Effectiveness of adalimumab in treating patients with active psoriatic arthritis and predictors of good clinical responses for arthritis, skin and nail lesions

Objectives:

To evaluate the effectiveness of adalimumab in patients with psoriatic arthritis (PsA) and identify predictors of good clinical response for joint and skin lesions.

Methods:

Patients received adalimumab 40 mg every other week in addition to standard therapy in this prospective, 12-week, open-label, uncontrolled study. Four definitions of good clinical response were used: ⩾50% improvement in American College of Rheumatology response criteria (ACR50), good response according to European League Against Rheumatism (EULAR) guidelines, a ⩾3-grade improvement in Physician Global Assessment of psoriasis (PGA) and a ⩾50% improvement in the Nail Psoriasis Severity Index (NAPSI). Response predictors were determined by logistic regression with backward elimination (selection level was 5%).

Results:

Of 442 patients, 94% completed 12 weeks of treatment. At week 12, 74%, 51% and 32% of the patients had achieved ACR20, 50 and 70, respectively; 87% and 61% experienced moderate and good responses according to EULAR criteria, respectively. The percentage of patients with PGA results of “clear/almost clear” increased from 34% (baseline) to 68%. The mean NAPSI score was reduced by 44%. No new safety signals were detected. A lower Health Assessment Questionnaire Disability Index (HAQ-DI) score, greater pain assessment, male sex and absence of systemic glucocorticoid therapy were strongly associated with achievement of ACR50 and good response according to EULAR criteria. In addition, greater C-reactive protein concentration and polyarthritis predicted ACR50, and non-involvement of large joints predicted a good response according to EULAR criteria.

Conclusions:

Adalimumab was effective in patients with PsA. Lower impairment of physical function, greater pain, male sex and no systemic treatment with glucocorticoids were factors that increased the chance of achieving a good clinical response.

Adalimumab effectively reduces the rate of anterior uveitis flares in patients with active ankylosing spondylitis: results of a prospective open-label study

Objective:

To evaluate the effect of adalimumab on the frequency of anterior uveitis (AU) flares in patients with active ankylosing spondylitis (AS).

Methods:

We determined the history of ophthalmologist-diagnosed AU in 1250 patients with active AS who were enrolled in a multinational, open-label, uncontrolled clinical study of treatment with adalimumab, 40 mg every other week for up to 20 weeks. All AU flares were documented throughout the adalimumab treatment period plus 70 days. We compared the rates of AU flares per 100 patient years (PYs) reported during the year before adalimumab treatment with rates during adalimumab treatment, in total and by patient subgroups.

Results:

The AU flare rates before adalimumab treatment were 15/100 PYs in all patients (n = 1250), 68.4/100 PYs in 274 patients with a history of AU flares, 176.9/100 PYs in 106 patients with a recent history of AU flares, 192.9/100 PYs in 28 patients with symptomatic AU at baseline and 129.1/100 PYs in 43 patients with a history of chronic uveitis. During adalimumab treatment, the rate of AU flares was reduced by 51% in all patients, by 58% in 274 patients with a history of AU, by 68% in 106 patients with a recent history of AU, by 50% in 28 patients with symptomatic AU at baseline and by 45% in 43 patients with chronic uveitis. AU flares during adalimumab treatment were predominantly mild. Two patients with periods of high AS disease activity had new-onset AU during the treatment period.

Conclusions:

Results of this prospective open-label study suggest that adalimumab had a substantial preventive effect on AU flares in patients with active AS, including patients with a recent history of AU flares.

Clinical trials:

ClinicalTrials.gov Identifier: NCT00478660.

NIHSS applied to cerebral neurological dive injuries as a tool for dive injury severity stratification

BACKGROUND

Evaluation via National Institutes of Health Stroke Scale (NIHSS) upon presentation in hospital triage following ischemic stroke is predictive of recovery or progression to neurological deficits. Cerebral injuries sustained while diving have symptoms similar to stroke. Applying the NIHSS to dive injuries may successfully summarize neurological dive injuries, providing a standardized tool for study of dive injury data.

METHODS

We retrospectively determined NIHSS scores for a diverse population of 192 divers presenting to the University of Hawaii recompression chamber from 1983-2002, both prior to initial treatment and after all treatment. Spinal and vestibular decompression sickness cases were excluded.

