FOLFOX6 and bevacizumab in non-optimally resectable liver metastases from colorectal cancer

BACKGROUND

In patients with colorectal liver metastases (CLM) R0 resection significantly improves overall survival (OS).

METHODS

In this report, we present the results of a phase II trial of FOLFOX6+bevacizumab in patients with non-optimally resectable CLM. Patients received six cycles of FOLFOX6+ five of bevacizumab. Patients not achieving resectability received six additional cycles of each. A PET-CT was performed at baseline and again within 1 month after initiating treatment.

RESULTS

From September 2005 to July 2009, 21 patients were enrolled (Male/Female: 15/6; median age: 65 years). An objective response (OR) was documented in 12 cases (57.1%; complete responses (CRs): 3, partial response (PR): 9); one patient died from toxicity before surgery. Thirteen patients underwent radical surgery (61.9%). Three (23%) had a pathological CR (pCR). Six patients (46.1%) experienced minor postsurgical complications. After a median 38.8-month follow-up, the median OS was 22.5 months. Patients achieving at least 1 unit reduction in Standard uptake value (SUV)max on PET-CT had longer progression-free survival (PFS) (median PFS: 22 vs 14 months, P=0.001).

CONCLUSIONS

FOLFOX6+bevacizumab does not increase postsurgical complications, yields high rates of resectability and pCR. Early changes in PET-CT seem to be predictive of longer PFS.

FOLFOX6 and bevacizumab in non-optimally resectable liver metastases from colorectal cancer

BACKGROUND

In patients with colorectal liver metastases (CLM) R0 resection significantly improves overall survival (OS).

METHODS

In this report, we present the results of a phase II trial of FOLFOX6+bevacizumab in patients with non-optimally resectable CLM. Patients received six cycles of FOLFOX6+ five of bevacizumab. Patients not achieving resectability received six additional cycles of each. A PET-CT was performed at baseline and again within 1 month after initiating treatment.

RESULTS

From September 2005 to July 2009, 21 patients were enrolled (Male/Female: 15/6; median age: 65 years). An objective response (OR) was documented in 12 cases (57.1%; complete responses (CRs): 3, partial response (PR): 9); one patient died from toxicity before surgery. Thirteen patients underwent radical surgery (61.9%). Three (23%) had a pathological CR (pCR). Six patients (46.1%) experienced minor postsurgical complications. After a median 38.8-month follow-up, the median OS was 22.5 months. Patients achieving at least 1 unit reduction in Standard uptake value (SUV)max on PET-CT had longer progression-free survival (PFS) (median PFS: 22 vs 14 months, P=0.001).

CONCLUSIONS

FOLFOX6+bevacizumab does not increase postsurgical complications, yields high rates of resectability and pCR. Early changes in PET-CT seem to be predictive of longer PFS.

Contrast-enhanced MRI and PET-CT in the evaluation of patients with suspected local recurrence of rectal carcinoma

PURPOSE

This study aimed to evaluate the role of contrast-enhanced magnetic resonance imaging (MRI) and positron emission tomography-computed tomography (PET-CT) in the assessment of local recurrence of rectal cancer.

MATERIALS AND METHODS

Among 200 patients scheduled for CT follow-up, 60 (48 low risk; 12 high risk) were selected due to CT findings suspicious for or suggestive of local recurrence. Patients underwent contrast-enhanced MRI and PET-CT within 2 weeks. Biopsy was considered the gold standard in 39 cases and follow-up at 6 and 12 months in the remaining 21.

RESULTS

Local recurrence was confirmed by histology in 15 cases (7 low risk; 8 high risk) and was excluded in 21 cases by long-term follow-up and in 24 by histology. Sensitivity, specificity, positive and negative predictive value and accuracy were 86.7%, 68.9%, 48.1%, 93.9% and 73.3% for contrast-enhanced MRI and 93.3%, 68.9%, 50%, 96.9% and 75% for PET-CT.

CONCLUSIONS

Contrast-enhanced MRI and PET-CT can help in the detection of local recurrence of rectal cancer, even though their roles in early detection remains debatable, as the value of these techniques in current surveillance protocols is still to be defined.

Bone mass evaluated by calcaneous ultrasound and radial peripheral computed tomography in 726 youngsters

AIM

To compare the results of ultrasound and computed peripheral tomography in evaluating bone mass in a population of normal children.

METHODS

Seven hundred and twenty-six healthy school children (260 males; age 8.3-20.9 y) underwent calcaneous ultrasound and peripheral computed tomography at the ultradistal radius. Broadband ultrasound attenuation (BUA) and areal and volumetric bone mineral density (aBMD and vBMD) were evaluated. The results were compared and correlated among them and with auxological parameters (height, BMI and pubertal stages) using the software package SPSS for Windows.

RESULTS

The three variables examined (BUA, aBMD and vBMD) all showed a progressive increase with age and a positive correlation with age, height and BMI. When the population was subdivided according to pubertal stages, all variables showed a progressive increase, the difference being significant when stages 1-2 were compared with stages 4-5. A significant correlation was present among BUA, aBMD and vBMD even if the Pearson correlation coefficient was not high.

CONCLUSIONS

The similar pattern of BUA, aBMD and vBMD with respect to age, height and pubertal stages indicates that ultrasound could be a reliable method to screen bone mass abnormalities in children. The low correlation coefficient, however, suggests that the methods employed measure different bone parameters. Moreover, the different skeletal locations could also account for these results.

Scintimammography with 99mTc-MIBI and magnetic resonance imaging in the evaluation of breast cancer

This study was performed to evaluate the sensitivity and specificity of technetium-99m methoxyisobutylisonitrile (99mTc-MIBI) scintimammography (SMM) and contrast-enhanced magnetic resonance imaging (MRI) in patients with breast masses, using the histological findings as the gold standard. Forty-five consecutive patients with a breast lesion, detected by self-examination, physical examination or screening mammography, underwent SMM and MRI. In 38 cases (84.5%), the histopathology was malignant; the breast cancers ranged from 3 to 100 mm in diameter (mean 22 mm). In the overall patient group, MRI showed a slightly higher sensitivity than SMM (92% vs 84%), but SMM showed a better specificity: 71% vs 42%. The accuracy was 82% and 84% for SMM and MRI respectively. To evaluate the influence of lesion size on the results, patients with lesions < or =20 mm and < or =15 mm were examined. In patients with lesions < or =20 mm, the sensitivity of SMM and MRI decreased to 64% and 82% respectively, while SMM again displayed considerably better specificity: 83% vs 50% for MRI. The accuracy of SMM and MRI was 64% and 82% respectively. In patients with lesions < or =15 mm, SMM again showed better specificity (75% vs 50%), while MRI displayed better sensitivity and accuracy (sensitivity, 81% vs 62%; accuracy, 75% vs 65%). In this study the specificity of SMM in patients with breast lesions was thus superior to that of MRI. The combination of SMM and MRI may be used in those patients with equivocal findings at mammography and ultrasound to reduce the number of unnecessary surgical biopsies.

