Resistance exercise and supraphysiologic androgen therapy in eugonadal men with HIV-related weight loss: a randomized controlled trial

The anabolic applications of androgens in older adults with functional limitations

Aging is associated with a progressive decrease in skeletal muscle mass, strength and power and impairment of physical function. Serum testosterone concentrations in men decrease with advancing age due to defects at all levels of the hypothalamic-pituitary-testicular axis. Testosterone administration increases skeletal muscle mass, strength and power in older men with low or low normal testosterone levels, but the effects on performance-based measures of physical function have been inconsistent. Adequately powered randomized trials are needed to determine the long-term safety and efficacy of testosterone in improving physical function and quality of life in older adults with functional limitations.

Effectiveness of anabolic steroids in improving outcomes for post-operative hip fracture patients: A randomized controlled trial

BACKGROUND

Post-operative elderly hip fracture patients require significant rehabilitation. Nandrolone is an anabolic steroid used to promote muscle growth. This study aims to examine the effect of nandrolone in improving rehabilitation and quality of life in elderly female patients with hip fractures undergoing hemiarthroplasty.

METHODS

This is a double-blinded prospective randomized-controlled-trial consisting of female patients above the age of 65 with an isolated neck of femur fracture planned for a hip hemiarthroplasty. Participants were randomized into two arms of the study - 50 mg intramuscular nandrolone vs normal saline placebo administered on post-operative day 0, and weeks 2, 6 and 12. The participants were followed up across a 1-year period following the surgery. Clinical outcomes such as time taken to achieve rehabilitation milestones, distance of ambulation and thigh muscle girth, and functional scoring with SF-36 questionnaire were recorded at intervals of 2, 6 and 12 weeks, 6 months and 1 year following the surgery.

RESULTS

There were a total of 23 subjects with 11 in the steroid group and 12 in the placebo group. There was no significant difference in demographics and injury patterns between both groups. There was no significant difference for time taken to achieve various rehabilitation milestones and distance of ambulation. SF-36 scores on discharge and at 1-year follow-up mark were comparable. There was no difference in the complication rate between both groups.

CONCLUSION

Intra-muscular Nandrolone after hip surgery in elderly female patients does not result in short to mid-term improved rehabilitation or functional outcomes. Nandrolone did not result in increased short-term complications after hip surgery.

LEVEL OF EVIDENCE

I.

Can conditions of skeletal muscle loss be improved by combining exercise with anabolic-androgenic steroids? A systematic review and meta-analysis of testosterone-based interventions

Sarcopenia, cachexia, and atrophy due to inactivity and disease states are characterized by a loss of skeletal muscle mass, often accompanied by reduced levels of anabolic hormones (e.g. testosterone). These conditions are associated with an increase in mortality, hospitalization and worsening in quality of life. Both physical exercise (EX) and anabolic-androgenic steroid (AAS) administration can improve the prognosis of patients as they increase physical functionality. However, there is a gap in the literature as to the impact of these therapies on the gains in strength and muscle mass and their implications for patient safety. Accordingly, we performed a random-effects meta-analysis to elucidate the effects of AAS and/or EX interventions on lean body mass (LBM) and muscle strength in conditions involving muscle loss. A systematic search for relevant clinical trials was conducted in MEDLINE, EMBASE, SCOPUS, Web of Science, and SPORTDiscus. Comparisons included AAS vs. Control, EX vs. Control, AAS vs. EX, AAS + EX vs. AAS and AAS + EX vs. EX. A total of 1114 individuals were analyzed. AAS increased LBM (effect size [ES]: 0.46; 95% CI: 0.25, 0.68, P = 0.00) and muscle strength (ES: 0.31; 95% CI: 0.08, 0.53, P = 0.01) when compared to a control group. EX promoted an increase in muscular strength (ES: 0.89; 95% CI: 0.53, 1.25, P = 0.00), with no effect on LBM when compared to the control group (ES: 0.15; 95% CI: -0.07, 0.38, P = 0.17). AAS did not demonstrate statistically significant differences when compared to EX for LBM and muscle strength. The combination of EX + AAS promoted a greater increase in LBM and muscular strength when compared to AAS or EX in isolation. Qualitatively, AAS administration had relatively few side effects. Significant heterogeneity was found in some analyses, which may be explained by the use of different AAS types and EX protocols. Our findings suggest that AAS administration in cachectic and sarcopenic conditions may be a viable interventional strategy to enhance muscle function when exercise is not a possible approach. Moreover, combining AAS with exercise may enhance positive outcomes in this population.

Low-Dose Testosterone and Evoked Resistance Exercise after Spinal Cord Injury on Cardio-Metabolic Risk Factors: An Open-Label Randomized Clinical Trial

The purpose of the work is to investigate the effects of low-dose testosterone replacement therapy (TRT) and evoked resistance training (RT) on body composition and metabolic variables after spinal cord injury (SCI). Twenty-two individuals with chronic motor complete SCI (ages 18-50 years) were randomly assigned to either TRT+RT (n = 11) or TRT (n = 11) for 16 weeks following a 4 -week delayed entry period. TRT+RT men underwent twice weekly progressive RT using electrical stimulation with ankle weights. TRT was administered via testosterone patches (2-6 mg/day). Body composition was tested using anthropometrics, dual energy x-ray absorptiometry, and magnetic resonance imaging. After an overnight fast, basal metabolic rate (BMR), lipid panel, serum testosterone, adiponectin, inflammatory and anabolic biomarkers (insulin-like growth factor-1 and insulin-like growth factor-binding protein 3 [IGFBP-3]), glucose effectiveness (Sg), and insulin sensitivity (Si) were measured. Total body lean mass (LM; 2.7 kg, p < 0.0001), whole muscle (p < 0.0001), and whole muscle knee extensor cross-sectional areas (CSAs; p < 0.0001) increased in the TRT+RT group, with no changes in the TRT group. Visceral adiposity decreased (p = 0.049) in the TRT group, with a trend in the TRT+RT (p = 0.07) group. There was a trend (p = 0.050) of a 14-17% increase in BMR following TRT+RT. Sg showed a trend (p = 0.07) to improvement by 28.5-31.5% following both interventions. IGFBP-3 increased (p = 0.0001) while IL-6 decreased (p = 0.039) following both interventions, and TRT+RT suppressed adiponectin (p = 0.024). TRT+RT resulted in an increase in LM and whole thigh and knee extensor muscle CSAs, with an increase in BMR and suppressed adiponectin. Low-dose TRT may mediate modest effects on visceral adipose tissue, Sg, IGFBP-3, and IL-6, independent of changes in LM.

Does perioperative oxandrolone improve nutritional status in patients with cachexia related to head and neck carcinoma?

Background

Cancer cachexia affects up to over 50% of advanced head and neck cancer (HNC) patients. To date, the potential utility of anabolic steroids in perioperative cachectic HNC patients has not been determined.

Methods

Retrospective review of pre- and post-oxandrolone administration prealbumin levels in 18 perioperative HNC patients between October 2007 and October 2014 at a tertiary academic medical center.

Results

The median pretreatment prealbumin was 88.5 mg/L. The median post-treatment prealbumin was 227 mg/L. The median interval improvement of the prealbumin level was 131.5 mg/L. The median differences between the pretreatment and post-treatment prealbumin levels were found to be statistically significant (P < .001). Subjective improvement in wound healing was also observed.

Conclusions

Perioperative administration of oxandrolone resulted in objective improvements in prealbumin levels and subjective improvements in surgical wounds. Oxandrolone administered 10 mg twice daily (BID) for 10 days may be a useful adjunct in the perioperative care of nutritionally deficient HNC patients who are at risk for or have demonstrated impaired wound healing.

