Australian clinicians' perceptions of patients with very high risk of fracture

BACKGROUND

International osteoporosis guidelines have recommended treatment approaches based on fracture risk stratification, in particular, anabolic therapy for patients with very high risk (VHR) of fragility fracture.

AIM

To summarise Australian clinicians' perceptions of patients at VHR of fracture.

METHODS

Australian clinicians invited to educational webinars on anabolic treatments for osteoporosis were surveyed in March and April 2021 about a typical patient they had most recently seen and identified as at VHR of fracture.

RESULTS

Of the 268 clinician attendees who were invited to complete the post-webinar surveys, 67 (25%) responded and permitted the publication of aggregated data. A typical patient perceived to have a VHR of fracture was a woman in her 80's, living at home, who had been diagnosed with osteoporosis between 5 and 10 years ago, and received treatment for 1-5 years' duration, most commonly denosumab. The patient frequently had a T-score below -3.0 SD (standard deviation), multiple fragility fractures and most commonly suffered a vertebral fracture in the past 12 months, whereas on an adequate regimen of osteoporosis medication. There was a mismatch between the patient being eligible for anabolic therapy (64.2%) and actually having been prescribed an anabolic treatment in the past (20.9%).

CONCLUSIONS

Australian clinicians' perceptions of patients with a VHR of fracture and the use of anabolic agents appear to be heavily influenced by local reimbursement criteria. The mismatch between patients deemed eligible for reimbursed anabolic therapy and those prescribed an anabolic agent suggests treatment inertia.

Application of Escherichia coli-Derived Recombinant Human Bone Morphogenic Protein-2 to Unstable Spinal Fractures

(1) Background: Recently, Escherichia coli-derived recombinant human bone morphogenetic protein-2 (E. coli-derived rhBMP-2) has been increasingly applied to different types of spinal surgeries and reported to achieve successful fusion. This pilot study aimed to evaluate the clinical efficacy and safety of rhBMP-2 in patients undergoing posterior instrumented fusions for unstable spinal fractures. (2) Methods: This study included ten consecutive patients undergoing spinal surgery using E. coli-derived rhBMP-2 with more than one year of follow-up. Radiologic outcomes were compared, including the average fracture healing period, local kyphosis correction, and clinical outcomes between preoperative and the last follow-up. (3) Results: The average time of radiographic union was 99.9 ± 45.4 (62-192) days, with an average use of 5.2 ± 3.9 months of anabolic agents. Radiologic parameters such as anterior vertebral height and vertebral wedge angle were significantly corrected postoperatively and at the last follow-up. Clinical outcomes other than leg pain were significantly improved after the surgery. In addition, four patients with preoperative neurologic deficits showed improved neurologic status. (4) Conclusions: Combined with the anabolic agents, applying E. coli-derived rhBMP-2 to the fractured vertebral body could be an effective surgical treatment for unstable spinal fractures. Further trials are needed to validate this result.

Effects of new anti-doping measures on sports performance in elite female athletes

Studies examining the effects of new anti-doping measures on sports performance in elite athletes are scarce. During the last decade a number of new antidoping methods for detection of anabolic androgenic steroids were developed. We hypothesized that the implementation of these methods may cause a decrease of performance in athletic disciplines where given subtances are widely used. For this purpose the performance results for 10 athletic disciplines from country (Country A), that was widely accused of systematic doping use, were gathered and pooled into 2012-2015 and 2016-2019 periods. These periods were seen as before and following the implementation periods, where the effects of new antidoping methods could be manifested. Also the performance results of their rival athletes from Country B were analysed for comparison. The incidence of antidoping rules violations for both countries were followed. The analysis revealed a decrease in performance results of Country A athletes in 8 of 10 disciplines. The performance results of Country B's athletes in 7 of 10 disciplines did not and in 3 disciplines did demonstrate statistically significant change. The decrease in performance of Country A athletes followed a high incidence of steroids detection cases by means of new antidoping methods. It is highly likely that cosenquent performance decrease is due to implementation of new antidoping methods. The results of the study brings new facts on effects of new antidoping methods implementation and demonstrate following decrease in performance results in population of athletes from the country widely accused of doping use.