Peripheral quantitative Computed Tomography (PQCT) in the evaluation of bone geometry, biomechanics and mineral density in postmenopausal women

AIM

Non-invasive assessment of bone geometry, biomechanics, and mineral content in postmenopausal women by peripheral quantitative Computed Tomography (pQCT).

MATERIAL AND METHODS

Total, trabecular and cortical mineral density (totBMD, cortBMD, trabBMD), and the geometrical (total area, trabecular area, cortical area) and biomechanical properties of bone (strength-strain index, cortical thickness) were assessed in 93 consecutive post-menopausal women (mean age: 63+/-7 yrs; age at menopause: 49+/-6 yrs; years since menopause: 14+/-9 yrs) by pQCT at the ultradistal radius of non-dominant forearm.

RESULTS

Compared with 50 healthy women at peak of bone mass, volumetric total, trabecular and cortical bone densities were significantly reduced in postmenopausal subjects (TotBMD: 318+/-106 mg/cm3 vs ctr 442+/-100, -28%, p<0.001; TrabBMD: 117+/-59 mg/cm3 vs ctr: 203+/-47, -42%, p<0.001; CorBMD: 764+/-159 mg/cm3 vs 921+/-111, -17%, p<0.001). The bone loss was greater in trabecular bone. Cortical area (0.7+/-0,1 cm2 vs ctr: 0.8+/-0.1, -12.5%, p<0.001), cortical thickness (0.151+/-0.02 cm vs ctr: 0.169+/-0.03, -11%, p<0.001), and strength-strain index (686+/-207 mm3 vs ctr: 883+/-165, -22%, p<0.001) were significantly lower in post-menopausal women in comparison with the controls. Years since menopause and age showed a significant negative correlation with bone mineral densities and biomechanical parameters.

CONCLUSIONS

In post-menopausal women pQCT showed: 1) osteopoenia in all bone compartments, greater at the trabecular level, related to age and years since menopause; 2) reduced cortical density and cortical thickness, consistent with a reduced ability of bone to absorb loading forces; 3) reduced strength-strain index, indicative of inability to adapt to mechanical use and augmented risk for fracture. We conclude that pQCT is a valuable tool for measuring the true volumetric mineral density and the geometrical and biomechanical indexes of bone, which could be proposed in current clinical practice for the assessment of osteoporosis.

[Peripheral quantitative Computed Tomography (pQCT), broad ultrasound attenuation (BUA) and speed of ultrasound (SOS) in a normal population (426 females) aged 8 to 20 years]

PURPOSE

To evaluate, in a population of young healthy females aged from 8 to 20 years the bone mass peak (or density), the normal ranges versus age and menarche-age using two methods: pQCT (peripheral Quantitative Computed Tomography) and ultrasound absorptiometry.

MATERIAL AND METHODS

From 1998 to 2000 selective measurement of Bone Mineral Density (BMD) of trabecular bone at the ultradistal radius using pQCT, BUA (Broad Band Attenuation) and SOS (Speed of Sound) was carried out on 426 healthy females (aged from 8 to 20 years) in north Italy. BMD was measured using a single photon miniaturized tomographic scanner in the ultradistal radius, SOS and BUA were measured at the same time, using a water bath device obtaining parametric bidimensional images of BUA and SOS. The population studied refers to normal females free of bone metabolism alteration, in pre and post-pubertal status.

RESULTS

A normal range of BMD, BUA and SOS versus age and menarche age were established. A linear correlation was found between BUA and BMD measured with pQCT. SOS does not show any correlation with BMD. The pre-puberty and the post-puberty groups show statistically significative differences between SOS, BUA and BMD. We found the peak bone density (measured with pQCT) in the trabecular bone at the ultradistal radius at 15 years of age (mean menarche age of 10 years). The same position of the peak was found for BUA, for SOS the situation is not well defined. The analytical fitting of the data highlights a polynomial correlation of BMD vs. age, SOS vs. age, BUA vs. age.

CONCLUSIONS

It appears that sexual growth influences the position of peak bone density. The results obtained show a statistically significant correlation between BUA and BMD and age, the menarche-age and the period of exposure of bone tissue to oestrogen. After all, pQCT and ultrasound are useful techniques to evaluate bone density and structure also in a growing population. The results of this study show that it is possible to use bidimensional quantitative ultrasound devices in clinical practice also in young populations taking in account age and sexual development.

How gender and age affect iodine-131-OIH and technetium-99m-MAG3 clearance

OBJECTIVE

The relationship between age and effective renal plasma flow (ERPF) results, as measured in nuclear medicine, is well known. This paper explores the relationships among gender, age, and ERPF measurements. After reading this paper, the nuclear medicine technologist should be able to: (a) discuss the importance of establishing normal range values for ERPF that include age and gender variables; (b) state how age affects ERPF results; and (c) state how gender affects ERPF results.

pQCT (quantitative peripheral tomography) and data evaluation of phosphocalcic metabolism in thalassaemic patients

pQCT is a method which allows the separate determination of cortical and trabecular bone mineral density in the peripheral skeleton. 21 thalassaemic patients (8 females, 13 males) aged from 10 to 32 years, were examined using pQCT at the ultra distal radius to evaluate SSI (Stress-Strain Index). ALP, serum calcium, hydroxyproline, magnesium, IGF-I, and body surface were determined. The results show a good correlation between cortical BMD and age, concentration of hydroxyproline in urine, serum bone Gla protein, body surface index, bone density of trabecular bone and SSI. Good correlation was found between trabecular bone density and age, IGF-I, BGP and PTH, and between SSI and cortical BMD, age and BSI. The linear relationships between age and cortical and trabecular density show an increase of cortical BMD with age and a decrease of trabecular density with age. The same results were obtained considering trabecular and cortical density versus SSI.

