The effect of complex contrast training with different training frequency on the physical performance of youth soccer players: a randomized study

Background

Complex contrast training (CCT) is potentially an efficient method to improve physical abilities such as muscle strength, power output, speed, agility, are extremely important in developing soccer players of different age categories.

Aim

This study aimed to analyze the effects of 6 weeks of CCT program applied in different training frequency (sessions per week) on youth soccer players performance.

Methods

Twenty-one youth soccer players (age: 15.3 ± 1.1 years; body mass 64.9 ± 0.7 kg; height 175.4 ± 0.7 cm) were randomized into three groups: a regular pre-season training control group (G0, n = 8), a group with regular pre-season training plus twice-a-week CCT (G2, n = 6), and a group with regular pre-season training plus thrice-a-week CCT (G3, n = 7). The CCT consisted of soccer skills-based exercises distributed across five stations, to be performed before common regular practice during a 6-week pre-season period. The agility (505 Agility test), sprint (S5 and S15), jump (SJ and CMJ), and free kick speed (11 m from the goal) of the groups were analyzed pre- and post-CCT intervention. During a 6-week pre-season period, the players integrated CCT into their regular training sessions. Furthermore, performance variables were compared between the groups.

Results

A statistical difference was identified for the timepoint for the players' CMJ (p = 0.023; η2 = 0.343) and the free kick speed (p = 0.013; η2 = 0.383) using ANOVA. The G3 showed a significant improvement in the CMJ (p = 0.001) and the free kick speed (p = 0.003) between pre- to post-CCT test. No other significant changes in performance were observed (p > 0.05).

Conclusion

The CCT training program with a weekly frequency of 3 days per week is effective in improving free kick speed and CMJ performance in young male soccer players (U-15 and U-17 categories). CCT training programs have the potential to refine an athlete's preparation for competition. However, certain performance tests did not demonstrate substantial enhancements. Consequently, additional investigations are required to ascertain the effectiveness of CCT.

Reduction of leptin levels during acute exercise is dependent on fasting but not on caloric restriction during chronic exercise: A systematic review and meta-analysis

BACKGROUND

The importance of leptin in controlling body mass has recently gained more attention. Its levels are directly associated with the amount of fat mass, but not necessarily dependent on it. Exercise has great potential in reducing leptin levels, however the response of exercise to this cytokine is still not well understood.

OBJECTIVE

The objective of the review was to analyze the effects of physical exercise on plasma leptin concentration, either acutely (post-exercise/training session) and/or after a training period (short- or long-term), as well as to investigate the existence of possible moderating variables.

METHODS

The studies included in this systematic review were published between 2005 and May 2023. Only peer-reviewed studies, available in English, performed with humans that evaluated the effects of any form of exercise on leptin levels were included. The search was conducted on May 03, 2023, in Embase (Elsevier), MEDLINE via PubMed®, and Web of Science (Core collection). The risk of bias in the included trials was assessed by the Physiotherapy Evidence Database tool, considering 11 questions regarding the methodology of each study with 10 questions being scored. The data (n, mean, and standard deviation) were extracted from included studies to perform random effects meta-analyses using standardized mean difference between the pre- and post-intervention effects.

RESULTS

Twenty-five studies (acute effect: 262 subjects; short- and long-term effect: 377 subjects) were included in this systematic review and meta-analysis. Short- and long-term physical exercise and caloric restriction plus exercise reduce plasma leptin levels, presenting statistically significant differences (p<0.001); as well as acute effect (p = 0.035), however the latter result was influenced by the pre-exercise meal as shown in the subgroup analysis. In this meta-analysis the effect of moderating factors on leptin reduction, not addressed by past reviews, is verified, such as the relationship with caloric restriction, exercise intensity and pre-exercise meal on acute responses.

CONCLUSION

Both acute and chronic exercise reduce leptin levels, yet the acute effect is dependent on the pre-exercise meal. In addition to having a long-term reduction in leptin levels, the minimum amount of weekly exercise to have a significant reduction in plasma leptin is 180 minutes of moderate-intensity exercise and 120 minutes of high-intensity exercise.

Acute Effect of Resistance Training With Blood Flow Restriction on Perceptual Responses: A Systematic Review and Meta-Analysis

CONTEXT

Several studies have compared perceptual responses between resistance exercise with blood flow restriction and traditional resistance exercise (non-BFR). However, the results were contradictory.

OBJECTIVES

To analyze the effect of RE+BFR versus non-BFR resistance exercise [low-load resistance exercise (LL-RE) or high-load resistance exercise (HL-RE)] on perceptual responses.

DATA SOURCES

CINAHL, Cochrane Library, PubMed®, Scopus, SPORTDiscus, and Web of Science were searched through August 28, 2021, and again on August 25, 2022.

STUDY SELECTION

Studies comparing the effect of RE+BFR versus non-BFR resistance exercise on rate of perceived exertion (RPE) and muscle pain/discomfort were considered. Meta-analyses were conducted using the random effects model.

STUDY DESIGN

Systematic review and meta-analysis.

LEVEL OF EVIDENCE

Level 2.

DATA EXTRACTION

All data were reviewed and extracted independently by 2 reviewers. Disagreements were resolved by a third reviewer.

RESULTS

Thirty studies were included in this review. In a fixed repetition scheme, the RPE [standardized mean difference (SMD) = 1.04; P < 0.01] and discomfort (SMD = 1.10; P < 0.01) were higher in RE+BFR than in non-BFR LL-RE, but similar in sets to voluntary failure. There were no significant differences in RPE in the comparisons between RE+BFR and non-BFR HL-RE; after sensitivity analyses, it was found that the RPE was higher in non-BFR HL-RE in a fixed repetition scheme. In sets to voluntary failure, discomfort was higher in RE+BFR versus non-BFR HL-RE (SMD = 0.95; P < 0. 01); however, in a fixed scheme, the results were similar.

CONCLUSION

In sets to voluntary failure, RPE is similar between RE+BFR and non-BFR exercise. In fixed repetition schemes, RE+BFR seems to promote higher RPE than non-BFR LL-RE and less than HL-RE. In sets to failure, discomfort appears to be similar between LL-RE with and without BFR; however, RE+BFR appears to promote greater discomfort than HL-RE. In fixed repetition schemes, the discomfort appears to be no different between RE+BFR and HL-RE, but is lower in non-BFR LL-RE.

Acute Responses in Blood Flow Restriction Low-intensity Aerobic Training: A Meta-analysis

The purpose was to determine the effect low-intensity training with blood flow restriction (LI-BFR) versus high-intensity aerobic training (HIT) on acute physiological and perceptual responses. The Cumulative Index to Nursing and Allied Health Literature, National Library of Medicine, Scopus, SPORTDiscus and Web of Science databases and the reference list of eligible studies were consulted to identify randomized experimental studies, published until July 4, 2022, that analyzed physiological or perceptual responses between LI-BFR versus HIT in healthy young individuals. Mean difference (MD) and standardized mean difference (SMD) were used as effect estimates and random effects models were applied in all analyses. Twelve studies were included in this review. During exercise sessions, HIT promoted higher values of heart rate (MD=28.9 bpm; p<0.00001; I ² =79%), oxygen consumption (SMD=4.01; p<0.00001; I ² =83%), ventilation (MD=48.03 l/min; p=0.0001; I ² =97%), effort (SMD=1.54; p=0.003; I ² =90%) and blood lactate (MD=3.85 mmol/L; p=0.002; I ² =97%). Perception of pain/discomfort was lower in HIT (SMD=-1.71; p=0.04; I ² =77.5%). In conclusion, LI-BFR promotes less pronounced physiological responses than HIT but with greater perception of pain.

Chronic Effects of Different Intensities of Interval Training on Hemodynamic, Autonomic and Cardiorespiratory Variables of Physically Active Elderly People

Interval training (IT) is a very efficient method. We aimed to verify the chronic effects of IT with different intensities on hemodynamic, autonomic and cardiorespiratory variables in the elderly. Twenty-four physically active elderly men participated in the study and were randomized into three groups: Training Group A (TG_A, n = 8), Training Group B (TG_B, n = 8) and control group (CG, n = 8). The TG_A and TG_B groups performed 32 sessions (48 h interval). TG_A presented 4 min (55 to 60% of HRmax) and 1 min (70 to 75% of HRmax). The TGB training groups performed the same protocol, but performed 4 min at 45 to 50% HRmax and 1 min at 60 to 65% HRmax. Both training groups performed each set six times, totaling 30 min per session. Assessments were performed pre (baseline) after the 16th and 32nd intervention session. The CG performed only assessments. Hemodynamic, autonomic and cardiorespiratory (estimated VO_2max) variables were evaluated. There were no significant differences between protocols and times (p > 0.05). However, the effect size and percentage delta indicated positive clinical outcomes, indicating favorable responses of IT. IT may be a strategy to improve hemodynamic, autonomic and cardiorespiratory behavior in healthy elderly people.