RESULTS

The performance of the NIHSS among this diving population was similar to its performance as an accepted tool in evaluation of ischemic stroke, although results are influenced by the abundance of mild injury cases in the data set. The estimated C-statistic with NIHSS predicting no observable deficit was 0.88, and predicting post NIHSS of 0-1 was 0.85 (vs. 0.86 when applied to stroke). Sensitivity for predicting recovery (NIHSS 0-1) at discharge was 0.99 (vs. 0.97 for stroke).

CONCLUSIONS

The NIHSS applied to cerebral dive injuries has adequate predictive ability and correlates with other measures of dive injuries, while providing a standardized, more graduated scale. The NIHSS may be useful as a standardized measurement for evaluation of treatment regimens and adjunctive therapy for diving injuries.

Higher frequency of dementia in older HIV-1 individuals: the Hawaii Aging with HIV-1 Cohort

BACKGROUND

Antiretroviral therapy has improved survival for HIV-1-infected individuals. The neuroepidemiologic implications of HIV-1 in an aging population are not well known, particularly the prevalence of HIV-associated dementia (HAD).

METHODS

The authors report a baseline cross-sectional analysis of 202 HIV-1-seropositive individuals enrolled into one of two groups of the Hawaii Aging with HIV Cohort: older (50 or more years old, n = 106) and younger (20 to 39 years old, n = 96). Neuropsychological, neurologic, medical, and laboratory data were obtained at enrollment. Participant cognitive status was classified (research case definitions) using American Academy of Neurology (1991) criteria in a consensus conference of physicians and neuropsychologists.

RESULTS

HAD was more frequent in older (25.2%) compared to younger (13.7%) individuals (p = 0.041) corresponding to an OR of 2.13 (95% CI: 1.02 to 4.44) for the older compared to the younger group. After adjusting for education, race, substance dependence, antiretroviral medication status, viral load, CD4 lymphocyte count, and Beck Depression Inventory score, the odds of having HAD among individuals in the older group was 3.26 (1.32 to 8.07) times that of the younger group.

CONCLUSIONS

Older age is associated with increased HAD in this HIV-1 cohort. Underlying mechanisms are unclear but do not appear related to duration of HIV-1 infection.

[A severe traffic accident--250 years ago. Medical history presentation]

During a scientific examination in July 1999 both crypts below the St. Martin's Church in Grünstadt, Germany, were opened and 9 coffins from the county family of Leiningen examined. This paper is concentrating on one of these persons: Georg Hermann (1679-1751), count of Leiningen-Westerburg-Altleiningen, who gave during the 18. century the city its barock character. He was also responsible for the rebuilding of the church. His skeleton revealed interesting pathological changes. Few years before his death the count had the accident to get run over by a heavy wagon which crushed the distal part of his legs. The fractures healed, but gave him an ancylotic and shortened left leg, which must have caused him a lot of suffering in his last years.

[Alf Brodal--the great brain scientist]

The use of scientific methods in the investigation of the central nervous system began at the beginning of the twentieth century, as gifted scientists like Gustav Adolf Guldberg (1854-1908), Fridtjof Nansen (1861-1930), and Georg Herman Monrad-Krohn (1884-1964) took up their research work. Dr Monrad-Krohn's renowned textbook, the so-called "Blue Bible", appeared in 1914 and enhanced the reputation of Norwegian science among specialists internationally. More than any other Norwegian scientist, Professor Alf Brodal (1910-88) brought brain research to new heights. This article presents a portrait of him in relation to his area of research.

Serologic and clinical outcomes of 1536 Alaska Natives chronically infected with hepatitis B virus

BACKGROUND

Knowledge of the outcome of chronic hepatitis B virus (HBV) infection is limited.

OBJECTIVE

To determine the incidence of and risk factors for adverse events (hepatocellular carcinoma and end-stage liver disease) and clearance of hepatitis B e antigen (HBeAg) and surface antigen (HBsAg) in carriers of HBV.

DESIGN

Population-based cohort study of hepatitis B carriers who were observed for a median of 12.3 years as part of an active surveillance program to detect carriers with hepatocellular carcinoma.

SETTING

126 communities in Alaska.

PATIENTS

1536 Alaska Natives with chronic hepatitis B.

MEASUREMENTS

Bivariate comparisons, multivariable models, and other statistical methods were used to examine the relationships of risk factors to outcomes and clearance of HBeAg and HBsAg.

