Fracture risk among older men: osteopenia and osteoporosis defined using cut-points derived from female versus male reference data.

SUMMARY: We explored the effect of using male and female reference data in a male sample to categorise areal bone mineral density (BMD). Using male reference data, a large proportion of fractures arose from osteopenia, whereas using female reference data shifted the fracture burden into normal BMD. INTRODUCTION: The purpose of this study was to describe fracture risk associated with osteopenia and osteoporosis in older men, defined by areal BMD and using cut-points derived from male and female reference data. METHODS: As part of the Geelong Osteoporosis Study, we followed 619 men aged 60-93 years after BMD assessments (performed 2001-2006) until 2010, fracture, death or emigration. Post-baseline fractures were radiologically confirmed, and proportions of fractures in each BMD category were age-standardised to national profiles. RESULTS: Based on World Health Organization criteria, and using male reference data, 207 men had normal BMD at the femoral neck, 357 were osteopenic and 55 were osteoporotic. Using female reference data, corresponding numbers were 361, 227 and 31. During the study, 130 men died, 15 emigrated and 63 sustained at least one fracture. Using male reference data, most (86.5 %) of the fractures occurred in men without osteoporosis on BMD criteria (18.4 % normal BMD, 68.1 % osteopenia). The pattern differed when female reference data were used; while most fractures arose from men without osteoporosis (88.2 %), the burden shifted from those with osteopenia (34.8 %) to those with normal BMD (53.4 %). CONCLUSIONS: Decreasing BMD categories defined increasing risk of fracture. Although men with osteoporotic BMD were at greatest risk, they made a relatively small contribution to the total burden of fractures. Using male reference data, two-thirds of the fractures arose from men with osteopenia. However, using female reference data, approximately half of the fractures arose from those with normal BMD. Using female reference data to define osteoporosis in men does not appear to be the optimal approach.

Effect of glucocorticoids on activation of leukemia virus in AKR mouse embryo cells.

The effect of glucocorticoids on activation and replication of leukemia virus in AKR mouse embryo cells was analyzed. The number of cells detected as positive by fluorescent antibody techniques as well as the virus production in cells chronically producing virus was doubled at optimal concentrations of glucocorticoids. The effect of the hormones in activated cells was found to be not on the process of activation per se but rather on synthesis of the viral components after activation has occurred. Intracellular reverse transcriptase levels were not changed by hormone treatment. The stimulation of virus synthesis by glucocorticoids requires binding of the steroid to a cytoplasmic receptor protein.

Alcohol-mediated effects on the level of cytochrome P-450 and heme biosynthesis in cultured rat hepatocytes.

Interaction of alcohol and drugs in the liver appears to involve common microsomal oxidative enzymes which utilize cytochrome P-450. Since alcohol augments the toxicity of a variety of drugs, the regulation of the P-450 hemoprotein, a primary component in hepatic drug metabolizing systems, may play a vital role in this phenomenon. We utilize an adult rat liver culture system as a model to explore the action of levels of alcohol below that which is necessary to produce intoxication in humans. The addition of 16 mM ethanol (70 mg/dl) to these hepatocytes results in a 49.5% decrease in cytochrome P-450 activity after 24 h, and a 3-fold increase in the activity of delta-aminolevulinate synthase, the rate-limiting enzyme in hepatic heme biosynthesis. Furthermore, ethanol treatment also causes a transient decrease in the level of intracellular heme. However, the diminished level of total heme does not appear to act as a repressor for delta-aminolevulinate synthase, since it occurs after the initial stimulation of the enzyme by ethanol.

Inhibition of steroid-mediated induction of delta-aminolevulinic acid synthase by 2-diethylaminoethyl-2,2-diphenylvalerate HCl (SKF 525-A).

The inhibition of the steroid-mediated induction of delta-aminolevulinate synthase, the rate-limiting enzyme in hepatic porphyrin-heme biosynthesis, by 2-diethylaminoethyl-2,2-diphenylvalerate HCl (SKF 525-A) as studied in cultured chick embryo liver cells. The formation of porphyrins in response to cyproterone, a synthetic steroid, was inhibited in a time-dependent manner by SKF 525-A, an inhibitor of several drug metabolizing enzyme systems. This action is a result of an inhibitory effect of SKF 525-A on the cyproterone-mediated induction of delta-aminolevulinate synthase; SKF 525-A also inhibited the induction of the enzyme by the naturally occurring 5 beta-H steroids, etiocholanolone and pregnanolone. Employing [3H]etiocholanolone, we provide evidence that this inhibition is not associated with either decreased uptake or an altered metabolism of the steroid. Moreover, approx 4-6-fold more radioactivity was associated with [3H]etiocholanolone-treated cells cultured in the presence of SKF 525-A. Alternative mechanisms for the induction of delta-aminolevulinate synthase by steroids are proposed which do not require the interaction of steroid-receptor complex with the genome.

