spinal cord injury

STUDY DESIGN

Retrospective chart review.

OBJECTIVES

To investigate the extent of renal deterioration in patients with spinal cord injury (SCI) and to identify risk indicators associated with renal deterioration.

SETTING

Clinic for Spinal Cord Injuries, Rigshospitalet, Hornbæk, Denmark.

METHODS

This study included 116 patients admitted to our clinic with a traumatic SCI sustained between 1956 and 1975. Results from renography and (51)Cr-EDTA plasma clearance were collected from medical records from time of injury until 2012, and the occurrence of renal deterioration was analysed by cumulative incidence curves. The impact of demographics, neurological level and completeness of SCI, urinary tract stones, dilatation of the upper urinary tract (UUT) and bladder-emptying methods were analysed with Cox proportional hazard ratios.

RESULTS

The bladder-emptying methods used for the longest period were reflex triggering (63%), bladder expression (22%), indwelling catheter (5%), normal voiding (4%), ileal conduit (3%) and clean intermittent catheterisation (2%). The cumulative risk of moderate renal deterioration (functional distribution outside 40-60% on renography or relative glomerular filtration rate (GFR) ⩽75% of expected according to age and gender) was 58%. The cumulative risk of severe renal deterioration (functional distribution outside 30-70% on renography or relative GFR⩽51%) was 29% after 45 years postinjury. Only dilatation of UUT and renal/ureter stone requiring removal significantly increased the risk of moderate and severe renal deterioration.

CONCLUSION

Renal deterioration occurs at any time after injury, suggesting that lifelong follow-up examinations of the renal function are important, especially in patients with dilatation of UUT and/or renal/ureter stones.

Short-term, high-dose glucocorticoid treatment does not contribute to reduced bone mineral density in patients with multiple sclerosis

Background:

Patients with multiple sclerosis (MS) are at increased risk of reduced bone mineral density (BMD). A contributing factor might be treatment with high-dose glucocorticoids (GCs).

Objectives:

The objective of this paper is to assess bone mass in patients with MS and evaluate the importance of short-term, high-dose GC treatment and other risk factors that affect BMD in patients with MS.

Methods:

A total of 260 patients with MS received short-term high-dose GC treatment and had their BMD measured by dual x-ray absorptiometry. BMD was compared to a healthy age-matched reference population ( Z-scores). Data regarding GCs, age, body mass index (BMI), serum 25(OH)D, disease duration and severity were collected retrospectively and analysed in a multiple linear regression analysis to evaluate the association between each risk factor and BMD.

Results:

Osteopenia was present in 38% and osteoporosis in 7% of the study population. Mean Z-score was significantly below zero, indicating a decreased BMD in our MS patients. Multiple linear regression analysis showed no significant association between GCs and BMD. In contrast, age, BMI and disease severity were independently associated with both lumbar and femoral BMD.

Conclusion:

Reduced BMD was prevalent in patients with MS. GC treatment appears not to be the primary underlying cause of secondary osteoporosis in MS patients.

Radionuclide leakage monitoring during hyperthermic isolated limb perfusion for treatment of local melanoma metastasis in an extremity

INTRODUCTION

The aim is to describe the importance of leakage monitoring in hyperthermic isolated limb perfusion (ILP). It is generally recommended that leakage should not exceed 10% because of risk of systemic toxicity.

MATERIAL AND METHODS

Data retrieved by retrospective analysis of 131 perfusions performed in 115 consecutive patients (77 women and 38 men; median age 66 years) with recurrent and/or clinically apparent, cutaneous or subcutaneous melanoma metastases in an extremity. Radionuclide monitoring was performed with continuous, precordial count rate determinations of an intravascular (99m) Tc-labelled tracer infused into the isolated limb circulation.