Cardiovascular and Perceptual Responses to Resistance Training with Practical Blood Flow Restriction Induced by a Non-Elastic Band vs. Pneumatic Cuff: A Crossover Randomized Study

Our purpose in this study was to analyze perceptual and cardiovascular responses in low-load resistance training (RT) sessions associated with a fixed non-elastic band compressed to the proximal region of the arms (p-BFR) versus a pneumatic cuff inflated to a pressure of 150 mmHg (t-BFR). Participants (16 healthy trained men) were randomly assigned to two conditions of low-load RT (20% one repetition maximum [1RM]) with BFR (p-BFR or t-BFR). In both conditions, the participants performed five exercises (4 sets/30-15-15-15) for the upper-limbs, but in one of the conditions, the exercises were performed with a p-BFR induced by a non-elastic band, while in the other, the exercises were performed with a t-BFR using a device with similar width. The devices used to generate the BFR had similar widths (5 cm). Brachial blood pressure (bBP) and heart rate (HR) were measured before, after each exercise and after the experimental session (5-, 10-, 15-, and 20 min post-session). Rating of perceived exertion (RPE) and rating of pain perception (RPP) were reported after each exercise and 15 minutes post-session. HR increased during the training session in both conditions, with no differences between p-BFR and t-BFR. Neither intervention increased diastolic BP (DBP) during training, but there was a significant post-session reduction in DBP in the p-BFR, with no differences observed between conditions. There were no significant differences in RPE and RPP in the two training conditions, with both conditions associated with higher RPE and RPP at the end versus beginning of the experimental session. We conclude that when BFR device width and material are similar, low-load training with t-BFR and p-BFR promotes similar acute perceptual and cardiovascular responses in healthy trained men.

TRAINING LOAD THROUGH HEART RATE AND PERCEIVED EXERTION DURING CROSSFIT®

ABSTRACT Introduction: Monitoring of CrossFit® training load should be considered to facilitate training outcomes and avoid overtraining. Objective: The purpose of the present study was to examine the heart rate (HR), rating of perceived exertion (RPE), and internal load responses to each segment of a CrossFit® training session. Methods: An observational, cross-sectional design was used in this study. Fifteen healthy male recreational athletes with at least six months experience in CrossFit® training participated in this study. Seven non-consecutive CrossFit® training sessions consisting of mobility, warm-up, skill, and workout segments were performed with a minimum of 48 hours between sessions. Exercise modalities within sessions were constantly varied according to the CrossFit® training programming template. HR was measured every two minutes throughout each session. Peak HR, average HR, RPE after each segment, and session RPE were recorded. Results: HR significantly increased during each segment of the training sessions (p < 0.01), except between the warm-up and skill segments (p = 0.180). Mean total session HR was 65.1 ± 5.4% HRmax and peak HR was 95.3 ± 4.1% HRmax. RPE and internal load increased significantly in each segment (p < 0.05). While intensity measurements increased during CrossFit® training, the HR responses differed from the RPE and internal load. Conclusion: When switching from one segment to another, HR fell below the HRpeak of the previous segment, which shows that the time spent switching between the training segments influenced the average HR of the entire session. Level of evidence III; Case control study; Investigating the results of treatment.

Myoelectric Activity and Fatigue in Low-Load Resistance Exercise With Different Pressure of Blood Flow Restriction: A Systematic Review and Meta-Analysis

Background: Low-load resistance exercise (LL-RE) with blood flow restriction (BFR) promotes increased metabolic response and fatigue, as well as more pronounced myoelectric activity than traditional LL-RE. Some studies have shown that the relative pressure applied during exercise may have an effect on these variables, but existing evidence is contradictory.

Purpose: The aim of this study was to systematically review and pool the available evidence on the differences in neuromuscular and metabolic responses at LL-RE with different pressure of BFR.

Methods: The systematic review and meta-analysis was reported according to PRISMA items. Searches were performed in the following databases: CINAHL, PubMed, Scopus, SPORTDiscus and Web of Science, until June 15, 2021. Randomized or non-randomized experimental studies that analyzed LL-RE, associated with at least two relative BFR pressures [arterial occlusion pressure (AOP)%], on myoelectric activity, fatigue, or metabolic responses were included. Random-effects meta-analyses were performed for MVC torque (fatigue measure) and myoelectric activity. The quality of evidence was assessed using the PEDro scale.

Results: Ten studies were included, all of moderate to high methodological quality. For MVC torque, there were no differences in the comparisons between exercise with 40–50% vs. 80–90% AOP. When analyzing the meta-analysis data, the results indicated differences in comparisons in exercise with 15–20% 1 repetition maximum (1RM), with higher restriction pressure evoking greater MVC torque decline (4 interventions, 73 participants; MD = −5.05 Nm [95%CI = −8.09; −2.01], p = 0.001, I² = 0%). For myoelectric activity, meta-analyses indicated a difference between exercise with 40% vs. 60% AOP (3 interventions, 38 participants; SMD = 0.47 [95%CI = 0.02; 0.93], p = 0.04, I² = 0%), with higher pressure of restriction causing greater myoelectric activity. This result was not identified in the comparisons between 40% vs. 80% AOP. In analysis of studies that adopted pre-defined repetition schemes, differences were found (4 interventions, 52 participants; SMD = 0.58 [95%CI = 0.11; 1.05], p = 0.02, I² = 27%).

Conclusion: The BFR pressure applied during the LL-RE may affect the magnitude of muscle fatigue and excitability when loads between 15 and 20% of 1RM and predefined repetition protocols (not failure) are prescribed, respectively.

Systematic Review Registration: [http://www.crd.york.ac.uk/prospero], identifier [CRD42021229345].

Effects of Resistance Training to Muscle Failure on Acute Fatigue: A Systematic Review and Meta-Analysis

BACKGROUND

Proper design of resistance training (RT) variables is a key factor to reach the maximum potential of neuromuscular adaptations. Among those variables, the use of RT performed to failure (RTF) may lead to a different magnitude of acute fatigue compared with RT not performed to failure (RTNF). The fatigue response could interfere with acute adaptive changes, in turn regulating long-term adaptations. Considering that the level of fatigue affects long-term adaptations, it is important to determine how fatigue is affected by RTF versus RTNF.

OBJECTIVE

The aim of this systematic review and meta-analysis was to compare the effects of RTF versus RTNF on acute fatigue.

METHODS

The search was conducted in January 2021 in seven databases. Only studies with a crossover design that investigated the acute biomechanical properties (vertical jump height, velocity of movement, power output, or isometric strength), metabolic response (lactate or ammonia concentration), muscle damage (creatine kinase activity), and rating of perceived exertion (RPE) were selected. The data (mean ± standard deviation and sample size) were extracted from the included studies and were either converted into the standardized mean difference (SMD) or maintained in the raw mean difference (RMD) when the studies reported the results in the same scale. Random-effects meta-analyses were performed.

RESULTS

Twenty studies were included in the systematic review and 12 were included in the meta-analysis. The main meta-analyses indicated greater decrease of biomechanical properties for RTF compared with RTNF (SMD - 0.96, 95% confidence interval [CI] - 1.43 to - 0.49, p < 0.001). Furthermore, there was a larger increase in metabolic response (RMD 4.48 mmol·L^-1, 95% CI 3.19-5.78, p < 0.001), muscle damage (SMD 0.76, 95% CI 0.31-1.21, p = 0.001), and RPE (SMD 1.93, 95% CI 0.87-3.00, p < 0.001) for RTF compared with RTNF. Further exploratory subgroup analyses showed that training status (p = 0.92), timepoint (p = 0.89), load (p = 0.10), and volume (p = 0.12) did not affect biomechanical properties; however, greater loss in the movement velocity test occurred on upper limbs compared with lower limbs (p < 0.001). Blood ammonia concentration was greater after RTF than RTNF (RMD 44.66 μmol·L^-1, 95% CI 32.27-57.05, p < 0.001), as was 48 h post-exercise blood creatine kinase activity (SMD 0.86, 95% CI 0.33-1.42, p = 0.002). Furthermore, although there was considerable heterogeneity in the overall analysis (I² = 83.72%; p < 0.01), a significant difference in RPE after RTF compared with RTNF was only found for studies that did not equalize training volumes.

CONCLUSIONS

In summary, RTF compared with RTNF led to a greater decrease in biomechanical properties and a simultaneous increase in metabolic response, higher muscle damage, and RPE. The exploratory analyses suggested a greater impairment in the velocity of movement test for the upper limbs, more pronounced muscle damage 48 h post-exercise, and a greater RPE in studies with non-equalized volume after the RTF session compared with RTNF. Therefore, it can be concluded that RTF leads to greater acute fatigue compared with RTNF. The higher acute fatigue after RTF can also have an important impact on chronic adaptive processes following RT; however, the greater acute fatigue following RTF can extend the time needed for recovery, which should be considered when RTF is used.

PROTOCOL REGISTRATION

The original protocol was prospectively registered (CRD42020192336) in the International Prospective Register of Systematic Reviews (PROSPERO).

Effects of Resistance Training Performed with Different Loads in Untrained and Trained Male Adult Individuals on Maximal Strength and Muscle Hypertrophy: A Systematic Review

The load in resistance training is considered to be a critical variable for neuromuscular adaptations. Therefore, it is important to assess the effects of applying different loads on the development of maximal strength and muscular hypertrophy. The aim of this study was to systematically review the literature and compare the effects of resistance training that was performed with low loads versus moderate and high loads in untrained and trained healthy adult males on the development of maximal strength and muscle hypertrophy during randomized experimental designs. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (2021) were followed with the eligibility criteria defined according to participants, interventions, comparators, outcomes, and study design (PICOS): (P) healthy males between 18 and 40 years old, (I) interventions performed with low loads, (C) interventions performed with moderate or high loads, (O) development of maximal strength and muscle hypertrophy, and (S) randomized experimental studies with between- or within-subject parallel designs. The literature search strategy was performed in three electronic databases (Embase, PubMed, and Web of Science) on 22 August 2021. Results: Twenty-three studies with a total of 563 participants (80.6% untrained and 19.4% trained) were selected. The studies included both relative and absolute loads. All studies were classified as being moderate-to-high methodological quality, although only two studies had a score higher than six points. The main findings indicated that the load magnitude that was used during resistance training influenced the dynamic strength and isometric strength gains. In general, comparisons between the groups (i.e., low, moderate, and high loads) showed higher gains in 1RM and maximal voluntary isometric contraction when moderate and high loads were used. In contrast, regarding muscle hypertrophy, most studies showed that when resistance training was performed to muscle failure, the load used had less influence on muscle hypertrophy. The current literature shows that gains in maximal strength are more pronounced with high and moderate loads compared to low loads in healthy adult male populations. However, for muscle hypertrophy, studies indicate that a wide spectrum of loads (i.e., 30 to 90% 1RM) may be used for healthy adult male populations.