Primary systemic vasculitis: clinical features and mortality.

BACKGROUND: Wegener's granulomatosis (WG), Churg Strauss syndrome (CSS) and microscopic polyangiitis (MPA) are primary systemic vasculitides (PSV), the clinical features of which have been described from tertiary centres. AIM: To provide the first clinical description of MPA from a general hospital and compare clinical features with WG and CSS. DESIGN: Retrospective analysis of patient records. METHODS: Records of 99 PSV patients attending a single hospital, from 1988 to 2000, were reviewed for: clinical features, date/age at diagnosis, sex, duration of illness, anti-neutrophil cytoplasmic antibodies (ANCA), treatment, comorbidity and deaths. Cases were classified using ACR, CHCC and Lanham criteria/definitions. Birmingham vasculitis activity scores (BVAS) and damage index (VDI) were calculated. Survival was assessed using Cox proportional hazards model and standardized mortality ratios (SMRs). RESULTS: Compared to previous reports there was more ENT (29%) and respiratory (29%) but less renal (92%) involvement in MPA, and less ENT involvement in WG (81%). CSS showed high neurological (72%), cardiovascular (28%) and gastrointestinal (17%) involvement and the highest median (range) VDI (p = 0.01 vs. WG; p = 0.001 vs. MPA). BVAS1 was significantly lower in MPA than in WG [median (range) 15 (4-29) vs. 21 (6-39), (p = 0.001)] but not in CSS [20 (7-28), p = 0.08]. SMR (95%CI) for PSV was 4.8 (3.0-6.6); 5-year survival was 45.1% for MPA, 75.9% for WG and 68.1% for CSS. Age was a significant risk, but only to the same extent as in the reference population. When age was adjusted for, no other significant factor was found. DISCUSSION: The clinical characteristics seen here are similar to those in previous series. There are difficulties in using the MPA CHCC definitions in classification. There is a high proportion of neurological involvement in CSS, causing permanent damage. MPA may have a poorer prognosis than WG or CSS.

Routine perioperative dipyridamole 201Tl imaging in diabetic patients undergoing vascular surgery.

OBJECTIVE: To assess the utility of dipyridamole thallium testing in symptomatic and asymptomatic patients with diabetes undergoing vascular surgery. RESEARCH DESIGN AND METHODS: Dipyridamole 201Tl myocardial scintigraphy was performed preoperatively in 93 consecutive patients with diabetes undergoing peripheral vascular procedures. The utility of clinical and thallium variables in predicting cardiovascular complications was assessed. RESULTS: Two groups of patients were identified: group A (36 patients) without clinical evidence of cardiac disease and group B (57 patients) with clinical evidence of cardiac disease. Dipyridamole thallium scans were abnormal in 21 of 36 (58%) of group A patients compared with 53 of 57 (93%) of group B patients (P < 0.0001). Compared with group B patients with perfusion defects, group A patients with perfusion abnormalities tended to have fewer defects per scan (2.7 +/- 1.5 vs. 3.6 +/- 1.9, P = 0.05). No perioperative cardiac complications occurred in group A patients while perioperative cardiac complications occurred in 9 of 57 (16%, 95% CI 7-28%) group B patients (P = 0.01). For the entire study population, the complication rate was 10%. CONCLUSIONS: Diabetic individuals without clinical markers for coronary artery disease appear to be at low risk for adverse postoperative cardiac events after vascular surgery. Preoperative myocardial perfusion imaging may add little to cardiovascular risk assessment in this subgroup of patients with diabetes.

Cyproterone-mediated stimulation of delta-aminolevulinic acid synthetase in chick embryo liver cells.

In cultured chick embryo liver cells, cyproterone and cyproterone acetate, synthetic anti-androgenic steroids, were found to be potent inducers of mitochondrial delta-aminolevulinic acid (ALA) synthetase, the rate-limiting enzyme in the heme biosynthetic pathway. Both steroids produced a detectable increase in enzyme activity at 5 muM and a maximal stimulation, 36-fold for cyproterone and 29-fold for cyproterone acetate, at 55 muM. The dose-response curves of the steroids differed, however, in that cyproterone acetate produced a greater mean stimulation of the enzyme at concentrations less than approximately 25 muM, whereas, at higher concentrations, cyproterone was the more effective inducer. Increased activity of ALA synthetase was not apparent until about 12 hours after the addition of cyproterone, and maximal activity was not achieved until 20-24 hours. The induction of ALA synthetase by these anti-androgens was prevented by actinomycin D, cordycepin, anisomycin, cycloheximide, and puromycin. These results suggest that new RNA and protein synthesis are necessary for enzyme induction. The cyproterone-mediated induction of the enzyme was inhibited 50% by 2 muM heme, the putative physiological inhibitor of ALA synthetase. These antiandrogens, unlike other potent steroid inducers of this enzyme in chick embryo liver, do not possess either a 5beta-pregnane or 5beta-androstane nucleus. The stimulation of hepatic ALA synthetase represents the first example of a direct effect of these steroids on enzyme induction.

