Severe postpartum osteoporosis with increased PTHrP during lactation in a patient after total thyroidectomy and parathyroidectomy.

We present a 27-year-old woman with hypoparathyroidism following total thyroidectomy for papillary carcinoma, who presented postpartum during lactation with several vertebral osteoporotic fractures, increase in bone turnover markers, and measurable parathyroid hormone-related protein (PTHrP) levels. Cessations of lactation led to gradual decrease in bone turnover markers and PTHrP and improvement in bone mineral density. Pregnancy- and postpartum-associated osteoporosis is an uncommon condition characterized by the occurrence of fractures during late pregnancy or the puerperium. The patient presented postpartum with severe back pain and multiple vertebral fractures. Metabolic evaluation performed at presentation revealed hypercalcemia, hypercalciuria, increased alkaline phosphatase, vitamin D insufficiency, normal serum protein immunoelectrophoresis, and a detectable level of PTHrP. Serum levels of bone turnover markers were markedly increased. Bone mineral density at the lumbar spine was severely reduced. After cessation of lactation, the PTHrP level became undetectable. Bone turnover markers gradually decreased to normal and bone mineral density improved. Several factors contributed to the reduced bone mass in this patient, including amenorrhea treated with oral contraceptives, suppressive levothyroxine treatment, and lactation of twins with increased PTHrP. Patients with severely reduced bone mass need surveillance during pregnancy and lactation and should possibly consider avoiding breastfeeding. Patients with hypoparathyroidism should temporarily reduce their alphacalcidiol dose while lactating.

Less-calcemic vitamin D analogs enhance creatine kinase specific activity and modulate responsiveness to gonadal steroids in rat skeletal tissues.

Vitamin D metabolites and analogs exert a variety of biological activities, such as regulation of cellular proliferation, differentiation and energy metabolism, exerted through the brain type isozyme of creatine kinase (CK) specific activity, serving to provide ATP generation. In the present study we assess the role of vitamin D in induction of CK in rat epiphyseal cartilage (Ep) and diaphyseal bone (Di). Skeletal tissues from female or male vitamin D-depleted rats showed lower CK than in vitamin D-replete rats in both Ep and Di. Moreover, estradiol-17beta (E2) or dihydrotestosterone (DHT), which increased CK in Ep and Di of intact female or male rats, respectively, stimulated CK in vitamin D-depleted rats to a much lower extent. Treatment of intact female rats for 1, 2 or 8 weeks with the less-calcemic vitamin D analogs JKF 1624F2-2 (JKF) or QW 1624F2-2 (QW) and the non-calcemic analog CB 1093 (CB), slightly affected CK, although there was an up-regulation of the E2- and DHT-induced CK response in Ep and Di from these rats. In intact female rats, all vitamin D analogs potentiated CK response to the SERM raloxifene (Ral) and tamoxifen (TAM) in these organs but the inhibitory effect of Ral or TAM on E2-induced CK was lost after this pre-treatment. CB induced a significant increase in estradiol receptor alpha (ERalpha) protein in both Ep and Di from intact female rats. Collectively, these results indicate that vitamin D analogs modulate CK in skeletal tissues and up-regulate its response and sensitivity to E2 and to SERM in these tissues, possibly via an increase in ERalpha protein. These results corroborate our previous studies in human bone cells, and further suggest that the vitamin D system plays an important physiological role in maintaining normal cell energy reservoir in the skeleton.

S1 gene characteristics and efficacy of vaccination against infectious bronchitis virus field isolates from the United States and Israel (1996 to 2000).