Extensive expertise in endocrinology: advances in the management of glucocorticoid-induced osteoporosis

Osteoporosis is a common consequence of long-term oral glucocorticoid therapy and the resulting fractures cause significant morbidity. Bone loss occurs rapidly after initiation of glucocorticoid therapy; the accompanying increase in risk of fracture is dose-dependent and occurs within a few months of starting therapy. The adverse effects of glucocorticoids on bone are mediated by inhibition of bone formation accompanied by an early but transient increase in bone resorption, due both to direct and indirect effects on bone remodelling. Fracture risk assessment should be performed as soon as possible after long-term glucocorticoid therapy (≥3 months) is initiated. FRAX can be adjusted for the dose of prednisolone but does not currently take fracture site, recency, or number into account and therefore may underestimate fracture risk, particularly in individuals with morphometric vertebral fractures. Vertebral fracture assessment should therefore be regarded as a routine part of fracture risk estimation in individuals receiving long-term glucocorticoid therapy. Bone protective therapy should be started promptly in individuals at high-risk, together with calcium and vitamin D supplements. Bisphosphonates are generally regarded as first-line options on the grounds of their low cost, but anabolic therapy should be considered as an alternative first-line option in very high-risk individuals.

Effort-based decision making in response to high-dose androgens: role of dopamine receptors

INTRODUCTION

Anabolic-androgenic steroids (AAS) are performance-enhancing drugs used by both world-class and rank-and-file athletes. AAS abuse has been linked with risky decision-making, ranging from drunk driving to abusing multiple drugs. Our lab uses operant behavior in rats to test the effects of AAS (testosterone) on decision making. In our previous study, testosterone caused rats to work harder for food reward during an effort discounting (ED) task. ED is sensitive to dopamine in the nucleus accumbens, and AAS alter accumbens dopamine receptor expression. Accordingly, we determined if testosterone increases response to dopamine receptor antagonists during ED.

METHODS

Rats were treated chronically with high-dose testosterone (7.5 mg/kg; n = 9) or vehicle (n = 9). We measured baseline preference for the large reward in an ED task, where rats choose between a small easy reward (one lever press for one sugar pellet) and a large difficult reward (2, 5, 10, or 15 presses for three pellets). Preference for the large reward was measured after administration of D1-like (SCH23390, 0.01 mg/kg) or D2-like (eticlopride, 0.06 mg/kg) receptor antagonists.

RESULTS

At baseline, testosterone- and vehicle-treated rats showed similar preference for the large reward lever (FR5, testosterone: 68.6 ± 9.7% and vehicle: 85.7 ± 2.5%). SCH23390 reduced large reward preference significantly in both groups (FR5, testosterone: 41.3 ± 9.2%; vehicle: 49.1 ± 8.2%; F(1,16) = 17.7; P < 0.05). Eticlopride decreased large reward preference in both groups, but more strongly in testosterone-treated rats (FR5: testosterone: 37.0 ± 9.7%; vehicle: 56.3 ± 7.8%; F(1,16) = 35.3; P < 0.05).

CONCLUSION

Testosterone increases response to dopamine D2-like receptor blockade, and this contributes to previously observed changes in decision-making behaviors.