High prevalence of low bone mineral density in pre-dialysis chronic kidney disease patients: bone histomorphometric analysis

Chronic kidney disease (CKD) leads to reduced bone mineral density (BMD) in pre-dialysis and dialysis patients. A few studies have used dual-energy x-ray absorptiometry (DEXA) to assess BMD in pre-dialysis CKD patients and have shown low BMD to be highly prevalent. Until now there have been no studies reporting the histological features of low BMD in pre-dialysis CKD patients.

AIM

To determine the prevalence and histological features of low BMD in pre-dialysis CKD patients.

METHOD

Pre-dialysis CKD patients (n = 103, 46 females/57 males), median creatinine clearance of 29 (10 - 78) ml/min/ 1.73 m2, were evaluated using biochemical analysis and DEXA. Bone biopsies were obtained from those with low BMD.

RESULTS

Fifty (48.5%) out of the 103 patients had low BMD (LBD group) and 53 (51.5%) had normal BMD (NBD group). The risk for low BMD was increased in those patients with alkaline phosphatase levels above 190 U/l and intact-PTH (iPTH) below 70 pg/ml (p < 0.05). Demographic and biochemical parameters from both groups were comparable, except for lower body mass index (BMI) in LBD subjects (p = 0.04). Women who had been post-menopausal for at least 1 year comprised 65% (13/20) and 50% (13/26) of the LBD and NBD groups, respectively (p = NS). In 40 LBD patients, bone histomorphometry revealed adynamic bone disease (ABD, 52.5%), osteomalacia (OM, 42.5%) and mixed bone disease (MBD, 5%). Trabecular bone volume (BV/TV) was lower in ABD and OM patients. A nearly significant association was found between ABD and iPTH < or = 150 pg/ml (p = 0.056), whereas higher values of iPTH were associated with OM. Total alkaline phosphatase < or = 190 U/l was significantly associated with ABD, whereas higher values were associated with OM. No correlation was observed between BV/TV and BMD.

CONCLUSION

Low BMD is frequent in pre-dialysis CKD patients, and low turnover bone disease, manifesting as ABD and OM, was the hallmark of this bone loss.

Pitfalls in pituitary diagnosis: peculiarities of three cases

Due to the increasing availability and sensitivity of diagnostic methods, biochemical and imaging abnormalities of pituitary function and anatomy are becoming more frequent. Hyperprolactinaemia was found in three women without any prolactin (PRL) related clinical features. All three patients had normal libido, regular menses with evidence of ovulation, no galactorrhoea, and normal FSH, LH, TSH and free T4 serum levels. Magnetic resonance imaging (MRI) of the sellar region showed images that were compatible with pituitary microadenomas in all three cases. Due to the discordance between laboratory and clinical features, we searched for the presence of PRL aggregates with high molecular weight and low biological activity (macroprolactinaemia). Initially, we screened with a polyethylene glycol precipitation method, and then confirmed the presence of macroprolactinaemia by chromatography. All three cases screened positive for the presence of macroprolactinaemia. MRI alterations, compatible with pituitary microadenomas, may be due to true microincidentalomas, normal anatomical variations or imaging artefacts. In conclusion, we have described the presence of double diagnostic pitfalls that might lead to unnecessary medical or surgical intervention.

Circulating forms of parathyroid hormone detected with an immunofluorometric assay in patients with primary hyperparathyroidism and in hyperparathyroidism secondary to chronic renal failure

In patients with uremia, intact parathyroid hormone (PTH) measurement appears to overestimate the biologically active hormone in circulation. The recent description of the accumulation in these patients of a non-intact PTH form measured by the standard immunometric assays, re-opened the question. In this study we submitted serum samples from 7 patients with primary hyperparathyroidism (PHP) and from 10 patients with hyperparathyroidism secondary to chronic renal failure (SHP) to preparative HPLC in order to discriminate the molecular forms measured by our currently used immunofluorometric assay for intact PTH. The elution profile obtained with the HPLC system showed two clearly defined peaks, the first one corresponding to a lower molecular weight form, and the second to the intact PTH (1-84) form. In patients with SHP the area under the curve for the first peak (mean 29.5%, range 20.6 to 40.4%) was significantly greater than that observed for patients with PHP (mean 15.6%, range 5.6 to 21.9%). This confirms previous studies showing accumulation of molecular forms of slightly lower molecular weight, presumably PTH (7-84), in patients with SHP and, to a lesser extent, in patients with PHP. The real necessity of assays that discriminate between these two molecular forms is debatable.

Osteoporotic fractures of proximal femur: clinical and epidemiological features in a population of the city of São Paulo

CONTEXT

It is believed that about 25% of menopausal women in the USA will exhibit some kind of fracture as a consequence of osteoporosis. Fractures of the proximal femur are associated with a greater number of deaths and disabilities and higher medical expenses than all the other osteoporotic fractures together.

OBJECTIVE

To study the clinical and epidemiological features of patients with proximal femur fracture in hospitals in São Paulo.

DESIGN

Transversal and retrospective study. LOCAL: Hospital São Paulo and Hospital Servidor Público Estadual "Francisco Morato Oliveira".

PARTICIPANTS

Patients aged sixty-five years or more hospitalized because of proximal femur fracture, from March to November 1996 (N = 73). This group was compared to patients of the same age without fracture of the proximal femur.

INTERVENTION

Evaluation of weight, height, body mass index; lifestyle habits (physical activity at home, ingestion of dairy calcium, drinking of coffee, smoking habit), gynecological history (ages at menarche and menopause, number of pregnancies and lactations), previous morbidity, use of medications, history of previous fractures, family history of osteoporosis.

MEASUREMENT

The comparison of the different data regarding lifestyle habits between the two groups was made using the chi-squared test. Other data were analyzed using the Mann--Whitney test. P pound 0.05 was considered significant.

RESULTS

We noted a predominance of proximal femur fracture among females in relation to males (a female/male ratio of 3.3:1) with a progressive increase in the frequency of proximal femur fracture with age in both sexes. The group with proximal femur fracture, in comparison with the control group, showed a lower body mass index, less physical activity, and a greater number of pregnancies and lactations. Other data were not different.

CONCLUSION

In accordance with the literature, we found a predomination of proximal femur fracture in women in relation to men, and a favorable effect of higher body mass index and physical activity for decreasing the frequency of proximal femur fracture. We also discuss the role of pregnancies and lactation on the frequency of proximal femur fracture.

Effect of hormone replacement therapy on the bone mass and urinary excretion of pyridinium cross-links

CONTEXT

The menopause accelerates bone loss and is associated with an increased bone turnover. Bone formation may be evaluated by several biochemical markers. However, the establishment of an accurate marker for bone resorption has been more difficult to achieve.

OBJECTIVE

To study the effect of hormone replacement therapy (HRT) on bone mass and on the markers of bone resorption: urinary excretion of pyridinoline and deoxypyridinoline.

DESIGN

Cohort correlational study.

SETTING

Academic referral center.

SAMPLE

53 post-menopausal women, aged 48-58 years.

MAIN MEASUREMENTS

Urinary pyr and d-pyr were measured in fasting urine samples by spectrofluorometry after high performance liquid chromatography and corrected for creatinine excretion measured before treatment and after 1, 2, 4 and 12 months. Bone mineral density (BMD) was measured by dual energy X-ray absorptiometry (DEXA) before treatment and after 12 months of HRT.

RESULTS

The BMD after HRT was about 4.7% (P < 0.0004); 2% (P < 0.002); and 3% (P < 0. 01) higher than the basal values in lumbar spine, neck and trochanter respectively. There were no significant correlations between pyridinium cross-links and age, weight, menopause duration and BMD. The decrease in pyr and d-pyr was progressive after HRT, reaching 28.9% (P < 0.0002), and 42% (P < 0.0002) respectively after 1 year.

CONCLUSIONS

Urinary pyridinoline and deoxypyridinoline excretion decreases early in hormone replacement therapy, reflecting a decrease in the bone resorption rate, and no correlation was observed with the bone mass evaluated by densitometry.

Increased hip bone mineral density in a woman with gluteal silicon implant

Conditions and artifacts such as aortic calcification, osteophytes, hip prostheses, and metallic objects can mislead the results of dual energy X-ray absorptiometry (DXA) scanning of the spine and hip. Gluteal silicon implants increasingly are being used for aesthetic purposes by women in Brazil, some of whom are at an age of high risk for the development of postmenopausal osteoporosis. We herein report a case of a woman whose hip bone mineral density by DXA clearly increased after the placement of bilateral gluteal implants of silicon. This case demonstrates the importance of inquiring about the presence of this artifact to avoid unnecessary evaluation of hip bone densitometry in these situations.

Evaluation of bone metabolism after the use of an inhaled glucocorticoid (flunisolide) in patients with moderate asthma

OBJECTIVE

We have investigated the effects of the inhaled corticosteroid flunisolide on bone metabolism and adrenal function in patients with moderate asthma.