RESULTS

1536 chronic HBV carriers were followed up for 19 430 person-years from their first HBsAg-positive test result. At the first serologic test, 641 were HBeAg positive and 893 were anti-HBe positive. Older carriers were more likely than younger carriers to clear HBeAg (P < 0.001). The observed probability of clearing HBeAg within 10 years of diagnosis was 72.5%. Clearance of HBsAg occurred in 106 (7%) of all carriers and was positively associated with older age and positive result on initial anti-HBe test. The incidence of adverse events was 2.3 per 1000 carrier-years, and the incidence of hepatocellular carcinoma was 1.9 per 1000 carrier-years (2.3 in men and 1.2 in women). Risk for hepatocellular carcinoma increased with age, among those of Yupik Eskimo ethnicity, and among carriers who reverted from anti-HBe to HBeAg.

CONCLUSION

In HBsAg-positive carriers, observed clearance of HBeAg was more than 70% during the first 10 years of follow-up.

Cancer incidence in Alaska Natives thirty-year report 1969-1998

The Alaska Native Tumor Registry includes data from 1969 to the present. This report provides incidence rates over the thirty year period, 1969 through 1998, and compares trends over time for Alaska Natives (AN) with those of US Whites and Blacks. To examine current rates, average annual age-adjusted incidence rates for AN for 1984-98 are compared with US Whites. Data from the registry document numerous differences in rates of occurrence of specific cancers compared to US Whites and Blacks. Studies of these differences may provide clues to the causes and risk factors for the cancers. Most importantly, these data show that although cancer was considered a rare disease in the Alaska Native population as recently as the mid-twentieth century, the incidence rate for all cancers combined among Alaska Natives is now as high as that of US Whites, and even higher in women. On the other hand, despite relative differences in rates, the most frequently diagnosed cancers among Alaska Natives are the same as US Whites. Cancers of the lung, colon/rectum, breast, and prostate are most frequently diagnosed among Alaska Natives and in the U.S. These four cancers comprise over 50% of all diagnosed invasive cancers. Cancer of the lung is almost entirely preventable by eradication of tobacco use. Screening and early detection have been proven to reduce mortality for cancers of the colon/rectum and breast. Primary and secondary prevention of these cancers could markedly improve morbidity and mortality.

Cancer mortality among Alaska natives, 1994-1998

Although overall cancer mortality rates in the U.S. declined throughout the 1990s, Alaska Native rates increased. This study compares mortality patterns of Alaska Natives for the period, 1994-1998, and U.S. Whites, and examines changes in rates since 1960-1969. We used death certificate data and Indian Health Service population estimates to create age-adjusted mortality rates for Alaska Natives. We compared these rates to NCHS mortality for U.S. Whites. In all, 597 Alaska Natives died of cancer over the five-year period, 1994-1998, their age-adjusted average annual mortality rate (224.5 per 100,000) was thirty percent higher than that of U.S. Whites (166.7 per 100,000), a statistically significant excess (OR = 1.3, 95% CI: 1.2-1.4). Alaska Natives were forty percent more likely to die of lung cancer than U.S. Whites (OR = 1.4, 95% CI: 1.2-1.6). This population also demonstrated elevated mortality rates for several other smoking-related cancers. Also, Alaska Natives are at excess risk for nearly all cancers of the digestive system. Alaska Natives experienced the same or lower mortality rates for genitourinary cancers excluding cancer of the kidney. Smoking related cancers, and particularly, lung cancer, were the major contributors to the excess mortality rates. These data suggest that the burden of cancer on the Alaska Native healthcare system will continue to increase as the population ages. Intensified efforts to modify behavioral risk factors are needed.

[Nose in the light of medical history]

Vanity, it seems, is one of the qualities that separate us from other species; indeed, we may said to possess it in excess. Decorating body and apparel with all kinds of objects in order to look attractive goes a long way back in time; even Stone Age man knew how to make himself look smart. This very human trait has not abated over the millennia, but the perception of what looks good has changed a great deal, just like fashion, and no part of the human body has probably been of such significance in this respect as the nose. This article presents a brief review of nasal fashion.