Differences in Nervous Autonomic Control in Response to a Single Session of Exercise in Bodybuilders Using Anabolic Androgenic Steroids

Considering the role of autonomic nerve activity in blood pressure control, this study aimed to investigate the cardiac autonomic nerve responses after an aerobic exercise session in Anabolic Androgenic Steroids (AAS) users. Twenty men (AAS, n = 9; control group, n = 11) performed an aerobic exercise session (60 min, 70 to 80% of HR_max). Heart rate variability (HRV) was assessed before and during a 60-min post-exercise recovery period. RMSSD (root mean square successive difference of the RR intervals) and the LF/HF ratio (low frequency/high frequency spectra) were also evaluated. The Student's t-test for independent samples was used to compare differences between initial group characteristics. Repeated measures ANOVA was used to compare pre- and post-exercise HRV recovery (p < 0.05). AAS had a lower SDNN (standard deviation of the intervals) (40.8 ± 16.8 vs. 71.6 ± 24.7 ms; p = 0.04, d = 1.4) and a higher LF/HF (3.4 ± 2.1 vs. 1.8 ± 0.9%; p = 0.03, d = 0.9) before exercise. AAS and controls had similar RMSSD (14.0 ± 15.8 vs. 18.9 ± 12.1 ms; p = 0.20) and a LF/HF (2.8 ± 1.6 vs. 2.4 ± 1.2 ms; p = 0.41) immediately post-exercise. The between-groups comparison revealed a higher HF/LF at 30 min (4.3 ± 1.4 vs. 2.5 ± 1.3%; p = 0.008, d = 1.3) and 60 min (5.0 ± 2.2 vs. 2.3 ± 0.8%; p = 0.001, d = 1.6) for the AAS group in the recovery time. This study demonstrated impaired parasympathetic activity at rest and immediately after the exercise session as an adverse effect of AAS usage, but similar behavior regarding the restoration of sympathetic activity.

Medical treatment of osteoporosis

Osteoporosis is a common chronic condition that markedly increases the risk of fractures. Osteoporotic-related fractures increase morbidity and mortality and impair quality of life. Therefore, a correct approach for fracture prevention seems mandatory. Lifestyle changes should be recommended to all patients, including weight reduction if patients are obese/overweight, increasing physical activity and avoiding alcohol consumption and smoking. Additionally, calcium and vitamin D3 should be prescribed until the vitamin D deficit is resolved. Osteoporosis treatment options mainly include antiresorptives (i.e. estrogens, selective estrogen receptor modulators, bisphosphonates, denosumab) and anabolic agents (i.e. teriparatide, abaloparatide, romosozumab). Although presenting differences in efficacy and side effects, they have all been shown to increase bone mineral density (BMD) and to reduce osteoporotic-related fractures. Monotherapy with antiresorptive agents, particularly oral bisphosphonates, should be considered routinely as the first option for treatment of postmenopausal women. However, in the case of side effects, therapeutic failure or the need for long-term use, anabolic agents may be considered. In high-risk patients, anabolic agents may be considered as an initial therapeutic option. The combination of antiresorptive and anabolic agents may be useful to increase BMD compared with monotherapy, but more information is warranted to determine the effects on fracture risk.

Bilateral Nipple Enlargement as a Secondary Effect of Anabolic Drugs: A Histopathological Mimicker of Smooth Muscle Hamartoma

Smooth muscle hamartoma are usually solitary and congenital, may affect the genital area and nipples. Histopathologically, they are characterized by the presence of mature smooth muscle bundles. We present a 40 year-old male with bilateral nipple enlargement excised with clinical suspicion of bilateral leiomyoma. Skin biopsy shows mature, irregularly arranged smooth muscle bundles and lactiferous ducts between them. Immunohistochemistry is positive for smooth muscle actin, desmin and fumarase, but negative for estrogen and progestogen receptors. The presence of lactiferous ducts excludes bilateral leiomyomas. Even when, histopathologically, this can be interpreted as the nipple-type of muscular hamartoma of the breast, clinical history favors an anabolic drug-induced lesion. Bodybuilders present gynecomastia and nipple enlargement as frequent problems, but we have not found any histopathological description of these nipple lesions. We consider that dermatologists should be aware of the presence of them and dermatopathologists should know their histopathological features to avoid misdiagnosis as neoplasms.