RESULTS

One hundred and sixteen of 131 procedures were completed. In 13%, a leakage of ≥10% was detected; in 6% (n = 8), the cytotoxic drug was never infused because of constant leakage; in 7% (n = 9), leakage ≥10% was measured during the perfusion resulting in two perfusions being terminated before 30 min, 5 perfusions were considered completed though with early termination (after 30 min, before 60 min), and 2 fully completed. No patients had systemic toxicity requiring treatment, whereas considerable or serious local toxicity were observed in 14%. Three of the patients with leakage ≥10% were successfully treated in a repeated procedure.

CONCLUSION

Leakage monitoring using a threshold of 10% during ILP saves the patients from systemic toxicity, however, at the expense of early termination or cancellation of ILP treatment in a few patients and repeated ILP procedures in some.

The diagnostic value of adding dynamic scintigraphy to standard delayed planar imaging for sentinel node identification in melanoma patients

PURPOSE

The aim of this study was to compare early dynamic imaging combined with delayed static imaging and single photon emission computed tomography (SPECT)/CT with delayed, planar, static imaging alone for sentinel node (SN) identification in melanoma patients.

METHODS

Three hundred and seven consecutive melanoma patients referred for SN biopsy (SNB) were examined using combined imaging. Secondary interpretation of only the delayed static images was subsequently performed. In 220 patients (72%), complete surgical and pathological information relating to the SNB was available. The number of SNs identified and number of patients with positive SNs were compared between the two interpretations of the imaging studies and, when available, related to pathology data.

RESULTS

A slightly higher number of SNs (mean 0.12/patient) was identified when interpreting only delayed static images compared to combined imaging. In a direct patient-to-patient comparison, the number of SN(s) identified on the combined vs static images only showed moderate agreement (kappa value 0.56). In 38 patients (17%), positive SNs were identified by the combined procedure compared to 35 (16%) by static imaging only. Thus by static imaging only, tumour-positive SNs were not identified in 3 of 38 patients (8%).

CONCLUSION

For SN identification in melanoma patients, dynamic imaging combined with delayed static imaging and SPECT/CT is superior to delayed static imaging only because the latter is more likely to fail to identify SNs containing metastases.

Axillary sentinel node identification in breast cancer patients: degree of radioactivity present at biopsy is critical

BACKGROUND

The radioactivity present in the patient (Act(rem) ) at sentinel node (SN) biopsy will depend on injected activity amount as well as on the time interval from tracer injection to biopsy, which both show great variations in the literature. The purpose of this study was to analyse the influence of varying Act(rem) levels on the outcome of axillary SN biopsy in patients with breast cancer (BC).

MATERIAL AND METHODS

Eight hundred and fifty-eight patients with BC were consecutively referred to SN biopsy, 21% for a same-day and 79% of the patients for a 2-day procedure. Four hundred and nineteen patients underwent scintigraphy and 439 did not. For same-day procedures, 50 MBq (99m) Tc-nanocolloid (Nanocoll(®) ) was injected, and for 2-day procedures 110 MBq. For the analysis of SN biopsy outcome, the patients were divided into three Act(rem) groups: <10 (56% of the patients), 10-20 (23%), and >20 MBq (21%). During surgery, SNs were located using a hand-held gamma probe supported by image information when available and blue dye injection. Pathology included haematoxylin-eosin staining followed by immunohistochemistry.

RESULTS

The number of SNs removed (mean value 1·87 versus 2·14, P = 0·0003) and the probability of finding a malignant SN (P = 0·034) were lower in the <10 MBq group of patients compared with higher Act(rem) >20 MBq. Of the 25 patients with SN non-detection, 20 patients had an Act(rem) <10 MBq. Imaging had no significant influence on the number of patients with a malignant SN (P = 0·48).

CONCLUSION

Act(rem) above 10 MBq for nanocolloid tracer appears important for appropriate identification of SNs in patients with BC.