The S1 genes of isolates of avian coronavirus infectious bronchitis virus (IBV) from commercial chickens in the US and Israel (20 isolates from each country) were studied using reverse transcription-polymerase chain reaction restriction fragment length polymorphism and sequencing. Partial sequences spanning the amino terminus region of S1 from amino acid residues 48 to 219, based on the Beaudette strain, were used for analysis. Phylogenetic clustering and high-sequence identity values were used to identify isolates that appeared to be derived from live IBV vaccines used in the two countries. Novel variant strains, unrelated by S1 sequencing and restriction fragment length polymorphism analyses to reference and vaccine strains, were also identified. Based on S1 sequence identity to available vaccines, the potential to use vaccination to control IBV infections was evaluated. Vaccination with commercial live strains Massachusetts (Mass), Arkansas (Ark) or DE/072/92, generally produced immunity against vaccine-related field isolates displaying high S1 sequence similarities (> or = 90%) to the respective vaccine strains. Immunization with a bivalent vaccine containing the Mass and Ark strains provided good cross-protection, averaging 81% against challenge with five variant isolates from the US having amino acid identity values ranging from 62 to 69% to Mass and from 68 to 83% to Ark, respectively. In contrast, the H120 vaccine strain induced low levels of protection, ranging from 25 to 58% against variant field isolates from Israel with amino acid identity values from 65 to 67%.

Differentiation of cultured mice bone marrow into osteoblast-like cells results in acquisition of sex-specific responsiveness to gonadal steroids.

We have previously demonstrated that mouse skeletal tissue, rat bone as well as rat or human derived bone cells in culture, show a sex-specific response to gonadal steroids in stimulation of the specific activity of the BB isozyme of creatine kinase (CK). This response could be modified by manipulation of the endocrine environment during early postnatal development. Moreover, pretreatment with vitamin D up-regulated the sex-specific responsiveness and sensitivity to gonadal steroids. In the present study we examine the differentiation pattern into osteoblast-like cells using dexamethasone (DEX) and 1,25 dihydroxy vitamin D3 (1,25D) and their effect on the acquisition of responsiveness to gonadal steroids by the differentiated cells. Cultured femoral bone marrow in the presence of DEX or 1,25D or both, were examined for their response to gonadal steroids by measuring the specific activities of alkaline phosphatase (AP) and CK BB. The constitutive level of CK in both male- and female-derived bone cells was decreased by DEX, by 1,25D or by both, whereas the constitutive level of AP was increased by DEX while decreased by 1,25D or by both. Following incubation of the bone marrow cultures with DEX, treatment with estradiol 17beta (E2, 30 nM, 24 h) stimulated CK activity in female derived bone cells, with no effect of treatment with dihydrotestosterone (DHT, 300 nM). In contrast, in male derived bone cells, DHT but not E2 increased CK activity. This sex-specific response was also achieved upon culturing with 1,25D and was significantly augmented by culturing with both. No response to gonadal steroids was seen with undifferentiated bone marrow cells. All cultures responded to IGF-I when cultured with or without DEX and/or 1,25D but with no augmentation by 1,25D. Gonadal steroids increased AP to a much lesser extent; but enzyme activity decreased in the presence of 1,25D. IGF-I stimulated AP slightly with no effect of 1,25D. These findings suggest that manipulation of the hormonal milieu in early stages of differentiation sequence of osteoblast-like cells, determines the subsequent selective responsiveness of the developing bone tissue to gonadal steroids.

A low-dose adrenocorticotropin test reveals impaired adrenal function in cancer patients receiving megestrol acetate therapy.

Megestrol acetate (MA) has glucocorticoid activity and can induce significant secondary adrenal suppression. We designed this study to determine the extent of adrenal insufficiency in cancer patients receiving MA by utilising a sensitive low-dose adrenocorticotropin (ACTH) stimulation test. Adrenal function was assessed by a low-dose (0.625 microg) ACTH (1-24) stimulation test in 30 patients receiving MA for metastatic cancer. 10 of the patients who failed this test underwent a standard (250 microg) test on another day. Adrenal function was also evaluated in 15 of the patients by measuring the excretion of free cortisol in 24-h urine samples. Peak serum cortisol levels following stimulation with low-dose (0.625 microg) ACTH (1-24) were <18 microg/dl in 16 of 30 (53%) patients, of whom 9 had a basal serum cortisol level of <5 microg/dl. Five of 16 poor responders to the low-dose test showed normal stimulation with the standard (250 microg) ACTH (1-24) test. Thus, adrenal insufficiency would fail to be detected by the standard high dose test in these patients. Patients who failed the low-dose ACTH (1-24) test had lower 24-h urinary free cortisol excretion (8.7+/-10.3 microg/24 h) than normal responders (35+/-12.7 microg/24 h). Impaired adrenal function is common in cancer patients receiving MA. The low-dose ACTH (1-24) test is apparently capable of revealing adrenal insufficiency undetected by the standard high-dose ACTH test. Patients receiving MA might have inadequate adrenal function during episodes of infection or after withdrawal of MA therapy and this may require prompt corticosteroid treatment.