Renal SPECT with Tc-99m DMSA in children with upper urinary tract infections using a triple-headed gamma camera

Renal cortical scintigraphy with Tc-99m DMSA provides an excellent imaging modality for the assessment of cortical damage secondary to upper urinary tract infection (UTI).

METHODS

The authors evaluated 48 children with UTI, 12 of whom had a history of vescico-ureteral reflux (from first of fourth degree), by planar scintigraphy and SPECT using a triple-headed gamma camera equipped with parallel-hole, high-resolution collimators.

RESULTS

SPECT images yielded positive findings in 36 kidneys, whereas planar scans yielded positive findings in 18 kidneys. The total number of lesions detected by SPECT was 51, whereas the number found with the planar technique was 23.

CONCLUSION

This study demonstrates the superiority of SPECT scanning in detecting kidney lesions in children with UTI.

Long-term in vitro precision of single slice peripheral Quantitative Computed Tomography (pQCT): multicenter comparison

In a multicenter evaluation the precision and stability of single slice peripheral Quantitative Computed Tomography (pQCT) systems were assessed. Compared to central Europe the peripheral QCT device is also widely used in the Italian health care system. Phantoms were measured frequently on each machine in four pQCT scanners over a two-year period using an identical automated software program. Intrasite and intersite phantom mineral densities, expressed in units of mg/cm3, were analyzed and examined. The short and long term precision were estimated from the consistency of these measurements using the root mean square error and expressed as coefficient of variation in percent (% CV). Short term precision was good (mean intrasite coefficient of variation (CV) 0.21 +/- 0.056 standard deviation (SD)). Intersite measurements of a single phantom revealed differences between machines of the same type of not more than 2.9 mg/cm3. At four sites frequent phantom measurements revealed a mean CV of 0.18% (range 0.12-0.28). No significant changes in the regression slopes (drift of the machine versus time) were observed. We conclude that the in vitro precision and stability of the single slice pQCT systems are sufficiently high and unlikely to negatively affect the in vivo precision.

[Diagnostic imaging of osteoid osteoma]

Conventional radiography, bone scintigraphy and Computed Tomography (CT) are the most useful tools to identify osteoid osteomas. We examined 26 patients (14 men and 12 women) with osteoid osteoma in different skeletal sites (13 femora, 3 tibiae, 3 hands, 2 peroneal bones, 2 humera, 2 spines and 1 talus) and compared the diagnostic yield of the above techniques. The fundamental radiographic findings in this benign bone lesion are the presence of a "nidus", with or without calcifications, perilesional sclerosis and periosteal new bone formation. Four patients in our series had soft tissue edema. In the majority of cases, conventional radiography is the imaging method of choice, because it is easily available and its diagnostic yield is adequate (17 patients in our series), especially if combined with bone scintigraphy-whose high diagnostic sensitivity was proved in all of our patients. CT is recommended for its better spatial resolution, in view of surgery, especially when soft tissues are involved. MRI is a highly valuable tool in bone tumor staging because it demonstrates cortical involvement and intramedullary and soft tissue spread. However, MR findings might be misinterpreted as indicating a more aggressive pathologic process.

An unusual adrenal metastasis secondary to Hürthle cell carcinoma of the thyroid

A 66-year-old woman with Hürthle cell thyroid carcinoma associated with a right adrenal gland metastasis suspected on a postradioiodine therapy scan, is reported. Histology specimens confirmed the suspicion. Adrenal metastases have never been reported previously in this kind of tumor. On radionuclide imaging, there was marked I-131 uptake in the tumor remnant and its metastases, and the tumor spread through both lymphatic and hematogenous routes, as shown by lymph node, bone, and lung metastases.

Periprosthetic bone density in uncemented femoral hip implants with proximal hydroxylapatite coating

The short term results of a prospective dual energy x-ray absorptiometry (DEXA) study of periprosthetic bone remodeling around titanium femoral stems proximally coated with hydroxyapatite are presented. Thirty patients underwent DEXA scanning on the 15th and 45th postoperative days, 12th, 18th postoperative month. DEXA showed global femoral periprosthetic remodeling during the first 18 postoperative months. However, no significant variation in bone mineral density occurred around the lateral metaphyseal regions, where cancellous bone is greatest.

Cytokeratin tumor marker levels in bronchial washing in the diagnosis of lung cancer

STUDY OBJECTIVE

The monitoring of serum concentrations of Cyfra 21-1, tumor polypeptide antigen (TPA), and tissue polypeptide specific antigen (TPS) has been demonstrated to be useful in the clinical treatment of patients with lung cancer. This study was planned to evaluate the clinical usefulness of the assay of these tumor markers on bronchial washing (BW) fluid and to compare it with serum assay in patients with neoplastic and nonneoplastic disease.

STUDY DESIGN

Serum and BW fluid levels of Cyfra 21-1, TPA, and TPS were measured in 40 subjects (10 control subjects, 11 with chronic bronchitis, 10 with squamous cell lung cancer, and 9 with nonsquamous cell lung cancer) undergoing diagnostic bronchoscopy. BW was performed using 25 mL of pyrogen-free saline solution instilled through the working channel of the bronchoscope, and successively aspirated. The quantity of the fluid recovered was measured and used for the assay of albumin, Cyfra 21-1, TPA, and TPS.

RESULTS

Mean BW concentrations of Cyfra 21-1, TPA, and TPS concentrations were significantly higher than serum concentrations (p < 0.01). Serum Cyfra 21-1, TPA, and TPS concentrations were significantly lower in controls and in those with chronic bronchitis than in patients with epidermoid and nonepidermoid carcinoma (p < 0.01). No difference in serum concentrations of the three markers was observed between controls and patients with chronic bronchitis. On the contrary, BW Cyfra 21-1 and TPA concentrations were significantly higher in those with chronic bronchitis and in cancer patients than in controls (p < 0.01), whereas they did not differ between patients with chronic bronchitis and cancer patients. No significant difference in BW TPS concentration was observed among the four groups. Sensitivity and specificity of the BW markers in diagnosing lung cancer were as follows: 68.4% and 61.9% for Cyfra 21-1; 68.4% and 66.6% for TPA; and 57.9% and 66.6% for TPS.

CONCLUSIONS

BW fluid concentrations of Cyfra 21-1 and TPA are increased in patients with chronic bronchitis and in patients with lung cancer. Being unable to distinguish malignant from nonmalignant inflammatory conditions, the measurement of airway concentrations of such markers has a too-low specificity to be considered useful in diagnosing malignant abnormalities of the lung.

