A randomized clinical trial comparing oral alendronate and intravenous pamidronate for the treatment of Paget's disease of bone.

Second and third generation bisphosphonates are the treatment of choice for Paget's disease of bone. These drugs are more effective than calcitonin and etidronate, but there have been no head to head, randomized controlled trials comparing potent bisphosphonates. We conducted a 2-year, randomized, open-label trial comparing oral alendronate and intravenous pamidronate in 72 subjects with Paget's disease. Randomization was stratified according to baseline plasma total alkaline phosphatase (ALP) and previous bisphosphonate treatment (yes or no). All previously treated patients had received pamidronate but not alendronate. Assigned treatments were pamidronate (60 mg) every 3 months as a single infusion or alendronate (40 mg) daily in 3-month blocks, continued until biochemical remission (defined as both ALP and urine deoxypyridinoline (DPD)/creatinine ratio in the reference range) or a clear plateau effect was observed. At 1 year, nonresponders to pamidronate were crossed over to alendronate treatment. At 1 year, 31/36 (86%) subjects randomized to alendronate achieved biochemical remission compared with 21/36 (56%) for pamidronate (P = 0.017). There was a significantly greater reduction in ALP (P < 0.001) and DPD/creatinine ratio (P < 0.001) for alendronate compared with pamidronate treatment. In previously untreated patients, alendronate resulted in remission in 20/22 (91%) subjects compared with 19/22 (86%) of pamidronate-treated subjects, which was not significantly different; however, alendronate resulted in a significantly greater reduction in ALP (P = 0.014) and DPD/creatinine ratio (P < 0.001). In previously treated patients, alendronate resulted in remission in 11/14 (79%) subjects compared with 2/14 (14%) for pamidronate (P < 0.001), with a significantly (P < 0.001) greater reduction in both ALP and DPD/creatinine ratio. Of subjects crossed over from pamidronate to alendronate, 10/14 (71%) achieved remission, including 9/11 (82%) previously treated patients. We conclude that, in patients with previously untreated Paget's disease of bone, alendronate and pamidronate have similar efficacy in achieving biochemical remission. In patients previously treated with pamidronate, alendronate is more effective.

A randomized trial comparing hormone replacement therapy (HRT) and HRT plus calcitriol in the treatment of postmenopausal osteoporosis with vertebral fractures: benefit of the combination on total body and hip density.

We report a prospective, randomized, multicenter, open-label 2-year trial of 81 postmenopausal women aged 53-79 years with at least one minimal-trauma vertebral fracture (VF) and low (T-score below - 2) lumbar bone mineral density (BMD). Group HRT received piperazine estrone sulfate (PES) 0.625 - 1.25 mg/d +/- medroxyprogesterone acetate (MPA) 2.5 - 5 mg/d; group HRT/D received HRT plus calcitriol 0.25 microg bd. All with a baseline dietary calcium (Ca) of < 1 g/ d received Ca carbonate 0.6 g nocte. Final data were on 66 - 70 patients. On HRT/D, significant (P < 0.001) BMD increases from baseline by DXA were at total body - head, trochanter, Ward's, total hip, intertrochanter and femoral shaft (% group mean delta 4.2, 6.1, 9.3, 3.7, 3.3 and 3.3%, respectively). On HRT, at these 6 sites, significant deltaS were restricted to the trochanter and Wards. Significant advantages of HRT/D over HRT were in BMD of total body (- head), total hip and trochanter (all P = 0.01). The differences in mean delta at these sites were 1.3, 2.6 and 3.9%. At the following, both groups improved significantly -lumbar spine (AP and lateral), forearm shaft and ultradistal tibia/fibula. The weightbearing, site - specific benefits of the combination associated with significant suppression of parathyroid hormone-suggest a beneficial effect on cortical bone. Suppression of bone turnover was significantly greater on HRT/D (serum osteocalcin P = 0.024 and urinary hydroxyproline/creatinine ratio P = 0.035). There was no significant difference in the number of patients who developed fresh VFs during the trial (HRT 8/36, 22%; HRT/D 4/34, 12% - intention to treat); likewise in the number who developed incident nonvertebral fractures. This is the first study comparing the 2 treatments in a fracture population. The results indicate a significant benefit of calcitriol combined with HRT on total body BMD and on BMD at the hip, the major site of osteoporotic fracture.

Acute pulmonary embolism: diagnosis with MR angiography.

