A randomized, double-blind, placebo-controlled trial of intravenous zoledronic acid in the treatment of thalassemia-associated osteopenia.

Beta-thalassaemia major is associated with low bone mass and fractures. We conducted a 2 year randomized controlled trial of zoledronic acid 4 mg administered intravenously every 3 months or placebo in the treatment of beta-thalassaemia-associated osteopenla. We recruited 23 subjects from 2 university hospitals with a T score of less than -1.0 at either the lumbar spine or hip, and 23 subjects completed the study (17 M, 6 F). Treatment groups did not differ significantly with respect to bone mineral density (BMD), age, height, weight and body mass index (BMI) at baseline. BMD was assessed at baseline, 12 months and 24 months by dual-energy X-ray absorptiometry (DXA) at the lumbar spine, femoral reek, total hip and total body. After two years average lumbar spine BMD was 8.9% greater (95%CI 2.3-15.5%, P = 0.011), average femoral neck BMD was 9.1% greater (95%CI 5.5-12.7%, P < 0.0001), average total hip BMD was 9.6% greater (95%CI 6.5-12.6%, P < 0.0001) and average total body BMD was 4.7% greater (95%CI 2.7-6.8%, P < 0.0001) in the treated group compared to placebo. The absolute change in BMD from baseline to 2 years and the annualized rate of change of BMD was significantly greater in treated patients at all four sites. Age, gender, height, weight and BMI did not interact with the effect of treatment and so unadjusted data was used. The serum total ALP decreased 45% by 12 months (P = 0.004) and urinary deoxypyridinoline/creatinine ratio decreased 47% by 3 months (NS). We conclude that zoledronic acid (4 mg i.v. 3 monthly) suppresses bone turnover and increases BMD in beta-thalassaemia-associated osteopenia.

Testing the gonadal regression-cytoprotection hypothesis.

Germinal damage is an almost universal accompaniment of cancer treatment as the result of bystander damage to the testis from cytotoxic drugs and/or irradiation. Cancer treatment for the most common cancers of the reproductive age group in men has improved such that most are now treated with curative intent, and many others are treated with likelihood of prolonged survival, so that the preservation of fertility is an important component of posttreatment quality of life. This has led to the consideration of developing adjuvant treatments that may reduce the gonadal toxicity of cancer therapy. One dominant hypothesis has been based on the supposition that the immature testis was resistant to cytotoxin damage. Hence, if hormonal treatment were able to cause spermatogenic regression to an immature state via an effective withdrawal of gonadotrophin secretion, the testis might be maintained temporarily in a protected state during cytotoxin exposure. However, clinical studies have been disappointing but have also been unable to test the hypothesis definitively thus far, due to the inability to completely suppress gonadotrophin secretion. Similarly, experimental models have also given conflicting results and, at best, a modest cytoprotection. To definitively test this hypothesis experimentally, we used the fact that the functionally hpg mouse has complete gonadotrophin deficiency but can undergo the induction of full spermatogenesis by testosterone. Thus, if complete gonadotrophin deficiency were an advantage during cytotoxin exposure, then the hpg mouse should exhibit some degree of germinal protection against cytotoxin-induced damage. We therefore administered three different cytotoxins (200 mg/kg procarbazine, 9 mg/kg doxorubicin, 8 Gy of X irradiation) to produce a range of severity in testicular damage and mechanism of action to either phenotypically normal or hpg mice. Testis weight and homogenization-resistant spermatid numbers were measured to evaluate the potential protective effects on spermatogenesis. Although the three cytotoxins produced a range of severity of spermatogenic damage, there was no evidence of cytoprotection in the hpg mice that were completely gonadotrophin deficient at the time of treatment. These findings cast doubt on the validity of the hypothesis that spermatogenic regression via gonadotrophin withdrawal can protect the mouse testis against cytotoxin-mediated spermatogenic damage.

Androgen effects on bioactive and immunoreactive gonadotrophin levels during puberty in male baboons.

The effect of androgens on changes in circulating LH and FSH during pubertal development was examined longitudinally in a 3 year study in male hamadryas baboons. Baboon LH and FSH were measured by a species-specific radioimmunoassay and bioactive LH (B-LH) was measured by the mouse in vitro Leydig cell bioassay. Control baboons (n = 5) progressed normally through puberty. Eight baboons were castrated prepubertally; of these four received testosterone implants at the chronological age (CA) of clinical puberty (4.0 +/- 0.1 yr, mean +/- SEM). The timing of the postcastration rise in B-LH levels ranged between 1 and 15 months later (median 3.5 months) (CA 3.5 +/- 0.2 yr) thus supporting the hypothesis that central activation of gonadotrophins occurs at the time of puberty, independent of gonadal influences. Similar results were seen for immunoreactive-LH (IR-LH) and IR-FSH levels. IR- and B-LH levels continued to rise with age (P < 0.0003) in the untreated castrated baboons, associated with an increased LH B/I ratio. Administration of testosterone resulted in temporary suppression of B-LH, IR-LH and IR-FSH levels; however gonadotrophin levels subsequently rose with age despite increased testosterone levels. Thus the mechanisms initiating puberty involve both gonad-independent events as well as alterations in negative androgenic feedback sensitivity on gonadotrophin secretion.

