Skeletal responsiveness to endogenous parathyroid hormone in postmenopausal osteoporosis.

To test the hypothesis that increased sensitivity of bone to PTH may be a major cause of bone loss in postmenopausal osteoporosis, we induced acute calcium deprivation and measured bone responsiveness to endogenous PTH under physiological conditions. Eighteen osteoporotic and 17 normal postmenopausal women with similar dietary calcium intakes were studied before and after 4 days of calcium deprivation (dietary calcium 230 mg/day and treatment with a calcium-binding agent). Despite decreased serum PTH values, the baseline indices of bone turnover (serum osteocalcin level and 24-h urinary excretions of total deoxypyridinoline/creatinine and pyridinoline/creatinine corrected for total body bone mineral content), were higher in the osteoporotic women. During calcium deprivation, the changes in bone markers from baseline were similar in both groups, except for serum osteocalcin and serum type I procollagen carboxy-terminal propeptide. Changes in the normal and the osteoporotic women were, respectively: serum ionized calcium concentration decreased 3.3% and 2.1%; serum intact PTH increased 65% and 56%; plasma 1,25-dihydroxyvitamin D3 increased 29% and 39%; pyridinoline/creatinine increased 12% and 11%; and deoxypyridinoline/creatinine increased 27% and 12%. Serum osteocalcin increased 2.3% and serum procollagen carboxy-terminal propeptide decreased 9.4% in the normal women but did not change in the osteoporotic women. We conclude that women with postmenopausal osteoporosis do not have increased skeletal responsiveness to PTH compared with age-comparable normal postmenopausal women. Therefore, the higher bone turnover in postmenopausal osteoporosis, despite lower serum intact PTH concentration, must be due to other factors. Assessment of acute changes in bone turnover during physiological alterations in endogenous PTH secretion is a useful test in metabolic bone diseases.


Correlations of language abnormalities with localization of mutations in the beta-thyroid hormone receptor in 13 kindreds with generalized resistance to thyroid hormone: identification of four new mutations.

Generalized resistance to thyroid hormone is an inherited disease characterized by unresponsiveness of pituitary and peripheral tissues to thyroid hormone. Genetic analysis of several kindreds linked this syndrome to the gene for the beta-form of the thyroid hormone receptor, and this led to the subsequent identification of various mutations in the ligand-binding domain of this receptor. In this region we now have found 4 new point mutations with reduced T3-binding affinities from separate kindreds by direct sequencing of polymerase chain reaction products. Similar to previously studied kindreds, the reduction in T3 binding of these four kindreds ranged from 2.5- to 5-fold, indicating that these are not neutral polymorphisms. Furthermore, the pattern of inheritance of these 4 kindreds is familial in 2, sporadic in 1, and unknown in 1. To date, 20 distinct mutations have been identified, of which 18 are clustered in 2 distinct topographical regions: 11 are within the tau i/dimerization subdomains of exon 9, and 7 are within the L2 subdomain of exon 10. The 4 newly identified mutations coupled to the 9 mutations our laboratory has previously identified provide new insights into the clinical aspects of generalized resistance to thyroid hormone. Kindreds with mutations in exon 9 compared with those in exon 10 have significantly more problems in language development, as manifested by articulation problems and/or wide discrepancies in verbal and performance IQs. Interestingly, marked variability in language deficiency as well as other clinical patterns were seen not only between kindreds but also within a kindred. Further identification and clinical correlations of new mutations will continue to enhance our understanding of the structure/function relationships and physiological role of the human thyroid hormone receptor.


Serum estradiol but not gonadotropin levels decrease acutely after insulin-induced hypoglycemia in cycling women.

Although corticotropin-releasing hormone (CRH) acutely suppresses gonadotropin-releasing hormone (GnRH) secretion in animal models, its effect on the hypothalamic-pituitary-gonadal axis in humans is not well defined. To further evaluate the acute effects of adrenal axis activation on the hypothalamic-pituitary-gonadal axis in humans, we employed a model of insulin-induced hypoglycemia to stimulate endogenous CRH secretion in eight cycling women. Serum samples were obtained immediately before and 15, 30, 45, 60, 75, 90, and 120 min following iv insulin (0.15 U/kg) or saline injection. To ensure that the degree of hypothalamic-pituitary-adrenal activation in our subjects was similar to that observed in severely ill patients with hypogonadotropism, serum cortisol (F) levels were also measured in a group of acutely ill patients selected to have hypogonadotropism. All women experienced symptomatic hypoglycemia after insulin injection. Differences between serum F levels in hypoglycemic vs. control sessions were evident at 30 min (P < 0.01) and maximum at 120 min (P < 0.0001) after insulin injection. Serum estradiol levels were significantly lower following hypoglycemia than during control sessions (P < 0.001). In contrast, serum LH and FSH levels were not significantly different between control and hypoglycemic sessions. Peak serum F levels in these hypoglycemic women were similar to F levels in critically ill patients with hypogonadotropism. These results demonstrate that stress and/or hypoglycemia can acutely decrease circulating estradiol levels. In addition, these data suggest that endogenous CRH does not play a major role in acute suppression of GnRH (over 2 h) in humans. Further studies are required to identify longer term effects of CRH on GnRH secretion which may be present in hypothalamic amenorrhea or hypogonadotropic hypogonadism of critical illness.


Longitudinal monitoring of bone mass accumulation in healthy adolescents: evidence for a marked reduction after 16 years of age at the levels of lumbar spine and femoral neck in female subjects.

The amount of skeletal mass acquired during adolescence is one of the most important determinants for the risk of postmenopausal and involutional osteoporosis. In both sexes, a large variance in bone mineral density (BMD) and content (BMC) is observed among healthy individuals at the beginning of the third decade. To determine the crucial pubertal years during which bone mass accumulation mainly occurs, we longitudinally monitored the gain in BMD/BMC at clinically important sites, such as lumbar spine and femoral neck, with respect to osteoporotic fracture risk. The changes in BMD (grams per cm2) and BMC (grams) were determined at 1-yr intervals at the level of lumbar spine vertebrae (L2-L4), femoral neck, and midfemoral shaft, using dual energy x-ray absorptiometry (Hologic QDR 1000), in 198 healthy adolescents (98 females and 100 males), aged 9-19 yr. Mean daily energy and calcium intakes, height, weight, and body mass index of the studied cohort were within the normal range for age. In females, the increment rate in BMD/BMC was particularly pronounced over a 3-yr period, i.e. from 11-14 yr of age. This increment dramatically fell after 16 yr and/or 2 yr after menarche. The mean gains in lumbar, femoral neck, and midfemoral shaft BMD were not statistically significant between 17-20 yr. In males, the gain in BMD/BMC was particularly high over a 4-yr period, i.e. from 13-17 yr. Then the increment rate markedly declined, but remained significant between 17-20 yr for L2-L4 BMD/BMC and midfemoral shaft BMD. In contrast, no significant increase was observed for femoral neck BMD. An impressive interindividual variation was observed between the yearly height increment and the bone mass accumulation. The bone mass-height gains relationship during puberty evolved according to a loop pattern, with maximal variance at Tanner stages P3-P4. This longitudinal study delineates the crucial pubertal years during which the skeletal mass accumulates at high, but various, rates at skeletal sites where the consequences of the osteoporosis are particularly dramatic. Furthermore, the results indicate that in a cohort of healthy females with apparently adequate intakes of energy and calcium, bone mass accumulation is drastically reduced by 16 yr of age in both lumbar spine and femoral neck.


Molecular analyses of a human sex hormone-binding globulin variant: evidence for an additional carbohydrate chain.

Genomic DNA was isolated from an individual who is homozygous for a sex hormone-binding globulin (SHBG) variant that resolves into three molecular weight forms of 56K, 52K, and 48K during electrophoresis under denaturing conditions (sodium dodecyl sulfate-polyacrylamide gel electrophoresis). This material was amplified using intron-specific oligonucleotide primers in a polymerase chain reaction to obtain the eight exons encoding SHBG. Sequence analysis of these exons revealed a point mutation encoding an amino acid substitution (Asp --> Asn) at residue 327 in the SHBG polypeptide, and the same mutation was identified in three siblings who also appear to be homozygous for this trait. This mutation introduces an additional consensus site for N-glycosylation at this position, and to confirm its utilization we introduced it into a human SHBG complementary DNA. The mutated complementary DNA was inserted into the pRc/CMV expression vector, and transfected into Chinese hamster ovary (CHO) cells. The product was secreted normally but proportionally less of it (54%) bound to concanavalin A when compared to normal SHBG produced by CHO cells (85%), or SHBG in the serum of either a normal individual or those who produce an electrophoretic variant (98%). Furthermore, when subjected to sodium dodecyl sulfate-polyacrylamide gel electrophoresis and Western blotting, the SHBG variant produced by CHO cells consisted of a 60K subunit as well as the heavy (52K) and light (48K) subunits associated with normal SHBG produced by CHO cells or in serum. This additional subunit is larger than the variant in serum and probably reflects a greater degree of complexity in the carbohydrate structures added to recombinant SHBG during synthesis in CHO cells. Nevertheless, its steroid-binding affinity was equal to normal SHBG produced by CHO cells or SHBG in serum.


Bromocriptine and Triac therapy for hyperthyroidism due to pituitary resistance to thyroid hormone.

Although a number of patients with generalized resistance to thyroid hormone have been treated with bromocriptine (Brc), only one previously reported patient with nontumoral TSH-mediated hyperthyroidism, presumably due to pituitary resistance to thyroid hormone (PRTH), has been successfully treated with bromocriptine (Brc). In addition, several studies suggested that the T3 analog 3,5,3'-triiodothyroacetic acid (Triac) may control hyperthyroidism in patients with PRTH. In the current study a patient with PRTH diagnosed at age 15 yr underwent separate therapeutic trials with Brc and Triac, during which time physical parameters, thyroid function tests, systolic time intervals (STI), and oxygen consumption (VO2) were measured. On Brc therapy (12.5 mg/day), heart rate decreased (108 to 72/min), TSH decreased (5.7 to 1.2 mU/L), T3 decreased (9.9 to 1.7 nmol/L), free T4 decreased (205 to 21 pmol/L), STI lengthened (left ventricular ejection time, 0.389 to 0.405 s), and VO2 did not change (164 to 162 mL/min). We found no significant clinical improvement with a maximal dose of Triac (2.1 mg/day), only minimal reduction in goiter size; mild decreases in T3 (9.9 to 6.7 nmol/L), free T4 (205 to 113 pmol/L), and TSH (5.7 to 5.4 mU/L); no change in STI (left ventricular ejection time, 0.389 to 0.401 sec); and an increase in O2 consumption (VO2, 164 to 209 mL/min). Thus, the results favor Brc as effective therapy for this patient with PRTH.


Impaired stimulation of gluconeogenesis during prolonged hypoglycemia in intensively treated insulin-dependent diabetic subjects.