Level of Evidence

3.

Risk Factors Associated with the Development of Transaminitis in Oxandrolone-Treated Adult Burn Patients

Oxandrolone has proven benefits in thermal burn injury and has become a standard of care. Transaminitis is the most frequent side effect of oxandrolone use, although no risk factors have been identified that increase the risk of transaminitis. The objective was to evaluate the frequency of transaminitis while on oxandrolone and to identify risk factors leading to an increased risk of transaminitis in adult burn patients. This multicenter retrospective risk factor analysis compared two patient groups with and without occurrence of transaminitis, which was detected by an aspartate aminotransferase (AST) or alanine aminotransferase (ALT) >100 mg/dL. Secondary outcomes included percentage increase from baseline for AST/ALT, length of stay, and mortality. After univariable analysis, a multivariable logistic regression analysis was performed to detect possible risk factors leading to transaminitis. A total of 309 patients were included, with transaminitis occurring in 128 patients (41.4%) after 13 (interquartile range [IQR] 8-23) days on oxandrolone. After multivariable analysis, age (odds ratio [OR] 0.91; 95% confidence interval [CI] 0.84-0.99 for a 5-year increase in age), intravenous vasopressor use (OR 1.85; 95% CI 1.05-3.27), and amiodarone use (OR 2.51; 95% CI 1.09-5.77) were independent predictors of transaminitis, controlling for TBSA%. Transaminitis was not significantly associated with length of stay or mortality after adjusting for age and TBSA%. We conclude that patients who are younger and have concurrent amiodarone or vasopressor use have the highest risk of developing oxandrolone induced transaminitis and should be monitored closely.

Physical activity, social support and socio-economic status amongst persons living with HIV and AIDS: a review

Physical activity can be used for the effective and comprehensive management of HIV and AIDS. Social support and socio-economic status (SES) are two factors that shape physical activity behaviours. Individuals of low SES carry a disproportionate burden of the HIV and AIDS epidemic. In addition, limited resources constitute socio-ecological barriers predisposing such individuals to physical inactivity. The purpose of this narrative review is to examine the available literature on physical activity, social support and SES and to generate recommendations for designing and implementing physical activity interventions targeting people living with HIV and AIDS (PLWHA) of low SES. The review used literature from Google, Google Scholar and PubMed on physical activity of PLWHA, social support for physical activity, and SES and physical activity. Qualitative and quantitative studies in English were included from 1970 to 2016. The results show that social support plays a major role in promoting physical activity and counteracting the barriers to PA in PLWHA of low SES. The results on the role of social support and the influence of SES are integrated to help design appropriate physical activity interventions for PLWHA of low SES. Well-designed interventions should utilise social support and be contextualised for PLWHA of low SES, whose living conditions present multiple barriers to physical activity.

Incidence of oxandrolone induced hepatic transaminitis in patients with burn injury

The benefits of oxandrolone in burn patients has led to its accepted use in the burn care community, however details regarding the most common adverse effect, transaminitis, remains unclear. The purpose of this study was to determine the incidence of transaminitis in patients with burn injury and identify risk factors associated with the development of transaminitis. This single-center, retrospective risk factor analysis compared burn patients on oxandrolone with and without the development of transaminitis, defined as any aspartate aminotransferase or alanine aminotransferase value >100mg/dL. Patient demographics, past medical history, lab values, and burn characteristics were recorded. Overall 28 out of 66 (42%) patients developed transaminitis. The transaminitis group had a significantly higher proportion of other concomitant medications with a transaminitis risk (p=0.045). No significant difference in liver dysfunction or length of stay was observed between the two groups. Oxandrolone induced transaminitis is occurring in patients significantly more frequently than previously reported warranting further research to guide monitoring requirements, use of concomitant medications, and to determine if rechallenging after resolution should be considered.

Anabolic steroids and tendons: A review of their mechanical, structural, and biologic effects

One of the suspected deleterious effects of androgenic-anabolic steroids (AAS) is the increased risk for tendon rupture. However, investigations to date have produced inconsistent results and it is still unclear how AAS influence tendons. A systematic review of the literature was conducted to identify studies that have investigated the mechanical, structural, or biologic effects that AAS have on tendons. In total, 18 highly heterogeneous studies were identified. Small animal studies made up the vast majority of published research, and contradictory results were reported frequently. All of the included studies focused on the potential deleterious effects that AAS have on tendon, which is striking given the recent use of AAS in patients following tendon injury. Rather than providing strong evidence for or against the use of AAS, this review highlights the need for additional research. Future studies investigating the use of AAS as a possible treatment for tendon injury/pathology are supported by reports suggesting that AAS may counteract the irreparable structural/functional changes that occur in the musculotendinous unit following rotator cuff tears, as well as studies suggesting that the purported deleterious effects on tendon may be transient. Other possible areas for future research are discussed in the context of key findings that may have implications for the therapeutic application of AAS. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:2830-2841, 2018.

Supervised Physical Activity and Improved Functional Capacity among Adults Living with HIV: A Systematic Review

Physical activity (PA) combats the effects of multimorbidity and antiretroviral therapy in people living with HIV (PLWH), but PLWH often don't meet recommended PA guidelines. The purpose of our review was to investigate whether supervised PA improved functional capacity in PLWH. Preferred Reporting Items for Systematic Reviews and Meta-Analyses were followed. Five databases were searched for randomized controlled trials in English, with participants ages 18 years and older, and a supervised PA intervention. A database search yielded 8,267 articles, with 15 eligible for review inclusion. We found a low risk of bias within and across studies. Combined aerobic/progressive resistance training (PRT) improved strength, cardiovascular, and flexibility outcomes; aerobic interventions alone showed no significant improvements; PRT improved strength outcomes; yoga or yoga/meditation showed no outcome differences; and t'ai chi showed cardiovascular and flexibility improvements. We found that supervised PA increased functional capacity in PLWH and that self-report was not a reliable assessment.

Effects of Testosterone Supplementation on Body Composition in HIV Patients: A Meta-analysis of Double-blinded Randomized Controlled Trials

This study was designed to evaluate the effects of testosterone supplementation (TS) on body composition in patients with HIV and the side effects of TS. A comprehensive literature search strategy was used to retrieve relevant randomized controlled trials (RCTs) examining the effects of TS on body composition. Atotal of 14 eligible studies were included, enrolling 388 and 349 randomized patients in TS and control groups, respectively. The quality of studies included was assessed, and data on total body weight (BW), lean body mass (LBM), fat mass (FM), serum total testosterone (TT), free testosterone (FT) levels, and adverse events were extracted and analyzed using Review Manager software 5.3. Meta-analysis results showed that TS was associated with a small but significant modification in total BW, serum TT, and FT levels in HIV-infected patients and in patients given various drug administrations. TS also significantly increased LBM in male patients, but no significant difference in LBM was observed between female counterparts treated with TS or not. Conversely, TS relative to placebo did not lead to a significant reduction in FM. No significant difference was observed between the two groups in terms of adverse effects. Our findings suggested that TS may be recommended to improve body composition in patients with HIV-related weight loss. However, owing to the high heterogeneity across included trials, further evaluations using large-scale, multi-center, blinded RCTs are needed.