Predictive value of quantitative dipyridamole-thallium scintigraphy in assessing cardiovascular risk after vascular surgery in diabetes mellitus.

Cardiac complications represent a major risk to patients undergoing vascular surgery. Diabetic patients may be particularly prone to such complications due to the high incidence of concomitant coronary artery disease, the severity of which may be clinically unrecognized. Attempts to stratify groups by clinical criteria have been useful but lack the predictive value of currently used noninvasive techniques such as dipyridamole-thallium scintigraphy. One hundred one diabetic patients were evaluated with dipyridamole-thallium scintigraphy before undergoing vascular surgery. The incidence of thallium abnormalities was high (80%) and did not correlate with clinical markers of coronary disease. Even in a subgroup of patients with no overt clinical evidence of underlying heart disease, thallium abnormalities were present in 59%. Cardiovascular complications, however, occurred in only 11% of all patients. Statistically significant prediction of risk was not achieved with simple assessment of thallium results as normal or abnormal. Quantification of total number of reversible defects, as well as assessment of ischemia in the distribution of the left anterior descending coronary artery was required for optimum predictive accuracy. The prevalence of dipyridamole-thallium abnormalities in a diabetic population is much higher than that reported in nondiabetic patients and cannot be predicted by usual clinical indicators of heart disease. In addition, cardiovascular risk of vascular surgery can be optimally assessed by quantitative analysis of dipyridamole-thallium scintigraphy and identification of high- and low-risk subgroups.

Severe Ankle Sprains.

In brief Severe (grade 3) ankle sprains with lateral ligament disruption are common in both athletes and nonathletes. Inadequate treatment leads to chronic ankle instability. Twenty-six patients underwent a 3-week treatment program using an ankle-foot orthosis (AFO), followed by a 4-week rehabilitation program. Of these patients, 96% returned to activity without restriction in about 2 1/2 months. Advantages of the AFO include ease of application, patient comfort and convenience, early ambulation, access for therapy, and rapid return to sports with a stable, asymptomatic ankle.

Lessons from atypical groin pain: presentation and treatment of a schwannoma.

A 16-year-old boy presented with pain in the right knee, groin, and hip after a touch football game. He was initially diagnosed as having a medial collateral ligament sprain of the right knee and an adductor muscle strain. Despite standard conservative therapy, he had persistent hip pain and migratory pain to the right lower abdomen and flank. A bone scan and abdominal CT scan were negative, but MRI revealed a mass in the cauda equina at L3-4, confirmed with myelography. A benign schwannoma was surgically excised without neurologic sequelae. The patient resumed daily activities 5 weeks after surgery.

A silicone splint for auricular hematoma.

Auricular hematomas are often encountered in a sports medicine practice, most commonly among wrestlers, but also in boxers, football and rugby players, and judo athletes.(1) A relatively new treatment, the use of a silicone splint, offers several advantages over other treatments with regard to the risk of recurrence, observation of the site, and return to competition.

Wind observations above an urban river using a new lidar technique, scintillometry and anemometry.

Airflow along rivers might provide a key mechanism for ventilation in cities: important for air quality and thermal comfort. Airflow varies in space and time in the vicinity of rivers. Consequently, there is limited utility in point measurements. Ground-based remote sensing offers the opportunity to study 3D airflow in locations which are difficult to observe with conventional approaches. For three months in the winter and spring of 2011, the airflow above the River Thames in central London was observed using a scanning Doppler lidar, a scintillometer and sonic anemometers. First, an inter-comparison showed that lidar-derived mean wind-speed estimates compare almost as well to sonic anemometers (root-mean-square error (rmse) 0.65-0.68 ms(-1)) as comparisons between sonic anemometers (0.35-0.73 ms(-1)). Second, the lidar duo-beam operating strategy provided horizontal transects of wind vectors (comparison with scintillometer rmse 1.12-1.63 ms(-1)) which revealed mean and turbulent airflow across the river and surrounds; in particular, channelled airflow along the river and changes in turbulence quantities consistent with the roughness changes between built and river environments. The results have important consequences for air quality and dispersion around urban rivers, especially given that many cities have high traffic rates on roads located on riverbanks.

Cytoplasmic receptor protein for etiochalanolone in chick embryo liver.