Defective glucose counterregulation commonly seen in intensively treated insulin-dependent diabetes (IDDM) is mediated in part by a failure of compensatory stimulation of hepatic glucose production. Since the response of the liver to insulin-induced hypoglycemia normally involves activation of gluconeogenesis, we measured [14C]alanine conversion to [14C]glucose (a qualitative index of gluconeogenesis) and glucose production (using [3-3H]glucose) in seven intensively treated type I diabetic subjects (hemoglobin-A1, 7.1 +/- 0.4%) during low dose infusion of insulin (0.3 mU/kg.min for 210 min). IDDM patients received insulin overnight to maintain euglycemia before study. Although insulin levels rose to a similar extent as those in normal control subjects (n = 6), the fall in plasma glucose was markedly greater in IDDM (2.5 +/- 0.2 vs. 3.64 +/- 0.2 mM in controls; P < 0.01). The glucagon response was totally lost in IDDM, and epinephrine release was delayed and slightly reduced compared to that in control subjects. In contrast to that in normal subjects, hepatic glucose production in the IDDM subjects remained persistently suppressed by about 60% throughout the study. The conversion of alanine and lactate to glucose remained virtually unchanged in the IDDM, whereas in controls it increased 2-fold above baseline during the last hour of the study. Our data suggest that the failure of gluconeogenesis to increase during hypoglycemia is an important factor contributing to the defective hepatic response observed in the intensively treated type I diabetic subjects.


Biosynthesis of interleukin-6 by cultured human chorion laeve cells: regulation by cytokines.

Intrauterine infection is an important cause of preterm labor and delivery and is characterized by increased production of inflammatory cytokines by gestational tissues. We evaluated the biosynthesis of the inflammatory cytokine interleukin-6 (IL-6) by human chorion laeve cells and its regulation by other cytokines essential to the inflammatory process. We found that cultured chorion cells secrete IL-6 in the presence of growth medium supplemented only with 10% fetal calf serum. IL-1 beta, tumor necrosis factor, and lipopolysaccharide all induced a significant concentration-dependent stimulation of IL-6 production by chorion cells. The concentration range of each cytokine tested (0.1-10 ng/mL) is within the range of values found in the amniotic fluid of women destined to deliver preterm due to infection of gestational tissues. Additionally, treatment of chorion cells with IL-1 beta in combination with actinomycin-D or cycloheximide attenuated the stimulatory action of IL-1 beta on IL-6 production. Northern blot analysis of total RNA from cultured chorion cells stimulated with IL-1 beta demonstrated that IL-6 mRNA increases over time. Our data suggest that IL-6 is produced by human fetal chorion in response to infection of maternal gestational tissues. In conjunction with other inflammatory mediators, fetally derived IL-6 may play a role in the pathophysiology of preterm labor due to infection.


Spontaneous and stimulated growth hormone release in adolescents with type I diabetes mellitus: effects of metabolic control.

Abnormalities in GH release have been found in adults with poorly controlled type I diabetes mellitus. During puberty, circulating GH concentrations transiently increase. To investigate in pubertal diabetic adolescents, the physiological relationship between metabolic control and GH release, we compared spontaneous and GH-releasing hormone (GHRH)-stimulated GH release in six pubertal subjects during poor (study A) and improved (study B) metabolic control. The subjects included two females and four males (mean age +/- SE, 15.5 +/- 1 yr; duration of diabetes, 8.6 +/- 0.9 yr; Tanner stages II-V). Serum samples for glucose and GH determinations were obtained at 20-min intervals over a 24-h period. Significant pulses of GH release were identified using a pulse detection algorithm (Cluster). Fourier expansion time series was used to document the occurrence of significant periodicities in the GH concentration-time data series. All subjects received 1.0 microgram/kg GHRH-44, iv, at 0800 h on the day after the 24-h monitoring for GH. After GHRH administration, samples were taken for glucose and GH determinations over 90 min. The overall mean glucose level (+/- SE) during the 24-h monitoring was 11.5 +/- 0.2 mmol/L during study A and 7.2 +/- 0.2 during study B (P = 0.0001). During the 4 weeks of improved control, glycated hemoglobin fell from 13.9 +/- 1.4% to 11.7 +/- 0.8% (mean +/- SE; P < 0.025). All subjects had significant pulses of GH release during poor or improved metabolic control. Relative to that at night, the daytime pulse frequency was higher in study A (P < 0.025). The overnight pulse frequency increased during study B (P < 0.01). Other pulse parameters, including maximal and incremental pulse amplitudes, pulse width, and interpulse valley mean, did not change during improved control. The mean +/- SE 24-h GH concentration was 4.1 +/- 0.7 micrograms/L during study A and 4.3 +/- 0.8 during study B. The amplitude of the circadian GH rhythm was not different by Fourier analysis. The overall mean glucose +/- SE after GHRH administration was 15.3 +/- 0.2 mmol/L in study A and 6.8 +/- 0.1 in study B. In spite of the marked hyperglycemia during study A, the GH responses were similar during studies A and B. Maximal GH levels were obtained at 15-30 min (mean +/- SE) and were 36.0 +/- 16.9 micrograms/L in study A and 38.7 +/- 18.9 in study B.(ABSTRACT TRUNCATED AT 400 WORDS)


Effects of testosterone supplementation in the aging male.

Serum androgen levels decline with aging in normal males, such that a significant number of men over 60 yr of age will have a mean serum total testosterone (T) level near the low end of the normal adult range. It is not known whether lower T levels in older men have an effect on androgen-responsive organ systems, such as muscle, bone, bone marrow, and prostate, nor are there data to evaluate the relative benefits and risks of T supplementation in older men. We assessed the physiological and biochemical effects of T therapy in 13 healthy men, 57-76 yr old, who had low or borderline low serum T levels (< or = 13.9 nmol/L). Intramuscular testosterone enanthate (TE; 100 mg weekly) and placebo injections were given for 3 months each. Before treatment and at the end of both 3-month treatment regimens, lean body mass, body fat, biochemical parameters of bone turnover, hematological parameters, lipoprotein profiles, and prostate parameters [such as prostate-specific antigen (PSA)] were evaluated. Serum T levels rose in all subjects with TE treatment, such that the lowest level of T during a week's period was 19.7 +/- 0.7 nmol/L (mean +/- SE). After 3 months of TE treatment, lean body mass was significantly increased, and urinary hydroxyproline excretion was significantly depressed. With TE treatment, there was a significant increase in hematocrit, a decline in total cholesterol and low density lipoprotein cholesterol, and a sustained increase in serum PSA levels. Placebo treatment led to no significant changes in any of these parameters. We conclude that short term (3 months) TE supplementation to healthy older men who have serum T levels near or below the lower limit of normal for young adult men results in an increase in lean body mass and possibly a decline in bone resorption, as assessed by urinary hydroxyproline excretion, with some effect on serum lipoproteins, hematological parameters, and PSA. The sustained stimulation of PSA and the increase in hematocrit that occur with physiological TE supplementation suggest that older men should be screened carefully and followed periodically throughout T therapy.


Serum propeptide and intact molecular osteocalcin in normal children and children with growth hormone (GH) deficiency: a potential marker of bone growth and response to GH therapy.

To establish a sensitive marker for bone formation we have developed a sandwich enzyme-linked immunosorbent assay for intact osteocalcin (OC) and its propeptide. Serum levels of these peptides were studied in 185 normal children, aged 4-15 yr, and in 23 GH-deficient children treated with GH. The serum levels of the propeptide in normal prepubescent children were 1.43 +/- 0.23 (mean +/- SE) micrograms/L in boys and 1.53 +/- 0.23 micrograms/L in girls. The peak value occurred at the age of 13 yr in boys (2.91 +/- 0.42 micrograms/L) and 11 yr in girls (2.34 +/- 0.34 micrograms/L). The serum intact OC levels in prepubescent boys and girls were 18.8 +/- 2.1 and 20.7 +/- 2.1 micrograms/L, respectively, and these levels increased to 41.0 +/- 3.7 micrograms/L in boys aged 13 yr and to 27.0 +/- 2.5 micrograms/L in girls aged 11 yr. In the GH-deficient patients, a 2.3-fold increase in the propeptide level and a 1.7-fold increase in the intact OC level was observed after 1 month of GH therapy. Serum propeptide and intact OC levels after 1 month of GH therapy correlated with the growth response after 12 months of GH therapy (r = 0.660 and P < 0.01, for propeptide; r = 0.537 and P < 0.01 for intact OC). These results show that since both propeptide and intact OC in serum were increased when the growth rate was elevated, these peptides are sensitive markers of bone formation. Serum levels of these peptides, particularly propeptide, after 1 month of GH therapy might be a helpful predictor of the growth response to long term GH therapy.


Preliminary characterization of circulating amino- and carboxy-terminal fragments of parathyroid hormone-related peptide in humoral hypercalcemia of malignancy.

PTH-related peptide (PTHrP) immunoreactivity in plasma from six well characterized patients with humoral hypercalcemia of malignancy was characterized by gel filtration chromatography. An immunoradiometric assay directed against the N-terminal 74 amino acids of PTHrP and a RIA directed against the C-terminal region (amino acids 109-138) of the peptide were used to assay column fractions. When examined using acid (pH 5.0) nondenaturing conditions, N-terminal PTHrP immunoreactivity eluted with an apparent M(r) of 30,000-40,000. The apparent M(r) of this PTHrP fragment shifted to approximately 25,000 when gel filtration was performed at pH 9.0. The apparent M(r) shifted further, to approximately 6,500, when chromatographed under denaturing conditions in 4 M guanidine-HCl. Carboxy-terminal PTHrP immunoreactivity in plasma eluted with an M(r) of approximately 12,000 under acid nondenaturing conditions, as did the synthetic C-terminal PTHrP column marker, PTHrP (109-138). Synthetic PTHrP (1-36) and (1-74), and recombinant PTHrP (1-141) as well as native PTHrP species found in milk and keratinocyte-conditioned medium migrated in their expected positions when analyzed under alkaline nondenaturing or under denaturing condition. We conclude that native, synthetic, and recombinant PTHrP peptides may migrate anomalously when examined using gel filtration under nondenaturing conditions, and such studies should be interpreted with caution. Plasma from patients with humoral hypercalcemia of malignancy contains at least two PTHrP species. One native N-terminal fragment appears, as assessed under denaturing conditions, to have an M(r) of approximately 6,500, and to therefore comprise approximately 50-60 amino acids of full-length PTHrP. A second chromatographically and immunologically distinct C-terminal fragment with an M(r) of approximately 12,000 under nondenaturing conditions is also present.


Subcutaneous growth hormone-releasing hormone therapy in growth hormone-deficient children: first year of therapy.

