Graves' disease in the Inuit population of Greenland. Presentation of five cases observed during a two month period

Thyroid hormones are important for metabolic regulation. A number of studies have dealt with the effect of arctic living on thyroid hormone secretion and metabolism in healthy animals and humans. Little is however known of the effect of arctic living on the occurrence of thyroid diseases. In a study from Upernavik, Greenland no cases of hyperthyroidism were observed over the 25 years period from 1950 to 1974. We present five cases of hyperthyroidism due to Graves' disease observed during a two month period in Nuuk Greenland. The discrepancy could be due to improved diagnostic methods and activity or to a real increase in incidence. Systematic studies of thyroid disorders in Greenland are warranted.

Patient perspective and self-help

Effective adaptation to PD demands that patients and their caregivers elaborate coping strategies that empower them and promote a more salutary orientation to formidable psychosocial difficulties and thus, perhaps, blunt or prevent depressive responses. Patients and their loved ones should be encouraged to seize the initiative in terms of promoting an acceptable life-style: in short, "breaking through" rather than "breaking down." The notion of a "healthy" PD patient is not necessarily a contradiction in terms if the patient and family can be encouraged to view organic disease as a learning opportunity, continuing to find meaning in life despite the inevitable threats to identity posed by PD (e.g., loss of work). PD patients and their families may benefit by grieving (over a finite interval) or observing other rituals associated with universal life changes. These adaptive processes should be promoted in the context of a trusting physician-patient alliance that addresses both the biochemical foundations and adverse psychosocial consequences of PD; the latter problems require that the clinician or nurse furnish both education and emotional support. Three well-established phenomena from the depression literature must be combatted: a normal depression reaction associated with the failure to attain closely held life goals; outer locus of control, in which PD patients may perceive that the disease is dictating their existences; and learned helplessness, which may result when coping behaviors are not positively reinforced.

Iodine in drinking water varies by more than 100-fold in Denmark. Importance for iodine content of infant formulas

The iodine intake level of the population is of major importance for the occurrence of thyroid disorders in an area. The aim of the present study was to evaluate the importance of drinking water iodine content for the known regional differences in iodine intake in Denmark and for the iodine content of infant formulas. Iodine in tap water obtained from 55 different locations in Denmark varied from <1.0 to 139 microg/l. In general the iodine content was low in Jutland (median 4.1 microg/l) with higher values on Sealand (23 microg/l) and other islands. Preparation of coffee or tea did not reduce the iodine content of tap water with a high initial iodine concentration. A statistically significant correlation was found between tap water iodine content today and the urinary iodine excretion measured in 41 towns in 1967 (r=0.68, P<0.001). The correlation corresponded to a basic urinary iodine excretion in Denmark of 43 microg/24h excluding iodine in water and a daily water intake of 1.7 l. The iodine content of infant formulas prepared by addition of demineralized water varied from 37 to 138 microg/l (median 57 microg/l, n=18). Hence the final iodine content would depend heavily on the source of water used for preparation. We found that iodine in tap water was a major determinant of regional differences in iodine intake in Denmark. Changes in water supply and possibly water purification methods may influence the population iodine intake level and the occurrence of thyroid disorders.

Opioid analgesics as noncompetitive N-methyl-D-aspartate (NMDA) antagonists

Much evidence points to the involvement of N-methyl-D-aspartate (NMDA) receptors in the development and maintainance of neuropathic pain. In neuropathic pain, there is generally involved a presumed opioid-insensitive component, which apparently can be blocked by NMDA receptor antagonists. However, in order to obtain complete analgesia, a combination of an NMDA receptor antagonist and an opioid receptor agonist is needed. Recent in vitro data have demonstrated that methadone, ketobemidone, and dextropropoxyphene, in addition to being opioid receptor agonists, also are weak noncompetitive NMDA receptor antagonists. Clinical anecdotes suggest that the NMDA receptor antagonism of these opioids may play a significant role in the pharmacological action of these compounds; however, no clinical studies have been conducted to support this issue. In the present commentary, we discuss evidence for the NMDA receptor antagonism of these compounds and its relevance for clinical pain treatment; an overview of structure-activity relationships for the relevant opioids as noncompetitive NMDA receptor antagonists also is given. It is concluded that although the finding that some opioids are weak noncompetitive NMDA receptor antagonists in vitro has created much attention among clinicians, no clinical studies have been conducted to evaluate the applicability of these compounds in the treatment of neuropathic pain conditions.