PURPOSE: To prospectively evaluate pulmonary magnetic (MR) angiography as a diagnostic examination for acute pulmonary embolism (PE). MATERIALS AND METHODS: Thirty-six consecutive patients (19 women, 17 men; age range, 28-84 years) underwent pulmonary digital subtraction angiography (DSA) and pulmonary MR angiography. MR angiograms were obtained during suspended respiration and the pulmonary arterial phase of gadolinium-based contrast medium injection. A steady-state gradient-recalled-echo sequence with free induction decay sampling was used. DSA studies were interpreted for the presence of acute PE by two independent radiologists; an adjudicator made the final decision on discordant interpretations. RESULTS: By using DSA, a total of 19 acute pulmonary emboli were depicted in 13 patients. Prospectively, 13 of these emboli were depicted by using MR angiography. MR angiography missed six emboli: Four required the DSA adjudicator to make the decision, and one was in a patient whose MR angiogram was acquired during breathing. Four of these six emboli were small subsegmental emboli, and two were segmental. CONCLUSION: Performed without pulmonary arterial catheterization, iodinated contrast media, or ionizing radiation, pulmonary MR angiography had a high accuracy for depicting lobar and segmental emboli, but was unable to depict four of five subsegmental emboli.

Mechanical and other problems of artificial valves.

This chapter has discussed the design, development, laboratory testing and clinical performance of artificial heart valve replacements. The published material on this subject is extensive and clearly this present chapter represents only a limited selection of the many topics and researchers associated with the production of clinically implantable valves. Any omissions should not be regarded as a criticism, but simply the result of economy of space. The field is still developing and the situation regarding the advantages and disadvantages of the various types of valves as illustrated in Table 3 still obtains notwithstanding the many improvements which have been made with current designs. Valve development is, and will continue to be, closely allied to advances in our understanding of the behaviour of the materials of construction. Ultimately, improved haemodynamic performances of the various valve configurations will result from designs based on data from computerised fluid dynamic analysis combined with finite element stress analysis according to recognised engineering design principles.

Valve data collection: problems and pitfalls.

Since 1981, the Department of Medical Physics and Clinical Engineering at the University of Sheffield has been responsible for the organization, management and data collection associated with the largest multicentre heart valve implant patient follow-up study in the Western world. At the present time, the database comprises information on over 16,000 valve implants, which have been provided by 57 surgeons working at 22 centres in the UK. All this data is available for in-depth statistical analysis. Over 30 individual valve models presently are included in the Study and these can be categorized into five main types: ball, disc, porcine, pericardial and homograft. Analysis includes descriptive statistics as well as valuable information on the various performances of the different valves. Survival and event-free survival graphs are obtained by actuarial methods and individual valve types can be studied in depth in terms of freedom from thromboembolic complications and valve dysfunction. Whilst this approach provides interesting and valuable survival data, it does not take account of the wide variation in prognostic factors which occur within large groups of patients. This latter problem can be addressed by the use of proportional hazards analysis and this paper provides details of this approach and typical results obtained from the use of this method. These include the comparative performances of the major types of valves currently in use in terms of the event-free survival of the patients.

Thirteen years evaluation of the Bjork-Shiley isolated mitral valve prosthesis. The Wessex experience.

Between 1973 and 1985, 349 patients had isolated mitral valve replacement by a Bjork-Shiley prosthesis with an overall early (30 day) mortality of 5.1%. Of the 331 survivors, 294 patients have been traced and their clinical outcome was followed for up to 13 years in order to define the long term performance of the mitral Bjork-Shiley models MBRP-standard, MBRC-convexo concave and MMSM-monostrut. Cumulative follow-up extends to 6620 patient years (mean 5.75 years). The MBRP valve was implanted in 236 patients, the MBRC valve used in 44 patients and the MMSM valve inserted in 14 patients. The late mortality and morbidity was 0.8% and 0.6% per patient year at 13 years respectively. Actuarial survival rate for the whole group excluding operative deaths was 85% at 5 years, 66% at 10 years and 58.5% at 13 years. The freedom from all valve related complications at 13 years was 70.75%. Bjork-Shiley models MBRP, MBRC and MMSM mitral valve prosthesis show excellent durability with only one case of mechanical failure over a 13 year period.

Breast-milk fatty acids of rural Gambian mothers: effects of diet and maternal parity.

The influence of diet and maternal parity on the fatty acid composition of mature breast milk have been studied in 23 rural Gambian mothers. The subjects' habitual diet was low in fat (16% total energy), groundnuts (peanuts) constituting the principal fat source. The high abundance of oleic and linoleic acids in groundnut fat were reflected in the proportions of these fatty acids in breast milk (47.0 +/- 1.5 and 13.0 +/- 0.3 g/100 g fat, respectively), which were elevated compared with mothers in other African communities. Estimates of daily breast-milk fatty acid secretion indicated that there was little risk of essential fatty acid deficiency in Gambian infants. The proportions of fatty acids synthesized de novo (10:0, 12:0, 14:0) were less than expected from published studies of mothers consuming low-fat diets, averaging 16.8 +/- 1.4 g/100 g fat. As the study was conducted at a time of food shortage and high energy expenditure, it is argued that mobilisation of body fat during negative energy balance increased the availability of long-chain fatty acids to the breast. The proportion of endogenous fatty acids was markedly reduced in the milk of mothers of very high parity (parity 1 = 19.3 +/- 1.6 g/100 g fat; parities 10 + = 11.4 +/- 1.5 g/100 g fat; p less than 0.01). It is hypothesised that this represents an impairment of the ability to synthesise breast-milk fatty acids de novo in these mothers.

