Prolonged hypocalcemia following denosumab therapy in metastatic hormone refractory prostate cancer

Prostate cancer is a leading cause of cancer death, frequently associated with widespread bone metastases. We report two cases of hypocalcemia following the first dose of denosumab in metastatic hormone refractory prostate cancer, the first case requiring 26 days of intravenous calcium therapy. This is the first report of prolonged hypocalcemia following denosumab in a patient with normal renal function.

Variability in total testosterone levels in ageing men with symptoms of androgen deficiency

The aim of this study was to determine the variability in total testosterone (TT) levels in healthy, non-obese ageing men with symptoms of androgen deficiency. Men aged ≥55 years were recruited from the community. Morning TT levels were measured on four occasions in a 12-month period. In all, 96 men aged 62.7 ± 6.8 years were studied. Geometric mean values (95% confidence interval) of TT levels for the cohort at each time point were 14.5 (13.4-15.7), 14.6 (13.5-15.8), 15.5 (14.4-16.8) and 15.0 (13.9-16.2) nmol/L. The maximum intra-individual difference in TT between the four samples was 4.1 nmol/L (interquartile range: 2.9-6.4). Using the average of two baseline TT values reduces the maximum difference to 2.3 nmol/L (1.0-3.8). Only 1 of 25 men with a documented TT <10 nmol/L at baseline had TT levels <10 nmol/L at all subsequent time points. A single TT level is a reliable predictor of repeat measures taken within a 12-month period for a cohort of healthy ageing men with symptoms of androgen deficiency. However, given that the diagnostic criteria for androgen deficiency are, in part, predicated upon serum TT, there is sufficient intra-subject variability to warrant repeat sampling to confirm an initial low TT level. Using an average of two baseline TT values reduces this variability.

Testosterone therapy prevents gain in visceral adipose tissue and loss of skeletal muscle in nonobese aging men

BACKGROUND

Trials of testosterone therapy in aging men have demonstrated increases in fat-free mass (FFM) and skeletal muscle and decreases in fat mass (FM) but have not reported the impact of baseline body composition.

OBJECTIVE

The objective of the study was to determine the effect, in nonobese aging men with symptoms of androgen deficiency and low-normal serum testosterone levels, of testosterone therapy on total and regional body composition and hormonal and metabolic indices.

METHODS

Sixty healthy but symptomatic, nonobese men aged 55 yr or older with total testosterone (TT) levels less than 15 nm were randomized to transdermal testosterone patches or placebo for 52 wk. Body composition, by dual-energy x-ray absorptiometry (FM, FFM, skeletal muscle) and magnetic resonance imaging (abdominal sc and visceral adipose tissue, thigh skeletal muscle, and intermuscular fat) and hormonal and metabolic parameters were measured at wk 0 and 52.

RESULTS

Serum TT increased by 30% (P = 0.01), and LH decreased by 50% (P < 0.001). Relative to placebo, total body FFM (P = 0.03) and skeletal muscle (P = 0.008) were increased and thigh skeletal muscle loss was prevented (P = 0.045) with testosterone therapy and visceral fat accumulation decreased (P = 0.001) without change in total body or abdominal sc FM; change in visceral fat was correlated with change in TT levels (r2 = 0.36; P = 0.014). There was a trend to increasing total and low-density lipoprotein cholesterol with placebo.

CONCLUSION

Testosterone therapy, relative to placebo, selectively lessened visceral fat accumulation without change in total body FM and increased total body FFM and total body and thigh skeletal muscle mass. Further studies are needed to determine the impact of these body compositional changes on markers of metabolic and cardiovascular risk.

Body composition, metabolic syndrome and testosterone in ageing men

The ageing process in men is marked by changes in body composition (loss of fat-free mass (FFM) and skeletal muscle, and gain in fat mass (FM)) and is associated with a decline in serum testosterone. Correlations between these aspects of ageing and the acknowledged role of exogenous testosterone in reversing the loss of FFM and gain in FM seen in adult men with congenital or acquired hypoandrogenism have led to the hypothesis that testosterone therapy in ageing men will result in favourable changes in body composition and may improve metabolic status and/or cardiovascular risk. Data from randomized controlled trials of testosterone therapy in ageing men addressing the endpoints of body composition and components of the metabolic syndrome and cardiovascular risk factors are reviewed, and the impact of the increasing prevalence of obesity on these relationships is considered.