An FT-Raman, FT-IR, and Quantum Chemical Investigation of Stanozolol and Oxandrolone

We have studied the Fourier Transform Infrared (FT-IR) and the Fourier transform Raman (FT-Raman) spectra of stanozolol and oxandrolone, and we have performed quantum chemical calculations based on the density functional theory (DFT) with a B3LYP/6-31G (d, p) level of theory. The FT-IR and FT-Raman spectra were collected in a solid phase. The consistency between the calculated and experimental FT-IR and FT-Raman data indicates that the B3LYP/6-31G (d, p) can generate reliable geometry and related properties of the title compounds. Selected experimental bands were assigned and characterized on the basis of the scaled theoretical wavenumbers by their total energy distribution. The good agreement between the experimental and theoretical spectra allowed positive assignment of the observed vibrational absorption bands. Finally, the calculation results were applied to simulate the Raman and IR spectra of the title compounds, which show agreement with the observed spectra.

Oxandrolone Augmentation of Resistance Training in Older Women: A Randomized Trial

INTRODUCTION

Sarcopenia is disproportionately present in older women with disability, and optimum treatment is not clear. We conducted a double-blind, randomized, placebo-controlled trial to determine whether oxandrolone administration in elderly women improves body composition or physical function beyond that which occurs in response to progressive resistance training (PRT).

METHODS

Twenty-nine sedentary women (age 74.9 ± 6.8 yr; 5.9 ± 2.8 medications per day) were randomized to receive high-intensity PRT (three times a week for 12 wk) combined with either oxandrolone (10 mg·d(-1)) or an identical placebo. Peak strength was assessed for leg press, chest press, triceps, knee extension, and knee flexion. Power was assessed for leg press and chest press. Physical function measures included static and dynamic balance, chair rise, stair climb, gait speed, and 6-min walk test. Body composition was assessed using dual energy x-ray absorptiometry.

RESULTS

Oxandrolone treatment augmented increases in lean tissue for the whole body (2.6 kg; 95% confidence interval (CI), 1.0-4.2 kg; P = 0.003), arms (0.3 kg; 95% CI, 0.1-0.5 kg; P = 0.001), legs (0.8 kg; 95% CI, 0.1-1.4 kg; P = 0.018), and trunk (1.4 kg; 95% CI, 0.4-2.3 kg; P = 0.004). Oxandrolone also augmented loss of fat tissue of the whole body (-1 kg; 95% CI, -1.6 to -0.4; P = 0.002), arms (-0.2 kg; 95% CI, -0.5 to -0.02 kg; P = 0.032), legs (-0.4 kg; 95% CI, -0.6 to -0.1; P = 0.009), and tended to reduce trunk fat (-0.4 kg; 95% CI, -0.9 to 0.04; P = 0.07). Improvements in muscle strength and power, chair stand, and dynamic balance were all significant over time (P < 0.05) but not different between groups (P > 0.05).

CONCLUSIONS

Oxandrolone improves body composition adaptations to PRT in older women over 12 wk without augmenting muscle function or functional performance beyond that of PRT alone.

Use and Effectiveness of Performance-Enhancing Substances

The use and effects of selected performance-enhancing drugs and nutritional supplements are reviewed. Recent sports medicine studies are mostly double blind and placebo controlled but contain relatively small sample sizes. Their data appear reliable and are reported in reputable journals. Definitions and methods used in sports medicine are provided to enhance the understanding of this literature. The use of performance-enhancing substances is probably under-reported. Anabolic-androgenic steroids are reportedly used in 0% to 1% of women, 0.5% to 3% of high school girls, 1% to 5% of men, 1% to 12% of high school boys, and up to 67% of some groups of elite athletes. The use of combinations of performance-enhancing substances is common. Carbohydrate loading, adequate protein intake, creatine, blood doping, and erythropoietin (epoetin alfa) appear to enhance performance. Anabolic-androgenic steroids enhance performance, but health risks limit their use. Growth hormones and β2 -selective adrenergic agonists may enhance performance, but additional studies are needed. Androstenedione, caffeine, amphetamines, and nonprescription sympathomimetics do not appear to enhance performance. Performance-enhancing drugs have shown some benefit in diseased patients with malnutrition and/or decreases in physical ability. Pharmacists and other health care providers have opportunities to improve the understanding, use, and monitoring of performance-enhancing substances.

Effects of a 2-Year Supervised Exercise Program Upon the Body Composition and Muscular Performance of HIV-Infected Patients

BACKGROUND

There is a lack of research investigating long-term effects of exercise training upon the body composition and muscle function in HIV-infected patients (PHIV). The study investigated the influence of a 2-year supervised exercise program on body composition and strength of PHIV under highly active antiretroviral therapy (HAART).

METHODS

A training program including aerobic, strength and flexibility exercises was performed by 27 PHIV (17 men/ 10 women; age: 48.7±7.0 years; HAART: 150.7±65.3 months) during 1 year and 18 PHIV (10 men/ 8 women; age: 50.6±5.2 years; HAART: 176.6±53.1 months) during 2 years. Body composition and knee isokinetic strength were assessed at baseline and at the end of each year of intervention.

RESULTS

Body composition remained stable along the whole experiment vs baseline (1-year - total muscle mass: Δ men=1.1%, P=0.21; Δ women=1.4%, P=0.06; trunk fat: Δ men=-0.1%, P=0.65; Δ women=-1.5%, P=0.45; 2 years - total muscle mass: Δ men=2.7%, P=0.54; Δ women=-1.9%, P=0.71; trunk fat: Δ men=4.4%, P=0.96; Δ women=10.0%, P=0.30). After 1-year, peak torque increased in men (Δ extension=4.2%, P=0.01; Δ flexion=12.2%, P=0.04) and total work reduced in women (Δ extension=-15.4%, P=0.01, Δ flexion=-17.5%, P=0.05). All strength markers remained stable vs baseline after 2 years of intervention (P>0.05). Only men showed significant reduction in the risk of disability due to sarcopenia (P=0.05) after 1 year of intervention, which remained stable after 2 years.

CONCLUSION

Long-term exercise training preserved strength and muscle mass in PHIV under HAART. Exercise programs should be part of HIV therapy to prevent sarcopenia of this population along the years.

TRIAL REGISTRATION

ACTRN12610000683033; UTN U1111-1116-4416.

Effects of aging and resistance exercise on determinants of muscle strength

Although the loss of muscle strength with aging is multifactorial, the primary factor is the loss of muscle mass. A preferential loss of Type II (fast-twitch) muscle fibers which produce more force than Type I fibers is also observed. The loss of muscle mass may be related to a reduction in the rate of muscle protein synthesis in the old versus the young. Changes in muscle quality and the ability to activate muscle appear to play a minor role in the loss of strength with age. However, co-activation of antagonist muscle groups does appear to reduce muscle force generating capacity in the elderly. Strength gains in response to resistance exercise training in the elderly, although substantial, may be less than in young individuals. Increases in muscle mass appear to be similar in elderly and young individuals as does the muscle protein synthetic response to resistance exercise. Muscle co-activation appears to be substantially and similarly reduced (improved) in young and elderly individuals as a result of resistance training.

Salivary testosterone is related to self-selected training load in elite female athletes

BACKGROUND

Testosterone has been related to improved acute neuromuscular performance in athletic populations. It is our contention that testosterone may also contribute to improved volitional motivation and, when monitored longitudinally, may provide one proxy marker for readiness to perform.

METHODS

Twelve female netball players provided saliva samples prior to five standardized training sessions in which they completed a maximal-distance medicine ball throw, and then 3 sets of bench press and then back squat using a self-selected load perceived to equal a 3-repetition maximum load. Additional repetitions were encouraged when possible and total voluntary workload was calculated from the product of the load lifted and repetitions performed.

RESULTS

Relative salivary testosterone levels as a group were correlated with bench press (r=0.8399; p=0.0007) and squat (r=0.6703; p=0.0171) self-selected workload, as well as maximal medicine ball throw performance (r=0.7062; p=0.0103).

