Vitamin D and bone metabolism in Graves' disease: a prospective study.

PURPOSE: Vitamin D and osteoporosis in Graves' disease (GD) have been examined in cross-sectional studies with divergent results. Here, we prospectively studied vitamin D metabolism and bone health in patients with newly diagnosed GD. METHODS: Thirty consecutive patients with de novo overt thyrotoxicosis diagnosed with GD were included. At diagnosis, none of the patients were treated with vitamin D or anti-osteoporotic drugs. All patients were initially treated with antithyroid drugs. Blood samplings were taken at baseline and at 6 weeks, 3, 6, 12 and 24 months after treatment start. Serum levels of 25OHD3, 1,25OH2D3, calcium, parathyroid hormone (PTH), and C-terminal telopeptides of Type I collagen (CTX-I) were analysed. Bone mineral density (BMD) was measured at baseline, and 1 and 2 years after treatment initiation. RESULTS: At diagnosis, patients with GD did not have vitamin D deficiency. There were no significant correlations between levels of 25OHD3 and thyrotoxicosis. Upon treatment of the thyrotoxicosis, serum calcium fell transiently, and PTH and 1,25OH2D3 increased. 25OHD3 fell within the normal range and stabilised at 6 months. CTX-I fell over 12 months, BMD increased significantly up to 2 years, p = 0.002, < 0.001 and 0.005 in the spine, left total hip and left femoral neck, respectively. CONCLUSIONS: The present data underline that thyrotoxicosis has a negative impact on bone health and demonstrate fine-tuned dynamics in bone and vitamin D metabolism. Upon treatment, bone health improved over a follow-up period of 24 months despite rising PTH. Increased conversion of 25OHD3 to 1,25OH2D3 occurs during treatment of GD.

Deaths among adult patients with hypopituitarism: hypocortisolism during acute stress, and de novo malignant brain tumors contribute to an increased mortality.

CONTEXT: Patients with hypopituitarism have an increased standardized mortality rate. The basis for this has not been fully clarified. OBJECTIVE: To investigate in detail the cause of death in a large cohort of patients with hypopituitarism subjected to long-term follow-up. DESIGN AND METHODS: All-cause and cause-specific mortality in 1286 Swedish patients with hypopituitarism prospectively monitored in KIMS (Pfizer International Metabolic Database) 1995-2009 were compared to general population data in the Swedish National Cause of Death Registry. In addition, events reported in KIMS, medical records, and postmortem reports were reviewed. MAIN OUTCOME MEASURES: Standardized mortality ratios (SMR) were calculated, with stratification for gender, attained age, and calendar year during follow-up. RESULTS: An excess mortality was found, 120 deaths vs 84.3 expected, SMR 1.42 (95% confidence interval: 1.18-1.70). Infections, brain cancer, and sudden death were associated with significantly increased SMRs (6.32, 9.40, and 4.10, respectively). Fifteen patients, all ACTH-deficient, died from infections. Eight of these patients were considered to be in a state of adrenal crisis in connection with death (medical reports and post-mortem examinations). Another 8 patients died from de novo malignant brain tumors, 6 of which had had a benign pituitary lesion at baseline. Six of these 8 subjects had received prior radiation therapy. CONCLUSION: Two important causes of excess mortality were identified: first, adrenal crisis in response to acute stress and intercurrent illness; second, increased risk of a late appearance of de novo malignant brain tumors in patients who previously received radiotherapy. Both of these causes may be in part preventable by changes in the management of pituitary disease.

Improved cortisol exposure-time profile and outcome in patients with adrenal insufficiency: a prospective randomized trial of a novel hydrocortisone dual-release formulation.