Radiographic absorptiometry for pre-screening of osteoporosis in patients with low energy fractures

Dual energy X-ray absorptiometry (DEXA) is the most accurate method and thus the method of choice for diagnosing osteoporosis. Due to the limited access to DEXA-scanners, screening of patients with low energy fractures (LEF) for osteoporosis is not routinely performed in Denmark. Pre-screening with a simple, less expensive device might be able to exclude patients with normal bone mineral density (BMD) from further DEXA-scans. We aimed to determine the frequency of osteoporosis in patients with LEF, and evaluate the diagnostic impact of a radiographic absorptiometry (RA) scanner in the casualty department of a major Danish county hospital. In a 5-month period, 136 adult patients with LEF were invited for BMD measurements. In 74 (54%) patients DEXA-scans (spine and femoral neck) and phalangeal RA-scans were performed. A total of 86% of the patients were female and 39% were suffering from osteoporosis (T-scores < or = -2.5) according to the DEXA results. RA-BMD and T-scores differed significantly between the two groups, with and without osteoporosis (p < 0.001). Comparing T-scores from RA with the lowest T-scores from DEXA, a highly significant correlation was found for women (R = 0.7, p < 0.001). Using a RA cut-off value (T-score < -1) for women ensuring 100% sensitivity for identifying women with osteoporosis, the positive predictive value was 46%. Up to 19% of DEXA-scans could be avoided in this setting. In our population the simple RA-BMD-method was cost-effective as a pre-screening tool for osteoporosis in women. However, the final diagnosis still relies on results from DEXA-scans.

Prostaglandin E2 (PGE2) Induces Headache in Healthy Subjects

The role of prostanoids in nociception is well established. The headache-eliciting effects of prostaglandin E2 (PGE2) and its possible mechanisms have previously not been systematically studied in man. We hypothesized that infusion of PGE2 might induce headache and vasodilation of cranial vessels. PGE2 (0.40 μg kg−1 min−1) or saline was infused for 25 min into 11 healthy subjects in a cross-over, double-blind study. Headache intensity was scored on a verbal rating scale from 0 to 10. In addition, we recorded mean flow in the middle cerebral artery (VMCA) by transcranial Doppler and diameter of the superficial temporal artery (STA) by high-resolution ultrasonography. All 11 subjects reported headache on the PGE2 day and no subjects reported headache on the placebo day ( P = 0.001). During the immediate phase (0–30 min) ( P = 0.005) and the postinfusion phase (30–90 min) ( P = 0.005), the area under the curve for headache score was significantly larger on the PGE2 day compared with the placebo day. PGE2 caused dilatation of the STA (23.5%; 95% CI 14.0, 37.8) and the MCA (8.3%; 95% CI 4.0, 12.6). We suggest that PGE2 induces headache by activation and sensitization of cranial perivascular sensory afferents.

The cholinomimetic agent carbachol induces headache in healthy subjects

The parasympathetic nervous system is likely to be involved in migraine pathogenesis. We hypothesized that the cholinomimetic agonist carbachol would induce headache and vasodilation of cephalic and radial arteries. Carbachol (3 microg/kg) or placebo was randomly infused into 12 healthy subjects in a double-blind crossover study. Headache was scored on a verbal rating scale from 0-10. Velocity in the middle cerebral artery (V(MCA)) and diameter of the superficial temporal artery (STA) and radial artery (RA) were recorded. Nine participants developed headache after carbachol compared with three after placebo. The area under the curve for headache was increased after carbachol compared with placebo both during infusion (0-30 min) (P = 0.042) and in the postinfusion period (30-90 min) (P = 0.027). Carbachol infusion caused a drop in V(MCA) (P = 0.003) and an increase in STA diameter (P = 0.006), but no increase in the RA diameter (P = 0.200). In conclusion, the study demonstrated that carbachol caused headache and dilation of cephalic arteries in healthy subjects.

Source analysis of epileptic discharges using multiple signal classification analysis

Multiple signal classification is an alternative to the traditional dipole fitting source analysis methods. Our aim was to assess the clinical usefulness of this algorithm and to compare the localization of the epileptiform electroencephalography discharges with the regions of altered cerebral blood flow in 10 patients with complex partial seizures undergoing preoperative investigation. We performed multiple signal classification analysis of ictal and interictal discharges, and registered single-photon emission computed tomography. Localization of the ictal, but not the interictal discharges, as determined by multiple signal classification analysis was consistent with the regions showing perfusion changes on the single-photon emission computed tomography. Multiple signal classification analysis is a promising tool in localizing foci in patients with complex partial seizures and may contribute to the preoperative evaluation.