CONCLUSIONS

Individual salivary testosterone, when viewed relatively over time, demonstrated strong relationships with self-selected workloads during an in-season training period in female netball players. As such, daily variations in testosterone may provide information regarding voluntary training motivation and readiness to perform in elite athletic populations. Psychological and behavioral aspects of testosterone may have the potential to enhance training adaptation by complementing the known anabolic and permissive properties of testosterone.

A systematic review of the effects of different types of therapeutic exercise on physiologic and functional measurements in patients with HIV/AIDS

Several studies have reported the benefits of exercise training for adults with HIV, although there is no consensus regarding the most efficient modalities. The aim of this study was to determine the effects of different types of exercise on physiologic and functional measurements in patients with HIV using a systematic strategy for searching randomized controlled trials. The sources used in this review were the Cochrane Library, EMBASE, MEDLINE, and PEDro from 1950 to August 2012. We selected randomized controlled trials examining the effects of exercise on body composition, muscle strength, aerobic capacity, and/or quality of life in adults with HIV. Two independent reviewers screened the abstracts using the Cochrane Collaboration's protocol. The PEDro score was used to evaluate methodological quality. In total, 29 studies fulfilled the inclusion criteria. Individual studies suggested that exercise training contributed to improvement of physiologic and functional parameters, but that the gains were specific to the type of exercise performed. Resistance exercise training improved outcomes related to body composition and muscle strength, with little impact on quality of life. Aerobic exercise training improved body composition and aerobic capacity. Concurrent training produced significant gains in all outcomes evaluated, although moderate intensity and a long duration were necessary. We concluded that exercise training was shown to be a safe and beneficial intervention in the treatment of patients with HIV.

Nonprescription steroids on the Internet

This study evaluated the degree to which anabolic-androgenic steroids are proffered for sale over the Internet and how they are characterized on popular Web sites. Searches for specific steroid product labels (e.g., Dianabol) between March 2006 and June 2006 revealed that approximately half of the Web sites advocated their "safe" use, and roughly one third offered to sell them without prescriptions. The Web sites frequently presented misinformation about steroids and minimized their dangers. Less than 5% of the Web sites presented accurate health risk information about steroids or provided information to abusers seeking to discontinue their steroid use. Implications for education, prevention, treatment, and policy are discussed.

Anabolic steroids in patients undergoing total knee arthroplasty

OBJECTIVES

To systematically review the evidence for using anabolic-androgenic steroids (AAS) to aid rehabilitation following total knee replacement (TKR).

DESIGN

Systematic review of all clinical study designs.

DATA SOURCES

MEDLINE, EMBASE, AMED, CINAHL and the Cochrane Library were searched from inception to August 2012.

ELIGIBILITY CRITERIA

All clinical study designs without language or patient demographic limits.

OUTCOME MEASURES

All functional, physiological and administrative outcomes as well as reporting of adverse events.

RESULTS

Only two small randomised controlled trials satisfied the inclusion criteria. Statistically significant improvements were reported in the AAS group for quadriceps strength at 3 (p=0.02), 6 (p=0.01) and 12 (p=0.02) months, Functional Independence Measure score at 35 days (p=<0.05) and Knee Society Score at 6 weeks (p=0.02), 6 months (p=0.04) and 12 months (p=0.03). However, differences in hamstring strength, bone mineral density, sit-to-stand testing, walking speed, length of hospital stay and need for further inpatient rehabilitation did not reach statistical significance. There were no reported adverse events.

CONCLUSIONS

There is insufficient evidence to recommend routine administration of AAS to patients undergoing TKR. However, pilot data suggest that AAS can be administered safely and may improve important postoperative outcome measures. This justifies a randomised trial sufficiently powered to identify between-group differences likely to be of clinical significance.

Anabolic steroids reduce muscle damage caused by rotator cuff tendon release in an experimental study in rabbits

BACKGROUND

Muscles of the rotator cuff undergo retraction, atrophy, and fatty infiltration after a chronic tear, and a rabbit model has been used to investigate these changes. The purpose of this study was to test the hypothesis that the administration of anabolic steroids can diminish these muscular changes following experimental supraspinatus tendon release in the rabbit.

METHODS

The supraspinatus tendon was released in twenty New Zealand White rabbits. Musculotendinous retraction was monitored over a period of six weeks. The seven animals in group I had no additional intervention, the six animals in group II had local and systemic administration of nandrolone decanoate, and the seven animals in group III had systemic administration of nandrolone decanoate during the six weeks. Two animals (group III) developed a postoperative infection and were excluded from the analysis. At the time that the animals were killed, in vivo muscle performance as well as imaging and histological muscle changes were investigated.

RESULTS

The mean supraspinatus retraction was higher in group I (1.8 cm; 95% confidence interval: 1.64, 2.02 cm) than in group II (1.5 cm; 95% confidence interval: 1.29, 1.81 cm) or III (1.2 cm; 95% confidence interval: 0.86, 1.54 cm). Histologically, no fatty infiltration was measured in either treated group II (mean, 2.2%; range, 0% to 8%) or III (mean, 1%; range, 0% to 3.4%), but it was measured in the untreated group I (mean, 5.9%; range, 0% to 14.1%; p = 0.031). The radiographic cross-sectional area indicating atrophy and the work of the respective muscle during one standardized contraction with supramaximal stimulation decreased in all groups, but the work of the muscle was ultimately highest in group III.

CONCLUSIONS

To our knowledge, this is the first documentation of partial prevention of important muscle alterations after retraction of the supraspinatus musculotendinous unit caused by tendon disruption. Nandrolone decanoate administration in the phase after tendon release prevented fatty infiltration of the supraspinatus muscle and reduced functional muscle impairment caused by myotendinous retraction in this rabbit rotator cuff model, but two of seven rabbits that received the drug developed infections.

Effects of long-term anabolic androgenic steroid administration on respiratory function

The purpose of this study was to investigate the effects of resistance training and long-term anabolic androgenic steroids (AASs) administration on respiratory function. Subject groups consisted of AAS users (n = 9) who were still using AAS at time of testing (SU); AAS users (n = 6) who had been abstinent for > 3 months (SA), bodybuilding controls (n = 8) (BC), and (n = 8) sedentary male controls (SC). FEV(1), FVC, and PEF were measured. The results found that all subjects were within normal range, and there were no differences between groups. Maximum inspiratory pressure (MIP), and grip strength were both significantly greater in SU (P < 0.05) compared with SC; no significant difference was found between the other groups. Their MIP and grip strength was significantly correlated (r = 0.57; P < 0.05). The data from this study suggest that the combination of resistance training and AAS administration produce a significant increase in MIP in a cohort of long-term AAS users.

The use of anabolic steroids as a strategy in reversing denervation atrophy after delayed nerve repair

BACKGROUND

Denervation atrophy is one factor contributing to suboptimal motor recovery following major nerve repair. The hypertrophic effects of anabolic steroids may have a potential role in improving reinnervated muscle strength after delayed repair.

METHODS

Forty-five immature female Sprague-Dawley rats underwent three surgeries and final testing. The tibial nerve was transected in the hind limb of the experimental (n = 13) and control (n = 14) animals and exposed, but not transected in the sham (n = 15) group animals. Three months later, once denervation atrophy was established, all transected nerves underwent repair using an autograft from the contralateral limb. After waiting an additional month to allow axonal regeneration to the gastrocnemius muscles, the rodents were implanted with a subcutaneous infusion pump. For the experimental group, nandrolone was administered over the next 30 days via this pump, while the control and sham group pumps were filled with carrier only.