Aluminium and fluoride in the water supply and their removal for haemodialysis.

Aluminium and fluoride in the water supply and their removal for haemodialysis have been investigated in the Trent Region, U.K., and wide variations noted. The efficiency of removal of these elements from the mains water supplying home haemodialysis units by different water treatment systems currently installed has been assessed and a follow-up study performed 8 months later. Some improvement in water treatment was noted, with the percentage of home dialysis units receiving waters within the proposed European Economic Community guidelines for aluminium rising from 61.7 to 72.1%. Removal of fluoride by the different treatment mechanisms is analogous to that for aluminium. A comparison of new and older water treatment systems has shown that there is a deterioration in performance with use. However, some cases of poor removal may be due to the installation of unsuitable equipment, or, more probably, due to a change in the waters used to supply the different homes. Thus, adequate maintenance of equipment and frequent sampling of both untreated and treated waters are required in order to maintain the provision of waters suitable for the preparation of dialysate.

In vivo incorporation of labeled fatty acids in rat liver lipids after oral administration.

Striking differences were found in the compartmentalization of fatty acids into liver lipid fractions. The saturated fatty acids--lauric, myristic, palmitic and stearic--were incorporated into phosphoglycerides at faster rates with increasing chain lengths, while triglyceride incorporation was almost uniform. The degree of incorporation of the unsaturated fatty acids into phosphoglycerides (structural) compared to triglyceride (storage and energy) was the converse of their oxidation rates. The incorporation of oleic, linoleic and alpha-linolenic acids was mainly into triglyceride, whereas dihomo-gamma-linolenic acid and arachidonic acid were preferentially incorporated into phosphoglycerides. The data suggest that distribution of each fatty acid is different depending on its destination for structural or energy function.

Interaction of adrenaline with neostigmine and tubocurarine at the skeletal neuromuscular junction.

The effects of neostigmine, and of neostigmine with adrenaline, on the response of the rat isolated hemidiaphragm to stimulation of the phrenic nerve are reported. Neostigmine augmented the response: a maximum augmentation occurred at a concentration of 6.4 X 10(-7) mol litre-1. At greater concentrations of neostigmine the response was reduced. Adrenaline in the absence of neostigmine produced no significant change in the contraction response. However, in the presence of neostigmine further augmentation occurred and achieved a maximum in the presence of adrenaline 3.2 X 10(-7)-1.3 X 10(-6) mol litre-1. Adrenaline 4.0 X 10(-8)-1.3 X 10(-6) mol litre-1 combined with neostigmine 4.0 X 10(-8)-6.4 X 10(-7) mol litre-1 reversed tubocurarine-induced neuromuscular blockade more effectively than neostigmine alone (P less than 0.001). Adrenaline appeared to enhance the antagonistic effect of neostigmine by increasing acetylcholine release and by enhancing the response at the post-junctional acetylcholine receptor.

Differential oxidation of saturated and unsaturated fatty acids in vivo in the rat.

The oxidation rates of lauric, myristic, palmitic, stearic, oleic, alpha-linolenic, linoleic, kappa-linolenic, dihomo-gamma-linolenic and arachidonic acids were studied by use of a radioisotope tracer technique in weanling rats at rest in a metabolism chamber over 24 h. Of the saturated fatty acids, lauric acid (12:0) was the most efficient energy substrate: the longer the chain length of the saturated fatty acids, the slower the rate of oxidation. Oleic acid (18:1) was oxidized at a remarkably fast rate, similar to that of lauric acid. Of the omega 6 essential fatty acids studied, linoleic acid (18:2 omega 6) was oxidized at a faster rate than any of its metabolites, with arachidonic acid (20:4 omega 6) being oxidized at the slowest rate. The rate of oxidation of gamma-linolenic acid (18:3 omega 3) was almost as fast as that of lauric and oleic acids.

Food intakes of children, the DHSS, and the prevention of heart disease.