Growth and hormone characteristics of pubertal development in the hamadryas baboon.

The semi-longitudinal collection of growth measurements in male and female hamadryas baboons has enabled documentation of the timing of puberty and the development of sexually dimorphic growth patterns in body weight, crown-rump length (CRL), limb lengths, and muscle mass. In addition, another sexually dimorphic characteristic appears to be the presence of a pubertal growth spurt in body weight, and possibly CRL, in male but not female baboons. Serum testosterone levels rose during male development; however, there was a progressive decrease in dehydroepiandrosterone sulfate levels indicating the absence of adrenarche. Insulin-like growth factor-I (IGF-I) and its major binding protein, IGFBP-3, both rose during pubertal development; however, a simultaneous rise in the IGF-I:IGFBP-3 molar ratio suggests other factors may enhance the bioactivity of IGF-I during puberty. A distinct rise in serum osteocalcin levels was also associated with puberty in male baboons. These growth and hormonal changes during puberty in the hamadryas baboon indicate that this species provides a close primate model for human puberty.

Androgens regulate circulating levels of insulin-like growth factor (IGF)-I and IGF binding protein-3 during puberty in male baboons.

To examine the role of androgens in initiating the pubertal rise in circulating insulin-like factor-I (IGF-I) levels, a longitudinal study of puberty in 13 male hamadryas baboons was conducted over 3 yr. The five control baboons commenced puberty (initial testicular enlargement) at a mean +/- SE age of 4.2 +/- 0.4 yr. Another eight baboons were castrated prepubertally; of those four received testosterone pellets (dose equivalent: 12.5-50 mg every 6 weeks) implanted se from the time of puberty. Body weight, crown-rump length, and limb length measurements, synchronized to pubertal onset, suggest that a pubertal growth spurt occurs in male baboons. Control baboons had a marked rise (4- to 5-fold; P < 0.0001) in circulating IGF-I levels; maximum IGF-I levels (168 +/- 9 nmol/L) were reached 42 months after the onset of puberty (mean chronological age 7.5 yr). Castrated baboons had no significant rise in IGF-I levels, however, administration of testosterone resulted in a close approximation of the normal pubertal rise in IGF-I (maximum values 140 +/- 8 nmol/L), confirmed by comparison of fitted sigmoid curves (r2 > 0.99; chronological age ED50 controls, 4.4 +/- 0.1 yr and castrate + testosterone, 4.3 +/- 0.1 yr). Serum IGF binding protein-3 levels paralleled the rise in IGF-I consistent with a common regulatory mechanism. In another study, castration of four sexually mature male baboons aged 11.12 +/- 1.16 yr had no effect on serum IGF-I levels (P = 0.5). This indicates that androgens are the predominant determinant of circulating IGF-I in the male baboon, and that this is an uniquely pubertal phenomenon.

Recombinant growth hormone and insulin-like growth factor I do not alter gonadotrophin stimulation of the baboon testis in vivo.

In vitro studies indicate a physiological role for insulin-like growth factor I (IGF-I) in paracrine regulation of testicular function and recent clinical studies suggest a potential role for growth hormone (GH) and/or IGF-I in the treatment of hypogonadotrophic states in males. This study aimed to examine the effects of pretreatment with recombinant human GH (rhGH) or rhIGF-I on the response to gonadotrophins of the non-human primate testis in vivo. Using a balanced Latin square design with repeated measures, six prepubertal male hamadryas baboons (Papio hamadryas hamadryas) were treated in a cross-over sequence for periods of 18 days with daily im injections of rhGH (0.4 IU.kg-1.day-1), rhIGF-I (0.1 mg.kg-1.day-1) or saline with a 2-week washout period between each treatment. A single im injection of hCG (1500 IU) increased serum testosterone (p = 0.0002) but neither rhGH nor rhIGF-I influenced the timing or magnitude of this response (p > 0.5). A single im dose of FSH (75 IU) stimulated immunoreactive inhibin (p = 0.01) but also was unaffected in magnitude or timing by pretreatment with rhGH or rhIGF-I (p > 0.2). Circulating IGF-I levels were increased independently by hCG (p = 0.01) and FSH (p < 0.0001) administration. These findings indicate that neither GH nor IGF-I pre-treatment enhance acute gonadal responses to gonadotrophin stimulation of the prepubertal non-human primate testis in vivo. These findings suggest that GH or IGF-I treatment of hypogonadotrophic men without somatotrophin deficiency is unlikely to be beneficial.