RESULTS

Final testing, 6 weeks later, showed improved muscle contraction strength in the steroid-treated animals (72% of sham group strength) compared to control animals (57% of sham group strength, p < 0.5). A trend towards increased weight and muscle belly diameter in the steroid-treated group was not statistically significant.

CONCLUSIONS

These findings support the potential role of anabolic steroids in improving recovery of atrophic muscle after delayed reinnervation.

Protocol for the measurement of fatty acid and glycerol turnover in vivo in baboons

Recognition of the strength of nonhuman primate models in investigating metabolic disorders has resulted in an expanded need for in vivo research techniques. We studied adipose metabolism in 10 baboons (13.0 ± 4.2 years old, 29.5 ± 5.5 kg). Part 1 evaluated the effect of different sedatives on the rate of appearance of plasma free fatty acids (RaFFA), assessed using ¹³C₄-labeled palmitate infusion (7 µmol/kg/min). Animals, were studied with no sedation, with complete isoflurane sedation, and with minimal midazolam infusion (0.04 mg/kg/h), with the last scheme allowing for the most consistent values and animals that were visually more calm. In Part 2, RaFFA and RaGlycerol (D₅-glycerol, 5 mg/kg lean body mass/h) were measured. From midnight to 0300, flux fell and came to a steady state between 0500 and 0700 h (RaFFA, 39.4 ± 29.8 μmol/kg fat mass/min; and RaGlycerol, 26.9 ± 7.3 μmol/kg/min). The RaFFA-to-RaGlycerol ratio was 1.5 ± 0.8 (49% reesterification). The decline in turnover throughout the night reflects natural circadian processes and was mirrored by reductions in FFA and glycerol to 0.62 and ± 0.14 and 0.16 and ± 0.03 mmol/l, respectively. The concurrent changes in both FFA and glycerol kinetics indicate physiologic validity of the method. These techniques will support needed research to determine mechanisms by which treatments act upon the adipocyte in vivo.

Bone and muscle loss after spinal cord injury: organ interactions

Spinal cord injury (SCI) results in paralysis and marked loss of skeletal muscle and bone below the level of injury. Modest muscle activity prevents atrophy, whereas much larger--and as yet poorly defined--bone loading seems necessary to prevent bone loss. Once established, bone loss may be irreversible. SCI is associated with reductions in growth hormone, IGF-1, and testosterone, deficiencies likely to exacerbate further loss of muscle and bone. Reduced muscle mass and inactivity are assumed to be contributors to the high prevalence of insulin resistance and diabetes in this population. Alterations in muscle gene expression after SCI share common features with other muscle loss states, but even so, show distinct profiles, possibly reflecting influences of neuromuscular activity due to spasticity. Changes in bone cells and markers after SCI have similarities with other conditions of unloading, although after SCI these changes are much more dramatic, perhaps reflecting the much greater magnitude of unloading. Adiposity and marrow fat are increased after SCI with intriguing, though poorly understood, implications for the function of skeletal muscle and bone cells.

Is there a relationship between physical performance and orchiectomy?

Bilateral orchiectomy is indicated for the treatment of patients with testicular cancer or advanced prostate tumours. The influence of hypogonadism on physical performance is still not known. The purpose of this work was to verify the effect of bilateral orchiectomy on physical performance. Sixteen rats were divided into two groups: Group 1 (Control), in which only skin incision and suture were made (n = 5) and Group 2, in which the rats were submitted to bilateral orchiectomy (n = 11). The animals ran on a treadmill at the speed of 20 m min(-1) until they were fatigued and felt once, during 10 s, when the experiment was interrupted. Time to running and weight of animals were verified. The results were compared using the Mann-Whitney test. There was no difference on time to running - minutes - (P = 0.14) and weight - grams - (P = 0.25) between the animals submitted to orchiectomy (100 ± 44 min and 359 ± 38 g) and the control Group (81 ± 40 min to run and 327 ± 25 g). Bilateral orchiectomy does not affect the physical performance of the rat.

Update on clinical trials of growth factors and anabolic steroids in cachexia and wasting

This article and others that focused on the clinical features, mechanisms, and epidemiology of skeletal muscle loss and wasting in chronic diseases, which include chronic kidney disease, cancer, and AIDS, were presented at a symposium entitled "Cachexia and Wasting: Recent Breakthroughs in Understanding and Opportunities for Intervention," held at Experimental Biology 2009. The clinical and anabolic efficacy of specific growth factors and anabolic steroids (eg, growth hormone, testosterone, megestrol acetate) in malnutrition and other catabolic states has been the subject of considerable research during the past several decades. Research on the effects of these agents in cachexia or wasting conditions, characterized by progressive loss of skeletal muscle and adipose tissue, focused on patients with AIDS in the early 1990s, when the devastating effects of the loss of body weight, lean body mass, and adipose tissue were recognized as contributors to these patients' mortality. These same agents have also been studied as methods to attenuate the catabolic responses observed in cancer-induced cachexia and in wasting induced by chronic obstructive pulmonary disease, congestive heart failure, renal failure, and other conditions. This article provides an updated review of recent clinical trials that specifically examined the potential therapeutic roles of growth hormone, testosterone, oxandrolone, and megestrol acetate and emerging data on the orexigenic peptide ghrelin, in human cachexia and wasting.

Performance-enhancing sports supplements: role in critical care

Many performance-enhancing supplements and/or drugs are increasing in popularity among professional and amateur athletes alike. Although the uncontrolled use of these agents can pose health risks in the general population, their clearly demonstrated benefits could prove helpful to the critically ill population in whom preservation and restoration of lean body mass and neuromuscular function are crucial. Post-intensive care unit weakness not only impairs post-intensive care unit quality of life but also correlates with intensive care unit mortality. This review covers a number of the agents known to enhance athletic performance, and their possible role in preservation of muscle function and prevention/treatment of post-intensive care unit weakness in critically ill patients. These agents include testosterone analogues, growth hormone, branched chain amino acid, glutamine, arginine, creatine, and beta-hydryoxy-beta-methylbutyrate. Three of the safest and most effective agents in enhancing athletic performance in this group are creatine, branched-chain amino acid, and beta-hydryoxy-beta-methylbutyrate. However, these agents have received very little study in the recovering critically ill patient suffering from post-intensive care unit weakness. More placebo-controlled studies are needed in this area to determine efficacy and optimal dosing. It is very possible that, under the supervision of a physician, many of these agents may prove beneficial in the prevention and treatment of post-intensive care unit weakness.

Macronutrient supplementation and food prices in HIV treatment

Infection caused by HIV and malnutrition have a complex interaction and often coexist geographically. Malnutrition has synergistic immune effects and HIV affects nutritional status. HIV care and treatment programs are compelled to confront this dual burden to optimize HIV outcomes. In this article, we review the published literature concerning intervention studies in adults and children and the effect of food prices on HIV treatment programs. While the evidence base is relatively incomplete for specific macronutrient interventions in the context of HIV treatment, it is clear that a new standard of care is needed, guided by experience, rationale, and existing data, in which malnourished patients may easily access nutritional therapies within HIV treatment. From this clinical foundation, we may both treat patients and evaluate novel therapies. Some HIV care and treatment programs provide food-based supplements; however, rising food costs and economic instability may jeopardize the success of these programs. HIV treatment programs may struggle to meet the needs of patients with potential increased rates of malnutrition and food insecurity in the setting of high food prices.