Bronchiectasis in Alaska Native children: causes and clinical courses

Although bronchiectasis has become a rare condition in U.S. children, it is still commonly diagnosed in Alaska Native children in the Yukon Kuskokwim Delta. The prevalence of bronchiectasis has not decreased in persons born during the 1980s as compared with those born in the 1940s. We reviewed case histories of 46 children with bronchiectasis. We observed that recurrent pneumonia was the major preceding medical condition in 85% of patients. There was an association between the lobes affected by pneumonia and the lobes affected by bronchiectasis. Eight (17%) patients had surgical resection of involved lobes. We conclude that the continued high prevalence of bronchiectasis appears to be related to extremely high rates of infant and childhood pneumonia. Pediatr Pulmonol. 2000;29:182-187. Published 2000 Wiley-Liss, Inc.

No seasonal variation of insulin sensitivity and glucose effectiveness in men

Insulin resistance is of pathogenetic importance for the development of non-insulin-dependent diabetes mellitus (NIDDM). However, not much is known about the variation in insulin sensitivity in the individual over longer periods. Consequently, we measured insulin sensitivity (Si) and glucose effectiveness (Sg) in healthy young men (N = 10) 5 times over a period of 15 months using a frequently sampled intravenous glucose tolerance test (FSIVGTT) with minimal-model analysis (study of seasonality). The maximal aerobic capacity (V(O2)max), fat-free mass, body mass index (BMI), and 24-hour ambulatory blood pressure (BP) were also assessed. Furthermore, we performed a study designed to evaluate the day-to-day variation in Si and Sg (study of day-to-day variation). Here, we studied Si and Sg in healthy young men (n = 8) within 2 weeks. In the study of seasonality, the coefficient of variation (CV) for Si was 24.0%, whereas the CV for Sg was 26.0%. Anticipating a seasonal variation in Si following a sine curve with a cycle length of 1 year and an unknown phase and amplitude, we tested this hypothesis with a multiple linear regression model that allows for different levels of Si between individuals, and failed to detect any impact due to this. Si (mean +/- SD, 1.17 +/- 0.28 x 10(-4) x min(-1) x pmol/L(-1), P = .38), Sg (0.023 +/- 0.006 min(-1), P= .71), fasting insulin (21.2 +/- 7.3 pmol/L, P= .98), V(O2)max (3.8 +/- 0.6 L/min, P= .13), and fat-free mass (64.9 +/- 2.5 kg, P = .92) were constant over time. In the study of day-to-day variation, we found a CV for Si of 17.3% and a CV for Sg of 23.3%. In conclusion, we found that the variations in Si and Sg were slightly higher than those found in studies performed to establish the day-to-day variation. However, no significant seasonal variation in Si and Sg was evident in this group of healthy young lean caucasian men. Consequently, indices of Si and Sg obtained at different times of the year appear comparable.

[Health status in Norway around the year 1000]

One thousand years is a very long period, especially in relation to medical history. More than 30 generations have lived over this space of time, and their thoughts and attitudes and their views on hygiene, sickness and treatment are heterogeneous. This paper will discuss the state of health in Norway at the time of the turn of the first millennium--at a time when Norway underwent profound political, social and religious changes, as well as structure of diseases.

Pap prevalence and cervical cancer prevention among Alaska Native women

The goals of the Alaska Native Women's Health Project (WHP) were to determine the following: (1) Pap prevalence based on chart review before and during an intervention period; (2) the level of understanding of cancer and cancer screening services with emphasis on cervical cancer; (3) use and satisfaction with current health maintenance services; and (4) improvement in knowledge and cancer screening rates following intervention. A random sample of 481 Alaska Native (Eskimo, Aleut, Indian) women living in Anchorage were interviewed face to face about their understanding of cancer risk factors (tobacco use, sexually transmitted diseases (STDs), reproductive issues), cancer screening examinations (Pap test, breast self-examination (BSE), breast exam by a provider, mammography), and their attitudes about health care and health care services. Sixty-two percent of control women were documented to have had at least one Pap test within the 3-year period prior to the beginning of the study; however, only 9% were documented to have had annual Pap screening. The intervention included distribution of educational materials, counseling on any woman's health issue, special evening clinics, and reminders (mail/phone call) of scheduled Pap appointments.

