Physical activity before radical prostatectomy reduces sick leave after surgery - results from a prospective, non-randomized controlled clinical trial (LAPPRO)

BACKGROUND

Studies have reported that early physical rehabilitation after surgical procedures is associated with improved outcome measured as shorter hospital stay and enhanced recovery. The aim of this study was to explore the relationship between the preoperative physical activity level and subsequent postoperative complications, sick-leave and hospital stay after radical prostatectomy for prostate cancer in the setting of the LAPPRO trial (LAParoscopic Prostatectomy Robot Open).

METHODS

LAPPRO is a prospective controlled trial, comparing robot-assisted laparoscopic and open surgery for localized prostate cancer between 2008 and 2011. 1569 patients aged 64 or less with an occupation were included in this sub-study. The Gleason score was <7 in 52 % of the patients. Demographics and the level of self-assessed preoperative physical activity, length of hospital stay, complications, quality of life, recovery and sick-leave were extracted from clinical record forms and questionnaires. Multivariable logistic regression, with log-link and logit-link functions, was used to adjust for potential confounding variables.

RESULTS

The patients were divided into four groups based on their level of activity. As the group with lowest engagement of physical activity was found to be significantly different in base line characteristics from the other groups they were excluded from further analysis. Among patients that were physically active preoperativelly (n = 1467) there was no significant difference between the physical activity-groups regarding hospital stay, recovery or complications. However, in the group with the highest self-assessed level of physical activity, 5-7 times per week, 13 % required no sick leave, compared to 6.3 % in the group with a physical activity level of 1-2 times per week only (p < 0.0001).

CONCLUSIONS

In our study of med operated with radical prostatectomy, a high level of physical activity preoperatively was associated with reduced need for sick leave after radical prostatectomy compared to men with lower physical activity.

TRIAL REGISTRATION

The trial is registered at the ISCRTN register. ISRCTN06393679 .

Patient-reported genitourinary dysfunction after laparoscopic and open rectal cancer surgery in a randomized trial (COLOR II)

BACKGROUND

This article reports on patient-reported sexual dysfunction and micturition symptoms following a randomized trial of laparoscopic and open surgery for rectal cancer.

METHODS

Patients in the COLOR II randomized trial, comparing laparoscopic and open surgery for rectal cancer, completed the European Organization for Research and Treatment of Cancer (EORTC) QLQ-CR38 questionnaire before surgery, and after 4 weeks, 6, 12 and 24 months. Adjusted mean differences on a 100-point scale were calculated using changes from baseline value at the various time points in the domains of sexual functioning, sexual enjoyment, male and female sexual problems, and micturition symptoms.

RESULTS

Of 617 randomized patients, 385 completed this phase of the trial. Their mean age was 67·1 years. Surgery caused an anticipated reduction in genitourinary function after 4 weeks, with no significant differences between laparoscopic and open approaches. An improvement in sexual dysfunction was seen in the first year, but some male sexual problems persisted. Before operation 64·5 per cent of men in the laparoscopic group and 55·6 per cent in the open group reported some degree of erectile dysfunction. This increased to 81·1 and 80·5 per cent respectively 4 weeks after surgery, and 76·3 versus 75·5 per cent at 12 months, with no significant differences between groups. Micturition symptoms were less affected than sexual function and gradually improved to preoperative levels by 6 months. Adjusting for confounders, including radiotherapy, did not change these results.

CONCLUSION

Sexual dysfunction is common in patients with rectal cancer, and treatment (including surgery) increases the proportion of patients affected. A laparoscopic approach does not change this.

REGISTRATION NUMBER

NCT00297791 (http://www.clinicaltrials.gov).

Health-related quality of life after laparoscopic and open surgery for rectal cancer in a randomized trial

Background

Previous studies comparing laparoscopic and open surgical techniques have reported improved health-related quality of life (HRQL). This analysis compared HRQL 12 months after laparoscopic versus open surgery for rectal cancer in a subset of a randomized trial.