Relationship between physical activity level and bone mineral density in two groups of female athletes

In order to evaluate the possible relationships among hormonal status, physical activity and bone density, we carried out a study on two groups of female athletes engaged in different levels of physical activity. We measured the following hormones: luteinizing hormone (LH), folliculo-stimulating hormone (FSH), 17-beta-oestradiol (E2), progesterone (PRG), prolactin (HPRL), estrone (E1), thyreo-stimulating hormone (TSH), free thyroxine (FT4), and the markers of phosphate-calcium metabolism: calcitonine (CT), parathormone (PTH), and osteocalcine (BGP). We also measured bone mineral density (BMD). All of these variables were related to the amount of work performed during training. The groups were defined as follows: medium workload (group M, n = 10) and heavy workload (group H, n = 20), engaged in 10 and 18 hours of weekly training at 35 and 60 average percent of VO2max, respectively. All of the hormones and the markers of calcium-phosphate metabolism studied were normal; BMD was also normal for all subjects except for two sisters in group M with reduced BMD. The group H athletes with regular menstrual cycles were found to have an upper limit normal BMD. From these data we conclude that in regularly menstruating athletes an increase in BMD induced by heavy physical activity is evident, while in dysmenorrhoeic athletes the effect of physical activity compensates, to some extent, for the hypothetical bone mineral reduction possibly caused by the hormonal imbalance.

A brain metastasis, with no uptake of 99mTc-ECD, secondary to Hurtle cell carcinoma of the thyroid

Visualization of cerebral perfusion with Single Photon Emission Computed Tomography (SPET) needs lipophil radiotracers which are able to cross the intact blood-brain-barrier (BBB); moreover local uptake must reflect regional cerebral blood flow. In the last decade many radiopharmaceuticals have been suggested and employed for this purpose. Recently a new molecule has been synthesized: technetium-99m-labeled ethyl cysteinate dimer (99mTc-ECD). Commonly, SPET of the brain with perfusion tracers is performed to identify ischemic regions. We describe a patient with a bulky cerebral metastasis, secondary to Hurthle cell carcinoma of the thyroid, which concentrated radioiodine. Brain metastases secondary to differentiated carcinoma of the thyroid are very rare and when treated with 131-I may provoke serious neurological problems. Therefore we decided to perform a brain SPET with 99mTc-ECD to exclude regional perfusion defects and deafferentation phenomena. Brain CT showed only the large metastasis. SPET images, reconstructed according to standard tomographic planes of the head: transverse, coronal and sagittal revealed no uptake of 99mTc-ECD within the metastasis and no regional perfusion defects related to compression phenomena or deafferentation. 99mTc-ECD has never been used to image cerebral neoplasm of whatever origin.

A case of bronchial carcinoid: diagnosis and follow-up with 111In-DTPA-octreotide

Scintigraphy with radiolabelled analogue of somatostatin is highly sensitive in detecting carcinoid tumors especially if performed with Single Photon Computed Tomography (SPECT). In this report we describe our experience with 111In-DTPA-Octreotide in a female patient affected by a small asymptomatic intrabronchial carcinoid demonstrated by CT scan and bronchial endoscopy performed after recurrent left pneumonias. Planar views and SPECT images, using 111In-DTPA-Octreotide, were collected before and four hours after the first endoscopic laser resection. All groups of SPECT images were positive in the left parahilar region but at a different degree. Scans performed after resection showed a low degree of uptake which was considered to be probably secondary to local swelling; CT scan was negative. Follow up endoscopic biopsy repeated at six months, showed a relapse always in the same site; CT scan of the thorax was again negative. 111In-DTPA-Octreotide images obtained at twelve months were positive always in the left parahilar region, CT scan was negative but another biopsy was not possible. Therefore it was suspected a relapse of the carcinoid which was probably growing only through the bronchial wall without spreading towards the bronchial lumen and/or the lung parenchima. In this occasion, it was also thought that images collected four hours after resection could be positive not only for swelling but for a relapse as well. In every scintigraphic session, SPECT images presented higher quality than planar. This case suggests that 111In-DTPA-Octreotide SPECT is a non-invasive diagnostic technique which could be applied as a follow-up tool especially to patients with no-secreting carcinoid neoplasm and/or with negative or doubtful endoscopic and radiological investigations.

131I MIBG/111In octreotide mismatch in a patient with liver metastases secondary to a carcinoid of unknown origin

Carcinoids, tumors arising from enterochromaffin cells, represent the most common type of gastrointestinal endocrine neoplasm; they are often multiple and may appear anywhere in the gut. Carcinoid tumors may also occur in bronchi and ovaries. Classic symptomatology includes secretory diarrhea, flushing, edema, bronchospasm and cutaneous teleangectasias; however, over 30% of patients with demonstrably elevated serotonin levels may not exhibit any symptoms at all. The diagnosis of carcinoid tumor is typically made by measurement of 24-hour urinary excretion of 5-hydroxyindoloacetic acid. Commonly, tumor localisation is established with CT, US, NMR and arteriography. MIBG scintigraphy is also used to visualize tumors deriving from neuroendocrine cells as carcinoid. These tumors may express somatostatin receptors located on the cell surface. Therefore 111In Octreotide (Octreoscan), a somatostatin analogue, can be employed for tumor localisation. A 32-years-old man with liver metastases secondary to a carcinoid tumor of unknown origin is presented. Classic carcinoid symptoms were absent. Diagnosis was supported by elevated values of urinary 5-hydroxyindolocetic acid and liver fine-needle aspiration. Abdominal US and CT scan detected only liver masses but not the primary tumor. Arteriography was not performed. 131I MIBG and 111I octreotide scans both failed in locating the primary cancer too; only the second tracer showed marked uptake in liver metastases. Beside localization, these two tracers give also informations about the following therapy especially in malignant tumors where local resection isn't an adequate treatment.

SPET imaging of intracranial tumours with 99Tcm-sestamibi

Single photon emission tomography (SPET) employing 99Tcm-sestamibi (MIBI) injected intravenously was performed in 27 patients for pre-surgical evaluation of intraparenchymal brain tumours. A computerized tomography (CT) scan was performed in 26 patients, magnetic resonance imaging (MRI) in 8 patients and digital subtraction angiography (DSA) in 14 patients. Visual analysis of the SPET scans was performed using a 4-point scale relating to background activity, to evaluate MIBI uptake in the tumour. The vascular supply and the cellular component were also evaluated using DSA and CT scans. In normal controls, MIBI uptake was observed in the scalp, in the choroid plexus and in the pituitary gland, but never in normal parenchyma. Among the astrocytoma group of patients, a trend between MIBI uptake and grade of tumour was noted. MIBI uptake in meningiomas depends primarily on the vascular supply. Our results support the hypothesis that vascular supply, integrity of the blood-brain barrier, the degree of malignancy of the neoplasm and the viability of the tumour cells may be related to MIBI uptake.