Epinephrine stimulates human muscle lipoprotein lipase activity in vivo

Lipoprotein lipase (LPL) is involved in lipoprotein metabolism and nutrient partitioning in both adipose tissue and skeletal muscle, and LPL activity is regulated by various hormones and the nutritional state. However, the action of catecholamines has not been thoroughly investigated in humans. Therefore, the effects of exogenous epinephrine on skeletal muscle LPL (SM-LPL) activity and whole-body lipid oxidation were studied. Muscle biopsies were obtained from eight healthy subjects before, during, and after epinephrine infusion. Somatostatin was infused to suppress endogenous insulin production and insulin was infused at a constant rate to maintain basal insulin levels throughout the study. After an equilibrium period (120 minutes), epinephrine (0.05 microg/kg/min) was infused for another 120 minutes. Epinephrine stimulated SM-LPL activity by 21.8%+/-6.8% above basal levels from 1.44+/-0.25 to 1.69+/-0.28 micromol free fatty acid (FFA)/h/g muscle (P<.02), increased plasma FFA 270% from 0.147 to 0.544 mmol/L (P<.05), and increased lipid oxidation 45% from 4.37 to 6.36 mg/kg/min (P<.05). The increase in SM-LPL activity was positively correlated with the increase in whole-body lipid oxidation (R=.75, P<.05). Finally, lipid oxidation and SM-LPL activity were negatively correlated with whole-body glucose oxidation. Overall, the results demonstrate that epinephrine is able to stimulate SM-LPL activity in humans, and thus may have opposite effects on adipose tissue and SM-LPL activity.

[On historical site--the Norwegian Medical Society's new headquarters]

The Norwegian Medical Association has built a new headquarters in the centre of Oslo. The site is one of the very oldest in the city and has a long history because of its many different functions--it has been a cemetery, riding ground, church site and petrol station. The interesting history of the site is described in this article.

[Henrik Wergeland's disease and death. 150th anniversary]

It is 150 years since the Norwegian poet Henrik Wergeland (1808-45) died. It is commonly assumed that the suffered from "phthisis" or--as we now call it--tuberculosis. This paper discusses the symptoms mentioned in Wergeland's own letters, which seem to indicate that the diagnosis was instead pulmonary cancer.

[From the early history of cancer treatment]

Skeletal finds have shown that tumorous diseases are as old as mankind itself. However, the appearance of such diseases have been rather differently understood, explained and treated throughout the history of medicine. This paper gives a brief survey of the development of cancer treatment and research, in Norway and in the other European countries.

Effect of needle biopsy from the vastus lateralis muscle on insulin-stimulated glucose metabolism in humans

To examine the cellular mechanisms behind conditions characterized by insulin resistance, the clamp technique is often combined with muscle biopsies. To test whether the trauma of a needle biopsy from the vastus lateralis muscle per se may influence insulin-stimulated glucose uptake, eight healthy subjects underwent two randomly sequenced hyperinsulinemic (insulin infusion rate: 0.6 mU.kg-1.min-1 for 150 min) euglycemic clamps with an interval of 4-6 wk. In one study (study B) a muscle biopsy (approximately 250 mg, i.e., larger than normal standard) was taken in the basal state just before the clamp procedure, whereas the other was a control study (study C). Insulin-stimulated glucose uptake was significantly reduced in study B (5.36 +/- 0.96 mg.kg-1.min-1) compared with study C (6.06 +/- 0.68 mg.kg-1.min-1; P < 0.05). Nonoxidative glucose disposal (indirect calorimetry) was decreased (2.81 +/- 1.08 vs. 3.64 +/- 1.34 mg.kg-1.min-1; P < 0.05), whereas glucose oxidation was unaltered. Likewise, endogenous glucose output ([3-3H]glucose) was identically suppressed during hyperinsulinemia. Circulating levels of epinephrine, glucagon, and growth hormone did not differ significantly in studies B and C. In contrast, plasma norepinephrine, serum cortisol, and free fatty acid rose after biopsy (P < 0.05). In conclusion, performance of a muscle biopsy may diminish insulin sensitivity by affecting nonoxidative glucose metabolism. This should be considered when assessing whole body insulin sensitivity after a percutaneous needle muscle biopsy.

[The Bartholinian era--anatomy at the time of Christian IV]

At the time of King Christian IV of Denmark and Norway the University of Copenhagen was one of the most famous universities in Europe because of the epoch making medical research carried out there. The author presents a dynasty of anatomists--the Bartholin family--who dominated medical teaching and science for a century.