Antigenic heterogeneity amongst the field isolates of Newcastle Disease Virus (NDV) in relation to the vaccine strain. Part II: studies on viruses isolated from domestic birds in Israel.

Forty three Newcastle disease virus (NDV) strains isolated before and during 1997 in Israel from domestic birds were studied by means of the three panels of monoclonal antibodies prepared against all the viral envelope proteins in order to reveal the possible antigenic differences between them and the VH strain used in Israel for poultry vaccination. Three isolates were found to have significant antigenic differences in the hemagglutinin-neuraminidase (HN) and fusion (F) glycoproteins as compared to the vaccine strain. As to the matrix protein, almost all the viruses isolated during the year 1997 were found to have considerable differences from the vaccine strain in two of four antigenic sites.

Marek's disease in turkeys. I. A seven-year survey of commercial flocks and experimental infection using two field isolates.

Marek's disease virus (MDV) causes immunosuppression and tumors in chickens, but the turkey is an unusual host for the virus, and tumors caused by MDV in turkeys are unique. We describe the prevalence of turkey tumors in Israel between 1993 and 2000, their molecular diagnosis by polymerase chain reaction (PCR), and the natural distribution of herpesvirus of turkeys (HVT). Most clinical cases with tumors in commercial turkeys were diagnosed as MDV. The reproduction of Marek's disease (MD) in turkeys by two turkey MDV strains, Ar and La, was analyzed, and it was shown that these strains can induce tumors in experimental trials. The severity of experimental disease differed from those features of the original outbreak, since a less severe disease was recorded.

Marek's disease in turkeys. II. Characterization of the viral glycoprotein B gene and antigen of a turkey strain of Marek's disease virus.

Marek's disease virus (MDV) causes immunosuppression and tumors in chickens. As sporadic cases of Marek's disease (MD) were recorded in turkeys, the antigenic and genomic characteristics of the MDV glycoprotein B (gB) gene and antigen of turkeys were compared to the chicken MDV gB. The whole chicken and turkey gB genes were sequenced and found identical. By immunoblotting of infected-cell culture lysates using chicken convalescent and gB monoclonal antibodies, the antigenic epitopes of the chicken and turkey viruses were found to differ. The turkey MDV had a unique epitope, compared to the chicken MDV and compared with our previous findings. While the chicken MDV had two epitope types, heat-labile but dithiothreitol (DTT)-stable and heat-stable but DTT-labile, the turkey MDV gB epitope is both heat and DTT-labile.

Molecular identification of the Marek's disease virus vaccine strain CVI988 in vaccinated chickens.

The study describes three polymerase chain reaction (PCR) systems for the CVI988 vaccine virus: the meq gene, the MDV BamHI-D/H 132 bp tandem repeat fragment and the MDV-gB gene. Whereas the PCR product of virulent MDV strains and of the CVI988 virus strain with the meq and the 132 bp primer sets differed for the two templates, the MDV-gB PCR products were similar. The sensitivity of the three PCRs was determined for the two templates: the CVI988 DNA was detected up to 2.48 plaque forming units, and a MDV-1 DNA, was amplified with the 132 bp primers up to the 10(-3) DNA dilution, and up to the 10(-2) with the MDV-gB and meq gene primers. As conventional detection for the CVI988 vaccine virus is by tissue culture, the aim was to analyse the feasibility of the molecular detection of the vaccine virus in the vaccinated chick. In two experimental trials employing specific pathogen free and commercial Lohmann chicks, respectively, the vaccine virus replicated to a limited extent; it was detected only in the spleen of up to 60% chicks at 2-4 weeks and in one chick at 3 weeks, respectively. The survey of three commercial Lohmann flocks, kept in biosecurity conditions, revealed the vaccine virus only in the spleen of 40% of 30-day-old chicks. The present study shows that CV1988 DNA is present in vaccinated chicks in a low quantity and it is difficult to detect directly from the chick, probably because vaccine viruses are latent in vivo. For an efficient detection it is pertinent to cultivate the vaccine virus on chicken embryo fibroblasts (CEF), as then the virus escapes the latent state, enters into the productive mode of replication, and a high viral copy number is produced.