Which Drug Next? Sequential Therapy for Osteoporosis

The proliferation of drugs with unique modes of action for treating osteoporosis has been most welcome. Fear of complications, even though rare, associated with long-term bisphosphonates (BPs) changed prescribing patterns. The BPs are stored in bone for years. Drugs not stored in bone; for example, abaloparatide, teriparatide, denosumab, and romosozumab have expanded our armamentarium for treating osteoporosis but have brought new challenges. Bone accrued during treatment with the last 3 drugs, and perhaps abaloparatide, is lost rapidly after their withdrawal due to rebound increase in bone resorption. Treatment with these drugs must be followed by administration of an antiresorptive agent. The article by Kendler et al. (1) in this issue of JCEM reports alendronate preserves bone accrued during administration of denosumab.

Oxandrolone in Patients on Venovenous Extracorporeal Membrane Oxygenation: A Case Series

Venovenous extracorporeal membrane oxygenation (VV ECMO) induces a systemic inflammatory response, which may progress to persistent inflammation, immunosuppression, and catabolism syndrome (PICS). The anabolic steroid oxandrolone may improve the metabolic aberrations of PICS. We report our experience with 3 patients on VV ECMO who received oxandrolone after demonstrating refractory catabolism on serial nitrogen balance (NB) studies or persistent weakness. Patients in cases 1 and 3 were started on oxandrolone on VV ECMO days 45 and 29, respectively, for negative NB despite nutrition optimization. The case 2 patient started oxandrolone for persistent weakness 68 days after cannulation. All patients demonstrated improvements in NB results. One patient developed mild transaminitis while on oxandrolone, which did not alter his medication course and resolved after the medication was discontinued. The impact of oxandrolone on functional capacity varied between patients. Oxandrolone may be beneficial in persistently catabolic VV ECMO patients to improve NB results. In some patients, this may support functional recovery. Additional research is needed to identify optimal patients for therapy and to investigate the impact of oxandrolone in this population.

Role of anabolic agents in colorectal carcinogenesis: Myths and realities (Review)

Colorectal cancer (CRC) is one of the four leading causes of cancer‑related mortality worldwide. Even though over the past few decades the global scientific community has made tremendous efforts to understand this entity, many questions remain to be raised on this issue and even more to be answered. Epidemiological findings have unveiled numerous environmental and genetic risk factors, each one contributing to a certain degree to the final account of new CRC cases. Moreover, different trends have been revealed regarding the age of onset of CRC between the two sexes. That, in addition to newly introduced therapeutic approaches for various diseases based on androgens, anti‑androgens and anabolic hormones has raised some concerns regarding their possible carcinogenic effects or their synergistic potential with other substances/risk factors, predisposing the individual to CRC. Notably, despite the intense research on experimental settings and population studies, the conclusions regarding the majority of anabolic substances are ambiguous. Some of these indicate the carcinogenic properties of testosterone, dihydrotestosterone (DHT), growth hormone and insulin‑like growth factor (IGF) and others, demonstrating their neutral nature or even their protective one, as in the case of vitamin D. Thus, the synergistic nature of anabolic substances with other CRC risk factors (such as type 2 diabetes mellitus, metabolic syndrome and smoking) has emerged, suggesting a more holistic approach.