Methods

The setting was a multicentre randomized trial (COLOR II) comparing laparoscopic and open surgery for rectal cancer. Involvement in the HRQL study of COLOR II was optional. Patients completed the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 and QLQ-CR38, and EuroQol – 5D (EQ-5D™) before surgery, and 4 weeks, 6, 12 and 24 months after operation. Analysis was done according to the manual for each instrument.

Results

Of 617 patients in hospitals participating in the HRQL study of COLOR II, 385 were included. The HRQL deteriorated to moderate/severe degrees after surgery, gradually returning to preoperative values over time. Changes in EORTC QLQ-C30 and QLQ-CR38, and EQ-5D™ were not significantly different between the groups regarding global health score or any of the dimensions or symptoms at 4 weeks, 6 or 12 months after surgery.

Conclusion

In contrast to previous studies in patients with colonic cancer, HRQL after rectal cancer surgery was not affected by surgical approach. Registration number: NCT0029779 (http://www.clinicaltrials.gov).

Definition of major bleeding in clinical investigations of antihemostatic medicinal products in surgical patients

The definition of major bleeding varies between studies on surgical patients, particularly regarding the criteria for surgical wound-related bleeding. This diversity contributes to the difficulties in comparing data between trials. The Scientific and Standardization Committee (SSC), through its subcommittee on Control of Anticoagulation, of the International Society on Thrombosis and Haemostasis has previously published a recommendation for a harmonized definition of major bleeding in non-surgical studies. That definition has been adopted by the European Medicines Agency and is currently used in several non-surgical trials. A preliminary proposal for a parallel definition for surgical studies was presented at the 54(th) Annual Meeting of the SSC in Vienna, July 2008. Based on those discussions and further consultations with European and North American surgeons with experience from clinical trials a definition has been developed that should be applicable to all agents that interfere with hemostasis. The definition and the text that follows have been reviewed and approved by relevant co-chairs of the subcommittee and by the Executive Committee of the SSC. The intention is to seek approval of this definition from the regulatory authorities to enhance its incorporation into future clinical trial protocols.

Tissue metabolite levels in different types of skeletal muscle during sepsis

The effect of sepsis on energy and metabolite levels in the white, fast-twitch extensor digitorum longus (EDL) and the red, slow-twitch soleus (SOL) muscles was studied in rats. Sepsis was induced by cecal ligation and puncture (CLP). Control rats were sham-operated. Sixteen hours later, metabolite levels in muscle tissue were determined. Adenosine triphosphate (ATP) levels and energy charge were reduced during sepsis in SOL, but were unchanged in EDL muscles. In contrast, phosphocreatine (PCr) concentration was reduced during sepsis in EDL, but not in SOL. Tissue glycogen levels were reduced and lactate concentrations were increased in both muscles during sepsis. Results suggest that sepsis affects energy metabolism differently in different types of skeletal muscle. Tissue lactate accumulation may be consistent with muscle hypoperfusion following CLP, although other mechanisms may also be involved.

Effect of the glucocorticoid receptor antagonist RU 38486 on muscle protein breakdown in sepsis

The role of glucocorticoids in muscle catabolism during sepsis was tested with the glucocorticoid receptor antagonist RU 38486. Sepsis was induced in male Sprague-Dawley rats (40 to 60 gm) by cecal ligation and puncture (CLP). Other animals underwent sham operation. Two hours before CLP or sham operation, rats received RU 38486 (5 mg/kg) or a corresponding volume of vehicle by gavage. Sixteen hours after CLP or sham operation, protein synthesis rate was determined by measuring incorporation of 14C-phenylalanine into protein in incubated extensor digitorum longus muscles. Total and myofibrillar protein breakdown rates were determined by measuring net release of tyrosine and 3-methylhistidine, respectively. The protein synthesis rate was approximately 30% lower in rats with sepsis than in sham operated rats and was not affected by treatment with RU 38486. The total protein breakdown rate was increased by approximately 70% and myofibrillar protein degradation was increased more than fivefold in muscle from rats with sepsis. Treatment with RU 38486 resulted in a 28% reduction of total and a 44% reduction of myofibrillar protein breakdown in rats with sepsis but did not affect proteolysis in muscle from sham-operated animals. The results support a role of glucocorticoids in accelerated muscle proteolysis during sepsis. It is not clear whether glucocorticoids are the only required mediator or they interact with other substances to induce muscle protein breakdown during sepsis.