The purpose of this study was to determine the efficacy and safety of GH-releasing Hormone [GHRH-(1-44)] therapy in GH-deficient children. Twenty previously untreated prepubertal children with GHRH deficiency were treated for 1 yr in a multicenter, open label, company-sponsored study with at least 20 micrograms/kg GHRH-(1-44), sc, half at bedtime and half upon awakening. The main effects were enhancement of linear growth, advancement in bone age, and alteration in general blood chemistries and hormonal values. The mean velocity of the entire group increased from 3.6 +/- 1.1 to 8.1 +/- 1.5 cm/yr (P < 10(-4)) at 1 yr of therapy. After 6 months of therapy, 16 were growing at a mean of 9.4 +/- 2.0 cm/yr and were continued on this dose. In 4 patients who were growing at a rate of 5.5 +/- 1.7 cm/yr, the dose was increased to 40 micrograms/kg daily for the second 6 months. The high dose group increased their mean linear growth velocity for the second 6 months while on the higher dose to 7.6 +/- 0.4 cm/yr (P < 10(-2)). This was equal to the mean velocity for the second 6 months of therapy of the 16 subjects who remained on the 20 micrograms/kg daily therapy (7.6 +/- 1.2 cm/yr). Mean advancement of bone age was 1.3 +/- 0.6 yr during the first year of therapy. No adverse changes in general biochemical, hormonal, or pituitary radiographic analyses were noted. No change in fasting glucose or insulin concentrations, or excessive generation of insulin-like growth factor-I concentrations occurred. We conclude that GHRH in a daily dose of 20-40 micrograms/kg for 1 yr was effective in increasing growth velocity in most GHRH-responsive GH-deficient patients. It was well tolerated without side-effects. Glucose intolerance was not noted.


Acute growth hormone (GH) response to GH-releasing hexapeptide in humans is independent of endogenous GH-releasing hormone.

The synthetic GH-releasing hexapeptide (GHRP: His-DTrp-Ala-Trp-DPhe-Lys-NH2) releases GH in man by an undetermined mechanism. To investigate whether acute GH response to GHRP is mediated by endogenous GHRH, we examined the effect of GHRP on GH release during pituitary desensitization to GHRH induced by short-term GHRH infusion. In five healthy men on six occasions, we infused saline (sal) or 1 microgram/kg.h GHRH-44 for 6 h. After 4 h, a bolus of sal, GHRH-44 1 microgram/kg body weight, or GHRP 1 microgram/kg body weight was given iv. GH concentration, measured by RIA, was analyzed by mean area under the curve (AUC) of GH released over the 2 h immediately after bolus injection. Infusion of GHRH had a biphasic effect on GH release; plasma GH increased to 12.7 +/- 3.3 micrograms/L within the first hour, with subsequent decrease to 2.9 +/- 0.3 micrograms/L during the last 2 h of infusion. GH AUC (hours 4-6 of infusion) microgram/L.2 h [table: see text] GH response to bolus GHRH was abolished by GHRH infusion, whereas GH response to GHRP persisted under the same conditions. Thus, we conclude that acute GH response to GHRP in humans is not mediated by endogenous GHRH.


Role of body fat distribution in the decline in insulin sensitivity and glucose tolerance with age.

The relationships of body composition and physical fitness [maximal aerobic capacity (VO2max)] to the decline in insulin sensitivity with age were examined in healthy older (47-73 yr; n = 36) and young (19-36 yr; n = 13) men. In 18 older men with normal glucose tolerance (OGTT), glucose disposal rates (M) during hyperinsulinemic euglycemic clamps correlated negatively with the waist to hip ratio (WHR; r = -0.77; P < .001) and percent body fat (r = -0.46; P < 0.05) and positively with VO2max (r = 0.54; P < 0.05), but not with age. Similar relationships existed in the 36 older men with a spectrum of OGTT responses; however, only WHR was independently related to M (r2 = 0.32; P < 0.01). In the older men with normal OGTT, M (mean +/- SEM, 7.88 +/- 0.43 mg/kg fat-free mass.min) was not different from that in the young men (8.56 +/- 0.47; P = NS). Furthermore, in older and young men with normal OGTT matched for WHR, percent fat, or VO2max, glucose disposal was comparable at sequential 15-min intervals during the clamp and in its relationship to insulin concentrations at the tissue level (multicompartmental analysis). In contrast, despite higher steady state plasma insulin levels during the clamp, M was significantly lower in the older men with a higher WHR, greater percent fat, lower VO2max, or impaired OGTT. Thus, in healthy older men up to the age of 73 yr, insulin sensitivity and glucose tolerance are affected primarily by the regional body fat distribution, not age, obesity, or VO2max.


Cloning and in vitro expression of the human selenoprotein, type I iodothyronine deiodinase.

The type I 5' iodothyronine deiodinase (5' DI) catalyzes the deiodination of T4 to the biologically active hormone T3 and accounts for a significant fraction of its production. We have recently cloned the complementary DNA (cDNA) for the rat 5' DI, which contains the rare amino acid selenocysteine, and used this to screen human liver and kidney cDNA libraries to identify a human 5' DI cDNA clone. From these, we constructed a cDNA encoding a functional 5' DI. The 2222 base pair human 5' DI cDNA is approximately 200 nucleotides shorter than the 2.4-kilobase hybridizing band in Northern blots of human liver, kidney, and thyroid, because of missing 5' untranslated sequence and the poly A tail. The deduced amino acid sequence codes for a protein of 28.7 kilodaltons assuming the UGA codon at position 382 encodes selenocysteine, and is highly homologous (88% similarity) to the rat. We transiently expressed the 5' DI in COS-7 cells to establish that it encodes a functional enzyme and to study its kinetics. These show saturable deiodination of rT3 (Ka 0.52 +/- 0.04 mumol/L and Vmax 63.2 +/- 16.4 pmol min-1 mg-1). T4 and gold thioglucose are competitive inhibitors of rT3 deiodination. 6-n-Propylthiouracil (PTU) is an uncompetitive inhibitor (with rT3) and competitive inhibitor (with dithiothreitol) of rT3 deiodination. 6-n-Propylthiouracil inhibits T4 to T3 conversion. Labeling of COS-7 cells transiently transfected with the human 5' DI cDNA with bromoacetyl-125I-T3 demonstrates a 28-kilodalton protein. This indicates that in the human, as well as in the rat messenger RNA, the UGA encodes selenocysteine and translation terminates at the UAA codon at nucleotides 754 to 756. Reverse T3 and gold thioglucose (100 nmol/L) block bromoacetyl-125I-T3 labeling of the transiently expressed human and rat 5' DI proteins. These results demonstrate that the human 5' DI is a selenoprotein, analogous to the rat enzyme. Given the previously demonstrated critical role of the selenium atom in catalyzing deiodination by this protein, we conclude that this trace element is essential for normal thyroid hormone action in man.


The expression of human chorionic gonadotropin/human luteinizing hormone receptors in ectopic human endometrial implants.

Our laboratory previously demonstrated that normal human endometrium contains hCG/human LH receptors. Since ectopic endometrial implants in endometriosis arise directly at least in part from uterine endometrium, we investigated whether the implants continue the expression of these receptors. The presence of hCG/LH receptor mRNA and/or immunoreactive receptor protein in ectopic endometrial implants on pelvic peritoneum, uterine endometrium, and unaffected or normal peritoneum from patients with (n = 12) and without (n = 14) clinically apparent endometriosis was examined by in situ hybridization and immunocytochemistry analyses. The results showed that the peritoneal biopsies with visible or microscopic endometrial implants contain receptor mRNA and receptor protein. The glands contain more receptor mRNA and receptor protein than stromal cells in implants similar to uterine endometrium from patients with or without endometriosis. However, there is no consistent difference in the expression of receptors in implants compared to uterine endometria from patients with or without endometriosis. Contrary to ectopic endometrial implants, unaffected or normal peritoneum contain neither receptor mRNA nor receptor protein. In summary, we conclude that ectopic endometrial implants contain hCG/LH receptor mRNA and receptor protein, which suggests new possibilities in the medical treatment of endometriosis.


Epithelial hyperplasia and decreased colloid content of the thyroid gland in triiodothyronine-predominant Graves' disease.

Patients with T3-predominant Graves' disease have an increased serum T3 level despite a normal or even lower level of serum T4 caused by antithyroid drug treatment. This study investigated the morphological characteristics of the thyroid gland in this type of hyperthyroidism. Ultrasound showed a similar thyroid echogenicity in both T3-predominant and ordinary Graves' disease, but thyroid weight was significantly greater in T3-predominant Graves' disease than in the controls [91 +/- 37 g vs. 48 +/- 17 g (mean +/- SD); P < 0.01]. The height of thyroid follicular epithelial cells were significantly greater in T3-predominant Graves' disease than in the controls (9.6 +/- 1.0 vs. 6.4 +/- 1.1 microns), but the epithelial height did not correlate significantly with the serum TSH receptor antibody titers. Epithelial cells occupied 26.4 +/- 10.9% of the total thyroid tissue in T3-predominant Graves' disease, while they occupied only 14.5 +/- 6.8% in the controls. Intracolloidal vacuoles also occupied a significantly greater area in the T3-predominant group (6.6 +/- 3.9% vs. 1.9 +/- 1.0% for controls). These findings suggest that the thyroid gland is more active in T3-predominant Graves' disease and has a more rapid turnover of intrathyroidal iodine than in the ordinary type of Graves' disease.


Histomorphological and immunohistochemical evidence that human nodular goiters grow by episodic replication of multiple clusters of thyroid follicular cells.

This study was aimed at dissecting the cellular mechanisms that underly the growth of actively expanding human goiter nodules. Thirty-two nodules from different patients, all removed because of steady recent growth, were serially sectioned and screened for 1) histomorphological signs of cell proliferation and 2) in situ expression of the immunohistochemically stained p21ras protooncogene product. Bovine, porcine, and rat thyroid glands (the latter from both T4- and perchlorate-treated animals) were used as controls. In normal glands, only a few follicular cells contain substantial amounts of stainable p21ras. Some of these cells are unusually large, but do not proliferate. In contrast, all goiter nodules contain areas where the epithelial cells are morphologically grossly altered and heavily loaded with p21ras. Cells of this type are mostly clustered in large cohorts coating whole follicles or entire groups of follicles. Only a small fraction of these activated cells actually proliferates at any one point in time. Actively replicating cells are scattered in tiny foci all over the nodules. The earliest proliferating buds are solid, but soon begin to generate microfollicles that enlarge by adding new cells to the follicular epithelium. Regionally heterogeneous p21ras content in morphologically identical cells suggests that growth occurs in bursts and waves. We conclude that goiter nodules grow by episodic proliferation of heterogeneous cohorts of epithelial cells from which new follicles are generated. Only a tiny fraction of all goiter cells proliferate at any one point in time. The molecular mechanisms governing these growth processes are unknown.


Evidence for the presence of the estrogen receptor in the ovary of the baboon (Papio anubis).