Position stand on androgen and human growth hormone use

Hoffman, JR, Kraemer, WJ, Bhasin, S, Storer, T, Ratamess, NA, Haff, GG, Willoughby, DS, and Rogol, AD. Position stand on Androgen and human growth hormone use. J Strength Cond Res 23(5): S1-S59, 2009-Perceived yet often misunderstood demands of a sport, overt benefits of anabolic drugs, and the inability to be offered any effective alternatives has fueled anabolic drug abuse despite any consequences. Motivational interactions with many situational demands including the desire for improved body image, sport performance, physical function, and body size influence and fuel such negative decisions. Positive countermeasures to deter the abuse of anabolic drugs are complex and yet unclear. Furthermore, anabolic drugs work and the optimized training and nutritional programs needed to cut into the magnitude of improvement mediated by drug abuse require more work, dedication, and preparation on the part of both athletes and coaches alike. Few shortcuts are available to the athlete who desires to train naturally. Historically, the NSCA has placed an emphasis on education to help athletes, coaches, and strength and conditioning professionals become more knowledgeable, highly skilled, and technically trained in their approach to exercise program design and implementation. Optimizing nutritional strategies are a vital interface to help cope with exercise and sport demands (). In addition, research-based supplements will also have to be acknowledged as a strategic set of tools (e.g., protein supplements before and after resistance exercise workout) that can be used in conjunction with optimized nutrition to allow more effective adaptation and recovery from exercise. Resistance exercise is the most effective anabolic form of exercise, and over the past 20 years, the research base for resistance exercise has just started to develop to a significant volume of work to help in the decision-making process in program design (). The interface with nutritional strategies has been less studied, yet may yield even greater benefits to the individual athlete in their attempt to train naturally. Nevertheless, these are the 2 domains that require the most attention when trying to optimize the physical adaptations to exercise training without drug use.Recent surveys indicate that the prevalence of androgen use among adolescents has decreased over the past 10-15 years (). The decrease in androgen use among these students may be attributed to several factors related to education and viable alternatives (i.e., sport supplements) to substitute for illegal drug use. Although success has been achieved in using peer pressure to educate high school athletes on behaviors designed to reduce the intent to use androgens (), it has not had the far-reaching effect desired. It would appear that using the people who have the greatest influence on adolescents (coaches and teachers) be the primary focus of the educational program. It becomes imperative that coaches provide realistic training goals for their athletes and understand the difference between normal physiological adaptation to training or that is pharmaceutically enhanced. Only through a stringent coaching certification program will academic institutions be ensured that coaches that they hire will have the minimal knowledge to provide support to their athletes in helping them make the correct choices regarding sport supplements and performance-enhancing drugs.The NSCA rejects the use of androgens and hGH or any performance-enhancing drugs on the basis of ethics, the ideals of fair play in competition, and concerns for the athlete's health. The NSCA has based this position stand on a critical analysis of the scientific literature evaluating the effects of androgens and human growth hormone on human physiology and performance. The use of anabolic drugs to enhance athletic performance has become a major concern for professional sport organizations, sport governing bodies, and the federal government. It is the belief of the NSCA that through education and research we can mitigate the abuse of androgens and hGH by athletes. Due to the diversity of testosterone-related drugs and molecules, the term androgens is believed to be a more appropriate term for anabolic steroids.

beta(2)-Adrenergic agonist administration and strength training

beta(2)-Adrenergic agonists (beta(2)AA) produce myriad effects throughout the human body. Prescribed concurrently with theophylline for the bronchodilatory effects they offer in the treatment of asthma and chronic obstructive pulmonary disease, beta(2)AA actions include many beneficial and adverse changes when administered to animals at supraphysiological doses. Beneficial changes include improved musculoskeletal health and function, which can be maintained because adverse changes are reduced if oral beta(2)AA are given at therapeutic dosages in humans with concurrent resistive exercise administration. Combined oral beta(2)AA-resistive exercise treatments have been shown to produce gains in musculoskeletal health and function in numerous healthy and disuse atrophy human models. The mechanism(s) by which beta(2)AA exert their effects are a function of multiple factors, not the least of which includes the type of model receiving the drug treatment. Combined oral beta(2)AA-resistive exercise treatments in humans showed that adverse effects were greatly reduced when prudent and safer drug administration practices were employed (eg, screening subjects for tolerance before drug treatment). Results from human research trials suggest that administration of the combined treatment improves musculoskeletal function and performance with minimal health risk if proper precautions are followed. A related issue is administration of the combined treatment as an ergogenic aid to athletic performance. Given the results presented in this article, physicians should be wary of potential drug abuse and administer beta(2)AA only under appropriate circumstances when such a treatment is warranted.

Usage of megestrol acetate in the treatment of anorexia-cachexia syndrome in the elderly

The aim of this review is to assess the efficacy and safety of megestrol acetate (MA) in geriatric cachexia. The paper presented here reviews a previously published study of MA use in 69 patients in a randomized double blind placebo-controlled trial. This paper will also address the underlying pathogenesis of cachexia (specifically, the role of cytokines) along with the use of MA, its mechanism of action and its side effects.

OBJECTIVE

To compare the effects of MA oral suspension (O.S.), 800 mg/day, versus placebo on weight in geriatric nursing home patients with weight loss or low body weight.

DESIGN

Twelve weeks, randomized, double-blind, placebo-controlled trial with a 13-week follow-up period.

PATIENTS

Northport VAMC Nursing home patients with weight loss of * 5% of usual body weight over the past 3 months, or body weight 20% below their ideal body weight.

INTERVENTIONS

Patients were randomly assigned to receive placebo or MA 800 mg/d for 12 weeks and were then followed for 13 weeks off treatment and mortality 4 years post treatment.

MEASUREMENTS

Primary outcome- weight and appetite change. Secondary outcome-sense of well being, enjoyment of life, change in depression scale, laboratory nutrition parameters, energy intake counts, body composition, and adverse events.

RESULTS

At 12 weeks there were no significant differences in weight gain between treatment groups, while MA-treated patients reported significantly greater improvement in appetite, enjoyment of life, and well being. At week 25 (3 months after treatment), 61.9% of MA-treated patients had gained * 1.82 kg (4 lbs) compared to 21.7% of placebo patients. There was no difference in survival between MA and placebo groups. Considering possible confounders, higher initial IL-6, initial TNFR-p75 levels, and final neutrophil percentage were associated with elevated mortality, whereas higher initial pre-albumin, initial albumin, final pre-albumin, final albumin and final weight gain were associated with decreased death.

Effects of a supraphysiological dose of testosterone on physical function, muscle performance, mood, and fatigue in men with HIV-associated weight loss

Testosterone increases fat-free mass (FFM) in men infected with human immunodeficiency virus (HIV), but its effects on muscle performance, physical function, mood, and quality of life are poorly understood. Sixty-one HIV-infected men with weight loss were randomized to receive weekly intramuscular injections of 300 mg of testosterone enanthate or placebo for 16 wk. The primary outcome of interest was physical function (walking speed, stair-climbing power, and load-carrying ability). Secondary outcome measures included body weight and composition, muscle performance, sexual function, mood, and quality of life. Serum nadir free and total testosterone levels increased (+188.0 +/- 29.6 and +720 +/- 86 ng/dl) in the testosterone, but not placebo, group. Testosterone administration was associated with increased FFM (2.8 +/- 0.5 kg), which was significantly greater than in the placebo group (P < 0.0001). Leg press strength increased significantly in testosterone-treated (P = 0.027), but not placebo-treated, men; the difference between groups was not significant. Other measures of muscle performance and physical function did not change significantly in either group. Men receiving testosterone demonstrated significantly greater improvements in mental health and quality-of-life scores than those receiving placebo and improvements in fatigue/energy and mood scores that were not significantly different from those receiving placebo. Sexual function scores did not change in either group. In HIV-infected men with weight loss, a supraphysiological dose of testosterone significantly increased FFM but did not improve self-reported or performance-based measures of physical function. Improvements in mood, fatigue, and quality-of-life measures in the testosterone group, although clinically important, need further confirmation.