CONTEXT: Patients with treated adrenal insufficiency (AI) have increased morbidity and mortality rate. Our goal was to improve outcome by developing a once-daily (OD) oral hydrocortisone dual-release tablet with a more physiological exposure-time cortisol profile. OBJECTIVE: The aim was to compare pharmacokinetics and metabolic outcome between OD and the same daily dose of thrice-daily (TID) dose of conventional hydrocortisone tablets. DESIGN AND SETTING: We conducted an open, randomized, two-period, 12-wk crossover multicenter trial with a 24-wk extension at five university hospital centers. PATIENTS: The trial enrolled 64 adults with primary AI; 11 had concomitant diabetes mellitus (DM). INTERVENTION: The same daily dose of hydrocortisone was administered as OD dual-release or TID. MAIN OUTCOME MEASURE: We evaluated cortisol pharmacokinetics. RESULTS: Compared with conventional TID, OD provided a sustained serum cortisol profile 0-4 h after the morning intake and reduced the late afternoon and the 24-h cortisol exposure. The mean weight (difference = -0.7 kg, P = 0.005), systolic blood pressure (difference = -5.5 mm Hg, P = 0.0001) and diastolic blood pressure (difference: -2.3 mm Hg; P = 0.03), and glycated hemoglobin (absolute difference = -0.1%, P = 0.0006) were all reduced after OD compared with TID at 12 wk. Compared with TID, a reduction in glycated hemoglobin by 0.6% was observed in patients with concomitant DM during OD (P = 0.004). CONCLUSION: The OD dual-release tablet provided a more circadian-based serum cortisol profile. Reduced body weight, reduced blood pressure, and improved glucose metabolism were observed during OD treatment. In particular, glucose metabolism improved in patients with concomitant DM.

Meal suppression of circulating ghrelin is normalized in obese individuals following gastric bypass surgery.

OBJECTIVE: It has been proposed that the success of maintained weight loss in morbidly obese subjects following Roux-en-Y gastric bypass (RYGBP) surgery depends on inappropriately low circulating concentrations of the appetite-stimulating peptide ghrelin, being unresponsive to food intake. In this study, this hypothesis was examined. DESIGN: Cross-sectional study with repeated blood samples in 40 subjects after 14 h of prolonged overnight fasting followed by a standardized mixed meal (770 kcal). SUBJECTS: Twenty men and 20 women were included: 10 middle-aged morbidly obese (body mass index (BMI) 43.9+/-3.3 kg/m(2)), 10 middle-aged subjects who had undergone RYGBP at the Uppsala University Hospital (BMI 34.7+/-5.8 kg/m(2)), 10 middle-aged non-obese (BMI 23.5+/-2.2 kg/m(2)) and 10 young non-obese (BMI 22.7+/-1.8 kg/m(2)). MEASUREMENTS: Ghrelin, glucose and insulin levels were analysed pre- and postprandially. RESULTS: In the morbidly obese, ghrelin concentrations were lower in the morning than in the RYGBP group and did not change following the meal. In the RYGBP group, fasting ghrelin levels fell after meal intake and showed similar suppression as both age-matched and young non-obese controls. The RYGBP surgery resulted in an increased meal-induced insulin secretion, which was related to the degree of postprandial ghrelin suppression. CONCLUSION: The present study demonstrates low circulating concentrations of ghrelin and blunted responses to fast and feeding in morbidly obese subjects. Marked weight reduction after RYGBP at our hospital is followed by a normalization of ghrelin secretion, illustrated by increased fasting levels compared to the preoperative obese state and regain of meal-induced ghrelin suppression.

Survival of clostridium perfringens during simulated transport and stability of some plasmid-borne toxin genes under aerobic conditions.

Clostridium perfringens is a pathogen of great concern in veterinary medicine, because it causes enteric diseases and different types of toxaemias in domesticated animals. It is important that bacteria in tissue samples, which have been collected in the field, survive and for the classification of C. perfringens into the correct toxin group, it is crucial that plasmid-borne genes are not lost during transportation or in the diagnostic laboratory. The objectives of this study were to investigate the survival of C. perfringens in a simulated transport of field samples and to determine the stability of the plasmid-borne toxin genes cpb1 and etx after storage at room temperature and at 4 degrees C. Stability of the plasmid-borne genes cpb1 and etx of C. perfringens CCUG 2035, and cpb2 from C. perfringens CIP 106526, JF 2255 and 6 field isolates in aerobic atmosphere was also studied. Survival of C. perfringens was similar in all experiments. The cpbl and etx genes were detected in all isolates from samples stored either at room temperature or at 4 degrees C for 24-44 h. Repeated aerobic treatment of C. perfringens CCUG 2035 and CIP 106526 did not result in the loss of the plasmid-borne genes cpb1, cpb2 or etx. Plasmid-borne genes in C. perfringens were found to be more stable than generally reported. Therefore, C. perfringens toxinotyping by PCR can be performed reliably, as the risk of plasmid loss seems to be a minor problem.