Stereotactic radiosurgery XVI: a treatment for previously irradiated pituitary adenomas

We report the use of stereotactic radiosurgery delivered through an adapted linear accelerator [stereotactic multiple arc radiation therapy (SMART)] for pituitary adenomas not cured by conventional therapy. All 21 patients had undergone conventional radiotherapy (45-50 Gy); 18 had also undergone prior surgery. This cohort comprised 13 patients with somatotrope adenomas, four with corticotrope adenomas, one with a lactotrope adenoma, and three with nonfunctioning pituitary adenomas (median follow-up: 33 months, range: 3-72 months). SMART has proven effective, safe, and rapidly acting. We observed an accelerated reduction in GH and IGF-I levels in acromegaly, with normalization of GH and IGF-I levels in 58%. Mean GH fell from 21.1 mU/liter to 7.9 mU/liter (7 ng/ml to 2.6 ng/ml, P < 0.01, median 25 months) faster than our predicted fall to 50% at 2 yr with conventional radiotherapy. Mean IGF-I fell from 624 ng/ml to 384 ng/ml (P < 0.001). Tumor growth was controlled in two of three nonfunctioning pituitary adenomas, and three of four corticotrope adenomas. There were no adverse effects from SMART. Notably there have been no visual sequelae or further loss of anterior pituitary function in this heavily pretreated group. Our data indicate that SMART is an effective complementary therapy for pituitary adenomas that have displayed a suboptimal response to conventional therapy including external irradiation.

Pituitary chondrosarcoma: an unusual cause of a sellar mass presenting as a pituitary adenoma

A 37-yr-old woman with clinical, endocrinological, and radiological features suggestive of a nonfunctioning pituitary tumor was found to have a chondrosarcoma of the pituitary sella. The bony structures around the sella were relatively uninvolved, other than showing minor erosion of the left side of the dorsum and the posterior wall of the sphenoid sinus. After partial resection of the tumor by the transsphenoidal route the patient received postoperative radiosurgery by a linear accelerator, stereotactic multiarc radiotherapy. Subsequent follow-up revealed reduction of the residual tumor. This case demonstrates that a chondrosarcoma may apparently arise directly from the pituitary fossa and suggests the efficacy of stereotactic radiosurgery, at least in the medium term. The origin, areas of involvement, management, and long-term prognosis of these rare tumors are reviewed.

Concurrent secretion of aldosterone and cortisol from an adrenal adenoma - value of MRI in diagnosis

A 43-year-old female with a 24-years history of hypertension presented for further investigation and management of primary hyperaldosternoism. Postural studies were not conclusive and magnetic resonance (MR) imaging demonstrated a 27 x 18 mm lesion of the right adrenal gland which showed no signal loss during in and out of phase imaging. Although these appearances were considered to be atypical of those seen on MR in patients with aldosterone producing adrenal adenomas the patient underwent an adrenalectomy with removal of a 3 x 3 x 2 cm right adrenal mass. Post-operatively she became hypotensive and a 0900 hours serum cortisol was undetectable (< 50 nmol/l), consistent with adrenal insufficiency. Following the administration of hydrocortisone there was normalization of the blood pressure and subsequent adrenal stimulation tests confirmed the presence of functioning adrenal tissue albeit with an inadequate response. Cortisol measurement from preoperative samples revealed loss of normal diurnal rhythm whereas DHEAS levels both pre and postoperatively were undetectable, consistent with ACTH supression resulting from autonomous cortisol secretion in addition to aldosterone. Concurrent secretion of cortisol should always be considered in Conn's adenomas particularly when atypical radiological features are present.

Alcohol problems and anxiety disorders--a critical review

The assumption that, within clinical populations, anxiety reduction is a major factor in the aetiology of drinking problems no longer appears to be a plausible explanation of the available data. There are many studies which document the occurrence of anxiety symptoms in problem drinkers but the difficulty lies in deciding which comes first, the alcohol problem or the anxiety. Evidence is reviewed which indicates that anxiety is likely, in most instances, to be a consequence rather than a cause of heavy drinking. This has implications for the treatment of patients with both disorders. The assessment and management of patients with a 'dual-diagnosis' of alcohol dependence and anxiety is discussed in the light of these findings.