Although intraovarian estrogen has been firmly established as an important factor in the regulation of ovarian follicular development and function in the rat, an autocrine-paracrine role for estrogen in the primate ovary is not yet established. Immunocytochemical identification of an estrogen receptor in the monkey follicle was negative, but it was positive for the granulosa cells of antral follicles of the human ovary. In the present study baboon ovaries obtained during the follicular phase were examined for the presence of estrogen receptor by immunocytochemical analysis of frozen sections and Northern blot analysis of RNA extracts of the ovaries. Immunocytochemistry identified the estrogen receptor in the granulosa cells of healthy appearing and atretic or cystic-like antral follicles and in occasional, but rare, thecal cells. The ovaries contained a prominent mRNA species for the estrogen receptor, approximately 7 kilobases in size, which was present in relatively low abundance compared to that in the nonpregnant baboon uterus, but in a similar abundance to the estrogen receptor mRNA content of the pregnant endometrium. These studies are the first to report the presence of estrogen receptor mRNA in the ovary of a primate. These results in conjunction with the immunocytochemical studies firmly establish the presence of the estrogen receptor in the primate ovary and suggest an autocrine-paracrine role for intraovarian estrogen in primate ovarian physiology.


Atypical McCune-Albright syndrome associated with growth hormone-prolactin pituitary adenoma: natural history, long-term follow-up, and SMS 201-995--bromocriptine combined treatment results.

A 35-yr-old woman is described as having atypical McCune-Albright syndrome, associated with acromegaly and hyperprolactinemia due to pituitary adenoma. The patient did not present sexual precocity, but primary amenorrhea. After transphenoidal adenomectomy, the GH plasma levels returned to normal, whereas the PRL values decreased; bromocriptine therapy normalized PRL levels and induced ovulatory menses. After 4 uneventful yr the patient developed relapse of active acromegaly that did not recover after a second neurosurgical exploration. Bromocriptine treatment maintained normal PRL levels but did not significantly reduce GH ones; the association with long-acting somatostatin analog SMS 201-995 by continuous sc pump infusion induced definitive control of GH and somatomedin-C secretion. These results suggest an additive inhibitory effect on GH secretion exerted by the two drugs.


Precocious puberty in girls: pituitary height as an index of hypothalamo-pituitary activation.

The pituitary heights in 47 girls having breast development before 8 yr were measured by magnetic resonance imaging and compared to the normal values for age and to clinical and laboratory data. They were classified into 3 groups: 1) premature thelarche (PT), isolated breast development with plasma estradiol less than 74 pmol/L (8 cases); 2) mild form of central precocious puberty (CPP1) with an LH/FSH peak ratio after the LH-releasing hormone test less than 1 (22 cases); 3) classical form of CPP (CPP2) with an LH/FSH peak ratio greater than 1 (17 cases). All girls with CPP had breast and pubic hair development before 8 yr, accelerated growth velocity, and no intracranial lesion. The mean ages at breast development [7.2 +/- 0.4 (SE), 6.5 +/- 0.4, and 7.2 +/- 0.3 yr] and the mean times between breast development and magnetic resonance imaging evaluation (0.8 +/- 0.1, 0.8 +/- 0.2, and 0.9 +/- 0.1 yr) were similar in the 3 groups. The mean pituitary heights were 4.9 +/- 0.2 in PT, 5.1 +/- 0.2 in CPP1, and 6.2 +/- 0.2 mm in CPP2. They were not significantly different in PT and CPP1 but were significantly greater in CPP2 than in PT (P < 0.001) or CPP1 (P < 0.001). Individual values of pituitary height were compared to those of age-matched girls: they were greater than or equal to mean +/- 2 SD in 8% of PT, 32% of CPP1, and 70% of CPP2. In the CPP group, the pituitary height was correlated with the LH/FSH peak ratio [correlation coefficient (r = 0.52, P < 0.01] and plasma estradiol (r = 0.60, P < 0.01). Four patients with high pituitary height despite LH/FSH peak ratios less than 1 had an increase of their breast development within 1 yr. We conclude that the pituitary height is normal for age in girls with premature thelarche or a mild form of CPP. Conversely, pituitary height is in the pubertal range in girls with the classical form of CPP. Its correlation with LH/FSH peak ratio suggests that pituitary height reflects changes in the degree of hypothalamo-pituitary activation and may provide an indication of its future development. It may therefore help in decisions on LH-releasing hormone analog therapy in certain cases.


Parathyroid hormone-related protein mRNA in avascular human amnion.

Previously, we found that preproendothelin-1 mRNA is present in human avascular amnion tissue. In this investigation, we evaluated the possibility that another vasoactive protein, namely, parathyroid hormone-related protein (PTH-rP), also is produced in amnion. Using a specific cDNA probe, we identified PTH-rP mRNA in amnion tissue and found that the level of PTH-rP mRNA in placental amnion was greater than that in reflected amnion tissue obtained from the same pregnancy. PTH-rP mRNA also was demonstrable in chorion laeve and in decidua, but the levels of this mRNA in these tissues were much lower than that in amnion. By radioimmunoassay, we found that human amnion cells in primary monolayer culture secrete immunoreactive PTH-rP into the medium. Importantly, the placental amnion covers the chorionic vessels that traverse over the chorionic plate prior to branching into the cotelydons; specifically, there is no intervening tissue between placental amnion and the adventitial tissue of the chorionic vessel wall. Thus, the potential exists for the production of endothelin-1, a potent vasocontractant, and PTH-rP, a vasorelaxant, in placental amnion for export to the adventitial surface of the chorionic vessels. Moreover, amnion cells respond to a number of agents (e.g., transforming growth factor-beta) that effect changes in the expression of these two peptides. Therefore, the possibility should be considered that amnion-derived vasoactive proteins may modulate fetal chorionic, umbilical, and villous vessel tone and thereby fetal-placental blood flow.


Interrelationships between the renin-angiotensin-aldosterone and calcium homeostatic systems.

Blood pressure is affected by both sodium and calcium intake. To determine if there is an interaction between the regulatory mechanisms for these two cations, eight normal male volunteers received the following 1-h infusions on three different days: 1) angiotensin II (AII), 2) the synthetic 1-34 amino terminal fragment of human PTH [hPTH(1-34)], and 3) AII and hPTH(1-34) together. Blood samples were obtained at t = 0 and every 20 min during each infusion and urine was collected for 3 h both before and after the start of each infusion. Infusion of AII produced an increase in intact PTH from 18 +/- 2 to 31 +/- 4 ng/L (P < 0.05), most likely in response to a small decrease in serum ionized calcium (1.25 +/- 0.01 to 1.23 +/- 0.01 mmol/L, P < 0.05). Urinary excretion of calcium was unchanged. Infusion of hPTH(1-34) at 200 U/h increased N-terminal PTH levels (18 +/- 3 to 268 +/- 42 ng/L, P < 0.05), decreased tubular reabsorption of phosphate (0.92 +/- 0.03 to 0.82 +/- 0.11, P < 0.05), and increased urinary cAMP (0.18 +/- 0.02 to 0.53 +/- 0.05 nmol/L of glomerular filtrate, P = 0.0001). hPTH(1-34) infusion suppressed endogenous intact PTH (18 +/- 3 to 14 +/- 2 ng/L, P < 0.005) and increased PRA from 0.14 +/- 0.02 to 0.32 +/- 0.05 ng/(L.s) (P < 0.05) without a change in serum ionized calcium which suggests direct effects of hPTH(1-34) on the parathyroid glands and the juxtaglomerular apparatus. The effects of AII and hPTH(1-34) were antagonistic with little change in serum ionized calcium, intact PTH, or PRA when both were infused together. These interrelationships between the major hormonal systems controlling sodium and calcium homeostasis suggest a mechanism underlying the close association of calcium and sodium in the regulation of blood pressure.


Abrogation by a potent gonadotropin-releasing hormone antagonist of the estrogen/progesterone-stimulated surge-like release of luteinizing hormone and follicle-stimulating hormone in postmenopausal women.

In both the rodent and primate, administration of progesterone elicits an acute surge-like release of LH in the setting of prior estrogen treatment. Whether these facilitative effects of estrogen and progesterone on gonadotropin secretion reside at pituitary or hypothalamic loci is not known. To further investigate the mechanisms by which estrogen combined with progesterone amplifies gonadotropin secretion, we studied the responses of seven estrogen-primed postmenopausal women to progesterone administration with or without cotreatment with a potent GnRH antagonist, [Ac-D2Nal1,D4ClPhe2,D3Pal3,Arg5,DGlu6(AA), DAla10]GnRH. Repetitive blood sampling for the later measurement of serum concentrations of LH, FSH, and PRL was begun 4 h before the administration of progesterone and continued for 36 h. We observed that progesterone administration after 72 h of priming with ethinyl estradiol resulted in a surge-like release of LH and FSH in all subjects. Concomitant administration of the GnRH antagonist abolished the surge-like release of both gonadotropins in all subjects. In contrast, administration of the antagonist had no effect on PRL release. These results indicate that endogenous GnRH action is an obligatory component of the progesterone-induced surge-like release of both gonadotropic hormones in the estrogen-primed human.


Mineral metabolism in Turner's syndrome: evidence for impaired renal vitamin D metabolism and normal osteoblast function.

We examined intact PTH and 1,25-dihydroxyvitamin D [1,25-(OH)2D] in both baseline and dynamic conditions (low calcium diet) in 14 patients with Turner's syndrome (mean age, 12.6 +/- 5.9 yr; range, 4.2-21.0 yr) and bone demineralization as well as in a control group of 15 healthy girls (mean age, 12.8 +/- 5.6 yr; range, 3.8-22.7 yr). In both groups we also measured osteocalcin serum levels in response to oral 1,25-(OH)2D3 administration (1.8 micrograms/m2/daily for 6 days) to assess osteoblast function. The low calcium diet decreased ionized calcium (Ca2+) levels and elevated PTH values to the same extent in both patients (Ca2+, -8.40 +/- 3.78%; intact PTH, +47.88 +/- 13.24%) and controls (Ca2+, -9.09 +/- 3.25%; intact PTH, +52.77 +/- 10.52%; P = NS vs. patients). While controls showed an increment in their serum 1,25-(OH)2D levels (+52.15 +/- 8.95%), patients did not (+10.93 +/- 4.71%; P = NS vs. baseline; P < 0.001 vs. controls). 1,25-(OH)2D3 administration caused a rise in the serum osteocalcin levels in a similar fashion in both groups (peak values: patients, +35.38 +/- 7.20%; controls, +34.09 +/- 7.98%; P = NS). We conclude that in patients with Turner's syndrome there is an altered renal vitamin D metabolism in response to physiological stimulus, while osteoblast function in response to 1,25-(OH)2D3 administration is not affected.


Superantigens: biology, immunology, and potential role in disease.

Superantigens are unique products of bacteria and viruses which, in combination with class II major histocompatibility complex molecules, are capable of stimulating a large fraction of T cells in an affected individual. This stimulation primarily involves the variable region of the T cell receptor beta chain (V beta). The discovery of superantigens and the elucidation of their immunologic properties have provided valuable tools for the investigation of the immune system in both normal and diseased animals. Most importantly, recent work suggests that superantigens play a role in a number of diverse pathological conditions, including toxic shock syndrome and autoimmune diseases such as rheumatoid arthritis.