Antimicrobial susceptibility of Swedish, Norwegian and Danish isolates of Clostridium perfringens from poultry, and distribution of tetracycline resistance genes.

This study was undertaken to determine the in vitro susceptibility of Clostridium perfringens, isolated from poultry to antimicrobials used in poultry production. The minimal inhibitory concentration (MIC) of eight antimicrobials, including the ionophoric coccidiostat narasin, was determined for 102 C. perfringens isolates, 58 from Sweden, 24 from Norway and 20 from Denmark. Susceptibility to each antimicrobial compound was determined by broth microdilution. The isolates were obtained from broilers (89), laying hens (9) and turkeys (4), affected by necrotic enteritis (NE) or by C. perfringens associated hepatitis (CPH), and from healthy broilers. All strains, regardless of origin, proved inherently susceptible to ampicillin, narasin, avilamycin, erythromycin and vancomycin. A low frequency of resistance to virginiamycin and bacitracin was also found. Resistance to tetracycline was found in strains isolated in all three countries; Sweden (76%), Denmark (10%) and Norway (29%). In 80% of the tetracycline-resistant isolates, the two resistance genes tetA(P) and tetB(P) were amplified by PCR whereas in 20% only the tetA(P) gene was detected. No tetM gene amplicon was obtained from any of the tetracycline-resistant isolates. The uniform susceptibility to narasin revealed in this study shows that the substance can still be used to control clostridiosis. In this study, C. perfringens also showed a low degree of resistance to most other antimicrobials tested. Despite the small amounts of tetracycline used in poultry, a considerable degree of resistance to tetracycline was found in C. perfringens isolates from Swedish broilers.

Molecular typing of isolates of Clostridium perfringens from healthy and diseased poultry.

The bacterium Clostridium perfringens can cause both clinical and subclinical disease in poultry. To study the pathogenesis and epidemiology of disease caused by C. perfringens, methods for typing its various strains need to be evaluated. C. perfringens isolates from healthy and diseased poultry from different parts of Sweden were analysed by polymerase chain reaction (PCR) in order to establish the presence of alpha-, beta-, beta2-, epsilon -, iota- and enterotoxin genes. In order to subtype C. perfringens isolates, the two methods amplified fragment length polymorphism (AFLP) and pulsed field gel electrophoresis (PFGE) were compared on 21 C. perfringens isolates from 10 different farms. In a second study, 32 isolates of C. perfringens type A from three broilers from a healthy flock reared without ionophorous anticoccidials were subtyped by PFGE. All 53 isolates analysed with PCR belonged to the toxin type A of C. perfringens, with the gene coding for alpha-toxin production. Two isolates possessed the beta2-gene as well, but none had the other toxin genes. Both AFLP and PFGE differentiated 21 strains into 10 different subtypes. This differentiation correlated closely with the origins of the isolates. Unique subtypes were isolated from seven farms. Only isolates from birds of one farm demonstrated more than one subtype of C. perfringens. The subtyping of the isolates from a healthy flock showed that each bird carried two to three different subtypes and two different subtypes were found in the same kind of tissue sample in four cases. Three of the four different subtypes found in this study were new, compared with the first study. AFLP and PFGE were found to be equally suitable for subtyping of C. perfringens isolates. The wide variation in subtypes in the healthy broilers could be the result of the antibiotic-free rearing of these birds.

Prevalence of antibody to chicken anaemia virus (CAV) in Swedish chicken breeding flocks correlated to outbreaks of blue wing disease (BWD) in their progeny.