SUBJECTS AND DESIGN

Twenty ambulatory patients (13 females, 7 males, mean age +/- SD of 36.4 +/- 12.4 years) with moderate asthma were recruited. None had taken corticosteroids for at least 1 month. Flunisolide 500 microg was given twice a day for 10 weeks, without any other medication. Blood and urine were collected before and at the end of treatment course. Cortisol (basal and 1 h after ACTH 250 microg i.v.) was measured to evaluate adrenal function. A peak cortisol response of 496 nmol/l was considered an adequate response. Serum ionized calcium, intact PTH, plasma osteocalcin (OC) and urinary pyridinoline (Pyr) and deoxy-pyridinoline (D-Pyr) were measured to evaluate bone metabolism. Wilcoxon paired test was performed for statistical analysis. Results are expressed as mean +/- SD.

RESULTS

In most patients (85%), there was no difference after treatment with flunisolide on basal and stimulated cortisol levels. We found a significant decrease of OC (3.55 +/- 1.42 to 2.97 +/- 1.05 nmol/l) and Pyr (66.4 +/- 20.0 to 59.5 +/- 24.9 pmol/micromol creatinine) levels after treatment (P < 0.05). We also observed a positive correlation between the variations seen in pre and post treatment values of OC and Pyr/D-Pyr.

CONCLUSIONS

The use of inhaled flunisolide 1000 microg/day for 10 weeks had no suppressive effect on adrenal function in the majority of asthmatic patients studied. However, the effects seen on bone and mineral metabolism, evidenced by the significant fall in osteocalcin and pyridinoline levels, may indicate a possible systemic effect of this drug. Clinical consequences of long-term treatment with flunisolide need to be further evaluated.

Specific insulin and proinsulin secretion in glucokinase-deficient individuals

Glucokinase (GCK) is an enzyme that regulates insulin secretion, keeping glucose levels within a narrow range. Mutations in the glucokinase gene cause a rare form of diabetes called maturity-onset diabetes of the young (MODY). An early onset (less than 25 years), autosomal dominant inheritance and low insulin secretion stimulated by glucose characterize MODY patients. Specific insulin and proinsulin were measured in serum by immunofluorimetric assays (IFMA) during a 75-g oral glucose tolerance test (OGTT). Two kindreds (SA and LZ) were studied and compared to non-diabetic unrelated individuals (control group 1) matched for age and body mass index (BMI). In one kindred, some of these subjects were also obese (BMI > 26 kg/m2), and other family members also presented with obesity and/or late-onset NIDDM. The MODY patients were also compared to a group of five of their first-degree relatives with obesity and/or late-onset NIDDM. The proinsulin profile was different in members of the two MODY kindreds. Fasting proinsulin and the proinsulin/insulin ratio were similar in MODY members of kindred LZ and subjects from control group 1, but were significantly lower than in MODY members of kindred SA (P < 0.02 and P < 0.01, for proinsulin and proinsulin/insulin ratio, respectively). Moreover, MODY members of family SA had higher levels of proinsulin and proinsulin/insulin ratio, although not significantly different, when compared to their first-degree relatives and to subjects from control group 2. In conclusion, we observed variable degrees of proinsulin levels and proinsulin/insulin ratio in MODY members of two different kindreds. The higher values of these parameters found in MODY and non-MODY members of kindered SA is probably related to the obesity and late-onset NIDDM background present in this family.

Pituitary glycoprotein hormone a-subunit secretion by cirrhotic patients

Secretion of the alpha-subunit of pituitary glycoprotein hormones usually follows the secretion of intact gonadotropins and is increased in gonadal failure and decreased in isolated gonadotropin deficiency. The aim of the present study was to determine the levels of the alpha-subunit in the serum of patients with cirrhosis of the liver and to compare the results obtained for eugonadal cirrhotic patients with those obtained for cirrhotic patients with hypogonadotropic hypogonadism. Forty-seven of 63 patients with cirrhosis (74.6%) presented hypogonadism (which was central in 45 cases and primary in 2), 7 were eugonadal, and 9 women were in normal menopause. The serum alpha-subunit was measured by the fluorimetric method using monoclonal antibodies. Cross-reactivity with LH, TSH, FSH and hCG was 6.5, 1.2, 4.3 and 1.1%, respectively, with an intra-assay coefficient of variation (CV) of less than 5% and an interassay CV of 5%, and sensitivity limit of 4 ng/l. The serum alpha-subunit concentration ranged from 36 to 6253 ng/l, with a median of 273 ng/l. The median was 251 ng/l for patients with central hypogonadism and 198 ng/l for eugonadal patients. The correlation between the alpha-subunit and basal LH levels was significant both in the total sample (r = 0.48, P < 0.01) and in the cirrhotic patients with central hypogonadism (r = 0.33, P = 0.02). Among men with central hypogonadism there was a negative correlation between alpha-subunit levels and total testosterone levels (r = -0.54, P < 0.01) as well as free testosterone levels (r = -0.53, P < 0.01). In conclusion, although the alpha-subunit levels are correlated with LH levels, at present they cannot be used as markers for hypogonadism in patients with cirrhosis of the liver.

[Hypocalcemia and convulsive syndrome in alcoholics--an association frequently not diagnosed]

Hypocalcemia can be a contributory factor for epilepsy and previous studies showed that ethanol decreases plasma calcium.

PURPOSE

To establish the prevalence of hypocalcemia in the general convulsive population and to ascertain if there was a specific group of risk for hypocalcemia.

METHODS

A prospective study of plasma ionized calcium measurement in 78 consecutive patients admitted owing to seizures at the Emergency Department of Escola Paulista de Medicina was performed. 22% of these patients were alcoholics. The plasma ionized calcium in 44 ambulatory non-convulsive alcoholics was also measured.

RESULTS

A high prevalence of hypocalcemia was found in the alcoholic convulsive population (32%), in contrast with the non-alcoholic convulsive group and the alcoholic non-convulsive group (no calcium disturbance in both groups). The alcoholic convulsive group had values of ionized calcium statistically lower than the non-alcoholic convulsive group using the Mann-Whitney test (p < 0.05) [median value = 1.20 mmol/L; range = 1.04-1.32 mmol/L/median value = 1.24 mmol/L; range = 1.16-1.29 mmol/L respectively]. The alcoholic non-convulsive group had values of ionized calcium between 1.17 and 1.32 mmol/L with median value of 1.26 mmol/L; these values were not different from those obtained with the non-alcoholic convulsive patients, however they were higher than the calcium levels in the alcoholic convulsive group (p < 0.05). PTH levels, liver function tests, phosphatemia and amylasemia were normal in all patients.

CONCLUSION

This study emphasizes the importance of serum calcium measurement in alcoholic patients presenting seizures and suggests that hypocalcemia correction might be important in these patients.

Y-chromosome identification by PCR and gonadal histopathology in Turner's syndrome without overt Y-mosaicism

OBJECTIVE

The frequency of gonadoblastoma is high in patients with Turner's syndrome bearing cells with Y or partial Y-chromosome. About 60% of patients with Turner's syndrome have a 45,X karyotype. In 30% of them a Y-sequence is disclosed by DNA analysis. To identify patients at risk of developing gonadoblastoma, a PCR based assay with SRY, ZFY and DYZ3 specific primers was carried out to detect different Y-sequences in the DNA of peripheral lymphocytes from patients with Turner's syndrome.

DESIGN AND PATIENTS

Peripheral blood karyotypes from 36 patients with Turner's syndrome were studied. Patients with proven Y-chromosomal material were excluded. Genomic DNA was extracted from peripheral blood. SRY and ZFY genes and DYZ3 repetion of Y-chromosome were amplified by PCR. Patients with clinical signs of hyperandrogenism or with positive Y-sequences by PCR underwent gonadectomy. The gonadal tissues were examined for Y-sequences using PCR, morphology and immunohistochemical study.

MEASUREMENTS

Turner's syndrome and signs of hyperandrogenism were evaluated both clinically and through laboratory tests. Haematoxylin and eosin staining was employed in gonadal morphology studies. The presence of testosterone was detected by immunohistochemistry using a monoclonal antibody.

RESULTS

Two patients who had Y-positive blood samples and three hyperandrogenic (2 hirsutes, 1 virilized) Y-negatives underwent gonadectomy. PCR was carried out on their gonadal tissue. The tissue from the two patients without hyperandrogenism was Y-positive. The gonadal tissue from the three hyperandrogenics was Y-negative. Gonadal morphology disclosed hilus cell hyperplasia in the 3 hyperandrogenic Y-negatives and in one Y-positive patient; stromal luteoma and hyperthecosis in the virilized patient, cystadenofibroma in one hirsute patient and gonadoblastoma in one Y-positive. Testosterone was detected immunohistochemically in the hilus cell hyperplasia, stromal luteoma and hyperthecosis found in the hyperandrogenic patients.

CONCLUSIONS

The molecular study was sensitive and useful in the evaluation of patients at risk of developing gonadoblastoma. Other nontumour, gonadotrophin-dependent and Y-independent mechanisms which deserve the same medical approach may be involved in the genesis of hyperandrogenic signs in Turner's syndrome.

Changes in renal hemodynamics and tubular function of surgically cured primary hyperparathyroid patients are probably due to chronic hypercalcemic nephropathy

To understand the mechanisms responsible for the persistent hypercalciuria and reduced glomerular filtration rate (GFR) previously found in 6 of 10 patients surgically cured of primary hyperparathyroidism (PHPx), the tubular handling of lithium, sodium, calcium, and phosphate as well as the renal hemodynamics were evaluated in these 10 PHPx patients, in 10 control subjects, and in 5 patients with renal hypercalciuria (RH), during fasting and after an oral calcium load. A positive correlation between the fractional excretions of calcium and sodium was found in all groups, but the PHPx patients excreted more calcium for the same amount of sodium than control subjects. The fractional proximal sodium reabsorption (FPRNa), distal delivery, and fractional phosphate reabsorption were similar in all groups; a significant positive correlation was found between the fractional calcium reabsorption and the FPRNa, indicating that proximal tubular function was preserved and that the urinary calcium losses in RH and in the hypercalciuric PHPx patients (h-PHPx) occurred in the distal nephron. However, only h-PHPx patients had reduced renal plasma flow, renal blood flow, and GFR, as well as a high renal vascular resistance, which was even more evident after the calcium challenge. These findings lead us to conclude that RH and h-PHPx patients are very different, as far as kidney dysfunction is concerned, and that a hypercalcemic nephropathy is the most probable cause of the alterations in distal calcium reabsorption and renal hemodynamics found in the h-PHPx patients.