Advances and Unmet Needs in the Therapeutics of Bone Fragility

The prevalence of fragility fractures increases as longevity increases the proportion of the elderly in the community. Until recently, the majority of studies have targeted women with osteoporosis defined as a bone mineral density (BMD) T score of < -2.5 SD, despite evidence that the population burden of fractures arises from women with osteopenia. Antiresorptive agents reduce vertebral and hip fracture risk by ~50 percent during 3 years but efficacy against non-vertebral fractures, 80% of all fractures in the community, is reported in few studies, and of those, the risk reduction is only 20-30%. Recent advances in the use of antiresorptives and anabolic agents has addressed some of these unmet needs. Zoledronic acid is now reported to reduce vertebral and non-vertebral fractures rates in women with osteopenia. Studies using teriparatide demonstrate better vertebral and clinical (symptomatic vertebral and non-vertebral) antifracture efficacy than risedronate. Abaloparatide, a peptide sharing amino acid sequences with teriparatide, reduces vertebral and non-vertebral fractures. Romosozumab, a monoclonal antibody suppressing sclerostin, reduces vertebral and non-vertebral fractures within a year of starting treatment, and does so more greatly than alendronate. Some recent studies signal undesirable effects of therapy but provide essential cautionary insights into long term management. Cessation of denosumab is associated with a rapid increase in bone remodeling and the uncommon but clinically important observation of increased multiple vertebral fractures suggesting the need to start alternative anti-resorptive therapy around the time of stopping denosumab. Antiresorptives like bisphosphonates and denosumab suppress remodeling but not completely. Antifracture efficacy may be limited, in part, as a consequence of continued unsuppressed remodeling, particularly in cortical bone. Bisphosphonates may not distribute in deeper cortical bone, so unbalanced intracortical remodeling continues to cause microstructural deterioration. In addition, suppressed remodeling may compromise the material composition by increasing matrix mineral density and glycosylation of collagen. As antiresorptive agents do not restore microstructural deterioration existing at the time of starting treatment, under some circumstances, anabolic therapy may be more appropriate first line treatment. Combining antiresorptive and anabolic therapy is an alternative but whether anti-fracture efficacy is greater than that achieved by either treatment alone is not known.

Osteoporosis: Current Concepts

Osteoporosis is a worldwide disease characterized by reduction of bone mass and alteration of bone architecture resulting in increased bone fragility and increased fracture risk. Causes of osteoporosis include increasing age, female sex, postmenopausal status, hypogonadism or premature ovarian failure, low body mass index, ethnic background, rheumatoid arthritis, low bone mineral density (BMD), vitamin D deficiency, low calcium intake, hyperkyphosis, current smoking, alcohol abuse, immobilization, and long-term use of certain medications. The diagnosis of osteoporosis is established by measurement of BMD of the hip and spine using dual energy X-ray absorptiometry. According to the World Health Organization criteria, osteoporosis is defined as a BMD that lies 2.5 standard deviation or more below the average value for young healthy women. Bone turnover biomarker detection may be useful in monitoring osteoporosis treatment and assessing fracture risk but not for diagnosis of osteoporosis. Management of osteoporosis consists of nonpharmacological interventions, which are recommended for all subjects, and pharmacological therapy in all postmenopausal women who have had an osteoporotic fracture or have BMD values consistent with osteoporosis.

Cancer Cachexia: Cause, Diagnosis, and Treatment

Patients with cancer frequently experience unintended weight loss due to gastrointestinal (GI) dysfunction caused by the malignancy or treatment of the malignancy. However, others may present with weight loss related to other symptoms not clearly associated with identifiable GI dysfunction such as anorexia and early satiety. Cancer cachexia (CC) is a multifactorial syndrome that is generally characterized by ongoing loss of skeletal muscle mass with or without fat loss, often accompanied by anorexia, weakness, and fatigue. CC is associated with poor tolerance of antitumor treatments, reduced quality of life (QOL), and negative impact on survival. Symptoms associated with CC are thought to be caused in part by tumor-induced changes in host metabolism that result in systemic inflammation and abnormal neurohormonal responses. Unfortunately, there is no single standard treatment for CC. Nutrition consequences of oncologic treatments should be identified early with nutrition screening and assessment. Pharmacologic agents directed at improving appetite and countering metabolic abnormalities that cause inefficient nutrient utilization are currently the foundation for treating CC. Multiple agents have been investigated for their effects on weight, muscle wasting, and QOL. However, few are commercially available for use. Considerations for choosing the most appropriate treatment include effect on appetite, weight, QOL, risk of adverse effects, and cost and availability of the agent.