Influence of sepsis in rats on muscle protein turnover in vivo and in tissue incubated under different in vitro conditions

We studied the influence of sepsis on muscle protein synthesis and degradation in vivo and in muscles, incubated flaccid or at resting length. Sepsis was induced in rats by cecal ligation and puncture (CLP). Control rats were sham-operated. A flooding dose of 14C-phenylalanine was used to determine muscle protein synthesis rate in vivo, and protein breakdown was calculated from the difference between protein synthesis and growth rates. Protein synthesis rate in vitro was assessed by determining incorporation of 14C-phenylalanine into protein in incubated extensor digitorum longus (EDL) and soleus (SOL) muscles. Total and myofibrillar protein breakdown rates were determined from release into incubation medium of tyrosine and 3-methylhistidine (3-MH), respectively. Muscle protein synthesis rate in vivo was reduced by 35%, similar to the reduction observed in muscles incubated flaccid or at resting length. The calculated protein breakdown rate in vivo was increased by 31% in septic rats. In incubated muscles, the increase in total protein breakdown (ie, tyrosine release) during sepsis was almost identical in muscles incubated flaccid or at resting length, ie, 83% to 88% in EDL and 47% to 49% in SOL. Myofibrillar protein degradation in vitro (ie, 3-MH release) was increased approximately 10-fold in EDL muscles incubated flaccid or at resting length, but was not significantly affected by sepsis in SOL. Results suggest that sepsis-induced changes in protein synthesis observed in muscles incubated either flaccid or at resting length reflect changes in vivo. Changes in protein breakdown were qualitatively similar in vivo and in vitro, but results in incubated muscles may overestimate the increase in muscle proteolysis caused by sepsis.

Reduced levels of mRNA for myofibrillar proteins in skeletal muscle from septic rats

The influence of sepsis on transcription of myofibrillar proteins in skeletal muscle was studied in rats. Sepsis was induced by cecal ligation and puncture (CLP); control rats were sham-operated. Sixteen hours later, muscle levels of mRNA for myofibrillar proteins were determined by using cDNA probes specific for transcripts for alpha actin and myosin heavy chain. Sepsis resulted in a 2-6 fold decrease in alpha actin mRNA levels and an even more pronounced reduction in myosin heavy chain mRNA levels. Results suggest that sepsis-induced reduction of muscle protein synthesis is at least partly regulated at the transcriptional level.

Interaction between corticosterone and tumor necrosis factor stimulated protein breakdown in rat skeletal muscle, similar to sepsis

Protein synthesis and breakdown rates were determined in incubated extensor digitorum longus muscles of rats treated with tumor necrosis factor (TNF; 20 micrograms/100 gm body weight), corticosterone (20 mg/100 gm body weight), or a combination of the two substances. Protein synthesis was measured as incorporation of carbon 14-labeled phenylalanine into protein. Total and myofibrillar protein breakdown rates were assessed as release of tyrosine and 3-methylhistidine, respectively. Administration of TNF alone did not affect muscle protein turnover rates. Corticosterone inhibited muscle protein synthesis and stimulated total and myofibrillar protein breakdown. When TNF was administered together with corticosterone, total and myofibrillar protein breakdown rates were increased further compared with rats treated with corticosterone alone. Because plasma corticosterone levels in rats treated with both TNF and the glucocorticoid were higher than in animals treated with corticosterone alone, it is possible that muscle proteolysis noted after TNF, injected together with costicosterone, was caused by the high glucocorticoid levels. To test that hypothesis, corticosterone alone or in combination with TNF was injected in rats that had undergone adrenalectomy. In these experiments, TNF did not increase plasma corticosterone levels or muscle protein breakdown rates. The results suggest that muscle catabolism induced by administration of TNF is mediated by glucocorticoids.