Bullous pemphigoid autoantibodies reactive with intracellular basal keratinocyte antigens: studies of subclass distribution and complement activation.

Using immunofluorescence (IF) and monoclonal antibodies (MoAbs) to IgG subclasses, terminal complement components, and S-protein/vitronectin, we have extended recent observations concerning reactivity of bullous pemphigoid autoantibodies with intracellular antigens located on the polar tips of basal human keratinocytes (HuK). Using three purified bullous pemphigoid IgG fractions, autoantibody reactivity with these intracellular antigens was present in all four IgG subclasses. When skin sections were used as substrate, an identical IgG subclass distribution of autoantibodies for each bullous pemphigoid IgG fraction was observed, but reactive with the basement membrane zone. All three bullous pemphigoid IgG preparations contained IgG subclass autoantibodies capable of complement fixation. Each IgG fraction resulted in fixation of all of the terminal complement components (C5, C6, C7, C8, and C9) and assembly of the membrane attack complex (MAC) on the polar tips of basal HuK. S-protein/vitronectin was not bound in a similar fashion. Normal IgG fractions yielded consistently negative reactions. Thus, bullous pemphigoid autoantibodies, fixed to polar tips of basal HuK, are found in all four IgG subclasses and will activate complement resulting in generation of MAC.


Cytokine release and dynamics of leukocyte populations after CD3/TCR monoclonal antibody treatment.

Cytokine release and clinical side effects resulting from the use of OKT3 and BMA 031 monoclonal antibodies in the treatment of kidney graft recipients were evaluated and compared. The rise observed in serum levels of interferon gamma. TNF alpha, and IL-8 was similar after administration of either monoclonal antibody. Furthermore, both OKT3 and BMA 031 resulted in rapid disappearance not only of virtually all T cells, but also of substantial percentages of all major leukocyte populations from the circulation; this effect is probably due to cytokine release activating endothelial cells and thereby causing extravasation even of leukocytes not specifically recognized by the administered antibodies. Evidence has thus been obtained that BMA 031 is as potent as OKT3 in inducing unequivocal signs of T cell activation in vivo. However, while OKT3 therapy was accompanied by adverse side effects in our study as in previous ones, we saw no such reactions in any of the patients receiving BMA 031. This contrast might be due to different mechanisms of leukocyte activation possibly inducing other mediators in the case of OKT3, which then, in combination with the cytokines, could generate treatment-associated morbidity.


Indeterminate western blot patterns in a cohort of individuals at high risk for human immunodeficiency virus (HIV-1) exposure.

Our objective was to map serial patterns of Western blot reactivity over time of a cohort of initially ELISA-negative, Western blot-indeterminate individuals from a high-risk group and to determine if these individuals were at increased risk of harboring occult HIV-1 infection. A 2-year prospective study used serial ELISA, two types of Western blot, immunologic profiles, HIV-1 culture, and analysis by polymerase chain reaction. Subjects were 20 ELISA-negative, Western blot indeterminate homosexual volunteers and 20 matched seronegative controls. Results showed that 19 of 20 study subjects completed a mean of 17.0 months of clinical and laboratory follow-up. Reactivities with p24 and/or with p55 were the two most commonly observed Western blot patterns, occurring in 70% of individuals. Specific Western blot reactivity was dependent upon the particular immunoblot preparation being used and varied considerably on a longitudinal basis. No individual pattern appeared predictive of an increased likelihood of subsequent seroconversion to HIV-1 relative to controls. By all other criteria including polymerase chain reaction analysis, samples from 17 of 19 individuals remained negative for HIV-1 at each time point. Two individuals evolved from an indeterminate to a positive Western blot and, simultaneously, from a negative to a positive polymerase chain reaction analysis, during follow-up. Our conclusions were as follows. ELISA-negative, Western blot-indeterminate individuals from a high-risk group show marked variability in immunoblot findings over time, and these patterns do not appear predictive of an increased likelihood of infection.(ABSTRACT TRUNCATED AT 250 WORDS)


Accelerated expression of secreted alpha-chain gene in anaphylactoid purpura.

The mechanisms of the elevation of serum IgA levels in anaphylactoid purpura were investigated. Serum IgA levels were significantly elevated within 2 weeks (5 to 14 days for all 12 patients) after onset in patients with anaphylactoid purpura. Serum IgM and IgG were not elevated. Although the percentages of surface IgA-bearing cells were not increased in the patients, the numbers of IgA-secreting cells within 2 weeks after onset in the patients with anaphylactoid purpura were significantly higher than those of controls. In northern blot analysis on lymphocytes, the secreted alpha (alpha s)-chain gene was well expressed compared with the membrane-bound alpha (alpha m)-chain gene, within 2 weeks after the onset of anaphylactoid purpura. Therefore, stimulation by a certain agent or a certain immune response may accelerate expression of the alpha s-chain gene in anaphylactoid purpura.


Elevated serum interleukin-6 levels in patients with acute hepatitis.

To study the mechanisms of hepatocyte injury, we examined serum interleukin-6 (IL-6) level in acute hepatitis patients. Based on their clinical features, these patients were divided into three groups, acute hepatitis (AH), severe acute hepatitis, and fulminant hepatic failure (FHF). The present study demonstrated that, in association with their clinical status, their serum IL-6 levels were gradually increased (16.5 +/- 14.5 pg/ml in AH, 26.3 +/- 19.0 pg/ml in severe AH, and 470.2 +/- 261.4 pg/ml in FHF; control level, 5.2 +/- 0.6 pg/ml). Furthermore, we found that a significant correlation between serum IL-6 level and prothrombin time existed in these patients and that the elevated serum IL-6 returned to a normal range after recovery from their hepatocyte injury. Thus, our study demonstrates that the serum IL-6 level is a possible marker for identifying the clinical status in acute hepatitis and that this cytokine may have some roles in hepatocyte injury.


Antimitochondrial (pyruvate dehydrogenase) autoantibodies in autoimmune rheumatic diseases.

Anti-pyruvate dehydrogenase (PDH) antibodies were determined in 1451 sera of patients with primary biliary cirrhosis (PBC) and several autoimmune rheumatic conditions by ELISA and immunoblotting. They were detected in sera of 93% of the patients with PBC (179 of 192 patients) in 60 of 277 (22%) patients with Sjogren's syndrome (SjS), 34 of 437 (8%) patients with scleroderma, 33 of 191 patients with SLE (17%), and 5 of 55 (10%) patients with rheumatoid arthritis (RA) but in none of the patients with polymyositis or the antiphospholipid syndrome. The ELISA studies were confirmed by immunoblots showing binding of autoimmune rheumatic sera to the same epitope (74 kd) of mitochondria that the PBC sera reacted with. The identical binding characteristics were also confirmed by protein competition assays with purified PDH. In 4 of 53 patients with SjS who were positive for anti-PDH, high titers as in PBC were detected. The anti-PDH antibodies in Sjogren's patients were associated with deranged liver function tests and extraglandular features but did not correlate with any other non-organ-specific antibody. Follow-up studies confirmed the association of the emergence of anti-PDH antibodies with defects in liver function tests. The antibodies were more prevalent in SLE and RA when they were associated with Sjogren's syndrome (30 and 18.8%, respectively). Among patients with different forms of scleroderma, anti-PDH antibodies were noted in subjects with systemic sclerosis, morphea, and Raynaud's phenomenon.(ABSTRACT TRUNCATED AT 250 WORDS)


Hyperprolactinemia inhibits natural killer (NK) cell function in vivo and its bromocriptine treatment not only corrects it but makes it more efficient.

We studied NK cell function in eight patients with pathological hyperprolactinemia by measuring 51Cr release by K562 cells exposed to their mononuclear cells and found it decreased compared to normal controls (P less than 0.01). Bromocriptine (BrC) treatment corrected NK function but also made it more efficient at 12:1 than at 25:1 or 50:1 effector:target ratios (ANOVA; P = 0.01). The study of NK cell function in agarose revealed that its decrease in hyperprolactinemia is due to their low active binding to target cells, active killing, and recycling capacity. BrC tended to correct them but also increased recycling capacity to levels higher than those of controls (P less than 0.05). Sequential studies in three hyperprolactinemic patients before and after BrC showed correction of NK function within 1 week but its increased efficiency at the 12:1 effector:target ratio required 8 weeks. We conclude that hyperprolactinemia decreases NK cell function. BrC corrects this by decreasing prolactin levels but also makes NK function more efficient by increasing the capacity of NK cells to recycle after killing.


[Quality management in healthcare. Evaluation and improvement].

Quality in healthcare is a concept ultimately determined by the satisfaction of the patient, or more broadly stated, society's needs. Improvement in quality begins with the review of health care organizations, in the degree to which their current role and function can and do meet these needs. Recent trends in quality evaluation have been along the lines of patients satisfaction, as well as structure, process, and outcome oriented aspects of health care delivery. Quality entails not only the science of medicine itself, but also health care delivery, as well as social and individual concerns. In 1990, Japan Hospital Quality Assurance Society was founded. The secretariat is located at this department. Currently, more than 60 hospitals participate for the development of standards and survey to the hospitals. The quality improvement effort has slowly begun to put the concept into practice. The public's growing concern is directed toward holding healthcare organizations accountable for the services they provide. The healthcare field, in turn, is recognizing the needs and merit of voluntary commitment to quality, and are placing emphasis on identifying pressing society needs, and developing effective leadership. Moving the entire healthcare field in the direction of continuous quality improvement will be the key to the survival into the 21st century.


[Partial purification of bone marrow cell-stimulating activity from the parenchymal liver cell supernatant].

Mouse bone marrow cell-stimulating activity has been found in the supernatants of mouse parenchymal liver cells. In order to clarify the character, we attempted to purify the activity by a four-step purification procedure involving concentration and chromatographies on DEAE-cellulose, Sephacryl S-300, and Superose 6. By DEAE-cellulose chromatography, the activity was found to be eluted stepwisely with 0.1 M (Peak 1) and 0.2 M (Peak 2) NaCl. Gel filtration revealed that the activities in Peak 1 and Peak 2 had molecular weights of 170,000 and 600,000, respectively. Both preparations of the activity finally obtained derived the cells which spread over the plastic dish from mouse bone marrow cells, but did not stimulate the proliferation of IL-3/GM-CSF dependent cell line, IC2. These results suggest the presence of the bone marrow cell-stimulating activities, which are different from GM-CSF and IL-3, in the parenchymal liver cell supernatants.


[A roentgenological study of Chilaiditi's syndrome].