Prediction of axillary lymph node involvement of women with invasive breast carcinoma: a multivariate analysis

BACKGROUND

The increasing use of systemic therapy for women with lymph node negative breast carcinoma and earlier stage of disease at mammographic detection raises questions regarding the need for routine axillary lymph node dissection. Predictive modeling for lymph node involvement may be one way to reduce the need for axillary lymph node dissection and its morbidity.

METHODS

A multivariate analysis of 12 factors predictive of axillary lymph node involvement was conducted in a population-based cohort of 4312 women with invasive breast carcinoma diagnosed between January 1, 1993 and December 31, 1996.

RESULTS

Clinical palpability, lymphatic or vascular invasion, lesion size, margin status, histology, and patient age were independent predictors of axillary lymph node involvement. The model correctly identified lymph node status in 76.6% of cases. Model accuracy and fit were equally high when applied to randomly selected halves of the study subjects. Approximately 32.0% of the patients in the study sample (1363/4312) were identified as having an extremely high (91%; n = 1102) or low (10%; n = 261) risk of lymph node involvement. In a second analysis, a clinically useable, three-variable model identified a very low risk group of patients (n = 147) with a 4.8% risk of lymph node metastasis and a high risk group of patients (n = 1008) with a 74.2% risk of lymph node metastasis. Greater than 90% of subjects in the high risk group received adjuvant systemic therapy even if they were lymph node negative pathologically.

CONCLUSIONS

A clinically useable, three-variable model employing tumor and lymph node palpability, size, and lymphatic or vascular invasion can identify women with invasive breast carcinoma in whom axillary lymph node dissection is very unlikely to alter recommendations regarding adjuvant systemic therapy.

Dextropropoxyphene acts as a noncompetitive N-methyl-D-aspartate antagonist

In order to elucidate whether opioid analgesics available on the Scandinavian market also act as noncompetitive N-methyl-D-aspartate (NMDA) antagonists, a series of commercially available opioids were screened for their affinity in [3H](RS)-5-methyl-10, 11-dihydro-5H-dibenzo[a,d]cycloheptene-5,10-imine ([3H]MK-801) binding assays and potential inhibitory actions on responses to NMDA in the rat cortical wedge preparation. Of the screened compounds (codeine, dextropropoxyphene, etorphine, fentanyl, and morphine), only dextropropoxyphene, with an IC50 value in [3H]MK-801 binding of 5 microM, was found to be active. Further characterization of the interaction of dextropropoxyphene with the NMDA response in the rat cortical wedge preparation illustrated the noncompetitive NMDA antagonist activity of dextropropoxyphene. Analysis of the dextropropoxyphene inhibition curve of NMDA gave an IC50 value of 190 microM and a Hill slope of 0.8.

Ketobemidone plus (RS)-3-dimethylamino-1,1-diphenylbut-1-ene (A29) is more potent at NMDA receptors than ketobemidone alone: evidence for A29 as a non-competitive NMDA receptor antagonist

The opioid, ketobemidone, has previously been shown to be a non-competitive N-methyl-D-aspartate (NMDA) receptor antagonist. In Denmark, ketobemidone is available in a formulation which contains ketobemidone and a spasmolytic compound, (RS)-3-dimethylamino-1,1-diphenylbut-1-ene, hydrochloride (A29), in a one to five ratio. Using in vitro receptor binding techniques and an in vitro electrophysiological preparation consisting of rat cerebral cortex, we have characterized the interaction between A29 and the different glutamate receptor subtypes. A29 selectively inhibited binding of the non-competitive NMDA receptor antagonist 3H-MK-801 with a Ki value 16 +/- 4.5 microM, but was inactive in assays measuring affinities for other glutamate receptors. In agreement with the binding studies, A29 was found to selectively inhibit responses to NMDA in the rat cortical wedge preparation, whereas responses to kainate and AMPA were unaffected. Analysis of dose response curves showed A29 to be a NMDA receptor antagonist with an IC50 value of 100 microM versus responses to 10 microM NMDA. The inhibitory effects of ketobemidone and A29 on responses to 10 microM NMDA were additive. These data show that the combination of A29 and ketobemidone exert more potent antagonism at the NMDA receptor than does ketobemidone alone.