A comparative study of p53 immunoexpression in parathyroid hyperplasias secondary to uremia, primary hyperplasias, adenomas and carcinomas

OBJECTIVE

To investigate immunoexpression of p53 in parathyroid tumors and hyperplasias and correlate it with the histopathological diagnosis and severity of hyperparathyroidism.

DESIGN

A total of 102 parathyroid tissues from archival paraffin-embedded specimens or obtained at surgery between 1988 and 1997 from 65 consecutive individuals with hyperparathyroidism were studied.

METHODS

p53 immunoexpression, gland mass, preoperative serum calcium and intact parathyroid hormone (PTH) were analyzed; 14 normal parathyroid glands were used as controls.

RESULTS

The histopathological findings were: adenomas (n = 28), primary hyperplasias (n = 12), secondary nodular and diffuse hyperplasias (patients with uremia, n = 57), carcinomas (n = 4) and carcinomatous metastatic tissue (n = 1). Nuclear p53 was detected in 36% of the adenomas, 42% of the primary hyperplastic glands, 72% of the diffuse hyperplasias, 44% of nodular hyperplasias and 40% of the carcinomatous tissues, and was absent from normal glands. p53 expression was significantly more frequent in diffuse hyperplasias than in adenomas (P = 0.037). Serum ionized calcium tended to be higher in p53-positive glands in all histopathological groups; however, the difference was only significant in nodular hyperplasias (P = 0.018). The same trend was observed for serum intact PTH levels of adenomas and nodular hyperplastic glands. Gland mass was not significantly different according to p53 staining.

CONCLUSIONS

p53 immunoexpression was not useful in differentiating between the histopathological parathyroid subgroups. p53 immunodetection was particularly frequent in secondary hyperplastic glands of uremic patients. Our study suggests that p53, whether wild-type or mutant, is regulated in parathyroid tumors and hyperplasias. Changes in wild-type p53 may be part of a cellular response to a hyperproliferative condition.

Parathyroid glands in uraemic patients with refractory hyperparathyroidism: histopathology and p53 protein expression analysis

AIMS

Refractory hyperparathyroidism is a state of parathyroid hyperfunction and hypercalcaemia in uraemic patients with previous secondary hyperplasia. We studied histopathological features and p53 expression in 49 parathyroid glands of uraemic patients (n = 21) with refractory hyperparathyroidism in order to investigate whether p53 abnormalities could be present in parathyroid hyperplasias of chronic renal failure.

METHODS AND RESULTS

Nodular hyperplasia was found in 77.5% of the glands (n = 38). The proportion of oxyphil cells and acinar cell arrangements was higher in nodular hyperplasia than in diffuse hyperplastic glands P < 0.001). Duration of renal disease and haemodialysis treatment tended to be longer in patients with nodular hyperplasia. There was no correlation between serum intact PTH (iPTH), calcium and hyperplasia pattern. A trend for a higher glandular mass was found in nodular type hyperplasia (1.88 +/- 2.13 g) than in diffuse type hyperplasia (0.87 +/- 1.28 g; P = 0.06). Nuclear p53 immunoreactivity was shown in 55% of the hyperplastic glands, whereas it was not detected in 12 normal parathyroid glands used as controls. p53 staining was present in c. 82% of the diffuse hyperplastic glands and in 47% of the nodular hyperplastic glands (P = 0.08).

CONCLUSIONS

Nodular type hyperplasia was the predominant histopathological pattern in uraemic patients with refractory hyperparathyroidism in our study. Nodular hyperplastic glands characteristically had higher percentage of oxyphil cells, acinar cell arrangements and mass than diffuse hyperplastic glands. A high prevalence of p53 protein expression was found in hyperplastic glands of uraemic patients. Our results suggest that p53 abnormalities might be involved in the pathogenesis of parathyroid hyperplasia in chronic renal failure.

Fractures of the proximal femur: correlation with vitamin D receptor gene polymorphism

Fractures are the feared consequences of osteoporosis and fractures of the proximal femur (FPF) are those that involve the highest morbidity and mortality. Thus far, evaluation of bone mineral density (BMD) is the best way to determine the risk of fracture. Genetic inheritance, in turn, is one of the major determinants of BMD. A correlation between different genotypes of the vitamin D receptor (VDR) and BMD has been recently reported. On this basis, we decided to determine the importance of the determination of VDR genotype in the presence of an osteoporotic FPF in a Brazilian population. We studied three groups: group I consisted of 73 elderly subjects older than 65 years (78.5 +/- 7.2 years) hospitalized for nonpathological FPF; group II consisted of 50 individuals older than 65 years (72.9 +/- 5.2 years) without FPF and group III consisted of 98 young normal Brazilian individuals aged 32.6 +/- 6.6 years (mean +/- SD). Analysis of VDR gene polymorphism by restriction fragment length polymorphism (RFLP) was performed by PCR amplification followed by BsmI digestion of DNA isolated from peripheral leukocytes. The genotype distribution in group I was 20.5% BB, 42.5% Bb and 37% bb and did not differ significantly from the values obtained for group II (16% BB, 36% Bb and 48% bb) or for group III (10.2% BB, 47.6% Bb and 41.8% bb). No differences in genotype distribution were observed between sexes or between the young and elderly groups. We conclude that determination of VDR polymorphism is of no practical use for the prediction of FPF. Other nongenetic factors probably start to affect bone mass, the risk to fall and consequently the occurrence of osteoporotic fractures with advancing age.

Prospective bone mineral density evaluation in patients with insulin-dependent diabetes mellitus

The bone mineral density (BMD) in patients with insulin-dependent diabetes mellitus (IDDM) was evaluated prospectively to assess the course of osteopenia in IDDM. We measured BMD in the lumbar spine, femoral region, and total body calcium in 23 patients aged 21-53 years with IDDM for 2.3 to 20 years using a dual energy X-ray absorptiometry. A second BMD measurement was done after 26.5+/-4.1 months in all patients. The blood glucose control, insulin dosage, and disease duration were also assessed. Eleven patients had osteopenia (1 Z-score below the mean values of normal gender- and age-matched individuals). These patients had a longer IDDM duration (8.6+/-5.1 years in osteopenics versus 4.6+/-3.75 years in non-osteopenics; p=0.03). The blood glucose control and insulin dosage were not significantly different throughout the study. The mean spinal BMD was higher in the second evaluation in both osteopenics (0.91+/-0.12 g/cm2 and 0.96+/-0.09 g/cm2, p=0.035) and non-osteopenics (1.24+/-0.15 g/cm2 and 1.29+/-0.16 g/cm2; p=0.02). In the end of the study, however, the osteopenic group persisted with lower subnormal BMD values than the non-osteopenic group (p < 0.001). The small BMD increment observed in the spine did not correlate with changes in the metabolic control or with IDDM duration, but occurred mainly in patients younger than 30 years old. There was no significant change in the femoral BMD or total body calcium. None of the patients developed or significantly worsened the osteopenia. We conclude that diabetic osteopenia, despite being a complication of high prevalence in IDDM, seems to be non-progressive in the majority of patients. In some patients, the spinal BMD increased during observation and may have been due to achievement of peak bone mass.

[Comparison of two strategies for the early detection of congenital hypothyroidism]

OBJECTIVE

Compare two different strategies in newborn screening for congenital hypothyroidism, primary TSH in the umbilical cord blood (method 1) and primary T4 in blood collected from the heel in the 2nd day of life (method 2).

METHODS

We compared both strategies in 10,000 newborns, measuring TSH by a sensitive immunofluorimetric assay and T4 by a radioimmunoassay.

RESULTS

Both strategies detected all cases of hypothyroidism (4 cases, 1/2,500 newborns). The recalling index owing to insufficient amount of blood to perform the assays was zero in method 1 and 8.5% (850 newborns) in method 2. The recalling index for confirmation of the results was 0.06% (6 newborns) in method 1 and 2.25% (225 newborns) in method 2; when method 2 included supplementary TSH, the recalling index was reduced to 1.63% (163 newborns).

CONCLUSION

Our data indicate the technical superiority of the umbilical cord blood compared to heel and primary TSH compared to primary T4 in the neonatal thyroid screening for congenital hypothyroidism.

Vitamin D receptor gene polymorphism: correlation with bone mineral density in a Brazilian population with insulin-dependent diabetes mellitus

Patients with insulin-dependent diabetes mellitus (IDDM) are at higher risk of developing osteoporosis. Among the genetic factors related to the development of osteoporosis, a possible association between vitamin D receptor (VDR) gene polymorphism and bone mineral density (BMD) has been described in some populations. We characterized the VDR gene polymorphism in a healthy adult Brazilian population and in a group of patients with IDDM and correlated these findings with densitometric values in both groups. The Brazilian population is characterized by an important racial heterogeneity and therefore is considered an ethnically heterogeneous population. We recruited 94 healthy adult Brazilian volunteers (63 women and 31 men), mean (+/- SD) age 32.4 +/- 6.5 years (range 18-49 years), and 78 patients with IDDM (33 women and 45 men) diagnosed before 18 years of age, mean (+/- SD) age 23.3 +/- 5.5 years (range 18-39 years). VDR genotype was assessed by polymerase chain reaction amplification followed by BsmI digestion on DNA isolated from peripheral blood leukocytes. Statistical analysis included Bonferroni t-test to compare densitometric values within different genotypes in both groups and multiple regression analysis of bone density adjusted for potential confounding factors. The IDDM group had a lower BMD compared with the control group. The VDR genotype distribution in the control group was 43 Bb (45.7%), 39 bb (41.5%) and 12 BB (12.8%). This distribution did not differ from that observed in the IDDM group: 39 Bb (50%), 26 bb (33.3%) and 13 BB (16.7%). In the IDDM group, patients with the Bb genotype had a higher body weight when compared with the BB genotype (p = 0.02). However, when diabetic patients were controlled for age, sex and body mass index, BB genotype was associated with a lower mean BMD at lumbar spine and femoral neck than in Bb and bb patients. BB patients had a shorter duration of IDDM than bb and Bb patients. These findings suggest a small influence of VDR gene polymorphism on BMD of a racially heterogeneous population with IDDM.