Corticosterone alone does not explain increased muscle proteolysis in septic rats

The mediators and mechanisms of muscle proteolysis in sepsis are not fully known. We investigated the role of corticosterone in increased muscle proteolysis during sepsis in rats. In one series of experiments, plasma corticosterone and total and myofibrillar protein breakdown rates, determined in incubated extensor digitorum longus muscles as release of tyrosine and 3-methylhistidine, respectively, were measured 16 hr after sham operation (control) or cecal ligation and puncture (sepsis). In other experiments, corticosterone (10 mg/100 g body wt) was injected subcutaneously twice over 16 hr; thereafter, plasma hormone levels and muscle protein breakdown rates were determined. Plasma corticosterone was increased from 14 +/- 1 micrograms/dl in control rats to 38 +/- 8 micrograms/dl in septic rats and total and myofibrillar protein breakdown rates were increased by 99 and 326%, respectively, in muscles from septic rats. When administration of corticosterone resulted in plasma levels similar to those observed in septic rats, total or myofibrillar protein breakdown rates were not altered. The results suggest that corticosterone alone is not responsible for increased muscle proteolysis in septic rats. The data, however, do not rule out the possibility that glucocorticoids may be a cofactor to some other substance or substances in the induction of muscle proteolysis during sepsis.

Effects of elevated temperature on protein breakdown in muscles from septic rats

Elevated temperature has been proposed to contribute to accelerated muscle protein degradation during fever and sepsis. The present study examined the effect of increased temperature in vitro on protein turnover in skeletal muscles from septic and control rats. Sepsis was induced by cecal ligation and puncture (CLP); control rats were sham operated. After 16 h, the extensor digitorum longus (EDL) and soleus (SOL) muscles were incubated at 37 or 40 degrees C. Protein synthesis was determined by measuring incorporation of [14C]phenylalanine into protein. Total and myofibrillar protein breakdown was assessed from release of tyrosine and 3-methylhistidine (3-MH), respectively. Total protein breakdown was increased at 40 degrees C by 15% in EDL and by 29% in SOL from control rats, whereas 3-MH release was not affected. In muscles from septic rats, total and myofibrillar protein breakdown was increased by 22 and 30%, respectively, at 40 degrees C in EDL but was not altered in SOL. Protein synthesis was unaffected by high temperature both in septic and nonseptic muscles. The present results suggest that high temperature is not the primary mechanism of increased muscle protein breakdown in sepsis because the typical response to sepsis, i.e., a predominant increase in myofibrillar protein breakdown, was not induced by elevated temperature in normal muscle. It is possible, however, that increased temperature may potentiate protein breakdown that is already stimulated by sepsis because elevated temperature increased both total and myofibrillar protein breakdown in EDL from septic rats.

Regulation of total and myofibrillar protein breakdown in rat extensor digitorum longus and soleus muscle incubated flaccid or at resting length

The present study characterized total and myofibrillar protein breakdown rates in a muscle preparation frequently used in vitro, i.e. incubated extensor digitorum longus (EDL) and soleus (SOL) muscles of young rats. Total and myofibrillar protein breakdown rates were assessed by determining net production by the incubated muscles of tyrosine and 3-methylhistidine (3-MH) respectively. Both amino acids were determined by h.p.l.c. Both total and myofibrillar protein breakdown rates were higher in SOL than in EDL muscles and were decreased by incubating the muscles maintained at resting length, rather than flaccid. After fasting for 72 h, total protein breakdown (i.e. tyrosine release) was increased by 73% and 138% in EDL muscles incubated flaccid and at resting length respectively. Net production of tyrosine by SOL muscle was not significantly altered by fasting. In contrast, myofibrillar protein degradation (i.e. 3-MH release) was markedly increased by fasting in both muscles. When tissue was incubated in the presence of 1 munit of insulin/ml, total protein breakdown rate was inhibited by 17-20%, and the response to the hormone was similar in muscles incubated flaccid or at resting length. In contrast, myofibrillar protein breakdown rate was not altered by insulin in any of the muscle preparations. The results support the concepts of individual regulation of myofibrillar and non-myofibrillar proteins and of different effects of various conditions on protein breakdown in different types of skeletal muscle. Thus determination of both tyrosine and 3-MH production in red and white muscle is important for a more complete understanding of protein regulation in skeletal muscle.