A serological survey for antibody to Chicken Anaemia Virus (CAV) was performed on broiler breeders as well as layer breeding birds in Sweden at the end of their rearing period. Grandparents (GP) of both types leaving quarantine were in 21 out of 26 cases free from antibody to CAV, but often became infected soon thereafter. A total of 10 outbreaks of blue wing disease (BWD) in 3 series were recorded in the broiler and layer parent generation, all of which were progeny of 3 late seroconverting GP-flocks. All but one of 22 layer parent flocks had been infected and had seroconverted during the rearing period. Subsequently BWD was not recorded from commercial layers. Broiler parent flocks were more protected from CAV infection during rearing. Eighteen out of 94 broiler parent flocks had not developed antibody to CAV before coming into lay. Outbreaks of BWD were reported in progeny flocks from all these broiler breeders, with the exception of those that had been vaccinated. Good hygienic routines along with isolation of the birds delayed the seroconversion to CAV in broiler breeders and vaccination of these breeders protected their progeny from outbreaks of BWD. Broiler flocks in houses where BWD had occurred recently had always antibodies to CAV at slaughter. It was possible to eradicate the infection from the house and prevent the infection between flocks by proper cleaning and disinfection of the broiler houses.

Gender differences in diurnal growth hormone and epinephrine values in young adults during ambulation.

BACKGROUND: In the present study, the impact of gender, oral contraceptives, and ambulation on serum growth hormone (GH) and urinary catecholamines was examined in healthy young adults. METHODS: Twenty-one medical student volunteers--7 men, 7 women, and 7 women taking oral contraceptives--were investigated. Serum samples were drawn every second hour during a 24-h period. At 0800 the first morning, serum samples were drawn while subjects were in the ambulatory state; the next morning, serum samples were drawn at 0800 while the subjects were still resting in bed. RESULTS: During the daytime, GH concentrations were sevenfold higher in the women than in the men, a difference larger than described previously. During the night, there was no gender difference. In the morning, ambulatory GH concentrations were 28-fold higher in the women than in the men, whereas supine GH concentrations were only 4.6-fold higher in the women than in the men. Daytime urinary output of epinephrine was lower in the women than in the men, whereas there was no difference at night. Women using estrogen-containing oral contraceptives had lower epinephrine and higher GH values than women not taking oral contraceptives. In women, morning GH concentrations were higher in the ambulatory than in the resting state, whereas they were lower in the ambulatory state than in the resting state in men. CONCLUSIONS: The secretion of GH and epinephrine is gender-dependent and differs during the daytime in a reciprocal manner, with higher GH and lower epinephrine in women than in men. Oral contraceptives appear to further increase such differences. It seems likely that the data reflect a gender difference in the utilization of substrates for energy production.

Gender differences in the effects of long term growth hormone (GH) treatment on bone in adults with GH deficiency.

We recently observed that among patients with GH deficiency due to adult-onset hypopituitarism, men responded with a greater increase in serum levels of insulin-like growth factor I (IGF-I) and biochemical markers of bone metabolism than women when the same dose of recombinant human GH (rhGH) per body surface area was administered for 9 months. In the present study, 33 of the 36 patients in the previous trial (20 men and 13 women) continued therapy for up to 45 months. The dose of rhGH was adjusted according to side-effects and to maintain serum IGF-I within the physiological range. This resulted in a significant dose reduction in the men; consequently, the women received twice as much rhGH as the men (mean +/- SD, 1.9 +/- 1.1 vs. 1.0 +/- 0.6 U/day; P < 0.01). The increases in serum IGF-I levels and serum biochemical markers of bone metabolism were similar in men and women with these doses. The total bone mineral content (BMC) was increased after 33 and 45 months of treatment up to 5.1% (P = 0.004 and 0.0001). Bone mineral density (BMD), BMC, and the area of the femoral neck and the lumbar spine were also significantly increased after 33 and 45 months of treatment. When analyzed by gender, total body BMC, femoral neck BMD and BMC, and spinal BMC were significantly increased in males, but not in females (P < 0.05-0.01). In conclusion, rhGH treatment continued to have an effect on bone metabolism and bone mass for up to 45 months of therapy. The changes in bone mass were greater in the men, although they received lower doses of rhGH than the women. The results indicate that the sensitivity to GH in adult patients with GH deficiency is gender dependent.

Detection of Newcastle disease virus-specific antibodies in ostrich sera by three serological methods.