Increased thyrotrophin levels and loss of the nocturnal thyrotrophin surge in Sheehan's syndrome

OBJECTIVE

Since panhypopituitarism in patients with Sheehan's syndrome is due to massive pituitary necrosis with only minor hypothalamic involvement, we hypothesized that serum TSH levels would be low but its circadian rhythm preserved in these patients.

DESIGN AND PATIENTS

Basal and TRH-stimulated mean afternoon (1500-1700 h) and nocturnal (0100-0300 h) TSH levels were determined in 10 patients with Sheehan's syndrome before and during T4/glucocorticoid replacement and in seven controls.

MEASUREMENTS

Serum concentrations of T3, T4, free T4 (fT4) and cortisol were measured by radio-immunoassay; TSH, GH, PRL and LH were determined by immunofluorimetric assay.

RESULTS

Afternoon TSH levels were markedly increased in Sheehan's syndrome patients compared with controls (3.3 +/- 1.0 vs 0.5 +/- 0.15 mU/l, respectively, P = 0.002). At night, TSH levels remained unchanged in Sheehan's syndrome patients (3.3 +/- 1.1 mU/l) but rose significantly in controls (1.1 +/- 0.34 mU/l, P = 0.016). The nocturnal TSH increment was significantly higher in controls than in patients (143 vs approximately 4.9%, respectively, P = 0.0001). In eight patients with normal serum fT4 levels during treatment, basal TSH levels decreased to 0.16 +/- 0.05 mU/l (P < or = 0.008), being barely detectable or undetectable in four patients. In the six patients with detectable TSH during treatment, nocturnal TSH increments were normal in four and blunted in two. There was a strong correlation between pre- and post-treatment basal TSH (r = 0.82, P = 0.012) and between pre- and post-treatment peak TSH after TRH (r = 0.91, P = 0.0017), but no significant correlation between TSH and thyroid hormone levels. The per cent ratio of peak TSH after TRH between treated patients and controls, an estimate of the relative size of the functional thyrotroph pool in Sheehan's syndrome patients, was 7%.

CONCLUSIONS

Loss of TSH rhythm in Sheehan's syndrome is usually secondary to hormonal deficiency and results from maximally increased secretory activity of a decreased pool of thyrotrophs. The paradox of increased TSH levels and decreased thyroid function in Sheehan's syndrome could result from decreased TSH bioactivity and/or from a critically reduced thyrotroph population that fails to sustain sufficient TSH secretion in the face of rising serum thyroid hormone levels.

Vitamin D receptor alleles and bone mineral density in a normal premenopausal Brazilian female population

Studies on the association between vitamin D receptor (VDR) polymorphism and bone mineral density (BMD) in different populations have produced conflicting results probably due to ethnic differences in the populations studied. The Brazilian population is characterized by a very broad genetic background and a high degree of miscegenation. Of an initial group of 164, we studied 127 women from the city of São Paulo, aged 20 to 47 years (median, 31 years), with normal menses, a normal diet and no history of diseases or use of any medication that could alter BMD. VDR genotype was assessed by PCR amplification followed by BsmI digestion of DNA isolated from peripheral leukocytes. BMD was measured using dual energy X-ray absorptiometry (Lunar DPX) at the lumbar site (L2-L4) and femoral neck. Most of the women (77.6%) were considered to be of predominantly European ancestry (20.6% of them reported also native American ancestry), 12.8% were of African-Brazilian ancestry and 9.6% of Asian ancestry, 41.0% (52) were classified as bb, 48.8% (62) as Bb and 10.2% (13) as BB. The BB, Bb and bb groups did not differ in age, height, weight, body mass index or age at menarche. Lumbar spine BMD was significantly higher in the bb group (1.22 +/- 0.16 g/cm2) than in the BB group (1.08 +/- 0.14; P < 0.05), and the Bb group presented an intermediate value (1.17 +/- 0.15). Femoral neck BMD was higher in the bb group (0.99 +/- 0.11 g/cm2) compared to Bb (0.93 +/- 0.12) and BB (0.90 +/- 0.09) (P < 0.05). These data indicate that there is a significant correlation between the VDR BsmI genotype and BMD in healthy Brazilian premenopausal females.

Ligation of the left renal vein in epm1-Wistar rats: functional and morphologic alterations in the kidneys, testes and suprarenal glands

OBJECTIVE

The ligation of the left renal vein (LLVR) in man is a controversial procedure in view of the risks of lesion to the renal parenchyma. With the objective of studying the morphologic and functional alterations caused by these lesions, we conducted experimental research with rats.

MATERIAL AND METHODS

64 male adult EPM1-WISTAR rats were used, divided into 8 groups-4 for LLRV and four for control. Each LLRV group and corresponding control group were sacrificed progressively on the 7th, 15th, 30th and 60th day after the initial surgery.

RESULTS

We found morphofunctional alterations only in animals that underwent LLRV in the four periods of sacrifice. The proteinuria creatinine in serum, testosterone in serum and serum corticosterone in serum showed practically no alteration in relation to the normal values for rats. Statistically significant severe histological lesions were found in the kidneys and testes of the LLRV groups. Lesions in the suprarenal glands were also present in these groups, but no sufficient to demonstrate statistical significance.

CONCLUSION

Based on these results we can conclude that the ligation of the left renal vein is a procedure of high risk in these animals.

[Monomeric plasmatic calcitonin and hypercalcemia in lung cancer patients]

BACKGROUND

Calcitonin (CT) is a peptidic hormone produced by the thyroid C cells and related to calcium metabolism. High plasmatic levels of this hormone are found in patients with medullary thyroid carcinoma, what makes it an excellent tumor marker for this disease. However, there are reports that showed an increase of plasmatic CT levels in patients with other tumors, mainly in lung cancer.

PURPOSE

These data prompt us to investigate the validity of the CT level determinations as a potential tumor marker in different histologic lung cancer, and its correlation with hypercalcemia, a very common complication in these tumors.

METHOD

Blood were sampled from 56 patients with malignant lung disease for the CT and ionized calcium determinations. Calcitonin was measured using a specific radioimmunoassay for the monomeric form of the molecule, in a previous silica extracted serum probe.

RESULTS

We did not find elevated levels of monomeric CT in lung cancer. Only 3 patients had mild elevated levels, while in the others CT was normal or undetectable. Hypercalcemia was found in 21.4% of these patients, but only one with supranormal CT levels.

CONCLUSION

Monomeric CT serum levels are normal in lung cancer, what makes the latter use an unreliable tumor marker.

Osteopenia occurs in a minority of patients with acromegaly and is predominant in the spine

Acromegaly may induce abnormalities in bone metabolism; however, there are limited data related to bone mineral density (BMD) in this condition. To evaluate the effects of an excess of growth hormone/ insulin-like growth fractor I (GH/IGF-I) in the skeleton, we measured the BMD in spine and femoral region, total body calcium and body composition in 45 patients (24 females and 21 males) aged 21-77 years (median 43 years) with acromegaly for 11.4 +/- 7.5 years (range 0.5-26 years) using a dual-energy X-ray absorptiometer (Lunar DPX). Thirty-four patients had had hypogonadism for 8.6 +/- 6.5 years (1-24 years). Mean serum GH and IGF-I levels were respectively 159 +/- 183 micrograms/l and 843 +/- 497 micrograms/l. Total body calcium was increased in the acromegalics (males: 1272 +/- 217 g, range 916-1816 g; females: 1041 +/- 223 g, range 739-1609 g) when compared with normal individuals (males: 1115 +/- 144 g, range 856-1398 g; females: 909 +/- 144 g, range 511-1311 g; p = 0.01). The lean body mass was significantly higher in acromegalic patients (p < 0.001) compared with normal individuals. There was a tendency for a lower fat percentage in the acromegalics; however, this difference was not significant. Osteopenia (1 Z-score below the mean) was found in the spine in 20% (n = 9) of the patients, while BMD was decreased in the femoral region in only 8.8% (n = 4). The group with osteopenia had a greater duration of hypogonadism than the normal BMD group (14 +/- 11 years vs 4.4 +/- 4.0 years; p = 0.01). A negative correlation was also found between the duration of hypogonadism and BMD in spine (r = -0.4; p = 0.003) and femoral region (r = -0.37; p = 0.013). The hypogonadal patients had a lower BMD in spine (p < 0.005), but not in other regions analyzed. No correlation was found between duration of hypersomatotropism, GH/IGF-I levels and BMD. We conclude that the majority of patients with acromegaly have preserved BMD despite the presence of hypogonadism.