Protein synthesis in liver following infusion of the catabolic hormones corticosterone, epinephrine, and glucagon in rats

The mediator(s) and mechanism(s) of acute-phase protein synthesis in the liver following injury and sepsis are not fully known. Elevated plasma levels of the catabolic hormones cortisol, glucagon, and epinephrine have been reported in trauma and sepsis. In previous reports, when these hormones were infused simultaneously (triple hormone infusion), several, but not all, of the metabolic alterations characteristic of sepsis occurred. In the current investigation, the effect of triple hormone infusion on hepatic protein synthesis was studied. Rats were infused intravenously during 16 hours with a solution containing corticosterone (4.2 mg/kg/h), glucagon (2.5 micrograms/kg/h), and epinephrine (6 micrograms/kg/h). Control animals were infused with a corresponding volume of vehicle. Total hepatic protein synthesis in vivo was measured with a flooding dose technique using [14C]-leucine. The synthesis of total secretory proteins and of the individual proteins albumin, complement component C3, and alpha 1-acid glycoprotein was measured in isolated, perfused liver using [3H]-leucine and a recirculating technique. Urinary excretion of nitrogen and plasma concentration of glucose were higher and plasma total amino acid concentration was lower in hormone-infused than in control rats. Total hepatic protein synthesis in vivo, expressed as the proportion of the protein pool that was replaced each day, was increased from 39% +/- 2% per day to 48% +/- 3% per day (P less than .05) by hormone infusion, but synthesis of secretory proteins in perfused liver was not significantly altered. The results suggest that although total hepatic protein synthesis may be increased by catabolic hormones, other mediator(s) are probably responsible for the stimulation of acute-phase protein synthesis in sepsis.

Total and myofibrillar protein breakdown in different types of rat skeletal muscle: effects of sepsis and regulation by insulin

Proteolysis is increased in sepsis, but it is not known whether myofibrillar and non-myofibrillar proteins are broken down in the same fashion, or respond to the same regulatory forces as in non-septic muscle. In this study, therefore, the effect of sepsis on total and myofibrillar protein breakdown in incubated rat extensor digitorum longus (EDL) and soleus (SOL) muscles was determined, and the response in vitro to different concentrations of insulin (10 to 10(5) microU/mL) of protein degradation was studied in incubated EDL muscles from control and septic rats. Sepsis was induced in rats weighing 40 to 60 g by cecal ligation and puncture (CLP). Control animals were sham operated. Sixteen hours after CLP or sham operation, intact EDL and SOL muscles were incubated for two hours in oxygenated Krebs-Henseleit bicarbonate buffer containing glucose (10 mmol/L) and cycloheximide (0.5 mmol/L), and total and myofibrillar protein breakdown was assessed from release into incubation medium of tyrosine and 3-methylhistidine (3-MH), respectively. Tyrosine and 3-MH were determined fluorometrically by high performance liquid chromatography (HPLC). Tissue levels of tyrosine and 3-MH remained stable both in control and septic muscles during incubation for two hours. The rate of tyrosine release was increased during sepsis by 58% (P less than .001) and 15% (NS) in EDL and SOL muscle, respectively. The corresponding figures for 3-MH were 103% (P less than .001) and 21% (NS). Tyrosine release was reduced by insulin at a concentration of 10(3) microU/mL in control muscle and at a concentration of 10(4) microU/mL in septic muscle.(ABSTRACT TRUNCATED AT 250 WORDS)

Urinary excretion of 3-methylhistidine and creatinine and plasma concentrations of amino acids in hyperthyroid patients following preoperative treatment with antithyroid drug or beta-blocking agent: results from a prospective, randomized study