Structure and segmental localization of glycogen in the diabetic rat kidney

Pathological accumulations of glycogen were studied in the kidney tubular epithelium in untreated STZ-induced diabetic rats of 50 days diabetes duration. Blood glucose concentrations were approximately 17 mM, and the animals had no ketonuria. At the termination of the experiment, the kidneys were perfusion-fixed, and serial sections were cut from the renal capsule to the tip of the papilla and stained with toluidine blue and periodic acid Schiff. By tracing tubular profiles from section to section in a light microscope, the outlines of nephrons were reconstructed, and abnormal glycogen accumulations were mapped in accordance with the outlines. The exact segmental localization, character, and extension of the glycogen accumulations were determined. The predominant location of the pathological glycogen accumulations was in the thick ascending limb of Henle's loop. Dot-shaped and diffuse-appearing glycogen accumulations were discretely distributed throughout the segment, and large confluent cytoplasmic accumulations of glycogen were also present. On a continuous basis, glycogen was present only in the cortical thick ascending limb of Henle's loop and the macula densa segment excluding the macula densa cells. In the distal convoluted tubule and the cortical collecting duct system, scattered dot-shaped and diffuse glycogen accumulations were discretely distributed. Furthermore, glycogen appeared as confluent, cytoplasmic accumulations in the initial part of the descending thin limb of Henle's loop. In addition, glycogen accumulations were found in nuclei within a narrow stripe of the outer stripe of the outer medulla in the medullary thick ascending limb of Henle's loop.

Fixation of the macula densa with fixatives of different osmolarities in normal and diabetic rats

The influence of different fixative osmolarities on the ultrastructure of the macula densa region has been studied in normal and in streptozotocin diabetic rats after 50 days' duration of diabetes. In vivo perfusion fixation of the kidneys was performed retrogradely through the aorta in five groups of controls and diabetic animals with a 1% glutaraldehyde fixative in a Tyrode solution. Between groups, the osmolarity of the fixative solution varied from 216 to 476 mosm/l. This was accomplished by variation of the NaCl concentration of the fixative vehicle. The tissue was embedded in Epon and midcortical tissue was prepared for electron microscopy. The volume density of the lateral intercellular spaces between the macula densa cells was measured applying a morphometric technique. The results confirmed that the lateral intercellular spaces are narrowed in diabetes and also showed that for all fixative osmolarities the difference is persistent between diabetic and non-diabetic animals, except at very low osmolarities. The abnormal macula densa ultrastructure has been suggested to be connected with the functional abnormalities in diabetes, i.e. the resetting of the tubuloglomerular feedback and subsequent increases in GFR. It is therefore of interest to further understand the mechanisms underlying the narrowing of the lateral intercellular spaces in diabetes. The present study has shown that the size difference in lateral intercellular spaces between diabetic and normal animals is reproducible over a wide range of fixative osmolarities, further indicating that it is an in vivo phenomenon. The diminution of the LIS in diabetes could perhaps indicate a decrease in signal function, previously reported at the MD level in diabetic animals, contributing to the increased GFR in diabetes.

[From the history of brain research]

This paper describes the understanding of the brain and central nerve system from antiquity up to our own century. It also describes the first attempts at brain research in the Nordic countries, and in Norway in particular.

[Asbestos in the work environment. The occurrence of pulmonary changes among workers exposed to asbestos at an electrotechnical factory]

A number of workers exposed to asbestos dust for more than three months were medically examined for lung diseases caused by asbestos. A follow-up examination four years later revealed that the lung capacity of these workers was significantly lower than in the normal population. 9% of them showed changes in the lungs caused by asbestos dust, but no case of cancer was discovered. There was no development of significance in these changes during the four years.

Ultrastructure of the macula densa in streptozotocin diabetic rats

Morphometric analyses of the macula densa in streptozotocin diabetic rats have revealed, that the volume density of the large lateral intercellular spaces, which are present in normal animals between the macula densa cells, decreases significantly in magnitude from 8.7 to 1.5% in diabetic animals. The volume density of cytoplasmic glycogen in the macula densa cells increases significantly from 5.4% in the controls to 14.8% in the diabetic animals, but the total volume density of mitochondria is the same in the two groups. The contact area between macula densa cells and the Goorgmaghtigh cells is increased by 38% in the diabetic animals compared with controls. The structural abnormalities in the macula densa in response to diabetes might be considered a structural counterpart to the alterations in the tubuloglomerular feedback mechanism and the increase in glomerular filtration rate in diabetes.