Total body nitrogen in children with chronic renal failure and short stature.

OBJECTIVE: To directly assess the body protein content of children with chronic renal failure (CRF) and short stature. SETTING: A tertiary referral paediatric hospital. SUBJECTS: There were: (i) 17 patients (10 male, nine pre-pubertal; mean age 12.90 +/- 3.20 years) with CRF and height standard deviation (SD) score < -2.00, and (ii) 43 normal children (18 male, 27 pre-pubertal; mean age 10.34 +/- 3.34 years). INTERVENTIONS: CRF patients had the following measurements: anthropometry, total body nitrogen (TBN) by neutron capture analysis, 4 day weighed food record and serum albumin levels. Control subjects had TBN and anthropometric measurements only. RESULTS: Although older than the controls, the CRF patients had significantly lower TBN values (645 +/- 265 vs 930 +/- 365 g, P < 0.01). Mean values for TBN and TBN/height (percentages of expected) in the CRF patients were significantly reduced to 54% and 63% respectively, when predicted from age. However, their TBN predicted from height was 100% of expected. %TBN (predicted from age) correlated significantly with height SD score (r = 0.79), weight SD score (r = 0.87), upper arm muscle area percentile (r = 0.62) and serum albumin (r = 0.62). Mean oral energy and protein intakes were 65% and 172% of recommended dietary intake respectively. CONCLUSIONS: Children with CRF and short stature are significantly protein-depleted for age although not for height. Chronic energy deficiency may contribute to impaired protein deposition which, in turn, may be important in the pathogenesis of growth failure in CRF.

Growth hormone (GH) regulation of circulating insulin-like growth factor-I levels during sexual maturation of the GH-deficient dwarf (dw/dw) male rat.

In many mammalian species, circulating levels of insulin-like growth factor-I (IGF-I) rise during puberty. Previous studies manipulating testosterone levels in rats with normal GH secretion suggested that the pubertal IGF-I rise is regulated by an interaction between GH and sex steroids. Therefore, in a reciprocal study, IGF-I levels were examined during sexual maturation of the GH-deficient dwarf (dw/dw) rat which has a selective genetic deficiency of GH but normal sex steroid levels. Male dw/dw rats were treated with daily injections of recombinant human GH (200 micrograms/100 g body weight) or saline vehicle, from 28 to 70 days of age. Sexual maturation was determined to occur primarily between 42 and 63 days of age based on testis and seminal vesicle growth and plasma testosterone levels. GH treatment had no effect on seminal vesicle weights, plasma testosterone or gonadotrophins. GH administration resulted in a 7% increase in absolute testes weight (P < 0.05), but a 50% increase in body weight (P < 0.0001). These results supported previous findings that the reproductive development of dw/dw rats is essentially normal. Untreated dw/dw rats had no rise in IGF-I levels during sexual maturation. In contrast, treatment with GH produced a marked sustained rise in IGF-I levels (P < 0.0001). LIgand blots demonstrated GH induction of IGF-binding protein-3 (IGFBP-3) and an IGFBP cluster at 32 kDa. The initially high immunoreactive IGFBP-1 levels (> 600 ng/ml) decreased by 49 days of age after which untreated dw/dw rats had significantly higher IGFBP-1 levels than GH-treated dw/dw rats (P < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Androgen regulation of circulating insulin-like growth factor-I during puberty in male hypogonadal mice.

This study aimed at determining the relationship of sex steroids, particularly in the perinatal period, to the pubertal insulin-like growth factor-I (IGF-I) surge in male mice. We used hypogonadal (hpg) mice, which have a major deletion in the gonadotrophin-releasing hormone (GnRH) gene, in order to have a model lacking all GnRH-induced gonadotrophin and sex steroid secretion throughout pre- and postnatal life. Cross-sectional data on body weights and weights of testes, seminal vesicles, kidneys, liver and spleen from 9 to 77 days of age were obtained in male hpg, heterozygous (Hz) and homozygous normal (N/N) littermates (n = 75-78/group). These data did not reveal any difference between Hz and N/N mice. Hpg mice had decreased body weights which by 70-77 days of age were approximately 18% less than normal controls. Testes and seminal vesicles of hpg mice did not demonstrate any significant postnatal growth. Relative to body weight, kidney weights were also markedly reduced in hpg mice (P < 0.0001), deviating significantly from normal by 28-35 days of age, reflecting the impact of androgen deficiency on a non-reproductive organ. From the cross-sectional data it was concluded that puberty commenced soon after weaning (21 days) in the male and that maturity was achieved within 4-5 weeks. Longitudinal study showed that, compared with normal controls, untreated hpg mice had an exaggerated pubertal IGF-I surge (P < 0.005) which peaked in mid-puberty.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of extraction methods for insulin-like growth factor-I in rat serum.