Evaluation of Tc-99m-tetrofosmin single-photon emission computed tomography for detection of chronic exertional compartment syndrome of the leg

Chronic exertional compartment syndrome (CECS) of the leg is a common, painful condition related to exercise and associated with increased muscle compartment pressure (CP). Invasive methods are currently the method of choice for diagnosing the condition. We investigated the use of Tc-99m-tetrofosmin perfusion single-photon emission computed tomography (SPECT) as a diagnostic tool compared with the gold standard, muscle CP measurement. In 14 subjects perfusion SPECT and CP were measured before and immediately after exercise leading to pain in the lower legs. Six subjects had increased pressures indicating the presence of CECS. In three (50%) of these muscular hypoperfusion was observed by perfusion SPECT. In eight subjects with normal CPs SPECT suggested muscular hypoperfusion. Because of the low diagnostic rates, sensitivity 50% and specificity 63%, Tc-99m-tetrofosmin perfusion SPECT seems not to be a useful method for diagnosing CECS.

[Acute multifocal osteomyelitis caused by haemolytic group B streptococci]

Invasive infections due to group B streptococci (Streptococcus agalactiae) usually occur in the peri- and neonatal setting or in adults with chronic underlying diseases. In the presented case a severe infection of haematogenous osteomyelitis caused by group B streptococci in a previously healthy 68-year-old woman is reported. Group B streptococci were isolated in three of three blood culture bottles drawn from the patient at the time of admission to hospital due to fever of unknown cause and pain in the upper and lower extremities as well as the back. A technetium scan showed involvement of the left shoulder, the left sacroilial joint, Th-9, Th-12 and L5. In addition, there was increased activity in the left foot, the right side of the mandibula and probably both hands (insufficiently scanned). The patient was successfully treated with penicillin G and subsequently with oral penicillin V for a total of 12 weeks.

Gamma-camera 18F-FDG PET in diagnosis and staging of patients presenting with suspected lung cancer and comparison with dedicated PET

It is not clear whether high-quality coincidence gamma-PET (gPET) cameras can provide clinical data comparable with data obtained with dedicated PET (dPET) cameras in the primary diagnostic work-up of patients with suspected lung cancer. This study focuses on 2 main issues: direct comparison between foci resolved with the 2 different PET scanners and the diagnostic accuracy compared with final diagnosis determined by the combined information from all other investigations and clinical follow-up.

METHODS

Eighty-six patients were recruited to this study through a routine diagnostic program. They all had changes on their chest radiographs, suggesting malignant lung tumor. In addition to the standard diagnostic program, each patient had 2 PET scans that were performed on the same day. After administration of 419 MBq (range = 305-547 MBq) (18)F-FDG, patients were scanned in a dedicated PET scanner about 1 h after FDG administration and in a dual-head coincidence gamma-camera about 3 h after tracer injection. Images from the 2 scans were evaluated in a blinded set-up and compared with the final outcome.

RESULTS

Malignant intrathoracic disease was found in 52 patients, and 47 patients had primary lung cancers. dPET detected all patients as having malignancies (sensitivity, 100%; specificity, 50%), whereas gPET missed one patient (sensitivity, 98%; specificity, 56%). For evaluating regional lymph node involvement, sensitivity and specificity rates were 78% and 84% for dPET and 61% and 90% for gPET, respectively. When comparing the 2 PET techniques with clinical tumor stage (TNM), full agreement was obtained in 64% of the patients (Cohen's kappa = 0.56). Comparing categorization of the patients into clinical relevant stages (no malignancy/malignancy suitable for treatment with curative intent/nontreatable malignancy), resulted in full agreement in 81% (Cohen's kappa = 0.71) of patients.