Localization of nonpancreatic secretory phospholipase A2 in normal and atherosclerotic arteries. Activity of the isolated enzyme on low-density lipoproteins

Secretory nonpancreatic type II phospholipase A2 (snpPLA2) hydrolyzes fatty acids at the sn-2 position in phospholipids releasing free fatty acids (FFAs) and lysophospholipids. These products may act as intracellular second messengers or can be further metabolized into proinflammatory lipid mediators. The presence of snpPLA2 in extracellular fluids and serum during inflammation has suggested a role of the enzyme in this process. However, the presence of snpPLA2 in a variety of normal tissues suggests that snpPLA2 may also have physiological functions. Atherosclerosis appears to have an inflammatory component. Here we report on the snpPLA2 localization in normal and atherosclerotic lesions and on the properties of the isolated enzyme. A strong snpPLA2 immunoreactivity was observed in the arterial media that was colocalized with alpha-actin-positive vascular smooth muscle cells (SMCs) in both normal and atherosclerotic vessels. In aortic atherosclerotic lesions, snpPLA2 was observed colocalized with CD68-positive macrophages and HHF-35-positive SMCs and extracellularly in the lipid core. snpPLA2 was isolated from human normal arteries and from aorta with lesions. The enzyme was isolated by acid extraction of normal arterial tissues followed by immunoaffinity chromatography. The purified snpPLA2 had an expected molecular weight of 14 kD by polyacrylamide gel electrophoresis and appeared as a single band in immunoblotting. The enzymatic activity was followed by measuring release of fatty acids from phospholipid liposomes or LDL as substrates. The enzymatic activity was inhibited with two specific inhibitors for human snpPLA2: (1) monoclonal antibody 187 and (2) LY311727, a synthetic selective inhibitor. The mRNA for snpPLA2 was detected with reverse transcriptase polymerase chain reaction. These results indicate that snpPLA2 is present in human arteries and that it is able to hydrolyze phospholipids in LDL. The results support the hypothesis that snpPLA2 can release proinflammatory lipids at places of LDL deposition in the arterial wall.

[Mortality among Norwegian addicts after admission to different types of institutions. A 10-year follow-up study 1985-94]

Ten years after enrollment in six different treatment and rehabilitation facilities in 1984-85, 482 drug addicts (158 women) were followed-up by means of official death records. 97 drug addicts (20%) had died, i.e. an incidence rate of 2.3 per 100 observation years. The incidence rate among those enrolled in psychiatry-oriented institutions was 2.8 for men and 2.0 for women. Among those enrolled in rehabilitation-oriented institutions the corresponding incidence rate was 2.0 and 0.6. The ratio between the incidence rates for the two types of institutions was 1.6 (95% CI 1.0-2.6). Excluding those who were 21 to 25 years of age in 1984-85, the death rate was significantly higher among the drug addicts in psychiatry-oriented institutions than among the addicts at institutions focusing on rehabilitation(relative risk 2.1, 95% CI 1.1-4.1).

Phenotypic and genotypic characterization of phenanthrene-degrading fluorescent Pseudomonas biovars

A total of 41 phenanthrene degraders were isolated from a former coal gasification site by using Pseudomonas-selective Gould's S1 medium. All isolates were found to belong to the fluorescent Pseudomonas group and were subjected to characterization by phenotypic methods, including classical taxonomic tests, API 20NE, and Biolog GN, and the strains were further characterized by the genotypic method repetitive extragenic palindromic PCR (REP-PCR). By using classical tests, the population was found to consist of 38 strains belonging to P. fluorescens, 2 P. putida strains, and 1 Pseudomonas sp. Bacteria in phenograms from Biolog GN and REP-PCR data were divided into groups, which were in good agreement with classical test and API 20NE results. We found a nonfluorescent group of 22 bacteria inconsistent with any Pseudomonas sp. in Bergey's Manual of Systematic Bacteriology. The group showed small differences in the genotypic test, indicating that all 22 isolates were not recent clones of the same isolate. Analyses of the nonfluorescent group indicated that it belonged to Pseudomonas, but the group could not be affiliated with P. fluorescens because of differences in DNA-DNA hybridization. Identifications using classical tests and API 20NE were found to correlate, but Biolog GN identifications after 24-h incubation resulted very often in the distantly related P. corrugata. The reproducibilities of individual tests of each phenotypic method were assessed, and low reproducibilities were mainly found to be associated with specific Biolog GN test wells. Classical tests and API 20NE proved to be the best for identification of isolates, whereas Biolog GN and REP-PCR were found to be the best tests for high resolution among these closely related isolates.