Sera from 211 ostriches were tested for the presence of Newcastle disease virus (NDV)-specific antibodies by the virus neutralisation test, the haemagglutination inhibition (HI) test and a recently developed avian paramyxovirus serotype 1 (PMV-1) specific monoclonal antibody blocking ELISA (b-ELISA). The virus neutralisation test was used as the reference for the estimation of the sensitivity and specificity of the b-ELISA and HI tests. Of the 211 sera, 140 contained NDV-specific neutralising antibodies, 130 were positive by the HI test and 122 by the b-ELISA. The sensitivity, specificity and predictive accuracy of the HI and b-ELISA tests relative to the virus neutralisation test were similar. The good agreement between the HI and b-ELISA test (kappa = 0.85) suggested that the two methods are interchangeable.

Marked gender differences in ambulatory morning growth hormone values in young adults.

The influence of gender on serum concentrations of growth hormone (GH) and 12 other endocrine analytes was investigated in sera drawn from 291 healthy medical students in the ambulatory state in the morning, after fasting overnight. GH was measured with a sensitive noncompetitive fluoroimmunoassay. The median GH value was 80-fold higher in women 21-26 years old than in age-matched men (14.4 vs 0.18 mIU/L), compared with a female/male ratio of 2.2 for 17beta-estradiol and a male/female ratio of 14 for testosterone. Furthermore, the values for sex hormone-binding globulin, follicle-stimulating hormone, luteinizing hormone, prolactin, and insulin-like growth factor 1 (IGF-1) were higher, whereas the values for free thyroxine, triiodothyronine, thyroid-stimulating hormone, and parathyroid hormone were lower in the women. The median GH value was 68-fold higher in women 27-43 years old than in age-matched men (10.9 vs 0.16 mIU/L). Women taking contraceptives with ethinyl estradiol and desogestrel or levonorgestrel had higher GH values, and the desogestrel group had lower IGF-1 values than women not taking contraceptives. The median GH values in these groups were 125- and 117-fold higher, respectively, than in men 21-26 years old. The results suggest that routine morning activity produces a marked GH response in >90% of young women but in very few age-matched men. The effect on GH was even more pronounced in women taking oral contraceptives, suggesting that the intake of ethinyl estradiol contributes to higher GH concentrations in these women.

Detection of NDV-specific antibodies and the level of protection provided by a single vaccination in young chickens.

Fourteen groups of young commercial chickens were immunized once with a live NDV vaccine using different vaccine doses and routes of vaccination in five experiments. Three to six weeks later, small groups were selected from each flock. Sera were tested by the haemagglutination-inhibition test and a monoclonal antibody blocking ELISA, and the birds were challenged with a virulent NDV strain. Degree of protection was dose-dependent in those groups where the vaccine was administered orally at 3 weeks of age. Aerosol and eye drop vaccinations performed in day-old chicks provided full protection at 5 or 6 weeks of age. There was a good agreement between the two serological methods and positive results in any of the tests were reliable forecasts of protection.

Detection of PMV-1 specific antibodies with a monoclonal antibody blocking enzyme-linked immunosorbent assay.

A highly reproducible monoclonal antibody (Mab) blocking ELISA (B-ELISA) has been developed and evaluated for the detection of NDV-specific antibodies. The Mab utilised is specific for a conserved PMV-1 serotype-specific epitope, as demonstrated by the indirect immunoperoxidase test. It reacted with all strains representing different serogroups within the PMV-1 serotype, but not with any strain belonging to other PMV serotypes. Sensitivity and specificity of the B-ELISA were compared with the haemagglutina-tion inhibition test (HI). Blocking and HI antibodies were detected in sera of chickens 8 days post-experimental infection. The B-ELISA proved consistently more sensitive than the HI test. In another survey, 62 sera from experimentally vaccinated chickens were tested; 95.2% proved positive by B-ELISA, 85.5% by indirect ELISA and 74% by HI test. When 504 field sera from vaccinated chickens and turkeys were tested, 98% were positive by B-ELISA, and 69% by HI. The specificity was evaluated by testing 1066 samples from NDV-free flocks, all of which proved negative by both methods. Other advantages of the B-ELISA include easy standardization and quality control, and ability to test sera from any species (including exotic or wild birds as well as mammals). The use of low dilution serum or egg-yolk samples makes the test quick and easy to perform and suitable for large-scale screening.