The DHSS recently reported on school children's food intakes (1). Although the type of fat eaten is clearly an important issue, the DHSS study did not analyse the fat intake for its saturated and essential fatty acid content. We have explored the intakes of the children for fibre, sugar and saturated fats as well as additional vitamins and trace elements, not reported by the DHSS. The data from the DHSS survey was presented as a summary of the main food types eaten. They aggregated some food groups e.g. meat and meat products, fish and fish products, cakes and biscuits. While this approach might make little difference to protein intakes, it may be expected to make a difference to fat and essential fatty acid intakes. We have re-analyzed the childrens food intakes keeping within the confines of the food groups reported. We had to rely on certain assumptions about the nature of an 'average' diet; we therefore explored the possibility that our assumption of an average diet was incorrect and examined a worse and a better situation to define how much the nutrient intake varied. The result of the analyses illustrate an important principle in the context of the present concern for food and health. The only way in which we could satisfy NACNE and COMA recommendations for fat, saturated fat, fibre and sugar, without a radical change in eating habits, was by simply replacing half the 'junk' foods by an isocaloric amount of fresh fruit and vegetables. In addition there was a marked improvement in the intakes fo beta-carotene, vitamin C, B6 and folic acid. These improvements in diet are of particular importance to children as it is well known that the period most vulnerable to nutritional distortions is during growth and development. No matter which way we looked at the data is clear that not only are the school children's diets unsatisfactory from the view point of prevention of cardiovascular disease in later life but they also leave much to be desired from the view point of the wide range of nutrients known to be important for general health, growth and development. If this is true for the mean values obtained, it will be even more true for the 'high risk groups'.

Aluminium release from the Sorbsystem D-3160 and D-3260 cartridges.

Recent clinical information indicates that the aluminium level of patients' serum can rise while they are being treated with the Sorbsystem haemodialysis system. Further evidence suggests that the quality of aluminium removed from the dialysing fluid by the sorbent cartridge utilized in this equipment is time-dependent. Evaluation of the sorbent cartridges D-3160 and D-3260 has shown that ultimately aluminium is satisfactorily removed from the dialysing fluid. However, the time taken to achieve the safe condition of less than 30 micrograms/litre of aluminium is dependent on the quantity of aluminium washed out from a new cartridge before being reabsorbed, and the highly variable quantity contained in the diluting water. The results have also shown that the level of aluminium recommended by the DHSS in April 1982 (30 micrograms/litre) is not reliably attained following the manufacturer's recommended pretreatment, and a further 60 min of operation in the 'dialyse' mode is necessary. It should be noted that, as a result of evaluation of the Sorbsystem, the DHSS have issued guidelines on the use of this equipment.

An investigation on the influence of steroidal contraceptives on milk lipid and fatty acids in Hungary and Thailand. WHO Special Programme of Research, Development and Research Training in Human Reproduction. Task Force on oral contraceptives.

A double-blind clinical trial to examine the effects of oral and long-acting injectable contraceptive steroids on milk lipid and its fatty acid content has been done in Szeged, Hungary, and Khon-Kaen, Thailand. In Szeged, a combined and a progestin-only pill did not significantly alter total milk lipid. In Khon-Kaen, treatment with the combined pill was followed by a significant increase in the proportion of milk lipid. In the group treated with the long-acting injectable contraceptive, depot-medroxyprogesterone acetate (DMPA), the milk lipid decreased significantly in the first six weeks in comparison with the control group and the individual pretreatment values. A similar but weaker effect was noticed with the progestin-only pill in Khon-Kaen. Few consistently significant differences were found in the shorter chain fatty acids (myristic, lauric and palmitic acids) during treatment. The percentage proportions were increased during the combined pill treatment in Szeged and Khon-Kaen, and reduced in DMPA and progestin-only treatment in Khon-Kaen milks. The possibility that these reflected a response to a milk volume decrease in the combined pill treatment and a reduction in milk lipid synthesis in association with DMPA and the progestin-only pill is discussed. In Khon-Kaen, linoleic acid (which is not synthesized in the body) was increased by comparison with the controls, as a percentage proportion of the fatty acids in the progestin-only and DMPA groups. Calculation of the amounts of linoleic acid per litre of milk revealed that there had been a significant decrease of linoleic, eicosadienoic, dihommo-gamma-linolenic, arachidonic, docosatetraenoic acids in the w6 family and alpha-linolenic acid in the w3 family in the first two post-treatment visits (3 and 4). This reduction in essential fatty acid output follows the reduction in milk volume. In Khon-Kaen, the combined pill group showed a significant decrease compared with the controls, in the proportions of dihommo-gamma-linolenic acid. The difference in response of the mothers in Khon-Kaen and Szeged is discussed in relation to their different nutritional backgrounds.

A review of, and improvements to, the techniques of trace element analysis of raw water for home dialysis.

The optimum operating conditions for the measurement of aluminium and iron concentrations in water by atomic absorption spectrometry have been determined experimentally. The characteristics of an ion-selective electrode for the measurement of fluoride have also been investigated. Contrary to other work, the addition of acid to samples did not improve their storage stability, although the acid-washing of polyethylene containers is recommended for the storage of water.