Comparative bioavailability study of an once-a-week matrix versus a twice-a-week reservoir transdermal estradiol delivery systems in postmenopausal women

An open-label, randomised, crossover study was conducted with in healthy postmenopausal women to compare the relative bioavailability of a matrix transdermal estradiol delivery system worn for 7 consecutive days, versus a reservoir transdermal patch worn for 4 days followed by its immediate replacement by another patch worn for further 3 consecutive days. There was a minimum 7-day washout period between the two study periods. Both systems were labelled to release approximately 50 micrograms/day of estradiol. Twenty-six subjects were evaluated with regard to estradiol serum levels. Blood samples were taken immediately before and at regular intervals until 192 h after the initiation of each study treatment (patch application) and assayed for estradiol. There was no difference between the patches with regard to Cmax. Based on the relative bioavailability, one matrix patch proved to be bioequivalent to two reservoir patches worn consecutively for 7 days. These results demonstrate the ability of one matrix patch to deliver consistent therapeutic levels of estradiol over a 7-day period.

Antibodies to bovine serum albumin in Brazilian children and young adults with IDDM

OBJECTIVE

To evaluate the prevalence of IgG antibodies to bovine serum albumin (BSA) in a cohort of Brazilian children and young adults with IDDM.

RESEARCH DESIGN AND METHODS

Sera from 81 subjects with < 1 year of IDDM (group 1), III subjects with > 1 year of IDDM (group 2), and 207 normoglycemic subjects were tested using an immunofluorimetric assay. A receiver-operating-characteristic curve was used to establish the threshold of anti-BSA antibody titers defining the positivity of the assay.

RESULTS

The distribution of the fluorimetric index (FI) of anti-BSA antibodies did not have a gaussian profile. Rank sum of FI was significantly higher in patients than in control subjects (P < 0.0001). Average logFI values of both IDDM groups were significantly higher than that of the control group (P < 0.005 for both groups). There was a trend toward higher FI levels in group 1 than in group 2 (P = 0.06). A FI cutoff of 0.7 optimized the ratio of true-positive to false-positive of the assay, with the best equilibrium between sensitivity and specificity. The prevalence of anti-BSA antibodies was 52% in group 1, 47% in group 2, and 28% in the control group (P = 0.0001). An independent association between anti-BSA antibodies and IDDM, with an odds ratio of 3.03 (P < 0.0001), was observed in a logistic regression analysis. However anti-BSA antibodies explained only 5% of the variability of IDDM versus NIDDM.

CONCLUSIONS

Our results confirm that the prevalence of anti-BSA antibodies is higher in IDDM subjects than in control subjects, even after 1 year of diabetes. However, a large overlap of antibody titers is observed in patients and control subjects, suggesting that anti-BSA antibodies are neither sensitive nor specific markers of IDDM.

The cause of maintained hypercalciuria after the surgical cure of primary hyperparathyroidism is a defect in renal calcium reabsorption

The hypercalciuria that eventually remains after the successful removal of a solitary parathyroid adenoma may originate from excessive intestinal calcium absorption, bone resorption or deficient renal reabsorption. In order to clarify this question, ten patients surgically cured from primary hyperparathyroidism (PHPx), ten age-matched normal subjects and five nephrolithiasic patients with renal hypercalciuria (RH) were studied after five days on a low calcium diet, either during fasting or after oral calcium load. Fasting serum calcium, amino-terminal and intact PTH levels and also urinary cAMP excretion were normal in every individual patient. Serum ionized calcium and inulin clearance (GFR) were used for calculations of the filtered load (FL Ca) and the fractional excretion of calcium (FE Ca). Six PHPx patients displayed fasting calciuria above the upper limit calculated for control subjects, despite having the lowest GFR and FL Ca (p < 0.05 vs control). These patients (h-PHPx) had a small calciuric response to oral calcium load. Serum 1,25-(OH)2D3 and 25OHD3 did not correlate with calciuria. Our findings exclude intestinal hyperabsorption and excessive bone resorption in h-PHPx patients, and strongly suggest a renal tubular defect in calcium reabsorption as the cause of their hypercalciuria. This defect could be primary, as in RH, but only three hPHPx patients had recurrent kidney stones before surgery. On the other hand, as a negative correlation between GFR and FE Ca was only found in PHPx patients, it seems probable that the disturbances in glomerular and tubular functions were secondary to the long standing hypercalcemic hyperparathyroidism.

1,25-Dihydroxyvitamin D3 stimulates growth and inhibits calcitonin secretion in a human C cell carcinoma cell line

1,25-Dihydroxyvitamin D3 (1,25D3), calcitonin (CT) and parathyroid hormone are the major calcium-regulating hormones. In addition, 1,25D3 has been reported to be a modulator of cell growth and differentiation in many tissues. Recently, a suppressive effect of 1,25D3 on CT secretion and synthesis in C cells was demonstrated in vivo and also in vitro, but there are no data about its effects on thyroid C cell growth. We investigated the effects of 1,25D3 on basal and stimulated CT secretion and on [3H]thymidine incorporation, using a human medullary thyroid carcinoma cell line (TT cells). After a 4-day exposure to 1,25D3, TT cells showed a dose-dependent inhibition of basal CT secretion (64% of the value for the control group at 100 nM 1,25D3). Calcium (3 mM) plus K+ (50 mM) greatly increased CT secretion in both the control and vitamin D-treated groups. However, in the cells preincubated with 1,25D3 the stimulated CT levels were less than observed in controls. A dose-dependent increase in [3H]thymidine incorporation (200% of the value for the control group at 100 nM 1,25D3) and in cell number (150% of the value for the control group at 100 nM 1,25D3 after 72 h) was observed in the groups treated with 1,25D3. 24,25D3 had no effect on CT secretion or cell growth compared to the control group. These data show that 1,25D3 decreased basal and Ca(2+)-stimulated CT secretion, a specialized function of these cells, and stimulated their growth. Hence, in contrast to its effects on other cell lines, 1,25D3 appears to induce a dedifferentiation on TT cells.

Monoclonal antibodies specific for the free alpha subunit of glycoprotein hormones and their use in the development of a sensitive immunofluorometric assay

Glycoprotein hormone free alpha subunit has been used as a marker for some pituitary tumors and to study the reactivity of glycoprotein hormone-producing cells under different circumstances. We describe a highly sensitive and specific immunofluorometric assay for the measurement of serum free alpha subunit levels. The assay is based on a monoclonal antibody, specific for free alpha subunit, bound to microtiter plates. As tracer antibody we employed an europium-labelled free/complexed alpha subunit specific monoclonal antibody. Using overnight incubation and 50-microliters samples, the least detectable dose was of the order of 4 ng/l. Cross-reactivity with LH, TSH, FSH and hCG was 6.5, 1.2, 4.3 and 1.1%, respectively. Normal adult males showed values ranging from 120 to 790 ng/l, not different from normal adult premenopausal females (88 to 604 ng/l). In post-menopausal females, serum concentrations were significantly higher, ranging from 341 to 4071 ng/l. In 56 patients with untreated pituitary tumors (18 "non-secreting", 25 GH-producing and 13 prolactin-producing tumors), 10 showed high values, 3 of them from the first group, 3 from the second and 4 from the third. We conclude that this highly sensitive assay can be a valuable tool for the diagnosis and follow-up of selected patients with pituitary tumors and in other circumstances in which the glycoprotein hormone-producing cells of the pituitary require evaluation.

Comparison of the determination of insulin by a monoclonal antibody-based immunofluorometric assay and by radioimmunoassay

This paper describes an immunofluorometric assay (IFMA) for insulin and compares it with the classical radioimmunoassay (RIA). Monoclonal antibodies against insulin were produced and used to develop the IFMA. One, immobilized on microtiter plates, was used for capture, the other, labelled with Europium, was used as tracer antibody. The IFMA presents sensitivity to an amount of insulin of 3 pmol/l and acceptable values for intra- and interassay error. The IFMA presented superimposable curves for human insulin, Arg65/Gly66-split proinsulin and des-Lys64,Arg65, and no cross-reactivity with human proinsulin, Arg32/Glu33-split and des-Arg31,Arg32. The RIA showed 100% cross-reactivity with human proinsulin, 90% with Arg32/Glu33-split, 193% with Arg65/Gly66-split, 340% with des-Arg31,Arg32 and 170% with des-Lys64,Arg65. The assays were used to measure insulin in 300 serum samples from 50 subjects submitted to an oral glucose tolerance test (OGTT). Twenty were normal, 10 had impaired glucose tolerance and 20 non-insulin-dependent diabetes mellitus. The mean value (+/- SEM) obtained by IFMA was 166.7 +/- 12.1 pmol/l and the mean value obtained by RIA was 339.6 +/- 18.6, with a correlation of r = 0.80 (P < 0.01). Comparison of basal insulin levels of the different groups of individuals using IFMA or RIA led to the same conclusions. The area under the curve showed statistically significant differences only for the comparison between normal lean subjects and individuals with impaired glucose tolerance, when measured by RIA. Our data stress the importance of methodology definition when comparing insulin results.(ABSTRACT TRUNCATED AT 250 WORDS)

Nocturnal urinary growth hormone excretion as a criterion for growth hormone deficiency