Antigenic heterogeneity among the field isolates of Newcastle disease virus (NDV) in relation to the vaccine strain: 1. Studies on viruses isolated from wild birds in Israel.

In order to reveal the viruses strongly differing from the VH NDV strain used in Israel for poultry vaccination, 54 NDV strains isolated during the last 15 years in Israel from feral birds were studied by means of the panels of 39 monoclonal antibodies. Six isolates were found to have considerable antigenic differences in envelope proteins as compared to the vaccine strain. In four cases, the differences were related mostly to the hemagglutinin-neuraminidase glycoprotein, in one case to the fusion glycoprotein, and in one case to the matrix protein.

Sudden death of a bearded vulture (Gypaetus barbatus) possibly caused by Newcastle disease virus.

An adult female bearded vulture (Gypaetus barbatus) in the Tel Aviv University Research Zoo was found dead without previous clinical signs. The predominant pathologic changes were considerable bloody content in the intestines and enlargement of the liver, which had a rubbery consistency with color changes. Microscopic lesions consisted of multifocal histiocytic infiltration in the liver. Newcastle disease virus (NDV) was isolated from a cloacal swab and from the lungs and liver. Intracerebral pathogenicity index of the virus, as estimated in 1-day-old chicks, was repeated three times and had an average value of 1.68, indicating a velogenic strain. Numerous Clostridium septicum bacteria were found on the intestinal surface, but bioassays in which they were orally administered into chickens and mice revealed that, even though they were heavily multiplied in the intestines, they were nonpathogenic. It seems that NDV, documented for the first time in a bearded vulture in Israel, was the likely cause of sudden death.

Benign occipital epilepsy mimicking a catastrophic intracranial event.

OBJECTIVE: To describe the rare, dramatic, presentation of benign occipital epilepsy. METHODS: We describe three children who presented to the pediatric emergency department from 1992 to 1996 with a clinical picture of catastrophic intracranial event. RESULTS: The main signs and symptoms were loss of consciousness in all patients, apnea in two, hemiclonus in two, general hypertonicity in two, eye deviation in two, fixed dilated pupils in one, and decorticate rigidity in two. All underwent emergency intubation, brain scan, and lumbar puncture, and all were treated with antibiotics, in addition to antiviral drugs in two. Two patients were also treated for suspected increased intracranial pressure. Two patients recovered within a few hours and one within 24 hours of admission without any residual neurologic deficit. Electroencephalograms, done within 48 hours after the event, revealed the classic pattern of occipital epilepsy in two patients and bilateral occipital slow wave in one. A 3- to 5-year clinical and electroencephalographic follow-up supported the diagnosis. CONCLUSION: Benign occipital epilepsy in children can mimic a catastrophic intracranial event. Electroencephalography, performed early in the Pediatric Intensive Care Unit, may avoid or shorten unnecessary and aggressive treatments such as hyperventilation, diuretic agents, and prolonged antiviral therapy.

Vitamin D deficiency and insufficiency in Orthodox and non-Orthodox Jewish mothers in Israel.