The opioid ketobemidone has a NMDA blocking effect

There are clinical observations that neurogenic pain can respond well to the opioid ketobemidone, in contrast to pethidine and morphine. This has led us to the hypothesis that the analgesic effect of ketobemidone in neurogenic pain may be due to both opioid as well as additional non-opioid effects. The present study was therefore made to evaluate the effects of ketobemidone. The study consists of two parts. (1) Single unit recordings were made from dorsal horn neurones in the halothane-anaesthetised rat. Neurones were activated by transcutaneous electrical stimulation of their receptive fields at C-fibre strength and their responses quantified. The wind-up of the neurones, due to N-methyl-D-aspartate (NMDA) receptor activation, leading to marked increases in C-fibre responses and an associated post-discharge was also measured. Ketobemidone, applied to the spinal cord, equivalent to an intrathecal injection, dose-dependently and selectively reduced C-fibre evoked responses. Ketobemidone was also found to block wind-up more effectively than morphine at equieffective doses, but unlike morphine in a non-naloxone-reversible manner. (2) In a binding study ketobemidone was shown to inhibit [3H]MK-801 binding with a Ki value of 26 microM. Therefore, ketobemidone appears to possess both mu opioid agonist as well as NMDA blocking effects.

Management of chronic non-malignant pain

Chronic non-malignant pain is often treated inadequately because of opiophobia. There is no scientific justification for this fear. With close monitoring and frequent controls, opioids are safe for this kind of pain. There is no scientific evidence that patients with chronic non-malignant pain are more prone to addiction or tolerance. It is also pertinent to consider that the endpoint of chronic pain treatment is not just freedom from pain but global wellbeing.

Extracellular phospholipase A2 expression in sarcoidosis

This study was conducted in order to focus upon the Ca2- dependent secretory non-pancreatic phospholipase A2 (npPLA2) enzyme and its possible role in the pathophysiology of sarcoidosis. Serum samples were taken from 24 patients with sarcoidosis to determine the levels of npPLA2. Moreover, in another group of patients with active chest x-ray stage II and III sarcoidosis, bronchoscopy with bronchoalveolar lavage (BAL) and transbronchial lung biopsies (TBL) were taken. Highly significant increase of npPLA2 in serum was found in patients compared to controls (p < 0.001). Furthermore, those patients with stable and inactive disease and those who were under treatment with corticosteroids, tended to have lower values than those with active disease and those who were untreated. An intense accumulation of npPLA2 was found in smooth muscle tissue in lung biopsy specimens, in close connection with fibroblast accumulation and deposition of collagen. These cells also stained positive for alpha-smooth muscle actin (alpha-SMA). In addition, when using the technique of in situ hybridization, expression of npPLA2-mRNA was found in the fibroblast layer surrounding the epitheloid cell granulomas. These fibroblasts did not stain positive for alpha-SMA. Our data suggest that npPLA2 is actively involved, and has an important role, in the pathophysiology of sarcoidosis.

Assessing toxicity and mobilisation of impregnation salts at a contaminated site

Severe soil contamination is often encountered at wood-impregnation plants due to spills, dripping and deposition of sludge associated with dissolved salts of copper, chromium and arsenic (CCA). Soil samples from a CCA-plant in southern Norway were analysed via a factorial extraction design to investigate mobilisation of contaminated soils. Various concentrations of organic acids, sea-salts, and pH showed that contaminants were not stable, and could be mobilised to the aqueous phase. To further investigate mobilisation of impregnation salts, soil solution collectors were installed at various depths at the site. Concentrations varied considerably. Hydrological changes revealed elevated levels of dissolved salts, which agree with the factorial experiment. Soil chemical processes (not total solid-phase concentrations) dominated the mobilisation and subsequent leaching. Soil solutions were tested for changes in toxicity by chemical analysis and degree of inhibition of luminescence in Vibrio fisheri (Microtox). Changes in toxicity corresponded to changes in soil solution.