The studies on Chilaiditi's syndrome reported in Japan have been mostly case reports on one or two cases. There have been studies on 356 cases in all. We have selected 262 cases with detailed data takes from the above 356 cases, together with 116 further cases of Chilaiditi's syndrome that we have encountered up to 1990, i.e. since our previous report in 1965. We also investigated roentgenograms, complications, interpositions and age distribution. The syndrome was mostly found in middle-aged and elderly patients of 50 years or older. More male patients were involved than female, however this is not necessarily true if the total number of patients under study is taken into account. Among the complications, gastric and duodenal diseases (ulcer and carcinoma) were most frequently found, accounting for 20.6% of the total reported cases in Japan. In our own study, the percentage was as high as 33.7% because radiography with contrast medium was positively conducted on the digestive tract. Of the interpositions, the colon accounted for 93.1% of our cases, and 72.9% of the total reported cases in Japan. The involved sites were mostly the right hepatic flexure of the colon and the transverse colon. From the reports by other researchers in the past and our data from 1965, 1975 and 1977, it appears that the incidence is about 0.003-0.03%. There were no subjective symptom specific to Chlaiditi's syndrome, and there may be various factors accounting for the occurrence of the syndrome. The symptoms were primarily based on the underlying diseases, and Chilaiditi's syndrome merely indicates the condition where the digestive tract interposes between the diaphragm and liver. Therefore, we regard this as a radiographical sign rather than a syndrome, and we propose that this should be called "Chilaiditi's sign". We also emphasize that the digestive tract must be strictly examined if this sign is to be noted.


[Wave form of intrabronchial spark sound on the chest wall and sound transmission in the lung-thoracic system].

A spark sound was generated in the canine bronchus and sound waves were observed on the surface (skin) and on each layer (pectoralis major muscle, intercostal muscle and parietal pleura) of the chest wall. The sound wave observed on the surface of the chest wall was 5-10 ms in duration, 400-500 Hz in dominant frequency and 0.6-1.2 ms in the duration of the initial deflection. Reverse dispersion of the waves, i.e., the later components of the wave having longer periods, was also recognized. These characteristics of the wave were similar to those of time-expanded wave-form of crackle, i.e., discontinuous adventitious lung sounds, in clinical cases. Both the spark sound and the sound wave observed on the visceral pleura were of short duration, being 0.7 ms and 1 ms, respectively. therefore, the main component of the sound wave observed on the chest surface was considered to reflect the physical properties of the chest wall itself. The analysis of place relationship within the chest wall suggested that transmission of the sound across the chest occurred not as a surface wave but as a longitudinal wave, therewith traversing the chest wall directly from the sound source. The arrival time of the sound was well correlated with the distance between the sound source and the positions of the pick-ups on the surface of the chest wall. Assuming that the medium between the source and the lung and in the chest wall were 71.5 and 29.6 m/sec, respectively. Further studies will be necessary to clarify the theory of the sound transmission through the living tissue as a viscoelastic body.


[Effect of indomethacin on delayed neuronal death of hippocampal CA1 sector in gerbil under different levels of controlled cranial temperatures].

Effect of indomethacin on post-ischemic changes of CA1 neurons was studied in the hippocampus of the Mongolian gerbil. The gerbil was employed because due to poor development of posterior communicating artery ischemia could be easily induced in the forebrain simply by occluding bilateral common carotid arteries. Indomethacin (5 mg/kg, i.p.) was administered 30 min before the occlusion. The occlusion lasted for 5 divided into four groups. In one group, the temperature was not controlled. In the remaining three groups, the temperature was kept at 35.5 degrees C, 37.5 degrees C, and 39.5 degrees C, respectively. Seven days after the occlusion neuronal density was assessed on histological sections stained with hematoxylin eosin. It was found that in all groups indomethacin was effective in preventing delayed neuronal death regardless of the difference in the cranial temperature. However, delayed neuronal death was the least in the lowest temperature group. The drug also prevented the post-ischemic hyperthermia observed in the temperature non-controlled group. These results indicate that indomethacin has its own pharmacological action to prevent delayed neuronal death.


[Utility of SCG (screening colonography) and combined sigmoidoscopy-SCG in thorough physical checkups].

Given the increasing incidence of colon cancer in recent years, it is important to establish a diagnostic system for early detection and introduce it into clinical practice. A double contrast examination that uses a disposable tip and tube with an enema reservoir filled with 200 ml of 60 w/v% barium sulfate, known as SCG (screening colonography) was used in this study. In order to assess its utility SCG was performed on 1,554 patients, and 2,004 patients were examined by a within 24 hours combination of sigmoidoscopy and SCG by way of screening for colon cancer. Given the brief duration of SCG, which ranged from 10 to 13 min in most patients in the study, the efficiency of the examinations was considered to be rather high. Furthermore, the barium reached the cecum in as many as 98.7% of the patients. Overall, SCG proved to have an excellent diagnostic capability. Sigmoidoscopy-SCG, on the other hand, detected colon cancer in 114 patients (5.7%) and colon polyps in 658 patients (32.8%). The rates of detection of colon cancers and polyps were higher in the patients who tested positive in immunological fecal examinations for occult blood. Judging from our results, it may be said that for many patients receiving thorough physical checkups to screen for colon cancer, our system will provide for efficient screening whereby patients are first examined for fecal occult blood and those who test positive undergo sigmoidoscopy and SCG within the same day.


Neurorehabilitation following right thalamic infarct: effects of cognitive retraining on functional performance.

We treated the cognitive impairments of a 69-year-old male, that persisted 7 months after an infarction in the distribution of the right posterior cerebral artery. The infarct produced a 20% reduction in right cerebral blood flow, established by positron emission tomography (PET). Neuropsychological status was characterized by marked hemivisuospatial inattention, visuoperceptual and perceptuomotor dysfunction, and impaired visual memory. A multiple-baselines across behaviors design was utilized to assess effects of specific interventions on targeted cognitive functions. We found significant improvement in attention to left hemispace in response to directed interventions. Considerable gains were also realized in perceptuomotor abilities, mobility, and activities of daily living. Results indicated process-specific effects of strategic cognitive interventions, initiated 7 months postonset.


Event-related potentials (ERPs) during repetition priming in Alzheimer's patients and young and older controls.

Although memory tested explicitly (e.g., recognition) is clearly deficient in the early stages of Alzheimer's disease, it is less clear if memory tested implicitly is similarly affected. To assess this, event-related potentials (ERPs) were recorded during a word-repetition priming paradigm, with semantic and orthographic orienting tasks, from 10 patients with mild probable Alzheimer's disease (PAD; mean age of 70.6), 10 young (24.1) and 10 older (69.8) controls. The extent of priming by word repetition was assessed using the new minus old ERP repetition effect. The young and older control groups showed clear ERP repetition effects that were larger during semantic than orthographic blocks. Although the PAD patients displayed the same general trends, their ERP repetition effects were not nearly as marked when compared to controls. To the extent that the ERP repetition effect recorded during this repetition priming paradigm is a measure of implicit performance, the data suggest that memory assessed in this fashion is spared in at least some Alzheimer's patients in the early stages of the disease.


Spatial cognition in Alzheimer's disease: subtypes of global-local impairment.

This study investigated whether subgroups of AD patients exhibit different patterns of impairment in analyzing global (configural) and local (detail) features of complex visual stimuli. A High Spatial AD subgroup (i.e., patients with better block constructions than naming) and a High Verbal AD subgroup (i.e., patients with better naming than block constructions) were impaired in analyzing both global and local forms. As predicted, however, the High Spatial AD patients exhibited greater impairment in analyzing the local forms than the High Verbal AD patients and normal controls. In contrast, the High Verbal AD patients exhibited greater impairment in analyzing the global forms than the High Spatial AD patients and normal controls. There was a striking separation of the subgroups: Using the local-global difference score, the hit rate for classifying these patients into the two subgroups was 91%. Robust correlations were found between the AD patients' ability to construct global and local forms and their scores on traditional visuospatial and verbal tests, respectively. The findings suggest that it may be misleading to subdivide AD patients using a verbal/spatial dichotomy, because even those AD patients who appear to have relative strengths on traditional visuospatial tests are likely to exhibit a primary impairment in analyzing local features of complex visual stimuli. The results underscore the importance of a process (qualitative) approach to neuropsychological assessment for a more valid understanding of the behavioral subtypes of Alzheimer's disease.


Letter matching: effects of age, Alzheimer's disease, and major depression.

We compared Alzheimer's disease (AD) patients and Major Depressive Disorder (MDD), Aged normal, and Young normal controls on a letter-matching task designed to measure the time needed to access overlearned linguistic information in long-term memory. Name identity (NI) and physical identity (PI) reaction time and the NI-PI difference were compared for ADs, MDDs, and Aged normals and separately for Aged and Young normal groups. AD subjects had slower NI and PI reaction times and a bigger NI-PI difference than Aged normal and MDD subjects, suggesting that speed of access to overlearned letter-name information in long-term memory is slowed for ADs. There were no reliable differences between Aged normal and MDD subjects. Aged normals had slower NI and PI reaction times and a bigger NI-PI difference than Young normals, suggesting that the highly practiced operations needed to access letter-name information slow with age. A discriminant analysis was used to evaluate the usefulness of the "easy to perform" letter-matching task for diagnostic purposes. Ninety percent of normal and MDD subjects but only 68% of AD subjects were classified correctly.


Inner speech in anarthria: neuropsychological evidence of differential effects of cerebral lesions on subvocal articulation.

The role of articulation in verbal short-term memory was investigated in two anarthric patients, C.M. and F.C., both showing normal comprehension for written and spoken language, above average intelligence and visuo-spatial abilities. Based on experimental results, we propose that subvocal articulation might be impaired in anarthric patients in different ways, according to the site of lesion: in 'locked-in' patients only the articulatory rehearsal processes necessary to enhance memory performances is involved, while in cortical anarthric patients the lesion affects the articulatory recoding processes involved in transferring visually presented material into an articulatory form for better retention.


Cognitive test performances related to early and late computed tomography findings after closed-head injury.

Computed tomography (CT) findings from early (less than 24 hours) and late scan (6 months) after closed-head injury (CHI) were compared to cognitive test scores obtained on an average of 4 months after injury in a consecutive series of 53 patients. The presence of parenchymal lesion was associated with poor test results, indicating cognitive inflexibility and disinhibition of routine response tendencies in novel tasks. These deficits have previously been found to be related in particular to frontal-lobe dysfunction, but the present study did not support the hypothesis that frontal lesion is the principal cause of this impairment in CHI. Parenchymal lesions in the right and left hemisphere were associated with spatial and verbal deficits, respectively. Ventricular enlargement in the late CT was related to cognitive inefficiency, both being strongly associated with age. The results suggest that parenchymal lesion in the early CT is an indicator of diffuse axonal injury, which results in cognitive inflexibility during recovery.


Cognitive performance in relatives of patients with probable Alzheimer disease: an age at onset effect?

Cognitive performance of 32 siblings and children of patients with probable Alzheimer disease was assessed longitudinally over an interval averaging 4 years. Mean scores were within normal limits for age on all measures at both test times. However, relatives of patients with early-onset dementia (less than or equal to 67 years) were more likely to show a decline in performance from the first to second testing than relatives of patients with late-onset dementia. Additional follow-up will be needed to determine the reliability of performance trajectories and to assess whether mild cognitive changes are related to future dementia. However, findings suggest that it may be important to consider family history of dementia in studies of normal cognitive aging.