CONCLUSION

Comparing results from a recent generation of gPET cameras obtained about 2 h later than those of dPET, there was a fairly good agreement with regard to detecting primary lung tumors but slightly reduced sensitivity in detecting smaller malignant lesions such as lymph nodes. Depending on the population to be investigated, and if dPET is not available, gPET might provide significant diagnostic information in patients in whom lung cancer is suspected.

Effects of advanced glycation end-product inhibition and cross-link breakage in diabetic rats

The accelerated formation of advanced glycation end-products (AGEs) due to elevated glycemia has repeatedly been reported as a central pathogenic factor in the development of diabetic microvascular complications. The effects of a novel inhibitor of AGE formation, NNC39-0028 (2,3-diaminophenazine), and a breaker of already formed AGE cross-links, N-phenacylthiazolium bromide (PTB), were investigated in streptozotocin-diabetic female Wistar rats. Diabetes for 24 weeks resulted in decreased tail collagen pepsin solubility, reflecting the formation of AGE cross-linking. Collagen solubility was significantly ameliorated by treatment with NNC39-0028, whereas PTB had no effect. Increased urinary albumin excretion (UAE) in diabetic rats was observed in serial measurements throughout the study period, and was not reduced by any treatment. Vascular dysfunction in the eye, measured as increased clearance of 125I-albumin, was induced by diabetes. NNC39-0028 did not affect this abnormality. This study demonstrated a pharmacological inhibition of collagen solubility alterations in diabetic rats without affecting diabetes-induced pathophysiology such as the increase in UAE or albumin clearance. Treatment with PTB, a specific breaker of AGE cross-links, had no effects in this study.

Effects of heparin on vascular dysfunction in diabetic rats

1. Treatment with heparin has beneficial effects in diabetic nephropathy. The occurrence of increased urinary albumin excretion in diabetic patients reflects general vascular dysfunction, including increased transcapillary permeability of macromolecules. The aim of the present study was to evaluate the effects of heparin on vascular dysfunction in diabetic rats. 2. Male Sprague-Dawley rats were used in two studies. Diabetes was induced by 65 mg/kg, i.v., streptozotocin. In one study, diabetic rats were dosed subcutaneously with different heparin fractions for 8 months and the transcapillary escape rate of albumin (TERalb) was measured in anaesthetized animals. In the other study, heparin was given for 6 weeks, followed by tissue albumin clearance measurements in awake rats. Normal and diabetic rats receiving saline served as controls. 3. Blood glucose did not differ among the diabetic groups and ranged from 22 to 26 mmol/L. The mean (+/- SD) TERalb was increased by diabetes compared with values in normal rats (17.5 +/- 3 vs 14.1 +/- 3.3%/h, respectively). Neither unfractionated nor low molecular weight heparin significantly affected this increase. [131I]-Albumin clearance was significantly increased in diabetic rats in the eye, skin and skeletal muscle tissues compared with normal rats (0.17-0.40 vs 0.1-0.23 microL plasma/g per min). Low molecular weight heparin treatment did not affect the increased organ albumin clearance. 4. In conclusion, heparin treatment does not affect diabetes-induced vascular dysfunction as expressed by increased TERalb and clearance of albumin in rats.