The menopausal transition: a dynamic approach to the pathogenesis of neurovegetative complaints

In our cross-sectional study we investigated the separate influence of three main factors, namely menopausal and estrogen status, and chronological age, on ten neurovegetative climacteric complaints reported in the scale of Kupperman et al. A multivariate statistical analysis was performed by a multivariate statistical approach on 1161 untreated women seen at the Menopause Center of the Ferrara University Hospital. Ninety women (age range, 41-54 years) were premenopausal; 492 women (age range, 38-55 years) were perimenopausal with irregular periods or amenorrhea for less than 12 months; 468 women (age range, 41-69 years) had a spontaneous menopause (age range, 37-66 years); 111 had had hysterectomy with bilateral ovariectomy while still regularly menstruating. Serum estrone was used as the indicator of the patients' estrogen status. A clear positive trend was demonstrated between menopausal status and the prevalence of depression, hot flushes, insomnia and joint pain. However, only the prevalence of hot flushes amongst these four symptoms was significantly related with the climacteric estrogen decline (beta = -0.006, P = 0.001). Moreover, menopausal status appeared to influence the intensity of fatigue, hot flushes, insomnia and paresthesia. Age was found to significantly (P = 0.053) co-vary only with the intensity of the hot flushes, with a positive relation (beta = 0.092, r = 0.104, P = 0.003), whereas estrone values did not significantly co-vary with any symptom. Furthermore, while neurovegetative symptoms are largely present also in the absence of hot flushes, when these latter are present, they exacerbate both the intensity and the prevalence of all the other symptoms.(ABSTRACT TRUNCATED AT 250 WORDS)

[Skeletal changes in the kidney transplant patient]

The skeletal status was investigated with noninvasive diagnostic procedures in 44 renal transplant patients (mean time since intervention: 5 to 195 months) treated with steroid and azathioprine (21 cases) or with steroid, azathioprine and cyclosporine (23 cases). 38.6% of the patients had reduced renal function (creatininemia: 1.6-3.0 mg/dl). Our patients underwent biochemical and hormonal tests of bone metabolism, digital radiographs of the skeleton and bone mineral density measurement with dual-energy X-ray absorptiometry (DXA, Hologic QDR 1000). All the patients exhibited moderate to severe osteopenia at both radiographic and densitometric investigations; the risk of fracture was high in 47% of cases. Radiographic signs of vertebral fractures were observed in 4.5% of cases. Other major radiographic patterns were the aseptic necrosis of femoral head (9%), of carpal bone (4.5%) and of humeral head (2.2%). Fibrous osteitis was demonstrated in three patients. Geodes in the wrist were also observed. The correlation of bone densitometry values and time since renal transplantation was statistically significant (r = 0.381; p < 0.01). Moreover, the grade of osteopenia correlated with serum levels of calcitonin and calcitriol--the latter especially in the patients with severe osteopenia.

Effect of different treatment regimes on linear growth and final height in beta-thalassaemia major

OBJECTIVE

The clinical picture of thalassaemia major has changed progressively over the years. Our study is a retrospective analysis of data on growth in a group of patients who have completed puberty spontaneously and have attained their adult height. Our objective was to evaluate the effect of different transfusion regimes and desferrioxamine administration on the growth pattern in beta-thalassaemia major.

DESIGN AND PATIENTS

We studied 64 patients (28 males and 36 females). The patients were divided into three groups (A, B and C) according to the different transfusion regimes and the schedules of chelating therapy. Group A consisted of 16 patients who were transfused regularly at low haemoglobin levels (on average 8.5 g/dl) from an early age and started subcutaneous chelation therapy during adolescence. Group B consisted of 19 patients who were transfused regularly at high haemoglobin levels (on average 10 g/dl) from an early age and started subcutaneous therapy during childhood. Group C consisted of 29 patients who were transfused regularly at high haemoglobin levels (on average 10.5 g/dl) from an early age and started subcutaneous chelation therapy very early, at a mean age of 2 years. Standard auxological measurements were made at 3-monthly intervals throughout childhood and puberty until adult height was achieved. For group C patients the data on linear growth are provided only until the age of 12 years.

RESULTS

Our study indicates that group A male and female patients did not grow significantly better than those in group B. Group C male and female patients, surprisingly, grew no faster than those who started chelation therapy late in childhood (group A). The most striking feature in the majority of both group A and B patients was reduced spurt in height at puberty. In addition, in both groups, a reduced sitting height due to spinal growth abnormality was found. An inverse correlation between sitting height and serum ferritin levels was observed in group A patients (r = -0.55, P < 0.05), whereas there was a direct correlation in group B patients (r = 0.42, P < 0.05).

CONCLUSIONS

These data suggest that an ideal therapeutic regime has yet to be found which avoids the toxic effect of iron overload and on the other hand avoids interference with growth, secondary to desferrioxamine. Therefore we recommend that the growth of thalassaemia patients be monitored routinely at every follow-up visit and documented on growth velocity charts in order to detect early changes in their growth pattern and to establish an appropriate protocol for investigation and treatment.

Continuing loss of vertebral mineral density in renal transplant recipients

This cross-sectional study examined bone abnormalities by digital radiography, bone densitometry and biochemical tests in 44 clinically asymptomatic renal transplant recipients 6-195 months after renal transplantation. Abnormal radiographs were obtained in 40 of the 44 patients. Dual-energy X-ray absorptiometry (DXA) performed at the lumbar spine (L2-L4)/showed a negative Z score in all patients, ranging from -1 to -1.9 in 28 patients and less than -2.0 in 16 patients. The severity of osteopenia increased with the length of time after transplantation and there was a significant correlation with parathyroid hormone values in patients with normal and low glomerular filtration rates. Our data suggest that decreased bone density values (Z score less than -2) are present in about one-third of patients with renal transplants. Bone loss appears to continue after transplantation. Steroid therapy and immunotherapy are probably the cause of this bone loss. Bone mineral measurements alone are helpful in identifying asymptomatic patients with low bone mass after transplantation.