Acute intermittent porphyria is a gentic disease associated with changes in the activity of some of the hepatic enzymes in the heme biosynthetic pathway and in the activity of delta4-5alpha-steroid reductase, an enzyme involved in steroid metabolism. Embryonic chick liver has been used as a model system to study the effects of several naturally occurring 5beta steroid metabolites on delta-aminolevulinic acid synthetase, the rate-limiting enzyme in the heme pathway (Granick, S., and Kappas, A. (1967) J. Biol. Chem. 242, 4587-4593). In this study we have identified in vitro a hepatic cytoplasmic receptor which binds [3H]-etiocholanolone (a 5beta-H androgen metabolite). The steroid-receptor complex has an apparent Kd value of 3.5 times 10(-6) M at 0-4degrees; the number of binding sites per cell is 23,000. The macromolecular complex sediments at approximately 4 S in a 5 to 20% sucrose gradient and is unaffected by KCl concentrations up to 0.4 M. The steroid-receptor complex can be destroyed by heat (60degrees) or proteolytic digestion and is inhibited by sulfhydryl-blocking agents. Competition studies revealed that among the nonradioactive steroids tested, all of the primary androgens and the progestins as well as their 5alpha and 5beta metabolites block the binding of [3H]etiochalanolone. Only the glucuronide derivative of etiocholanolone, glucocorticoids and their metabolites, 17beta-estradiol, and cyproterone compete poorly for the receptor. The steroid receptor described here appears to be different from the androgen receptor isolated from rat liver and prostate.

Evaluation of the Sørensen diagnostic criteria in the classification of systemic vasculitis.

OBJECTIVES: To evaluate the use of the diagnostic criteria for Wegener's granulomatosis (WG) and microscopic polyangiitis (mPA) proposed by Sørensen et al. in the classification of primary systemic vasculitis (PSV). METHODS: We applied to our cohort of PSV patients the American College of Rheumatology (ACR) criteria for WG, Churg-Strauss syndrome (CSS) and polyarteritis nodosa (PAN), the Chapel Hill Consensus Conference (CHCC) definitions for WG, mPA and CSS, the Hammersmith criteria for CSS and the Sørensen criteria for WG and mPA. RESULTS: Ninety-nine PSV cases were identified. Fifty-six fulfilled criteria for WG (ACR), 60 for PAN (ACR) and 15 for CSS (ACR). Four fulfilled the Hammersmith criteria for CSS. Thirty-nine were defined as mPA (CHCC). Fifty-three patients fulfilled the Sørensen criteria for WG and three for mPA. Five of six patients classified as WG (ACR) who did not meet the Sørensen criteria were excluded by eosinophilia. Six patients who did not fulfil WG (ACR) met the Sørensen criteria for WG. CONCLUSION: The classification of systemic vasculitis is complicated and many cases fulfil more than one set of criteria. The Sørensen criteria for WG is limited by its exclusion of eosinophilia despite reports of an association. We recommend that tissue eosinophilia or peripheral eosinophilia of <1.5x10(9)/l should not exclude a diagnosis of WG. With this modification, the Sørensen criteria for WG may be a useful method of classification, especially in confirming the classification of WG in patients who fulfil both WG (ACR) and mPA (CHCC). Few patients fulfilled the Sørensen criteria for mPA which suggests that they are not of value in classification.

Rheumatoid vasculitis: becoming extinct?

BACKGROUND: Systemic rheumatoid vasculitis (SRV) is a relatively rare complication of RA. The incidence of SRV appeared to increase during the 1970s and 1980s from 6.0 to 12.5/million. During the 1990s there have been major changes in the treatment of RA, with more aggressive control of inflammation. Our aim was to study the epidemiology of SRV in a stable, well-defined population over a 15-yr period. METHODS: Since 1988 we have maintained a prospective register of all patients with systemic vasculitis attending the Norfolk and Norwich University Hospital. Patients presenting with new-onset SRV, as defined by the criteria of Scott and Bacon, and registered with general practitioners in the former Norwich Health Authority area between 1988 and 2002 were identified. The population in 2002 was estimated to be 445 000 (215 000 males). RESULTS: Fifty-one patients (24 male) with SRV were identified, with median age 61 yr and disease duration 16.8 yr. The overall annual incidence was 7.9/million (95% CI 5.9-10.4) (males, 7.7/million; females, 8.1/million). During the first quinquennium (1988-92) the incidence was 11.6/million (95% CI 7.4-17.0) and during the third (1998-2002) it was 3.6/million (95% CI 1.6-7.1). A rolling 3-yr average showed that the peak incidence was in 1992-94, at 15.2/million (95% CI 9.1-23.8), and the nadir was in 1998-2000, at 3.0/million (95% CI 0.8-7.8). A similar pattern was seen for males and females. There was no difference in age or disease duration at onset of SRV between the three quinquennia. CONCLUSIONS: The incidence of SRV has declined dramatically since the 1980s. This could be due to better control of inflammatory disease or changes in smoking habits.