Nocturnal urinary growth hormone (U-hGH) levels measured by a sensitive immunoenzymometric assay were compared with hGH levels in serum before and after a clonidine test in healthy children and in children with short stature to determine whether U-hGH measurement is useful for the screening of hGH deficiency. The study was carried out on 19 healthy children (10 prepubertal and 9 pubertal subjects) and on 20 children with short stature, 10 with growth hormone deficiency (hGHD) and 10 with constitutional growth retardation. The diagnosis of hGHD was based on a blunted response to two provocative hGH tests in the appropriate clinical setting. Overnight urinary hGH secretion (mean of 3 collections) was measured by an immunoenzymometric assay. The best discrimination was obtained when the results were expressed as ng/h. Only one individual in the prepubertal group (U-hGH, 0.05 ng/h) and one patient in the growth retardation group (U-hGH, 0.08 ng/h) had a urinary hGH value below the highest value (0.17 ng/h) observed in the growth hormone deficiency group. The coefficient of correlation between urinary hGH in ng/h and post-clonidine peak was 0.50 (P = 0.0015), between urinary hGH in ng/l and post-clonidine peak was 0.48 (P = 0.0025), between urinary hGH in ng/l per hour and post-clonidine peak was 0.47 (P = 0.0027). The highest specificity (0.93), sensitivity (0.90), false negative rate (0.96) and false positive rate (0.82) were obtained when U-hGH was expressed as ng/h per night. Measurement of urinary nocturnal hGH excretion is a useful, simple, noninvasive method for the diagnosis of hGH deficiency.(ABSTRACT TRUNCATED AT 250 WORDS)

Development and clinical application of an immunofluorometric assay for intact parathyroid hormone

Parathyroid hormone (PTH) is a linear peptide of 84 amino acids that is found in serum mainly in the form of carboxyl-terminal fragments. The biological activity of PTH depends on the presence of the amino-terminal portion and in circulation is limited to the intact molecule. We describe an immunofluorometric assay for the measurement of PTH-(1-84) based on a chicken egg yolk-derived amino-terminal antibody bound to microtiter plates by an anti-chicken Ig monoclonal antibody. As tracer antibody we employed a Europium-labelled carboxyl-terminal specific monoclonal antibody produced from a mouse immunized with hPTH-(53-84)-BSA conjugate. The assay included an initial overnight incubation of the sample and the solid phase-bound amino-terminal antibody, followed by washing and addition of the tracer antibody, and an additional two hours of incubation prior to fluorescence reading. The least-detectable dose was in the order of 2.5 pg/ml and preliminary studies in 40 normal adults showed values in the range of 4 to 70 pg/ml; for 12 patients with surgery-proven primary hyperparathyroidism values ranged from 109 to 743 pg/ml and for 34 patients with humoral hypercalcemia of malignancy from 2.5 to 66 pg/ml. We conclude that this assay, with its increased sensitivity and specificity, will be a valuable tool in the study of PTH secretion in normal and pathological situations.

Serum levels of androstanediol glucuronide, total testosterone, and free testosterone in hirsute women

OBJECTIVE

To determine the serum levels of androstanediol glucuronide (3 alpha-diol G), total T, and free T in hirsute and nonhirsute women.

DESIGN

Controlled clinical study.

PATIENTS

Hirsute women with oligomenorrhea, hirsute women with regular ovulatory cycles, and nonhirsute women with regular cycles were selected.

MAIN OUTCOME MEASURE

Serum levels of 3 alpha-diol G, total T, and free T were measured in 8 hirsute with oligomenorrhea and 11 hirsute women with regular ovulatory cycles and compared with 20 nonhirsute women with regular cycles (control group). Serum 3 alpha-diol G was also measured during the follicular, periovulatory, and luteal phases in hirsute women with regular cycles.

RESULTS

Serum levels of 3 alpha-diol G did not change during the menstrual cycle, in addition we observed that there was no difference between the levels of 3 alpha-diol G, total T, and free T in hirsute women with regular cycles when compared with normal women. These three serum androgens were elevated only in the hirsute women with oligomenorrhea. Besides, there was better correlation between total T and free T (r = 0.81) than total T and 3 alpha-diol G (r = 0.49) or free T and 3 alpha-diol G (r = 0.66).

CONCLUSION

The findings suggest that serum 3 alpha-diol G does not provide additional benefit as a marker of hirsutism than serum total or free T.

Serum levels of prostate-specific antigen in normal boys throughout puberty

Serum levels of prostate-specific antigen (PSA) were measured in a group of 132 normal boys distributed in stages 1-5 of puberty. A highly sensitive (0.005 ng/mL) immunofluorometric assay was developed and used in the study. PSA levels were generally undetectable in state I and rose sharply from stage II to III and from stage III to IV. A significant positive correlation was found between PSA and testosterone levels, PSA and LH levels, PSA and age, PSA and testicular volume, as well as PSA and pubertal stage. Our findings indicate that PSA levels measured with highly sensitive assays can be of utility in the hormonal evaluation of puberty in boys.

Prevalence and magnitude of osteopenia associated with insulin-dependent diabetes mellitus

The authors evaluated the prevalence, magnitude, and contributing factors for osteopenia in insulin-dependent diabetes mellitus (IDDM). We measured bone mineral density (BMD) in the lumbar spine and femoral region in 90 patients aged 18-54 years with IDDM using dual-energy x-ray absorptiometry. The blood-glucose control, insulin dosage, duration of disease, and presence of chronic complications of diabetes were evaluated. Serum ionized calcium, magnesium, phosphorus, alkaline phosphatase (ALP), 25-hydroxycholecalciferol, immunoreactive parathyroid hormone (iPTH), and urinary calcium, phosphorus, and hydroxyproline were also analyzed. Thirty-one patients (34%) were classified as having a reduced BMD (less than 2 SD below the mean). The comparison between normal and low BMD patients showed that the osteopenics had a tendency to be younger (median, 28 years versus 32 years), showed a higher mean plasma glucose (15.5 +/- 5.0 mmol/L versus 12.9 +/- 3.8 mmol/L; p = 0.018), longer duration of disease (11.2 +/- 2.1 years versus 5.0 +/- 1.3 years; p = 0.004), and needed a higher insulin dosage (56 +/- 17 U/day versus 43 +/- 16 U/day; p < 0.001). There was a positive correlation between mean glucose levels, duration of disease, insulin dosage, and bone-mass decrease. A higher incidence of chronic complications, mainly retinopathy (58% versus 25%) and neuropathy (52% versus 22%) was found in the low BMD group. There was no alteration of serum calcium, phosphorus, iPTH, 25-hydroxycholecalciferol, and urinary calcium and phosphorus. The ALP levels were significantly higher in the osteopenic group, and magnesium and hydroxyproline levels were lower in the whole diabetic group, but these measurements did not correlate with BMD reduction.(ABSTRACT TRUNCATED AT 250 WORDS)

Prevalence and magnitude of osteopenia in patients with prolactinoma

1. The association between hypogonadism and osteoporosis has been reported. We conducted a study to establish the prevalence and magnitude of osteopenia in patients with prolactinoma and the relationship of bone loss with the duration of hypogonadism. 2. We measured the bone mineral density (BMD) of spine and femur (a site that has not been analyzed earlier) in 35 patients with prolactinoma using a dual-energy X-ray absorptiometer. The patients were classified as normal BMD and low BMD (osteopenics). 3. Seventeen patients (48%) showed osteopenia. The mean bone loss in the different regions was: spine, 13%; femoral neck, 15%; trochanter, 11%; Ward's, 22%. This difference was only significant when the spine and Ward's region were compared. The duration of hypogonadism was significantly greater in the low-BMD group (11.3 vs 4.9 years) when compared to the normal BMD group. There was a positive relationship between the duration of hypogonadism and magnitude of bone loss in both spine and femur (P = 0.04; r = 0.6). 4. A high prevalence of osteopenia in both spine and femur was found in patients with prolactinoma, and was highly associated with the duration of hypogonadism. Early treatment of this condition seems important to prevent bone loss.

Long-acting injectable bromocriptine (Parlodel LAR) in the chronic treatment of prolactin-secreting macroadenomas

OBJECTIVE

To evaluate the efficacy and tolerability of Parlodel LAR (Sandoz, Basel, Switzerland), a long-acting injectable bromocriptine, in PRL-secreting macroadenomas.

DESIGN

Eleven patients with macroprolactinomas were studied in an academic environment in an open and prospective protocol. Ten patients were followed for 6 months and 8 for 1 year. Fifty to 200 mg IM of Parlodel LAR were administered every 28 days.

RESULTS

At the end of the 1st month, 64% of the patients had PRL suppression of > 75% of baseline values. After 1 year, 88% of the cases had PRL suppression of > 90%. Persistent PRL normalization was seen in three cases. Tumor shrinkage was seen in 64% of the patients on day 5, in 73% on day 28, and in 90% after 6 months of treatment. Early visual field improvement was seen in 83% of the cases. All patients had improvement of clinical symptoms.

CONCLUSION

Parlodel LAR is well tolerated and very effective in the long-term treatment of patients with PRL-secreting macroadenomas.

[Prevalence of hypercalcemia in patients with lung cancer]

Although hypercalcemia is a serious and frequent complication of lung cancer, it is not commonly investigated in our country. We studied the prevalence of hypercalcemia in 90 random lung cancer patients from the Department of Pneumology, Escola Paulista de Medicina. The following histological types were found: 35 Squamous cells carcinomas (CEC), 30 Adenocarcinomas (AdenoCa), 11 Small cells carcinomas (CIPC), 2 Large cells carcinomas (TGC), 1 Carcinoid, 1 Mesothelioma, 2 Undifferentiated carcinomas, 1 Adenosquamous, 1 in situ carcinoma and 4 metastatic tumors. Ionized Ca (Ca-i) was measured in blood samples of all patients. Hyperparathyroidism was excluded by PTH and cAMP determinations in the hypercalcemic patients (Ca-i > 1.29 mmol/L). We found elevated levels of Ca-i (range = 1.30 to 2.0 mmol/L) in 18 patients (20%), being: 12 CEC (66.7%), 3 AdenoCa (16.7%), 2 CIPC (11.1%) and 1 TGC (5.6%). The PTH levels were low or suppressed in all 18 patients, but cAMP determinations were elevated in 6 out of 12 patients. Hypercalcemia is then a very frequent complication of lung cancer (20%), and PTH measurement was able to exclude a hyperparathyroidism in all cases studied.