Profile of Abaloparatide and Its Potential in the Treatment of Postmenopausal Osteoporosis

Abaloparatide (previously known as BA058) is a synthetic 34-amino acid peptide and novel selective activator of parathyroid hormone receptor 1 (PTHR1) currently under development as a new anabolic agent in the management of osteoporosis. This paper reviews the profile and potential of abaloparatide in the treatment of postmenopausal osteoporosis.

This paper is based on clinical trials and a PubMed search. Search terms used were “abaloparatide”, “BA058”, and “PTHrP”. This review outlines the effects of this anabolic PTHR1 activator, which increases bone mineral density in patients at high risk for osteoporosis. The potential adverse effects of abaloparatide are also summarized.

Abaloparatide has 41% homology to parathyroid hormone (PTH) (1-34) and 76% homology to parathyroid hormone-related protein (PTHrP) (1-34). The molecule was meticulously selected to retain stability and potent bone anabolic activity, and it has a limited effect on bone resorption (hence, a low calcium-mobilizing potential). Abaloparatide has shown promising results in a reduction of new onset vertebral (approximately 86% reduction) and nonvertebral fractures (approximately 43% reduction). In clinical trials to date, abaloparatide appears to have a good safety and tolerability profile with a significantly lower degree of hypercalcemia compared to that of teriparatide. Based on the clinical trials, the optimum dose of abaloparatide is 80 mcg subcutaneous once daily.

Pharmacological Treatment of Bone Loss

Bone loss is common in clinical practice, such as health assessment of postmenopausal women, treatment of tumor metastasis, side-effects of glucocorticoids, and skeletal manifestations of inflammatory diseases. The imbalance of remodeling between bone resorption and bone formation, the pathophysiological basis of bone loss, increases bone fragility. The treatment of bone loss is mainly carried out from the treatment of osteoporosis. There are various pharmacological therapies for bone loss, which will be introduced in 3 aspects, including antiresorptive agents, anabolic agents and new medications. Each kind of medication has its advantages, shortcomings and side-effects. Antiresorptive agents are widely applied in the treatment of bone loss, but can lead to overall decrease of bone turnover rate. Anabolic agents, mainly PTH, are usually combined with other anti-resorptive drugs, and PTHrP might be a promising pure anabolic agent for osteoporosis. In recent years, some novel therapies have been raised and tested in clinical trials which can be promising choices available for osteoporosis treatment. Future drug targets will mainly come from RANK-RANKL-OPG system and Wnt/β-catenin signaling pathway., and the pre-existing drugs could be explored in new patterns.

Therapeutic Drugs in Bone Loss-Associated Disorders: Clinical Outcomes and Challenges

Current therapeutic drugs for the treatment of bone loss-associated disorders such as osteoporosis and metastatic bone disease have limited clinical outcomes, namely in terms of efficiency and sustainability. Given the ageing of population in developed countries and the cumulative costs with treatment, bone loss-associated disorders represent a major socioeconomic burden worldwide. In this review, the therapeutic agents targeting bone loss tested in clinical and pre-clinical trials are summarized, as well as the challenges encountered by clinicians and patients. In an effort to attain costeffective clinical outcomes, potential cellular and signalling targets are disclosed.

Anabolic-androgenic steroids decrease dendritic spine density in the nucleus accumbens of male rats