Gemcitabine: clinical and economic impact in inoperable non-small cell lung cancer

This study assesses retrospectively the clinical and economic impact of gemcitabine monotherapy on the management of inoperable stage III/IV non-small cell lung cancer in Germany. Based on current methods of clinical practice and using the best outcome data available, the costs and benefits of gemcitabine were compared to a dual therapy (ifosfamide/etoposide). While the two treatments showed broadly equivalent efficacy in terms of tumour response rate and survival, a cost analysis showed the potential for savings with gemcitabine. These largely related to hospital hotelling costs, due to the fact that gemcitabine may be given as an out-patient therapy. Further savings were found in investigative procedures and the management of treatment toxicity. Excluding the cost of the chemotherapy, gemcitabine was associated with potential savings of DM3,026 over two cycles of therapy, which included a 40% decrease in hospitalization costs and a 54% decrease in the cost of managing adverse events. We conclude that gemcitabine monotherapy could offer considerable cost savings while offering the potential for improved quality of palliative treatment compared to existing in-patient treatments, and it may have a place in shifting care from an in-patient to an out-patient setting in line with recent health care reforms.

Prostate-specific membrane antigen: evidence for the existence of a second related human gene

Prostate-specific membrane antigen (PSM) is a glycoprotein recognised by the prostate-specific monoclonal antibody 7E11-C5, which was raised against the human prostatic carcinoma cell line LNCaP. A cDNA clone for PSM has been described. PSM is of clinical importance for a number of reasons. Radiolabelled antibody is being evaluated both as an imaging agent and as an immunotherapeutic in prostate cancer. Use of the PSM promoter has been advocated for gene therapy applications to drive prostate-specific gene expression. Although PSM is expressed in normal prostate as well as in primary and secondary prostatic carcinoma, different splice variants in malignant tissue afford the prospect of developing reverse transcription-polymerase chain reaction (RT-PCR)-based diagnostic screens for the presence of prostatic carcinoma cells in the circulation. We have undertaken characterisation of the gene for PSM in view of the protein's interesting characteristics. Unexpectedly, we have found that there are other sequences apparently related to PSM in the human genome and that PSM genomic clones map to two separate and distinct loci on human chromosome 11. Investigation of the function of putative PSM-related genes will be necessary to enable us to define fully the role of PSM itself in the development of prostatic carcinoma and in the clinical management of this malignancy.

Ketobemidone, methadone and pethidine are non-competitive N-methyl-D-aspartate (NMDA) antagonists in the rat cortex and spinal cord

The opiate agonists, ketobemidone, methadone and pethidine, were evaluated as N-methyl-D-aspartate (NMDA) receptor antagonists using the rat cortical wedge preparation and the neonatal rat spinal cord preparation for electrophysiological studies and [3H](RS)-5-methyl-10,11-dihydro-5H-dibenzo[a,d]cyclohepten-5,10-im ine ([3H]MK-801) binding experiments using rat forebrain homogenates. Ketobemidone, methadone and pethidine were inhibitors of [3H]MK-801 binding with Ki values of 26 microM, 0.85 microM and 47 microM, respectively. In the cortex, 1 mM ketobemidone and 1 mM methadone reduced NMDA responses, but not (RS)-2-amino-3-(3-hydroxy-5-methylisoxazol-4-yl) propionic acid (AMPA) or kainate responses in an use-dependent manner, whereas 1 mM pethidine was devoid of antagonist activity. In the spinal cord preparation, the activities of ketobemidone and methadone were weaker than in cortex. In contrast, pethidine was equipotent with ketobemidone in the spinal cord. These results suggest that ketobemidone and methadone may be useful therapeutic agents in conditions where a combined opiate agonist and NMDA antagonist treatment is desired.