The aim of this investigation was to compare the effects of a beta 1-selective adrenoceptor blocking agent and an antithyroid drug on urinary excretion of creatinine (Cr) and 3-methylhistidine (3-MH) and plasma concentrations of amino acids in hyperthyroid patients. beta-adrenoceptor blocking agents are increasingly used in the treatment of hyperthyroid patients, and the effects on clinical signs and symptoms mainly reflect beta 1-adrenoceptor blockade. The consequences of this treatment on metabolic alterations in hyperthyroidism are not fully known. In the present study, 30 hyperthyroid patients were randomized to preoperative treatment with the antithyroid drug methimazole + thyroxine (group I) or the beta 1-selective adrenoceptor blocking agent metoprolol (group II). Urinary excretion of Cr and 3-MH and plasma concentrations of amino acids were measured at the time of diagnosis, following preoperative treatment and 6 months postoperatively. Serum triiodothyronine (T3) was comparably elevated in the two groups of patients at the time of diagnosis and was normalized during preoperative treatment in group I but remained elevated during preoperative treatment in group II. Urinary excretion of creatinine was lower at the time of diagnosis than postoperatively, suggesting reduced muscle mass during hyperthyroidism. Urinary excretion of Cr increased during preoperative treatment in group I but was not significantly altered during treatment with metoprolol. The 3-MH/Cr ratio, which was higher at the time of diagnosis than postoperatively, indicating accelerated protein breakdown in skeletal muscle during hyperthyroidism, was reduced during preoperative treatment in group I but not in group II.(ABSTRACT TRUNCATED AT 250 WORDS)

Protein degradation in skeletal muscle during experimental hyperthyroidism in rats and the effect of beta-blocking agents

beta-Blocking agents are increasingly used in the management of hyperthyroid patients. The effect of this treatment on increased muscle protein breakdown in the hyperthyroid state is not known. In the present study, experimental hyperthyroidism was induced in rats by daily ip injections of T3 (100 micrograms/100 g BW) during a 10-day period. Control animals received corresponding volumes of solvent. In groups of rats the selective beta-1-blocking agent metoprolol or the nonselective beta-blocker propranolol was infused by miniosmotic pumps implanted sc on the backs of the animals. Protein degradation was measured in incubated intact soleus and extensor digitorum longus muscles by determining tyrosine release into the incubation medium. The protein degradation rate in incubated extensor digitorum longus and soleus muscles was increased by 50-60% during T3 treatment. Metoprolol or propranolol did not influence muscle protein breakdown in either T3-treated or control animals. The results suggest that T3-induced increased muscle proteolysis is not mediated by beta-receptors, and muscle weakness and wasting in hyperthyroidism might not be affected by beta-blockers.

A retrospective analysis of a consecutive series of patients splenectomized for various hematologic disorders

At our hospital, 47 out of 184 consecutive splenectomies performed over 7 recent years were carried out on patients afflicted with various hematologic diseases. The results of these 47 splenectomies were the subject of a careful retrospective analysis. The majority of the splenectomies (81%) were therapeutic. Cytopenia, particularly thrombocytopenia, was the most common indication for surgery. As a whole, good therapeutic responses with rapid improvements in peripheral blood picture and/or diminished symptoms of pressure discomfort from an enlarged spleen were obtained. There was no peri- or postoperative mortality; 23% major and 26% minor postoperative complications were recorded. In patients with perioperative bleeding and various postoperative complications, the spleens were larger than in subjects who run an uneventful peri- and postoperative course. During the follow-up period, 4 septicemias occurred in 3 patients. In 2 of these patients, the septicemias coincided with a cholecystitis and a pneumonia, respectively. None of the infections was lethal. It is concluded that elective splenectomy for hematologic disease in well selected and carefully prepared patients is beneficial and can be performed without mortality or major hazards.