Acknowledging alcohol problems. The use of a visual analogue scale to measure denial

Despite the frequent mention of denial in the alcohol treatment literature, there appears to be no consensus about its measurement. At its most basic, an operational definition of the term should contain the notion of the drinker refusing to acknowledge or at least minimizing the role of alcohol in his or her difficulties. Visual analogue scales provide a technique for measuring subjective experiences of this type. Subjects from a community-based voluntary agency and an alcohol treatment unit were asked to indicate the magnitude of their problems with alcohol on this scale. Both groups acknowledged high levels of problems with alcohol. Despite this, there was evidence of systematic bias in that half of the sample underestimated the severity of their drinking in comparison to an interviewer's rating using the same scale. A small group was identified that seemed to fit the stereotype of the alcoholic "denier" mentioned so frequently in the treatment literature. There was no relationship between "denial" and subsequent compliance with treatment.

Psychological symptoms, psychiatric disorder and alcohol dependence amongst men and women attending a community-based voluntary agency and an Alcohol Treatment Unit

One-fifth of clients attending a community-based voluntary agency presented for treatment with an alcohol problem complicated by affective disorder, phobic anxiety or personality disorder. A matched sample of patients recruited from an Alcohol Treatment Unit, and assessed using the same stringent clinical criteria, had similar levels of formal psychiatric disorder, except for a small group of women. One quarter of women in this group were phobic with some overlap of affective disorder. Rates of psychological symptoms as opposed to psychiatric disorder were high in both samples and appeared to be associated with severity of dependence on alcohol. No sex differences were apparent in the rates of psychological symptoms. The practical as well as theoretical implications of these findings were discussed.

Glasgow Council on Alcohol: trends and developments in a community based voluntary organisation (1968-1989)

Since 1968, Glasgow Council on Alcohol has steadily increased the scope and variety of its efforts to help problem drinkers and their families. Apart from a large increase in client numbers over the last 20 years, there has been a number of interesting developments in identifying 'at risk' groups and directing them into the helping process. Prevention of alcohol problems has also become a major issue for this agency.

Characteristics and help-seeking patterns of attenders at a community-based voluntary agency and an alcohol and drug treatment unit

The assumption that clients using community-based facilities in the form of Councils on Alcohol have less serious alcohol problems uncomplicated by the physical, social and psychological difficulties found in those attending Alcohol Treatment Units was not confirmed. One of the most striking findings were the similarities, rather than the differences between the two samples. Both groups had attenders who were heavily dependent on alcohol and were experiencing a wide range of problems. Attenders at both agencies, women as well as men, had help seeking patterns similar to those described for other populations which were discontinuous and uncoordinated and featured multiple contacts and simultaneous use of different services. The need for co-ordination was discussed in the light of the improved outcome which can be expected given appropriate matching of clients to treatment. Some suggestions as to how this might be achieved were discussed.

Women, life events and drinking problems

Do women drink excessively for the same reasons as men? A growing body of opinion suggests not. Beckman's (1975) views are representative— “Alcoholism and heavy drinking in women appear more likely to be linked to psychological stress and a specific precipitating circumstance or situation than is alcoholism or heavy drinking in men”.

Stressful life events and alcohol misuse in women: a critical review

The literature on stressful life events and alcohol misuse in women is critically reviewed. Many researchers have suggested that women begin to misuse alcohol in response to stress linked to precipitating circumstances or life events. Middle-aged women are felt to be especially at risk because of the nature of the events that they are likely to experience, e.g., divorce, bereavement and departure of children from the home. Evidence for these views has been collected by asking patients to recall particular events in their past that they considered may have caused their heavy drinking. This approach has several methodological problems, most notably the failure to deal with the possibility that heavy drinking produced an increased frequency of stressful life events rather than vice versa. It has been speculated that women are more likely to attribute their heavy drinking to causes that are more likely to elicit sympathy than condemnation. None of the studies discussed has considered the possibility that the link between life events and heavy drinking reflects the activities of a sizable subgroup of women described as "sociopathic" alcoholics, the disturbance producing an excess of both events and excessive alcohol consumption. Considerable criticism has been leveled at the use of poorly validated concepts such as "mid-life crisis" and the tendency to use terms such as "menopausal syndrome" as an explanation for almost any difficulty experienced by women in middle age. It is concluded that the hypothesis that stressful life events cause excessive drinking remains to be empirically demonstrated.

Self-reported alcohol consumption and dissimulation in a Scottish urban sample

The interaction between demographic variables and underreporting of personal alcohol consumption systematically obscured the genuine relationships among demographic variables and alcohol consumption.