BACKGROUND: The modest clothing that Orthodox Jewish women wear exposes very little of their skin to sunlight. Under these conditions they may develop vitamin D deficiency, even in sunny Israel. OBJECTIVES: To determine and compare the vitamin D nutritional status in Jewish orthodox mothers to that of non-orthodox mothers who live in the same metropolitan area in Israel. METHODS: 25-Hydroxyvitamin D was measured by competitive protein-binding radioassay in the sera of 341 Jewish Israeli mothers (156 orthodox and 185 non-orthodox). The sera were obtained 48-72 hours after childbirth during the late summer of 1998 and the spring of 1999. RESULTS: The mean (SD) serum concentration of 25-OHD was significantly (P < 0.002) lower (13.5 +/- 7.5 ng/ml) in the orthodox than in the non-orthodox mothers (18.6 +/- 9.6 ng/ml). Vitamin D deficiency (< 5 ng/ml) and insufficiency (< 10 ng/ml) were more common in the orthodox mothers (5.1% and 32.7% respectively) than in the non-orthodox mothers (2.7% and 13%, respectively). In subgroups of mothers supplemented with 400 units of vitamin D daily during pregnancy, vitamin D deficiency and insufficiency were less common (2.2% and 13%, respectively) in orthodox and non-orthodox mothers (0% and 8.1%, respectively). Vitamin D insufficiency was more common in the winter than in the summer only among non-orthodox mothers. CONCLUSIONS: The high prevalence of vitamin D deficiency and insufficiency in Israeli mothers raises the question whether vitamin D supplements should be given to pregnant women in Israel, at least to orthodox mothers.

Physicians' attitudes towards patients' rights legislation.

Patients' rights laws, bills and charters aim at delineating the patient-physician relationship in regard to consent to medical treatment, confidentiality and related issues. The need to shape such an intimate relationship by way of legislation seems anomalous to some, but imperative to others. We present for the first time an insight into Israeli physicians' attitudes towards Israel's patients' rights laws, in a changing medical and socio-legal environment. The research results suggest that physicians are reluctant to participate in the implementation of such laws, demonstrated by the level of their misunderstanding of the law's norms and regulations, and subjective attitudes and perceptions. In order to ensure the medical community's participation in augmenting patients' rights, efforts should focus on improved legal and ethical education, enhanced cooperation of professional associations and joint action with legislators to assure a productive composition of these important acts.

The role of the vitamin D receptor in regulating vitamin D metabolism: a study of vitamin D-dependent rickets, type II.

In vitro studies and animal experiments suggest that the production of 1,25-dihydroxyvitamin D [1,25-(OH)(2)D] and 24,25-(OH)(2)D is reciprocally controlled by 1,25-(OH)(2)D. To investigate the role of the vitamin D receptor (VDR) in controlling vitamin D metabolism in humans, we studied 10 patients with vitamin D-dependent rickets type II due to a defective VDR. After a period of high dose calcium therapy, 7 of the patients had normal serum calcium, phosphorus, alkaline phosphatase, and plasma PTH levels (PTH-N), and 3 showed increased serum alkaline phosphatase and plasma PTH (PTH-H). Serum calcium, phosphorus, alkaline phosphatase, PTH, vitamin D metabolites, urinary calcium/creatinine, and renal phosphate threshold concentration were compared with unaffected family members that comprised the control group. Vitamin D metabolites were measured before and after an oral load of 50,000 U/m(2) cholecalciferol. Compared with the control group, 1,25-(OH)(2)D levels were significantly higher and 24,25-(OH)(2)D levels were lower in the PTH-N group and even more so in the PTH-H group. 1alpha-Hydroxylase (1-OHase) and 24-OHase activities were estimated by the product/substrate ratio. In the PTH-N group, 1-OHase activity was higher and 24-OHase activity was lower than in controls. In the PTH-H group, 1-OHase activity was even higher, probably due to an additive effect of PTH. Thus, 1,25-(OH)(2)D-liganded VDR is a major control mechanism for vitamin D metabolism, and PTH exerts an additive effect. Assessment of the influence of 1,25-(OH)(2)D shows reciprocal control of enzyme activity in man, suppressing 1-OHase and stimulating 24-OHase activity.

The hormonal milieu in early stages of bone cell differentiation modifies the subsequent sex-specific responsiveness of the developing bone to gonadal steroids.