This study was undertaken to compare various extraction methods for insulin-like growth factor-binding proteins (IGFBPs) from insulin-like growth factor-I (IGF-I) in rat serum systematically, before measurement of IGF-I by radioimmunoassay (RIA). The values obtained in the IGF-I RIA following acid-ethanol (AE), acid-ethanol cryoprecipitation (AEC) and formic acid-acetone (FA) extraction methods were compared with the IGF-I values obtained following high-performance liquid chromatography (HPLC), which was the reference method. Radioligand blots were used to determine the pattern and degree of IGFBP removal by these methods. Over a wide range of circulating IGF-I levels, AE and AEC extraction gave IGF-I levels comparable with those obtained following HPLC. FA extraction resulted in IGF-I levels that were consistently higher (P < 0.01) than those obtained following HPLC and gave non-parallel displacement curves in comparison with recombinant IGF-I standards (P <0.01). Ligand blots demonstrated a similar pattern of IGFBP removal among the three methods with almost complete removal of IGFBP-3 but only 30-40% removal of the lower molecular weight IGFBPs. These lower molecular weight IGFBPs did not interfere with the RIA measurements of IGF-I from AE and AEC extracts. Therefore the AE extraction method of Daughaday, originally validated for use in human serum, is also satisfactory for use in rat serum. The complete removal of IGF-binding activity does not appear essential for accurate measurement of IGF-I by RIA, although this may depend on the specific binding characteristics of the IGF-I antiserum.

Hyperglycaemia complicating haemolytic uraemic syndrome.

The occurrence of hyperglycaemia and insulin deficiency in a young child receiving peritoneal dialysis during the course of haemolytic uraemic syndrome (HUS) is described. This unusual complication may have been due to microvascular disease involving the pancreas. Plasma glucose should be monitored during HUS, particularly if dialysis with fluids containing high dextrose concentrations is required.

Carbohydrate metabolism on high dose growth hormone therapy in children treated for leukaemia.

The effect on carbohydrate metabolism of a high dose growth hormone (GH) regimen (1.2 U/kg per week) was assessed on 24 children who had previously been treated for leukaemia. Sixteen patients received high dose GH and eight patients received a conventional dose of GH (0.6 U/kg per week). Oral glucose tolerance tests (OGTT) were performed at baseline and after 3 months of treatment with GH. For the entire group between 0 and 3 months, there was a significant increase in mean (and standard deviation) fasting plasma glucose (0.3 +/- 0.6 mmol/L), fasting insulin level (11 +/- 26 mU/L), and 2 h insulin level (20 +/- 40 mU/L). One patient, who received a conventional dose of GH, developed substantial carbohydrate intolerance. For the entire group, there was no change in response to a carbohydrate load at 3 months as measured by the area under the plasma glucose or insulin curve. There was no significant difference between conventional and high dose groups at 3 months as assessed by these parameters. This study demonstrates that a higher dose of GH may be used in these children in an attempt to improve their final height, without increased risk of carbohydrate intolerance in the short term.

Looking, moving and seeing.

Why are there eye movements? To shift images across the retina. There is a system for fast centering of an image on the retina, a system for tracking a slowly moving image, and a vestibular system for maintaining the same field of view. How is the perception of the visual world rendered stable in the face of all these eye movements and yet the movement of particular objects within the environment is accurately seen?

Environmental standards for intraocular lens implantation.

Successful implantation of prosthetic devices depends upon their freedom from postoperative inflammation and infection. Techniques and lessons learned in orthopaedic and other implant surgery should be applied to intraocular lens implantation. The avoidance of contamination by particles and micro-organisms is one essential principle of the surgical procedure. Practical steps are described to reduce both types of contamination. These measures taken together are recommended for adoption as a standard of environmental safety for lens implantation.

A clinicopathological report of a posterior chamber lens implant.

This report describes the clinical and pathological findings of a C-loop posterior chamber intraocular lens 73 days after implantation. The supporting loops of the optic were seated in the iridociliary sulcus for almost 300 degrees of its circumference. Morphological changes included minimal degranulation of the pigmented epithelium adjacent to the loop and moulding of the lens capsular remnant around the loop. There was no erosion into uveal tissue. These findings are discussed with reference to the shape of the haptic element of this lens.