Blue wing disease of chickens: isolation of avian reovirus and chicken anaemia agent.

Viruses were regularly isolated from chickens affected with blue wing disease (BWD). All of the isolates in chicken embryo liver (CEL) cells except one were avian reoviruses as identified by size, morphology and cross-agar gel precipitation. An additional agent was isolated in a T-lymphoblastoid cell line, MDCC-MSB1. This agent has physico-chemical properties similar to those of CAA and it cross reacts with the reference Gifu-1 strain of CAA in an indirect immunofluorescence test.

Blue wing disease of chickens: experimental infection with a Swedish isolate of chicken anaemia agent and an avian reovirus.

Isolates of an avian reovirus and chicken anaemia agent (CAA) from a field case of blue wing disease (BWD) in Sweden were inoculated into groups of SPF, one-day-old chicks as follows: Expt 1, an organ suspension from the field case; Expt 2, a selected non-purified reovirus isolate grown in chicken embryo liver cells. Expt 3, a plaque-purified reovirus strain; Expt 4, the CAA isolate from the organ suspension and Expt 5, a combination of reovirus (from Expt 3) and CAA (from Expt 4). The inoculations were given intraperitoneally. In a sixth experiment the isolates were given intramuscularly. The chicks in Expts 1, 2, 5 and 6 became ill after two weeks, and several birds died or were killed when moribund between 13 and 22 days of age. These birds had lesions similar to those found in field cases of BWD, i.e., atrophy of the thymus and the bursa of Fabricius and petechial haemorrhages in the skin. All of them had atrophie bone marrow. The chicks inoculated with the cloned reovirus strain (Expt 3) or CAA alone (Expt 4), did not show any apparent signs of disease. In Expt 4, lesions were found in the thymus, bursa of Fabricius, and bone marrow but to a less severe degree. In Expts 1, 2 and 5 both the reovirus and the CAA were successfully reisolated.

Gizzard erosions as a cause of mortality in White Leghorn chickens.

Increased mortality connected with gizzard erosions has been observed in several flocks of White Leghorn chicks in Sweden. Bacterial infection of the gizzard wall was a common finding in chicks that had died from the disease. Infection with Clostridium perfringens is supposed to be the main cause of mortality, but the primary cause of the gizzard lesions has not been established.

Immunohistochemical detection of infectious bursal disease and infectious bronchitis viral antigens in fixed, paraffin-embedded chicken tissues.

Immunoperoxidase and immunofluorescent techniques were used to detect and localise infectious bursal disease virus (IBDV) and infectious bronchitis virus (IBV) in fixed, paraffin-embedded chicken tissues. A modified Bouin's solution (9 parts of 1% picric acid to 1 part of 10% neutral buffered formalin and 5% acetic acid) proved to be the fixative of choice. Tissues fixed in 10% neutral buffered formalin showed heavy background staining, whereas enzyme treatment of these tissues succeeded in exposing viral antigens and thus giving a specific reaction. For routine diagnostic purposes it will prove advantageous to detect IBDV and IBV in fixed, paraffin-embedded material.

Blue wing disease of chickens: signs, pathology and natural transmission.

A new peracute disease of chickens is described. The disease is called blue wing disease (BWD) and has occurred frequently in all parts of Sweden since the first outbreak in 1972. Most of the outbreaks have affected broilers at the age of 2 to 4 weeks with a mortality rate of 1 to 60%. BWD is characterised by skin lesions in the form of ecchymotic haemorrhages, most frequently on the wings. These lesions are often infected secondarily by bacteria, leading to a gangrenous dermatitis. Infectious bursal disease, inclusion body hepatitis and infectious aplastic anaemia, which also have been associated with gangrenous dermatitis, are not found in the outbreaks of BWD. BWD is closely related to certain parent flocks, which suggests that the disease is transmitted vertically. The parent flocks which transmit the disease do not show any signs of disease themselves.