Effects of beta-blocking agents on urinary excretion of 3-methylhistidine during experimental hyperthyroidism in rats

Beta-blocking agents are increasingly used as preoperative treatment of hyperthyroid patients. Relatively little is known about the effects of these drugs on metabolic alterations in hyperthyroidism. The aim of this investigation was to study the effects of two different beta-blocking agents on the urinary excretion of 3-methylhistidine (3-MH) during experimental hyperthyroidism in rats. Experimental hyperthyroidism was induced by daily intraperitoneal injections of triiodothyronine (T3; 100 micrograms/100 g body weight) for 3 days. Control animals were injected with corresponding volumes of solvent. Groups of rats received food enriched with metoprolol (8.8 mmol/kg of diet) or propranolol (3.3 mmol/kg of diet) or food without additions. Urinary 3-MH excretion was increased by about 40% during experimental hyperthyroidism. A similar increase of 3-MH excretion was found in animals receiving T3 + metoprolol, whereas the excretion of 3-MH was reduced to control level in hyperthyroid rats receiving propranolol. No effects of metoprolol or propranolol on 3-MH excretion were found in control animals. Although the source of 3-MH cannot be exactly defined, the present results indicate that increased proteolysis in skeletal muscle and/or other tissues during experimental hyperthyroidism was reduced by propranolol.

Effects of thyroid hormone and beta-blocking agents on plasma amino acids in rats

Experimental hyperthyroidism was induced in rats by daily intraperitoneal injections of triiodothyronine (T3; 100 micrograms/100 g bw) for 3 days (short-term experiment) or by subcutaneous injections of T3 (30 micrograms/100 g bw) on alternate days during 6 weeks (long-term experiment). Control rats received corresponding volumes of solvent. Groups of rats were fed normal pellets or pellets enriched with the selective beta-1-blocker metoprolol (8.8 mmol/kg of diet) or with the non-selective beta-blocker propranolol (3.3 mmol/kg of diet). Plasma amino acids were determined 24 hours after the last T3 injection. In the short-term experiment, most individual amino acids were increased in T3-treated rats, also if beta-blocker had been given, but the increase in plasma concentration of some amino acids (valine, leucine, lysine and histidine) was prevented by propranolol. In the long-term experiment, several amino acids showed reduced plasma concentration during T3 treatment, also when the rats received beta-blocker. The plasma concentration of threonine, however, was normalized by propranolol during T3 treatment. The results indicate that metabolic alterations induced by T3 and producing changes in plasma amino acid concentrations are mainly unaffected by beta-blockade. However, as some plasma amino acid changes were prevented by propranolol but not by metoprolol, certain T3-induced metabolic derangements may be beta-2-receptor mediated.

The effect of beta-adrenergic blockade on the myopathic changes in experimental hyperthyroidism in rats

Hyperthyroidism is frequently associated with myopathy. Beta-blocking agents, which are increasingly used in the treatment of hyperthyroidism, have been reported to have a possible beneficial effect on thyrotoxic myopathy. We have studied the myopathic changes in experimental hyperthyroidism in rats and the effect of the beta-blocking agents metoprolol and propranolol on these changes. During experimental hyperthyroidism, conversion of type 1 to type 2 fibres and accumulation of intracellular lipid, increased amounts of mitochondria, and reduced size of muscle fibers were noticed. None of these changes were prevented by metoprolol or propranolol. The results indicate that histochemical and morphological changes in skeletal muscle induced by thyroid hormone are not mediated by beta-receptors. The results of this investigation make dubious a beneficial effect of beta-blocking agents on thyrotoxic myopathy.

Protein turnover in different types of skeletal muscle during experimental hyperthyroidism in rats

Experimental hyperthyroidism was induced in rats by daily ip injection of triiodothyronine (T3; 100 micrograms/100 g body weight) during 3 or 10 days. Protein synthesis and degradation were measured in incubated soleus and extensor digitorum longus (EDL) muscles by determining rate of tyrosine incorporation into protein and release of tyrosine to the incubation medium respectively. Protein synthesis was unaffected by T3 administration during 3 or 10 days. Protein breakdown was significantly increased in soleus but unchanged in EDL in the 3-days experiment. Following administration of T3 for 10 days proteolysis was increased in both muscles. Weight of the soleus muscle was reduced after T3 for 3 days. After 10 days weight and protein content were reduced in both muscles. The study demonstrated that reduced muscle protein content following administration of T3 was the result of increased proteolysis, not decreased protein synthesis. The results further indicate that slow muscle (soleus) is more sensitive to the effects of thyroid hormone than fast muscle (EDL).