We have established previously that rat bone tissue, as well as rat and human-derived bone cells in culture, show a sex-specific response to gonadal steroids in stimulation of the specific activity of the BB isozyme of creatine kinase (CK) and DNA synthesis. This response could be modified by manipulation of the endocrine environment during early stages in rat development. To further examine the influence of changing hormonal steroid milieu and vitamin D status on the action of gonadal steroids in developing bone tissue, we used two models of ectopic bone formation: demineralized tooth matrix (DTM) implanted under the skin, and femoral bone marrow (BM) transplanted under the kidney capsule of a syngeneic recipient mouse. The response to gonadal steroids in ossicles developed from implanted DTM depended on the recipient's gender; injection of estradiol 17beta (E2; 5 microg) into young female mice 21 days after DTM implantation increased, 24 h later, CK activity in the newly formed ossicles by approximately 60%, whereas injection of dihydrotestosterone (DHT; 50 microg) had no effect on CK activity. In contrast, in male mice, DHT but not E2 increased CK activity in the ossicles by approximately 50%. This sex-specific response was abolished in gonadectomized mice resulting in a similar response of the ossicles to both E2 and DHT. When DTM was implanted into vitamin D- deficient female mice, there was a lower basal CK activity and a significantly diminished response to E2 in the newly formed bone tissues. When BM, which contains mesenchymal and stromal cells and committed osteoprogenitor cells, was transplanted into 6-week-old intact or gonadectomized female or male mice, the response of the newly formed bone ossicles, 21 days after transplantation, to E2 or to DHT was according to the gender of the donor. Bone formed from BM obtained from female mice responded to E2 only and those formed from male BM responded to DHT only. Ossicles developed from BM obtained from gonadectomized mice showed lack of response to either gonadal steroid. Furthermore, only approximately 25% of the BM transplants obtained from castrated (CAST) male donors developed into ossicles. Ossicles formed from BM obtained from vitamin D-deficient female donors showed lack of response to gonadal steroids. These findings suggest that the manipulation of the hormonal milieu in early stages of the differentiation sequence of bone cells modifies the subsequent selective responsiveness of the developing bone tissue to gonadal steroids.

Molecular typing of infectious bursal disease virus of Israeli field and vaccine strains by the reverse transcription/polymerase chain reaction/restriction fragment length polymorphism assay.

Infectious bursal disease viruses (IBDVs) were examined by testing bursa samples from 37 commercially reared chicken flocks and three vaccine strains by the reverse transcription (RT)/polymerase chain reaction (PCR)/restriction fragment length polymorphism assay (RFLP). The assay was conducted with a 717-bp fragment of the VP2 gene with the restriction enzymes BstNI and MboI. The presence of a restriction site for SspI was used to predict a very virulent phenotype. Results indicated the existence of two molecular groups within the field isolates; four samples showed one pattern of RFLPs, and the majority, 30 out of the 37 tested, showed a second RFLP pattern. Three samples tested negative for IBDV. Eight bursa samples, representing the two molecular groups, were also tested by the RT/PCR/RFLP assay as developed by Jackwood. A comparison of the RFLP profiles by the two methods indicated that four isolates belonged to molecular group 6 and 30 isolates belonged to a new molecular group. All field isolates had a very virulent phenotype. One vaccine strain, produced from a local isolate, was classified as molecular group 6. The other two vaccine strains had RFLPs that differed from those of the field isolates.

The comparative antigenic characterization of Newcastle disease virus strains isolated in Kenya and Kazakhstan.

Twenty six Newcastle disease viruses--12 reference strains and 14 strains isolated in Kenya and Kazakhstan--were characterized by means of a large panel of 38 monoclonal antibodies (MAB) directed against all the three envelope proteins: matrix, hemagglutinin-neuraminidase and fusion. The essential distinctions were revealed between the viruses isolated in Kenya and Kazakhstan while the differences amongst the viruses belonging to the same local group were much smaller. The heterogeneity amongst the viruses isolated in Kenya was more expressed as compared to the Kazakhstanian strains.