Continuous recognition memory tests: are the assumptions of the theory of signal detection met?

Two continuous recognition memory tests were administered to 20 males and 20 females using the confidence rating procedure to determine if the underlying assumptions of the theory of signal detection (TSD) are met by these tasks. Z-score transformed ROC curves proved to be straight lines parallel to the positive diagonal of the ROC graph. These findings suggest that the distributions of familiarity for old and new stimuli are normal and of equal variance for the Continuous Recognition Memory and Continuous Visual Memory Tests. TSD interpretation of test data appears to be justified.


CNV evidence for the distinctiveness of frontal and posterior neural processes in a traumatic brain-injured population.

The association between certain behavioral tests of executive functions in humans and the integrity of the prefrontal lobes has rested primarily on studies comparing subjects with frontal versus other loci of damage. Another approach is to compare the within-group variation on a physiological index of frontal functioning with the behavioral tests of interest. In the present study, subjects with traumatic brain injury (TBI) were given four behavioural measures of executive function, two measures of posterior nonexecutive function, and a Contingent Negative Variation (CNV) task, a proposed electrophysiological index of frontal-lobe functioning. We found that three of the four executive function tests were significantly related to the CNV, accounting for 23-52% of the variance, while the CNV did not correlate at all with the posterior tasks.


Longitudinal sensitivity of the Fuld cholinergic profile to Alzheimer's disease.

The diagnostic sensitivity of a profile (Fuld, 1984) thought to mark cholinergic changes in Alzheimer's Disease (AD) was examined in a sample of 53 patients meeting criteria for AD on two occasions and in 19 patients for three occasions. The low obtained sensitivities of the Fuld profile (17%-26%) across testings is consistent with previous studies that used a single time point. The findings also revealed unstable positive and negative profiles over time. There were no performance differences on intellectual or memory measures when comparing subjects identified as positive or negative by the Fuld index. The results demonstrate that the index is insensitive to the dementing process and is a poor diagnostic marker for AD.


Individual trajectories of cognitive decline in patients with dementia of the Alzheimer type.

The course of decline was studied in 16 patients with probable or definite dementia of the Alzheimer type (DAT) over 2.7 to 6.8 years from first to last evaluation. Overall severity of dementia was measured with the Wechsler Adult Intelligence Scale (WAIS), the Dementia Rating Scale (DRS), and the Mini-Mental State Examination (MMSE), at approximately annual intervals. An initial plateau phase, during which language and cognitive functions did not change for periods of 9 to 35 months, was observed in 5 patients who initially had an isolated memory impairment without significant impairment of nonmemory language or visuospatial function. Once nonmemory functions began to decline, the rate of decline was remarkably steady in most individual patients but varied markedly among patients. The initial rate of decline after the plateau phase, as measured with the WAIS and DRS, was a significant predictor of subsequent rate in individual patients (r = .66, p less than .01, and r = .67, p less than .01, for the WAIS and DRS, respectively). The MMSE was a less reliable measure of longitudinal change in dementia severity and did not predict future rates of decline (r = .29). These results demonstrate a biphasic trajectory of decline in patients with DAT. Stable interindividual differences in rate of decline may provide a basis for designing more sensitive studies of treatments intended to slow or halt the progress of DAT.


Verbal and nonverbal skill discrepancies in hydrocephalic children.

This study evaluated a large sample (N = 90) of 5- to 7-year-old children with hydrocephalus caused by aqueductal stenosis or prematurity-intraventricular hemorrhage or associated with spina bifida. Comparison groups of normal controls, children with spina bifida and no shunt, and premature children with no hydrocephalus were also evaluated. Comparison of skill discrepancies at two occasions separated by 1 year revealed that hydrocephalic children, as a group, showed poorer nonverbal than verbal skills on measures from the McCarthy Scales of Children's Abilities, the WISC-R, and composites of neuropsychological skills. No discrepancies in verbal-nonverbal memory were found nor were any discrepancies attributable to etiology or motor demands of the tasks. Consistent with current hypotheses concerning the role of the cerebral white matter in cognitive development, these results show that hydrocephalic children in this age range generally have poorer development of nonverbal cognitive skills relative to their language development.


A five-factor model for motor, psychomotor, and visual-spatial tests used in the neuropsychological assessment of children.

Previous confirmatory factor analysis has supported a distinction between simple and complex motor skill tests in a modified and expanded Halstead Reitan test battery (HRB). The present study used a sample of 722 right-handed boys and girls, aged 9 through 12, and expanded the sample of motor, psychomotor, and visual-spatial tests to further clarify this distinction. Restricted maximum-likelihood factor analysis resulted in correlated factors of Simple Motor Skill, Complex Visual-Spatial Relations, Simple Spatial Motor Operations, Motor Steadiness, and Speeded Motor Sequencing. These results provide additional evidence for the discriminant validity of this particular battery of tests, and explicate further the skills and abilities measured in neuropsychological assessments of children referred for evaluation.


Dichotic listening in aphasics: response to Niccum and Speaks.

Since the dichotic listening technique was first described (Broadbent, 1954; Kimura, 1961), researchers have been interested in its ability to document hemispheric dominance for language and other functions in a noninvasive fashion. Numerous articles have been published using normal healthy subjects as well as others using patients who have suffered neurological disease or damage. Much controversy has been generated over the use of dichotic listening in the latter population, however, since unilateral brain lesions might be expected to alter normal perception. This paper responds to one recently published by Niccum and Speaks (1991) that attempted to explain why a lesion effect, and not hemispheric reorganization, is the best explanation for findings of left-ear advantage in recovering aphasics.


Serum placental protein 14 (PP14) reflects endometrial status during hormone replacement therapy.

Healthy post-menopausal women were randomly assigned to treatment groups receiving 28 day treatment cycles of oestradiol valerate (2 mg, days 1-28) sequentially combined with levonorgestrel (75 micrograms, days 17-28) (n = 19); oestradiol valerate (2 mg, days 1-28) continuously combined with cyproterone acetate (1 mg, days 1-28) (n = 18), or placebo (n = 22). Treatment continued for 2 years. After therapy, the women receiving the sequential combination had an early secretory phase (74%) or atrophic endometrium (26%). All women receiving the continuous combination or placebo had inactive or atrophic endometrium, or the tissue was inadequate for assessment. Biochemical parameters of endometrial secretion [oestradiol dehydrogenase (EDH), isocitrate dehydrogenase (ICDH)] measured in endometrial tissue and placental protein (PP14) measured in serum were all low in the groups receiving the continuous combination and placebo. During sequential treatment, all biochemical parameters showed significantly higher mean values. Serum PP14 accurately reflected this pattern. Furthermore, in the sequentially treated group, serum PP14 correlated highly significantly with EDH (r = 0.70; P less than 0.001) and ICDH (r = 0.57; P = 0.01). These correlations were of the same magnitude as the correlations between the endometrial markers, which indicates that serum PP14 reflects the endometrial status. Furthermore, serum PP14 measurements at 3 months and at 2 years of treatment were highly correlated, reflecting the long-term validity of the measurement. The present data suggest that PP14 measured in serum may be used to assess endometrial status. Further studies are required to determine whether serum PP14 will discriminate pathological endometrial conditions.


Effect of RU 486 on the endometrial response to deciduogenic stimulus in ovariectomized rhesus monkeys treated with oestrogen and progesterone.

Using the artificial plaque--decidual cell model in rhesus monkeys, the potential role of progesterone in the process of of epithelial and stromal cell responses was investigated by time-adjusted application of an antiprogestin, RU 486. Epithelial plaque formation is an immediate response of the endometrium to either trauma or invading trophoblast cells. To study this process, RU 486 (2.5 mg/kg body weight) or vehicle (ethanol/saline, 7:3, v/v, i.m.) was administered to the first group of monkeys immediately following traumatization (days 16 and 17 of treatment cycle). Histometric analysis revealed that treatment with RU 486 led to significant inhibition (P less than 0.001) in the recruitment of epithelial cells into plaque acini and consequent reduction (P less than 0.001) in the spread of the plaque reaction compared with control monkeys. In the second group of monkeys, experimental treatment was delayed until plaque formation had occurred (days 21 and 22 of cycle). RU 486 induced increased degeneration (P less than 0.01) in plaque cells. Thus the transformation and the maintenance of the epithelial plaque response appears to be progesterone-dependent. Glandular epithelium showed only marginal changes (P less than 0.05) in maximum cell height, amount of pseudostratification and secretory activity of glands as a consequence of RU 486 treatment; however, the antiprogestin induced a higher incidence of glandular apoptosis (P less than 0.01 for both groups). It has been suggested that the higher degree of apoptosis in the glandular epithelium could be a consequence of the progesterone receptor blocking action of RU 486. No distinctive change in endothelial cell ultrastructure was evident following RU 486 treatment; however, venular diameter was significantly increased (P less than 0.01, group I; P less than 0.001, group II) along with an apparent reduction in the extent of oedema. There was increased extravasation (P less than 0.01) and leukocytic infiltration (P less than 0.001, group I; P less than 0.05, group II) following RU 486 treatment. RU 486 induced vascular responses and increased diapedesis could presumably have resulted from its progesterone blocking action in vascular cells. RU 486 accelerated the incidence (P less than 0.01) of stromal decidualization (group I), as well as quantitatively accentuating (P less than 0.001) the decidual cell reaction (group II). It is possible that RU 486 may inhibit specific functions of decidual cells, despite morphologically consistent decidual transformation.


Pure human follicle stimulating hormone has a role in the treatment of severe male infertility by assisted reproduction: Norfolk's total experience.

Fifty patients [79 in-vitro fertilization (IVF) cycles] with severe male factor infertility were included in an experimental clinical trial running from October 1987 to March 1991 to assess the potential of systemic follicle stimulating hormone (FSH) treatment to improve sperm fertilizing ability in IVF. Two groups were defined: a secondary group (24 patients, 33 IVF cycles) with a history of failed fertilization in previous IVF attempts and a primary group (26 patients, 46 IVF cycles) with poor sperm parameters which suggested that fertilization would not occur according to previously established criteria. Basic semen analysis and a battery of endocrine radioimmunoassays [serum FSH, luteinizing hormone (LH), oestradiol, prolactin and testosterone] were performed in these patients. Bioactive-FSH and LH were also determined in some patients. For this study, pure FSH was administered (150 IU i.m. three times per week) for at least 3 months, after which the semen analysis and endocrine tests were repeated. Although no significant changes were observed after FSH therapy, either in the endocrine profile or in the basic semen parameters, except for FSH radioimmunoassay levels, the fertilization rate of pre-ovulatory oocytes was significantly improved from 2 to 54.4% in the secondary group; the primary group showed a 52.3% fertilization rate. Eighteen clinical pregnancies were achieved, 11 in the primary group and seven in the secondary group, giving 30 and 26% term pregnancy rates per transfer respectively. These results, which are in complete agreement with our preliminary study, re-emphasized the benefits of systemic FSH administration as an adjunct to assisted reproduction in selected cases of severe male factor infertility.(ABSTRACT TRUNCATED AT 250 WORDS)


Effect of the ratio of follicle-stimulating hormone to luteinizing hormone on rat granulosa cell proliferation and oestradiol-17 beta secretion.