Recent studies have demonstrated that anabolic-androgenic steroids (AAS) modify cognitive processes such as decision making and behavioral flexibility. However, the neural mechanisms underlying these AAS-induced cognitive changes remain poorly understood. The mesocorticolimbic dopamine (DA) system, particularly the nucleus accumbens (Acb), is important for reward, motivated behavior, and higher cognitive processes such as decision making. Therefore, AAS-induced plasticity in the DA system is a potential structural substrate for the observed cognitive alterations. High doses of testosterone (the most commonly-used AAS) increase dendritic spine density in limbic regions including the amygdala and hippocampus. However, effects on Acb are unknown. This was the focus of the present study. Adolescent male Long-Evans rats were treated chronically for 8weeks with high-dose testosterone (7.5mg/kg in water with 13% cyclodextrin) or vehicle sc. Brains were stained by Golgi-Cox to analyze neuronal morphology in medium spiny neurons of the shell region of Acb (AcbSh). Eightweeks of testosterone treatment significantly decreased spine density in AcbSh compared to brains of vehicle-treated rats (F1,14=5.455, p<0.05). Testosterone did not significantly affect total spine number, dendritic length, or arborization measured by Sholl analysis. These results show that AAS alter neuronal morphology in AcbSh by decreasing spine density throughout the dendritic tree, and provides a potential mechanism for AAS to modify cognition and decision-making behavior.

Recreational Anabolic-Androgenic Steroid Use Associated With Liver Injuries Among Brazilian Young Men

BACKGROUND

The recreational use of anabolic-androgenic steroids (AAS) has reached alarming levels among healthy people. However, several complications have been related to consumption of these drugs, including liver disorders.

OBJECTIVE

To evaluate the prevalence of liver injuries in young Brazilian recreational AAS users.

METHODS

Between February/2007 and May/2012 asymptomatic bodybuilders who were ≥18 years old and reported AAS use for ≥6 months were enrolled. All had clinical evaluations, abdominal ultrasound (AUS), and blood tests.

RESULTS

182 individuals were included in the study. The median age (interquartile range) was 26.0 years (22.0-30.0) and all were male. Elevated liver enzyme levels were observed in 38.5% (n = 70) of AAS users, and creatine phosphokinase was normal in 27.1% (n = 19) of them. Hepatic steatosis was observed by AUS in 12.1% of the sample. One individual had focal nodular hyperplasia and another had hepatocellular adenoma. One case each of hepatitis B and C virus infection was found. A diagnosis of toxic liver injury was suggested in 23 (12.6%) AAS users without a history of alcohol or other medications/drugs consumption, or evidence of other liver diseases.

CONCLUSIONS/IMPORTANCE

Young Brazilian recreational AAS users presented a wide spectrum of liver injuries that included hepatotoxicity, fatty liver, and liver neoplasm. They also presented risk factors for liver diseases such as alcohol consumption and hepatitis B and C virus infection. The results suggest that the risk of AAS use for the liver may be greater than the esthetic benefits, and demonstrate the importance of screening AAS users for liver injuries.

Anabolic-androgenic steroid use among Brazilian bodybuilders

This cross-sectional, quantitative, exploratory study investigated the prevalence and profile of anabolic-androgenic steroids (AAS) users amongst a convenience sample of 510 bodybuilders from 52 gyms, in João Pessoa, Brazil, with a structured questionnaire containing selected questions about socioeconomic and training variables on the use of AAS. Data were analyzed using frequency and chi-square tests. AAS prevalence use was 20.6%; mostly young men (98.1%), of a low education level (46.7%), who trained for more than 4 years (49.5%). The use of AAS was related to the use of dietary supplements. About 81% of consumed AAS consisted of Deca-Durabolin, Winstrol, and Sustanon. Study's limitations are noted.

Adverse cardiovascular effects from the use of anabolic-androgenic steroids as ergogenic resources

This review evaluates the documented cardiovascular functioning among anabolic-androgenic steroid (AAS) users. AAS users manifest a reduction in HDL cholesterol, increased inflammatory markers, and oxidative stress. Strong evidence associating AAS use with blood pressure at hypertensive levels, as well as hypertrophy and cardiac dysfunction has also been reported. Both epidemiological and autopsy studies attest the relationship between AAS use and early mortality. The review's limitations are noted.