Pubertal development in thalassaemic patients after allogenic bone marrow transplantation

To obtain further insight into gonadal function, a series of 50 prepubertal patients with beta-thalassaemia major (24 boys and 26 girls) aged from 12.6 to 18 years (mean 15 years) who had received a bone marrow transplantation (BMT) during childhood or the peripubertal period, at the age of 3.6-14.5 years (mean 10.8 years), were periodically re-evaluated at intervals of 6-12 months. The last evaluation was done 1-9 years (mean 4.2 years) after BMT. At each examination we measured height, pubertal stage, plasma gonadotrophins (LH and FSH) before and after the GnRH stimulation test (i.v.), sex steroids (total and free testosterone in males, and 17 beta-oestradiol in females), serum ferritin and bone age. Fourty percent of patients entered or passed through puberty normally despite clinical and hormonal evidence of gonadal dysfunction in most of them. A correlation was not found between the pubertal stage and age at BMT, and no statistical difference between patients who did not enter into puberty and patients with spontaneous pubertal development was found in serum ferritin levels. Our data confirm that gonads in male and female thalassaemic patients are exposed to the cytotoxic effects of the preparative transplant regime with alkylating agents. In some patients absence of pubertal development was due to gonadotrophin insufficiency, probably secondary to previous iron overload. These findings emphasize the need for a vigilant long-term follow up study of thalassaemic patients who have had BMT.

Pharmacokinetics of sex steroids in patients with beta thalassaemia major

AIMS

To assess the pharmacokinetics of oral, intramuscular, or transdermal hormone replacement in patients with beta thalassaemia major.

METHODS

Oral (testosterone undecanoate 40 mg) and intramuscular (testosterone propionate 15 mg, phenylpropionate 30 mg, isocaproate 30 mg and decanoate 50 mg) testosterone and transdermal (17 beta oestradiol 25 micrograms and 50 micrograms) oestradiol were evaluated in 21 male (16-29 years) and 11 female (19-26 years) patients with beta thalassaemia major and various forms of hypogonadism.

RESULTS

In male patients given oral testosterone, peak testosterone concentrations were observed either two to four hours or seven hours after administration; intramuscular testosterone produced peak values seven days after injection. Transdermal 17 beta oestradiol given to female patients produced a biphasic pattern with an initial peak concentration occurring at 36 hours and a secondary rise at 84 hours.

CONCLUSIONS

The results indicate that oral androgens should be given twice daily in cases of hypogonadism, and where growth is incomplete, lower than recommended doses. If intramuscular testosterone is used, smaller doses of 10-25 mg should be given every one to two weeks. Transdermal administration of 25-50 micrograms 17 beta oestradiol generally produces a plasma E2 value in the early to mid-follicular phase range (100-300 pmol/l). This is appropriate in adults but excessive for prepubertal girls. Diffuse iron infiltration of tissues does not seem to interfere with the absorption of androgens and oestrogens from the gut, muscle, or skin.

[Osteoporosis and the thalassemia "trait"]

The authors evaluated the prevalence of the thalassemia trait in a general population affected with femoral neck fractures. Our research was aimed at assessing whether hemoglobinopathy might affect osteoporosis, which is responsible for femoral fractures. Two hundred and thirty-eight patients admitted to St. Anna Hospital, Ferrara, for proximal femoral fractures, were retrospectively studied. The patients were 68 males and 170 females, aged 58 to 83 years (mean age: 70.4 years). The thalassemia trait was seen in 11.76% of cases, versus in 7-8% of the general population. The high prevalence of heterozygous beta-thalassemic subjects probably means that the beta-thalassemia condition is a further "variable" which is responsible for the more frequent occurrence of fractures of the proximal femur and is certainly related to an osteopenic condition much more severe than usual.

[The radiology of osteogenesis imperfecta]

The term "osteogenesis imperfecta" refers to a heterogeneous group of hereditary diseases characterized by osteopenia, increased bone fragility, blue sclerae and dentinogenesis imperfecta. The abnormal synthesis of type-I collagen is responsible for the pathologic changes occurring not only in bone, but also in skin, tendons and ligaments, sclerae and teeth. The clinical and radiographic features of 5 cases (2 males and 3 females; age range: 1 month to 29 years) were analyzed. The patients were unrelated with each other. The diagnosis of the different types of osteogenesis imperfecta is as difficult as the identification of the various genotypes which are responsible for the different clinical pictures. The most characteristic radiographic pattern--which is observed in any type of the disease--consists in osteopenia associated, in most cases, with multiple fractures and deformities--e.g., micromelia, large metaphysis, archon long bones. Typically, "pop corn" calcifications are observed in both epiphysis and metaphysis of long bones. Dentinogenesis imperfecta is one of the most significant clinical patterns, and it can be the only bone abnormality. The prognosis of osteogenesis imperfecta is as varied as its genetics--i.e., the fractures discovered at birth are not necessarily a negative prognostic sign.

Low-dose intravenous calcitriol treatment of secondary hyperparathyroidism in hemodialysis patients. Italian Group for the Study of Intravenous Calcitriol

Intravenous calcitriol is known to directly suppress PTH secretion and release. We evaluated the effect of four months of treatment with low-dose intravenous calcitriol on PTH levels in 83 hemodialysis patients. The criteria for including patients in the study were a serum PTH levels at least four times the normal limit, a serum total calcium less than 10 mg/dl and good control of the serum phosphorus level. All patients underwent standard bicarbonate or acetate dialysis; dialysate calcium level was maintained at the usual 3.5 mEq/liter concentration. Initial calcitriol dose was 0.87 +/- 0.02 (SEM) micrograms (0.015 micrograms/kg body wt) thrice weekly at the end of dialysis, and it was reduced in case of hypercalcemia or elevated calcium-phosphate product. Seven out of 83 patients dropped out during treatment. Among the 76 patients who completed the study, 58 (76%) showed a highly significant decrease of intact PTH levels (average reduction 48%) and of alkaline phosphatase levels after four months of therapy. Total serum calcium increased slightly but significantly in the responder group but remained unchanged in the non-responders. No significant changes in ionized calcium levels could be detected, even in responders. Treatment was well tolerated by patients, but 60% of them had transient episodes of hyperphosphatemia. Mean serum phosphate was 4.95 mg/dl at the beginning of the study. It increased significantly after four months of treatment in patients who showed a decrease of PTH levels, although it remained within acceptable limits, below 5.5 mg/dl. Twenty-eight of 76 patients (37%) reduced the dose of calcitriol because their calcium-phosphate products exceeded 60.(ABSTRACT TRUNCATED AT 250 WORDS)

Circadian rhythm of calcitonin gene-related peptide in uncomplicated essential hypertension

OBJECTIVE

To assess the existence of an altered circulating pattern of calcitonin gene-related peptide (CGRP) in hypertension.