The present study examined the effects of the ratio of follicle-stimulating hormone (FSH) to luteinizing hormone (LH) on granulosa cell proliferation and oestradiol-17 beta secretion. For these studies, ovarian segments from either immature rats or those primed with pregnant mares serum gonadotrophin (PMSG) were incubated for 5 h with [3H]thymidine and FSH (0-100 mIU/ml) with or without equivalent doses of LH. After incubation, granulosa cells were isolated and their mitotic activity estimated by determining the amount of [3H]thymidine incorporated into the DNA. The amount of oestradiol secreted into the media was measured by radioimmunoassay. Compared to granulosa cells from immature ovaries, granulosa cells from PMSG-primed ovaries required significantly less FSH to stimulate incorporation of [3H]thymidine, had a 9-fold higher basal level of oestradiol production and increased oestradiol secretion in response to gonadotrophins. At pharmacological serum levels (10-20 mIU of total gonadotrophin), FSH:LH ratios of less than or equal to 2 increased oestradiol secretion from PMSG-primed ovaries but did not increase the rate of [3H]thymidine incorporation. Conversely, FSH:LH ratios of greater than or equal to 3 stimulated [3H]thymidine incorporation without altering oestradiol secretion. These data demonstrate that granulosa cells of immature follicles not secreting oestradiol are relatively unresponsive to gonadotrophins at any dose tested. Once the capacity for oestradiol secretion develops, then both the dose and ratio of FSH and LH play major roles in determining whether the follicle will grow or secrete oestradiol.


Effects of short-term GnRH agonist--human menopausal gonadotrophin stimulation in patients pre-treated with progestogen.

The recent use of gonadotrophin-releasing hormone agonist in a short-term regimen has allowed the effectiveness of human menopausal gonadotrophin (HMG) stimulation to be markedly improved. It seems to be related to the flare-up effect of the agonist in the early follicular phase of the cycle. However, individual hormonal responses to the agonist are quite variable and four patterns of oestradiol secretion have been described. The present study indicates that in women pre-treated with progestogen, only two patterns of serum oestradiol are observed in the flare-up period, with a significant increase in 57% of patients. Significant correlations are observed between oestradiol values and the endogenous gonadotrophin surge (positively with luteinizing hormone, r = 0.38; P less than 0.05 and negatively with follicle stimulating hormone, r = 0.48; P less than 0.005). Furthermore, there was a significant relationship between the hormonal flare-up and the ovarian parameters following HMG stimulation. In conclusion, in progestogen-pre-treated women, the serum oestradiol level during the flare-up period is a reliable index to predict subsequent effectiveness of ovarian stimulation with HMG.


Polycystic ovary syndrome: low-dose follicle stimulating hormone administration is a safe stimulation regimen even in previous hyper-responsive patients.

We studied 23 women with polycystic ovarian syndrome (PCOS), resistant to clomiphene citrate, who had a previous history of multifollicular ovarian development on gonadotrophin stimulation. Each woman had one cycle of gonadotrophin-stimulating hormone agonist/human menopausal gonadotrophin (GnRHa/HMG) stimulation and then one cycle of low-dose follicle stimulating hormone (FSH) stimulation. All GnRHa/HMG cycles were multifollicular. On the low-dose FSH protocol, 10 cycles were unifollicular, while two to three follicles were observed in nine cycles, and four cycles were multifollicular. The ovarian hyperstimulation syndrome ensued in one of the FSH cycles versus 13 of the GnRHa/HMG cycles. Despite decreasing luteinizing hormone (LH) levels and increasing FSH levels, androgen levels increased during stimulation on both protocols. There was one pregnancy in the GnRHa/HMG cycles versus six pregnancies following the FSH cycles. In conclusion, low-dose FSH administration seems a safe stimulation regimen with a satisfactory conception rate even in PCOS women with a previous record of multifollicular ovarian development.


Is continuation of a gonadotrophin-releasing hormone agonist (GnRHa) necessary for women at risk of developing the ovarian hyperstimulation syndrome?

A total of 28 women scheduled for in-vitro fertilization used buserelin and human menopausal gonadotrophin (HMG) for ovarian stimulation. One group (I) of 17 women was given human chorionic gonadotrophin (HCG 10,000 IU) to trigger ovulation, but the resulting embryos were electively cryopreserved because of the risk (serum oestradiol greater than or equal to 3500 pg/ml) of developing the ovarian hyperstimulation syndrome (OHSS). Six women continued the buserelin therapy in the luteal phase and eleven did not. In group II (n = 11), the HMG injections were discontinued because of an exaggerated ovarian response and the HCG was omitted. Six of these women continued the buserelin injections until the onset of menses and five did not. In both groups, the ovarian response to induction of ovulation (serum oestradiol concentrations and number of follicles) was similar for those who did or did not continue buserelin therapy. There was no difference in the rate of ovarian quiescence (weekly fall in serum oestradiol concentration following the stimulation) between those women who did or did not continue the buserelin therapy in either group. The serum luteinizing hormone concentrations remained low in all women in both groups. We conclude that the omission of buserelin therapy after discontinuing the HMG in women at risk of developing OHSS does not affect subsequent ovarian quiescence.


The effect of gonadotrophin-releasing hormone (GnRH) agonist in the follicular phase on in-vitro fertilization outcome in normo-ovulatory women.

Sixty-three normo-ovulatory infertile women were randomly divided into two groups. All women were first desensitized with the gonadotrophin-releasing hormone agonist (GnRHa), buserelin. Thereafter, ovarian stimulation with human menopausal gonadotrophins (HMG) was started in both groups but in group A the GnRHa was stopped on the same day. In group B, the GnRHa was continued during HMG treatment until the ovulatory human chorionic gonadotrophin stimulus was given. Premature luteinization was not observed in either group, although the preovulatory basal luteinizing hormone (LH) secretion was significantly higher in group A. An equal number of embryos of comparable quality was transferred in both groups and the pregnancy outcome was similar. However, the supernumerary embryos of group A were of a lower morphological quality and survived the cryopreservation process less well. We concluded that the continuous administration of a GnRH agonist during HMG treatment resulted in better quality of supernumerary embryos.


The role of oocyte donation in women who are unsuccessful with in-vitro fertilization treatment.

Oocyte donation improves the chances of becoming pregnant in some women who are unsuccessful with in-vitro fertilization (IVF) treatment. A total of 119 IVF cycles achieved a pregnancy rate per cycle of 2.5% whereas the same women, when treated with 45 cycles of oocyte donation, achieved a 24.5% pregnancy rate per cycle. To ascertain which women may be helped by oocyte donation, IVF data were analysed according to the outcome of oocyte donation. There was a difference in the number of previous natural conceptions and live births, and in the IVF fertilization rate. There was no difference in the age of the women and the numbers of oocytes collected per cycle of IVF. New criteria are therefore suggested for recommending oocyte donation to women who have previously failed to become pregnant with IVF treatment.


Oocyte and embryo donation: evaluation of 412 consecutive trials.

A total of 199 patients (412 consecutive cycles) were treated by oocyte-embryo donation in 336 replacement cycles. Of these, 296 involved intra-uterine embryo transfers, 38 zygote intra-Fallopian transfers (ZIFT) and two gamete intra-Fallopian transfers (GIFT). Of the 336 replacements, 244 (73%) constituted transfers of fresh concepti and 92 (27%) of frozen-thawed ones. A total of 85 pregnancies were achieved of which 16 ended in preclinical abortions, giving a clinical pregnancy rate of 34.7% per patient, 20.5% per transfer and a take-home baby rate of 29.1% per patient. The pregnancy rate was significantly higher (P less than 0.05) following fresh gamete or embryo replacement (23%; 56/244) than following that of frozen-thawed embryos (14.1%; 13/92). No significant difference was observed when intra-Fallopian replacement was applied (27.5%; 11/40) as opposed to intra-uterine (19.6%; 58/296). Ovarian function was not found to be of significant importance to the achievement of pregnancies after oocyte donation since comparable pregnancy rates per replacement and per started cycle were obtained in patients with ovarian failure and in those with functional ovaries (19% and 15.4%; 24.2% and 20.2% respectively). Comparison of the implantation and abortion rates between these two groups did not reveal any significant difference (11.1% and 11.1% versus 14.8% and 16.6%). The highest pregnancy rate among patients with ovarian failure was observed in those with primary ovarian failure (26.4%; 14/53), while the lowest was among women who had received chemotherapy and/or radiotherapy (9%; 1/11).(ABSTRACT TRUNCATED AT 250 WORDS)


Clinical and meiotic studies in an infertile man with Y;13 translocation.

Clinical and meiotic studies were done on an infertile man with a translocation between Yq and 13q, who was identified through the birth of his son with partial trisomy 13q. Seminal plasma transferrin showed preserved Sertoli cell function while lactate dehydrogenase C4 indicated hypospermatogenesis. A quadrivalent in diakinesis and spermatogenic arrest in the second meiotic division was detected.


In-vitro fertilization in cases with severe sperm defect: use of a swim-across technique and medium supplemented with follicular fluid.

The purpose of this study was to evaluate a new method of in-vitro fertilization (IVF) in patients with severe sperm defects. Unlike the conventional swim-up method, spermatozoa and oocytes are placed in opposite corners of the bottom of the incubation dish so that sperm swimming is horizontal instead of vertical. Another difference between the swim-across and swim-up techniques is that the incubation medium is supplemented with 20% follicular fluid. After a randomized series (protocol I) of 15 IVF attempts had demonstrated that swim-across was more effective than swim-up in terms of fertilization and cleavage, we began a second series (protocol II) using only swim-across. A total of 124 couples with motile sperm counts less than 1 x 10(6) spermatozoa/ml of semen were included in protocol II. Clinical parameters (age, tubal damage) and number of recovered oocytes were recorded and compared in patients who did (group A: n = 94) and did not (group B: n = 74) achieve fertilization. In group A the fertilization rate was 36.7% and, out of the 94 transfers that were made, there were 21 clinical pregnancies and 12 full-term pregnancies with 16 live births. The number of oocytes collected (12 versus 7.7, P less than 0.001) and the incidence of tubal damage (50% versus 24.3%, P less than 0.001) was significantly higher in group A than in group B. Using logistic regression analysis, we showed a significant correlation between fertilization and progressive motility, percentage normal spermatozoa, number of recovered oocytes and tubal damage.(ABSTRACT TRUNCATED AT 250 WORDS)