Cost-effectiveness of clinical interventions for AIDS wasting

Economic studies of HIV/AIDS interventions are important for providing cost-effective care. This paper presents a costeffectiveness study of a three-arm clinical trial conducted at Tufts University School of Medicine/New England Medical Center in Boston, Massachusetts that treated 50 patients with AIDS wasting from March 1998 through January 2001. This study compared the costs and impacts of a nutritional counseling intervention alone (NC arm), the nutrition intervention with oxandrolone (OX arm), and the nutrition intervention with progressive resistance training (PRTarm) for the treatment of AIDS wasting. The cost of each intervention was derived for both the three-month clinical trial and a six-month estimated community model (ECM), its projected adaptation to community-based medical care. The cost determination involved obtaining and multiplying unit economic costs and quantities expended of each resource within each study arm. The ECM average cost per client in the cost-effectiveness analysis incorporated both institutional and societal perspectives. The costeffectiveness analysis compared the cost of each intervention to its quality-adjusted life-year (QALY) gain (Zeckhauser and Shepard, 1976). From a societal perspective, for the NC arm, the cost per client totaled US dollars 983 for the actual and US dollars 596 under the ECM. For the OX arm, the cost per client totaled US dollars 3,772 for the actual study and US dollars 3,385 under the ECM. For the PRT arm, the cost per client totaled US dollars 3,189 for the actual study and US dollars 2,987 under the ECM. Under the societal perspective the cost per QALY was US dollars 55,000 (range: US dollars 51,000 to US dollars 83,000) for the NC arm, US dollars 151,000 (range: US dollars 149,000 to US dollars 171,000) for the OX arm, and US dollars 65,000 (range: US dollars 44,000 to US dollars 104,000) for the PRTarm. When using only an institutional perspective, the cost per QALY was US dollars 45,000 (range: US dollars 42,000-US dollars 64,000) for the NC arm, US dollars 147,000 (range: US dollars 147,000 to US dollars 163,000) for the OX arm, and US dollars 31,000 (US dollars 21,000 to US dollars 44,000) for the PRTarm. This paper shows that cost and cost-effectiveness analyses can be adapted to a community setting by combining information from community practice and costs with data from a randomized trial. Compared to other AIDS treatments, such as highly active antiretroviral therapies, all three interventions were affordable, but their cost-effectiveness was intermediate. Oxandrolone was the least cost effective of the interventions, even compared to nutrition alone, as it included similar or somewhat greater costs for less of an increase in quality of life. PRT was the most cost-effective treatment for AIDS wasting, particularly from an institutional perspective. Third party payers should consider coverage of PRT.

Use of Diet, Nutritional Supplements and Exercise in HIV-Infected Patients Receiving Combination Antiretroviral Therapies: A Systematic Review

Background

The use of combination antiretroviral therapy (cART) has improved the prognosis of HIV infection, but it has also been linked to a spectrum of body composition changes and metabolic alterations known as the lipodystrophy syndrome. Nutritional status could influence body composition changes.

Methods

We performed a systematic search of published peer-reviewed data on the effects of diet, nutrition support and exercise on body composition and metabolic complications in patients receiving cART.

Results

Few controlled studies, most of them with small sample size, were found. Oral nutritional support increases protein and energy intake, and results in body weight and fat mass gains. Resistance exercise, with or without an aerobic component, increases lean mass and can improve insulin resistance. Low-fat diets or exercise can result in loss of fat mass, and they should be used with caution in subjects with lipoatrophy.

Conclusions

Nutritional support and exercise result in small but significant body composition changes and can be used as complementary interventions. There is a need for further research on nutritional interventions in HIV-infected patients receiving cART.

Low sex hormone-binding globulin and testosterone levels in association with erectile dysfunction among human immunodeficiency virus-infected men receiving testosterone and oxandrolone

INTRODUCTION

Men with acquired immunodeficiency syndrome (AIDS) wasting and hypogonadism are frequently treated with testosterone and oxandrolone, an orally administered anabolic-androgenic steroid hormone. We observed reductions in testosterone and sex hormone-binding globulin (SHBG) levels, in association with complaints of erectile dysfunction, after prolonged exposure to this therapeutic regimen.

AIM

First description of an association between long-term receipt of oxandrolone with erectile dysfunction, low SHBG and testosterone.

METHODS

Case report of three human immunodeficiency virus-infected hypogonadal male patients receiving treatment for wasting syndrome and hypogonadism, and highly active antiretroviral therapy. All three patients received long-term oxandrolone in addition to testosterone replacement therapy.

RESULTS

Testosterone and SHBG levels for patients 1, 2, and 3, respectively: total testosterone 183, 71, and 151 ng/dL (260-1,000 ng/dL); free testosterone (not done for patient 3) 58.3 and 26.9 pg/mL (50-210 pg/mL); SHBG 6, 9, and 6 nmol/L (7-50 nmol/L). No other hormonal abnormalities were detected. Following discontinuation of oxandrolone, levels of total testosterone rose, consistent with increase in SHBG. One patient received repeat SHBG assay documenting rise in SHBG level. Patient 2 reported return of libido and early morning erections several weeks after discontinuation of oxandrolone.

CONCLUSIONS

Patients had erectile dysfunction in association with low testosterone and SHBG, in spite of exogenous testosterone replacement. Discontinuation of oxandrolone led to the normalization or improvement of testosterone levels in all three patients with symptomatic improvement in one patient. First pass metabolism of orally administered oxandrolone may decrease hepatic synthesis of SHBG, allowing exogenously supplied testosterone to be excreted. Further work is necessary to elucidate the relationship.

Megestrol acetate in cachexia and anorexia

The aim is to review major clinical trials that have used megestrol acetate (MA) in the treatment of cachexia across several disease states. A review of general usage and potential side-effects are discussed. A theory that the newly approved nanocrystal formation of MA can better deliver this potent medication for treatment will also be reviewed.

Quantification of testosterone and epitestosterone in human urine samples by stir bar sorptive extraction – thermal desorption – gas chromatography/mass spectrometry: Application to HIV-positive urine samples

A simple method is described for the measurement of testosterone (T) and epitestosterone (ET) in human urine samples. The deconjugated steroids were extracted directly from the samples by stir bar sorptive extraction (SBSE) and derivatized in situ on the stir bar by headspace acylation prior to thermal desorption and GC/MS. Extraction and derivatization parameters, namely salt addition, temperature, and time, were optimized to improve the recovery of T and ET by SBSE. The limits of quantification (S/N 10) were 0.9 ng/mL for T and 2.8 ng/mL for ET. Quantification of the steroids in urine samples was performed using standard addition to avoid the influence of matrix effects. The method was applied for the measurement of urinary T and ET in a group of healthy volunteers and HIV+ patients. Decreased levels of T were detected in the HIV+ group, whereas the excretion of ET was comparable for the two groups. Further clinical research is required to elucidate the biomarker significance of the T/ET ratio in HIV infection.

Physiological Basis of Fatigue

This work summarizes our knowledge of the physiological basis of fatigue and the effects of exercise and pharmacological interventions on fatigue. Fatigue may be defined as physical and/or mental weariness resulting from exertion, that is, an inability to continue exercise at the same intensity with a resultant deterioration in performance. The concept of deconditioning in patients is discussed as well as the implications for their rehabilitation and exercise. Because fatigue may result from a number of causes, including loss of muscle mass, deconditioning, nutritional deficiencies, oxygen delivery, and anemia, it should be treated comprehensively. Antifatigue therapy should be the standard of care for most chronic conditions associated with fatigue.