DESIGN

The 24 h variation in plasma CGRP was measured and compared in 10 patients affected by uncomplicated essential hypertension and in nine age- and sex-matched healthy volunteers. The diurnal variations in blood pressure, atrial natriuretic peptide (ANP), plasma renin activity (PRA), plasma aldosterone and plasma cortisol were also assessed.

METHODS

Recumbency studies were performed under standardized, drug-free conditions beginning at 0800 h. Venous samples were drawn every 4 h for 24 h and hormone levels were assessed with specific radioimmunoassays. The blood pressure was measured every 15 min with a SpaceLabs 90207 monitor.

RESULTS

The mean 24-h plasma CGRP concentrations were significantly lower in the hypertensive group than in the control group. In both groups a circadian rhythm was present with the same pattern, but at a lower level in hypertension. A temporal sequence starting with the nocturnal rise in plasma CGRP concentrations and progressing with the elevations of ANP, PRA, and plasma aldosterone and cortisol was apparent in both groups. The nocturnal rise in the CGRP and ANP concentrations coincided with the blood pressure and the heart rate falls.

CONCLUSIONS

Our data show that CGRP is lower than normal but maintains its circadian variability and its relationship with the diurnal variations in blood pressure and other hormones known to be active on the cardiovascular system.

Hypoparathyroidism in chronic alcohol intoxication: a preliminary report

It is well known that osteoporosis is more common in chronic alcoholists than in age-matched controls. Possible aetiological factors could be: malabsorption of calcium and vitamin D, liver disease, abnormal parathyroid function. With this study, the authors investigated parathyroid hormone (PTH) behaviour in thirteen selected patients with alcohol abuse, free from any clinical or humoral sign of hepatopathy, and in ten healthy subjects as a control group. In alcohol abusers a significant reduction of plasmatic PTH, compared to normal calcium levels were found. A possible direct interaction effect between ethyl alcohol and PTH may be suggested, even if further studies are required.

Effectiveness of partial splenic embolization as treatment for hypersplenism in thalassaemia major: a 7-year follow up

Partial splenic embolization is an alternative procedure to total splenectomy in patients with hypersplenism, and was performed in 10 patients with beta-thalassaemia major who were then followed for 5 to 7 years. The results were compared with those of a 7-yr follow-up of 6 splenectomized thalassaemics. The blood consumption decreased and the leucocyte counts increased in both groups of patients. However, after partial splenic embolization, severe thrombocytosis--which is typical of splenectomized patients--did not develop and there were no severe complications from the operation, such as infections or reappearance of hypersplenism. In addition, the minor surgical injury and avoidance of abdominal scars were further advantages of partial splenic embolization over total splenectomy.

Differences in blood pressure regulation of congestive heart failure, before and after treatment, correlate with changes in the circulating pattern of atrial natriuretic peptide

The mechanisms underlying altered BP regulation in congestive heart failure are unknown. This study examines the possibility that differences in circadian blood pressure (BP) regulation between the normal and the failing heart correlate with changes in the circulating pattern of atrial natriuretic peptide (ANP). Twelve normotensive patients with coronary artery disease were studied over two separate 24-h periods, the first during acute exacerbation of congestive heart failure (radionuclide-determined ejection fraction at rest was less than 30%) and the second after therapy-induced functional recovery (ejection fraction was more than 40%). BP monitoring at 10-min intervals and intra-atrial blood samples for ANP assays at hourly intervals were obtained. Significant correlation between ejection fraction and the indexes of circadian BP variability (standard deviation of the 24-h pressure mean and day-night pressure difference) were found both before and after treatment. Ejection fraction was independent of the BP means (24-h, daytime and night-time). BP variability, 24-h mean and daytime mean were higher after treatment. ANP means were lower after treatment, whereas ANP variability was higher. The indexes of BP and ANP variability correlated both before and after treatment, whereas the BP and the ANP means were independent. These findings demonstrate that differences in BP regulation of CHF before and after effective treatment correlate with changes in the circulating pattern of ANP. We speculate that by modulating ANP release, the heart could be actively involved in BP regulation as part of the compensatory mechanisms aimed at protecting against circulatory overload.

[Diagnostic imaging in renal vascular diseases: old and new ways. Role of nuclear medicine]

Using the nuclear medicine procedures it is possible to evaluate the renovascular hypertension via the captopril test. Decreased renal blood flow due to stenotic vessel may produce a variety of findings on the renogram using both OIH-I131 and DTPA-Tc99m. Delayed transit time and excretion also may be detected. In this situation the sensitivity and specificity of Nuclear Medicine for RAS detection is very low. Using Captopril test is possible to detect enhanced modification on the shape of renogram due to Angiotensin Converting enzyme inhibition.

[Bone disease in multiple myeloma. A study of 237 cases]

From 1984 to 1990 the authors reviewed the radiologic-clinical charts of 237 patients affected with multiple myeloma (MM). The series included 127 males and 110 females (mean age: 66 years) who had been classified according to Durie and Salmon clinical criteria. All the patients underwent X-rays of the skeleton, as recommended in international literature; moreover, 148 subjects underwent whole-body bone scintigraphy, and 130 bone marrow scintigraphy. A selected group of cases (18 male/female patients) were submitted to bone densitometry employing both quantitative computed tomography (QCT) and dual-energy X-ray absorptiometry (DXA). The results follow: 1) in the first stage of the disease, a high number of patients (29.5%) exhibits no skeletal abnormalities on X-rays; the most common lesion locations include the spine (49%), skull (35%), pelvis (34%), ribs (33%), humeri (22%), femora (13%) and mandible (10%); 2) the most frequent pattern is osteolysis, as a characteristic "punched-out" multiple lesion; the second most frequent lesion is osteopenia (43%), especially in the spine; pathologic fractures are common (54%) in the ribs, vertebral bodies, limbs; typical associations of features and sites are seen on X-ray images, which sometime make diagnosis easier; 3) whole-body scintigraphy, revealing aspecific uptake only in the presence of pathological fractures, is not recommended in the first staging of the disease, but is considered as a valuable technique in the follow-up, when the patients become symptomatic; 4) bone marrow scintigraphy, especially in the "marrow expansion" pattern, might be considered as an attempt made by the body to recover the central space which was destroyed by myelomatous involvement. The prognostic value of this technique is still to be assessed; 5) bone densitometry, by confirming the grade of osteopenia, reveals that osteoporosis is a peculiar pattern of bone disease in MM, which is not related to age only; 6) conventional radiography of the skeleton is the method of choice in the diagnosis of lytic areas of MM, and remains, as yet, irreplaceable. The other diagnostic techniques--i.e., CT and MRI--can be used to evaluate the extent of bone and soft tissue involvement, in the cases with questionable diagnosis, and to assess the degree of marrow involvement.