Acute gastric hemorrhage secondary to wandering spleen

A patient presenting with acute life-threatening upper gastrointestinal hemorrhage caused by a wandering spleen is reported. Emergency laparotomy revealed profuse gastric bleeding, large engorged varicose veins in the gastric wall, and a normal liver parenchyma. Gastroscopy after arrest of the hemorrhage showed varicose veins in the fundus without esophageal varices. Angiography revealed an ectopic spleen, occlusion of the splenic vein, and large venous collaterals in the gastric fundus. Elective splenectomy was performed. Wandering spleen as a cause of left-sided portal hypertension, also referred to as segmental splenic hypertension, is discussed.

Protein metabolism in skeletal muscle tissue from hyperthyroid patients after preoperative treatment with antithyroid drug or selective beta-blocking agent. Results from a prospective, randomized study

Protein metabolism in skeletal muscle tissue was studied in three groups of patients undergoing thyroid surgery: group I (n = 8), hyperthyroid patients preoperatively treated with an antithyroid drug and T4; group II (n = 8), hyperthyroid patients preoperatively treated with the beta 1-selective adrenoreceptor blocking agent metoprolol; group III (n = 5), euthyroid patients operated on for nodular goiter or adenoma. The study was prospective and hyperthyroid patients were randomly allocated to one of the two preoperative regimens. During operation a biopsy was taken from the sternohyoid muscle and rates of protein synthesis and degradation were measured in incubated muscle tissue. Clinical improvement was equal in the two groups of hyperthyroid patients during preoperative treatment but serum T3 concentrations remained elevated in patients treated with metoprolol. Thus, these patients were biochemically hyperthyroid at the time of operation. The rate of protein degradation was significantly higher in hyperthyroid patients treated with metoprolol than in patients of groups I and III. A significant positive correlation was found between serum T3 and rate of protein degradation in skeletal muscle. Protein synthesis rates were similar in the three groups of patients. This study demonstrated for the first time increased proteolysis in skeletal muscle tissue from patients with high serum T3 concentrations. The results indicate that changes of skeletal muscle protein metabolism in hyperthyroid patients are not normalized by beta 1-blockade despite the fact that this treatment effectively controlled symptoms and signs of hyperthyroidism.

Primary anorectal malignant melanoma

Eleven patients with primary anorectal melanoma were analyzed retrospectively. Clinical symptoms and signs were rather unspecific; bleeding in nine, a palpable mass in five, and local pain in three patients. Two patients had the tumor diagnosed accidentally. In all patients the primary tumor was in an advanced stage. A summary of the histopathological characteristics is given in all patients. Six patients were subjected to abdominal perineal resection, four to local excision, and one to a colostomy followed by radiotherapy. All patients developed metastatic disease after a median time of 10 months. The median survival time was 14 months after both abdominal perineal resection and local excision. One patient is still alive after 11 years. Pertinent data form the literature are given.

Effects of food on plasma catecholamine and gastrin levels in patients with duodenal ulcer and normal volunteers

Changes in plasma concentrations of adrenaline, noradrenaline, dopamine and gastrin in response to a standard meal were studied in 6 normal volunteers and 8 patients with chronic duodenal ulcer (DU) disease. Before the meal plasma gastrin and noradrenaline, but not adrenaline or dopamine, were higher in DU patients than in the controls. Food induced significant increments in plasma gastrin and noradrenaline concentration in both groups, whereas plasma adrenaline and dopamine levels remained unchanged. Plasma gastrin and noradrenaline concentrations were higher in DU patients than in the normal controls both during and after the meal. The results do not support the hypothesis that adrenaline is involved in the pathogenesis of duodenal ulcer disease, whereas the role of the increased plasma noradrenaline concentrations in this disease remains unclear.