The effects of oxandrolone and exercise on muscle mass and function in children with severe burns

OBJECTIVES

Severe burns are associated with a significant loss of muscle and strength. Studies have reported that oxandrolone improves lean body mass in muscle-wasting conditions. Also shown previously in burned children is that an exercise program increases lean body mass and muscle strength. We hypothesized that oxandrolone, in combination with exercise, would increase lean body mass and muscle strength in severely burned children more than oxandrolone alone or exercise alone.

METHODS AND PATIENTS

Fifty-one burned children (> or = 40% total body surface area burned) were randomly assigned to receive oxandrolone alone (0.1 mg/kg per day orally; n = 9), oxandrolone and exercise (n = 14), placebo and no exercise (n = 11), or placebo and exercise (n = 17). Administration of oxandrolone was started at discharge and continued until 1 year after burn. The 12-week exercise training program was started 6 months after burn. Serum hormones, lean body mass, muscle strength, and peak cardiopulmonary capacity were assessed at 6 (baseline) and 9 months after burn. Data were analyzed using a 1-way analysis of variance, and significance was set at P < .05.

RESULTS

The mean percentage of change or increase in weight and lean body mass in the oxandrolone and exercise group was significant compared with placebo and exercise, as well as with the oxandrolone alone group or placebo and no exercise group. Furthermore, lean body mass was significantly improved in the oxandrolone and exercise, oxandrolone alone, and placebo and exercise group compared with the group only receiving placebo. Muscle strength significantly increased in oxandrolone and exercise, placebo and exercise, and the oxandrolone alone group when compared with the placebo and no exercise group. The peak cardiopulmonary capacity was significantly higher in both exercise groups. Insulin-like growth factor 1 was significantly increased in the oxandrolone alone group compared with placebo and exercise and placebo and no exercise. Both exercise groups showed significant changes in insulin-like binding-protein-3 when compared with groups without exercise.

CONCLUSIONS

Oxandrolone, in combination with exercise, is beneficial in severely burned children, thus improving their rehabilitation.

Advances in burn critical care

BACKGROUND

Management of burn patients requires a complex interaction of surgical, medical, critical care, and rehabilitation approaches. Severe burn patients are some of the most challenging critically ill patients who may have multiple-system organ failure with life-threatening complications.

OBJECTIVE

To review and highlight some of the recent advances in burn critical care. We focused on some of the new treatment modalities in the management of respiratory complications, advances in burn resuscitation, management of the metabolic response to burns, and recent ideas in burn immunotherapy.

DATA SOURCE

A search of the MEDLINE database and manual review of published articles and abstracts from national and international meetings. DATA SYNTHESES AND CONCLUSIONS: The respiratory management of burn patients includes strategies to minimize iatrogenic injury with low tidal volume ventilation, to improve ventilation/perfusion mismatch, and to diagnosis pneumonia. Many aspects of burn resuscitation remain controversial, and the best form of fluid resuscitation has yet to be identified. Recent research in the metabolic response to thermal injury has identified many potentially beneficial treatments. Although immunomodulation therapy is promising, currently most of these treatments are not clinically viable, and further clinical and translational research is warranted.

Effects of a supervised home-based aerobic and progressive resistance training regimen in women infected with human immunodeficiency virus: a randomized trial

BACKGROUND

Women infected with human immunodeficiency virus (HIV) increasingly demonstrate abnormalities in fat distribution and metabolism; however, the effects of a home-based exercise regimen in this group have not been investigated.

METHODS

We conducted a 16-week randomized intervention study of a supervised home-based progressive resistance training and aerobic exercise program in 40 HIV-infected women with increased waist-hip ratio and self-reported fat redistribution. Cross-sectional muscle area and muscle attenuation were measured by computed tomography. Cardiorespiratory fitness was determined by calculated maximum oxygen consumption (VO2max) and strength by 1-repetition maximum.

RESULTS

Cardiorespiratory fitness (VO2max) was markedly lower at baseline (median [95% confidence interval], 15.4 [8.3-25.2] mL x kg(-1) x min(-1)) than reported values for healthy female subjects (26-35 mL x kg(-1) x min(-1)). Subjects randomized to exercise had significant improvement in mean +/- SEM VO2max (1.5 +/- 0.8 vs -2.5 +/- 1.6 mL x kg(-1) x min(-1); P<.001) and endurance (1.0 +/- 0.3 vs -0.6 +/- 0.3 minute; P<.001). Strength increased at the knee extensors, pectoralis, knee flexors, shoulder abductors, ankle plantar flexors, and elbow flexors (all P<.001). Total muscle area (6 +/- 1 vs 2 +/- 1 cm2; P = .02) and attenuation (2 +/- 1 vs -1 +/- 1 Hounsfield unit; P = .03) increased in the exercise group. No significant difference was seen in lipid levels, blood pressure, or abdominal visceral fat between the groups, but subjects randomized to exercise reported improved energy and appearance.

CONCLUSIONS

A 16-week, supervised, home-based exercise regimen improved measures of physical fitness in HIV-infected women. The effects on strength were most significant, but improvements in cardiorespiratory fitness, endurance, and body composition were also seen.

Exercise interest and preferences among patients diagnosed with primary brain cancer

GOALS OF THE WORK

The purpose of the present investigation was to examine the interest and exercise preferences of an institution-based sample of brain tumor patients. Secondary aims were to examine potential differences in participant's interest and preferences by exercise behavior and select demographic/medical variables.

MATERIALS AND METHODS

Using a cross-sectional design, 106 brain tumor patients (age range, 32 to 83 years) who received treatment at the Preston Robert Tisch Brain Tumor Center (BTC) at Duke completed a questionnaire that assessed self-reported exercise behavior, exercise interest and preferences during active and off-treatment periods.

MAIN RESULTS

For exercise program preferences, participants were significantly more interested and felt more capable of participating in an exercise program following compared to during adjuvant therapy. Approximately equal proportions of brain tumor patients preferred to exercise at home with their spouse or other family members. These preferences were consistent across both cancer treatment-related time periods. For exercise information preferences, a higher proportion of respondents preferred receiving information via technologically based approaches (i.e., Internet, CD-ROM, and mailed correspondence) compared with more traditional methods (i.e., mail or face-to-face counseling). Chi-square analyses revealed that a small number of exercise program and information preferences were modified by exercise, medical, and demographic variables.

CONCLUSIONS

Brain tumor patients may have unique and varied preferences compared with other cancer populations. Incorporating patient's preferences into rehabilitation programs and clinical exercise investigations may optimize the potential benefits of this modality for patients with neurologic malignancies.

Effects of oxandrolone on outcome measures in the severely burned: a multicenter prospective randomized double-blind trial

Severe burns induce pathophysiologic problems, among them catabolism of lean mass, leading to protracted hospitalization and prolonged recovery. Oxandrolone is an anabolic agent shown to decrease lean mass catabolism and improve wound healing in the severely burned patients. We enrolled 81 adult subjects with burns 20% to 60% TBSA in a multicenter trial testing the effects of oxandrolone on length of hospital stay. Subjects were randomized between oxandrolone 10 mg every 12 hours or placebo. The study was stopped halfway through projected enrollment because of a significant difference between groups found on planned interim analysis. We found that length of stay was shorter in the oxandrolone group (31.6 +/- 3.1 days) than placebo (43.3 +/- 5.3 days; P < .05). This difference strengthened when deaths were excluded and hospital stay was indexed to burn size (1.24 +/- 0.15 days/% TBSA burned vs 0.87 +/- 0.05 days/% TBSA burned, P < .05). We conclude that treatment using oxandrolone should be considered for use in the severely burned while hepatic transaminases are monitored.