Comparative evaluation of RAST and MAST-CLA for six allergens for the diagnosis of inhalant allergic disease in 232 patients

The aim of this study was to compare a recent multiple allergosorbent chemiluminescent assay (MAST-CLA) with the RAST for the diagnosis of inhalant allergic disease in 232 patients with rhinitis and/or bronchial asthma. As judged by concordance of clinical history, skin prick tests to a range of six allergens common to our geographic area, and by nasal provocation tests, 70 patients were non-allergic and 162 allergic: 70 to grasses, 46 to mites, four to mugwort, eight to pellitory, and 34 were sensitive to several allergens. In our patient sample that, among other things, comprises subjects with fairly rare monoallergies, MAST-CLA testing gave results which closely corresponded to positive RAST for the allergens studied, and demonstrated a close correlation with the diagnosis of inhalant-specific allergy. Our results showed that, for overall allergens, MAST-CLA was lightly less sensitive and more specific than RAST (the two in vitro tests gave an identical overall efficiency).

Evaluation of bone metabolic markers as indicators of osteopenia in climacteric women

Lumbar bone mass (LBM) determination by quantitative computerized tomography in pre-, peri- and postmenopausal women was utilized to identify subjects at risk to develop osteoporosis. The results were related to determinations of bone metabolic markers (serum osteocalcin and urinary calcium excretion). Osteocalcin was the only metabolic marker which underwent significative changes. However, we found very poor correlations between LBM and metabolic markers and it is concluded that bone mass determination remains the method of choice to select women for preventive therapy.

Loss of nocturnal increase in plasma concentration of atrial natriuretic peptide in hypertensive chronic renal failure

Diurnal change of plasma atrial natriuretic peptide (ANP) concentration was investigated in 12 patients with hypertension due to chronic renal failure (CRF) and in 12 patients with essential hypertension (EH) of comparable degree. Blood pressure (BP) monitoring was performed at 15-min intervals, while peripheral blood samples were obtained at 4-hour intervals starting from 8.00 h. The mean 24-hour plasma levels (+/- SEM) of ANP were 24.3 +/- 1.8 pmol/l in EH and 23.4 +/- 1.2 pmol/l in CRF. In EH, plasma ANP concentration was highest at 4.00 h (33.5 +/- 0.8 pmol/l) and lowest at 16.00 h (15.5 +/- 0.6 pmol/l). In CRF, no significant circadian change was present (22.2 +/- 3.1 and 20.4 +/- 3.6 pmol/l, respectively), and the nocturnal fall in BP was lost. Our data demonstrate that in CRF the loss and possible reversal of the nocturnal decline in BP is associated with the disappearance of any significant circadian variation in the circulating concentrations of ANP. These findings suggest a role for ANP in the alteration of BP variability of CRF, possibly mediated by autonomic dysfunction, and are further evidence for the existence of a relation between the circadian rhythms of ANP and BP.

Hypoparathyroidism in beta-thalassemia major. Clinical and laboratory observations in 24 patients

In the last 18 years, we have observed 24 cases of hypoparathyroidism (HPT) in beta-thalassemia major. At present, 4.5% of patients followed regularly in our department have this complication. HPT is thought to be mainly the consequence of iron deposition in the parathyroid glands. The age of our patients when HPT was diagnosed ranged from 11 to 24 years (mean 16.5 years). Their serum ferritin levels ranged from 810 to 15,200 ng/ml (mean 3,772 ng/ml). The severity of HPT varied widely. In only 3 patients was hypocalcemia severe with signs of tetany, seizures or cardiac failure. The onset of HPT was preceded or followed in most patients by other endocrine and/or cardiac complications. We found no clear relationship between HPT and serum ferritin levels in our patients, suggesting either an individual sensitivity to iron toxicity or early damage of the parathyroid gland before chelation had reduced the iron overload. However, the diagnosis of no new cases of HPT in the last 3 years coinciding with the much improved regime of chelation therapy suggests that chelation may have helped to prevent the development of HPT.

Circadian profile of plasma calcitonin gene-related peptide in healthy man

Calcitonin gene-related peptide (CGRP) is known to exert potent cardiovascular effects and is presumed to participate in the neural control of circulation and blood flow. It has been assayed in many physiological and disease conditions, yet virtually nothing is known of the normal fluctuations in its circulating levels. We have studied the variability throughout a 24-h period of plasma concentrations of CGRP in eight recumbent healthy volunteers (four men and four women, 25-37 yr old), after careful standardization of their daily diet and routine schedules. A correlation with the circadian rhythms of blood pressure (BP), heart rate (HR), and plasma aldosterone (PA), PRA, plasma cortisol (PC), and atrial natriuretic peptide (ANP) was also made. Plasma CGRP concentrations ranged from a mean peak value of 18.1 +/- 1.5 pmol/L to a mean lowest value of 11.7 +/- 0.4 pmol/L (P less than 0.05). The mean circadian acrophase of CGRP (calculated by cosinor analysis to occur at 2314 h) anticipated the corresponding acrophases of the other hormones (0122, 0528, 0809, and 0840 h for ANP, PRA, PA, and PC, respectively). Instead, BP and HR rhythms seemed to be antiphasic with the ANP rhythm (calculated acrophases occurred at 1356, 1339, and 1314 h for systolic BP, diastolic BP, and HR, respectively). Our data demonstrate that, like many other hormones, CGRP circulates in plasma with a circadian rhythm. There seems to be a temporal sequence starting with the nocturnal rise in plasma CGRP concentrations and progressing with the ensuing elevations of ANP, PRA, PA, and PC, whereas BP and HR are kept to their lowest values. These findings are in favor of a physiological role of CGRP in the complex regulation of BP homeostasis.