Proteoglycan expression in the normal rat kidney

Proteoglycans constitute a heterogenous group of complex macromolecules, consisting of a backbone core protein and a variable number of sulfated polysaccharide side chains covalently linked to the core. A dual function for these polyanionic glycosaminoglycans in kidney physiology has been proposed: to maintain a fixed negative charge in the glomerular filtration barrier, and to bind and sequester cytokines essential for renal development and function. With the aim of identifying proteoglycan genes expressed in kidney glomeruli, we have performed in situ hybridization for selected proteoglycan core proteins in the normal rat kidney. Syndecan-4, glypican-1 and biglycan were all expressed in normal glomeruli, whereas syndecan-1, perlecan and versican mRNAs were confined to the papillary area. Decorin mRNA was detected in interstitial cells found between tubuli and surrounding larger vessels. No signal for betaglycan mRNA could be detected. By hybridizing adjacent sections with a probe for the podocyte-specific PTPase GLEPP-1, the glomerular cells containing mRNA for syndecan-4 and glypican-1 could be identified as podocytes, whereas the cells expressing biglycan were identified as mesangial cells. These results demonstrate that seven out of the eight proteoglycans investigated are expressed in the normal kidney in detectable amounts and, importantly, that each proteoglycan gene shows a unique pattern of expression. The constitutive expression of syndecan-4, glypican-1 and biglycan in glomerular cells points to a role for these polyanionic molecules in maintaining the integrity of the glomerular filtration barrier.

Effects of heparin and aminoguanidine on glomerular basement membrane thickening in diabetic rats

The effects of heparin and aminoguanidine on glomerular basement membrane thickening were studied in streptozotocin diabetic Sprague-Dawley rats. A placebo-treated group and a non-diabetic group served as controls. All diabetic rats remained severely hyperglycaemic (23 mmol/l) throughout the 8-month study period. At the end of this time relative kidney weight was significantly increased in diabetic control rats (4.9 +/- 0.5 g/kg b.w.) compared with non-diabetic rats (3.3 +/- 0.3 g/kg). This increase was not affected by the intervention treatments. Glomerular basement membrane thickness increased 32% in diabetic control rats (240 +/- 24 nm) compared with non-diabetic rats (182 +/- 20 nm). This increase was prevented by s.c. treatment with both unfractionated and low molecular weight heparins, while basement membrane thickness was the same in animals treated with oral heparins and aminoguanidine and untreated diabetic rats. Macroscopic malignant kidney tumours were seen in three aminoguanidine-treated rats. In conclusion, subcutaneously administered heparin prevents diabetes-induced glomerular basement membrane thickening.

Ceftriaxone versus latamoxef in febrile neutropenic patients: empirical monotherapy in patients with solid tumours

121 patients with 132 febrile episodes were randomised to ceftriaxone or latamoxef monotherapy in order to compare antibiotic efficacy in neutropenic patients treated with cytotoxic chemotherapy for solid tumours. In 80 evaluable episodes no significant differences were observed between the two groups with respect to efficacy and fatal failure rates. Of episodes treated with ceftriaxone, 67% showed a favourable clinical response vs. 61% in the latamoxef group. The clinical response rates in episodes with documented bacterial infections were 67 and 56% in the two treatment groups. In 18% of the episodes with documented initial infections the patients died of presumably uncontrolled infection. The convenient once daily dosage schedule combined with fewer severe adverse reactions favours the use of ceftriaxone instead of latamoxef. Although a relative high degree of response was seen, empirical antibiotic monotherapy apparently does not offer a sufficient antibacterial cover in infections in this type of patient with defective host immunity.

Effects of thyrotropin-releasing hormone on regional cerebral blood flow in man

To assess the regional changes in cerebral blood flow, 10 healthy volunteers were given 400 micrograms thyrotropin-releasing hormone iv in a double-blind, randomized, cross-over study. Regional cerebral blood flow was determined simultaneously in two slices of the brain, using a single photon emission computerized tomograph and inhalation of 133Xe. Thyrotropin-releasing hormone caused a significant mean increase of 3.7% (range -8.8-22.7) in blood flow in a region consistent with the left thalamus compared to placebo (3.2% decrease). In 25 other regions no significant change was detected. The thalamic region has previously been shown to be a region especially affected by thyrotropin-releasing hormone in animal studies. The thyrotropin-releasing hormone injection was followed by a minor rise in systemic blood pressure, but not a rise that could affect the cerebral blood flow. The effect of thyrotropin-releasing hormone on the regional cerebral blood flow in the thalamic region was much lower compared to changes found in sedated animals given a hundredfold higher dose of thyrotropin-releasing hormone.