The influence of concomitant use of alcohol, tobacco, cocaine, and anabolic steroids on lipid profiles of Brazilian recreational bodybuilders

Anabolic-androgenic steroids (AAS) are used to enhance physical performance and/or appearance. The aim of this study was to evaluate the influence of the concomitant use of alcohol, tobacco, cocaine, and AAS on blood lipid profiles of 145 asymptomatic male bodybuilders from the Northeast region of Brazil. Interviews, clinical exams, and serological evaluations were performed on all participants between 2007 and 2009. All subjects' self-reported use of testosterone or its derivatives, 118 individuals reported alcohol intake, 27-reported cigarette smoking, and 33 confirmed cocaine use. Four subjects were users of all drugs at the same time. Higher levels of total cholesterol and LDL-cholesterol were observed among concomitant users of alcohol, tobacco, cocaine, and AAS. The study's limitations are noted.

Therapies for musculoskeletal disease: can we treat two birds with one stone?

Musculoskeletal diseases are highly prevalent with staggering annual health care costs across the globe. The combined wasting of muscle (sarcopenia) and bone (osteoporosis)-both in normal aging and pathologic states-can lead to vastly compounded risk for fracture in patients. Until now, our therapeutic approach to the prevention of such fractures has focused solely on bone, but our increasing understanding of the interconnected biology of muscle and bone has begun to shift our treatment paradigm for musculoskeletal disease. Targeting pathways that centrally regulate both bone and muscle (eg, GH/IGF-1, sex steroids, etc.) and newly emerging pathways that might facilitate communication between these 2 tissues (eg, activin/myostatin) might allow a greater therapeutic benefit and/or previously unanticipated means by which to treat these frail patients and prevent fracture. In this review, we will discuss a number of therapies currently under development that aim to treat musculoskeletal disease in precisely such a holistic fashion.

Emerging therapeutic targets for osteoporosis treatment

INTRODUCTION

To date, osteoporosis still remains a major public health burden especially for the aging populations. Over the last few decades treatments for osteoporosis have largely focused on anti-resorptive agents represented by bisphosphonates and estrogen therapy that dominated the market. Unsatisfactory efficacy, non-specificity and long-term safety of current therapies necessitate the need for new targets effectively preventing and treating of osteoporosis.

AREAS COVERED

This review expatiates on the mechanism of osteoporosis occurrence and bone remodeling cycle in detail. New targets of antiresorptive and anabolic agents based on the functions of osteoblasts and osteoclasts as well as associated signaling pathways are outlined.

EXPERT OPINION

Advanced understanding in the fields of bone remodeling, functions of osteoblasts, osteoclasts and osteocytes associated with osteoporosis occurrence offers the emerging bone-resorptive or bone-formative targets. Currently, molecules involving RANK-RANKL-OPG system and Wnt/β-catenin signaling pathway act as the most promising targets.

A Young Man with Myocardial Infarction due to Trenbolone Acetate; a Case Report

Over the four decades, a significant decrease has been observed in age-related mortality caused by cardiovascular disease. People in developing countries suffer from CAD at a relatively younger age and about half of MI occurs under the age of fifty years. Abuse of anabolic steroids is one of the less common causes of atherosclerosis. In this report, a 23-year-old body builder male referred to emergency department (ED) with myocardial infarction (MI) following chronic Trenbolone acetate consumption. It seems that a comprehensive history of steroid consumption in young patients referred to ED with the chief complaint of chest pain or its equivalents is necessary in adjunct to other cardiac risk factors.

Anabolic steroid induced hypogonadism in young men

PURPOSE

The use of anabolic androgenic steroids has not been traditionally discussed in mainstream medicine. With the increased diagnosis of hypogonadism a heterogeneous population of men is now being evaluated. In this larger patient population the existence of anabolic steroid induced hypogonadism, whether transient or permanent, should now be considered.

MATERIALS AND METHODS

We performed an initial retrospective database analysis of all 6,033 patients who sought treatment for hypogonadism from 2005 to 2010. An anonymous survey was subsequently distributed in 2012 to established patients undergoing testosterone replacement therapy.

RESULTS

Profound hypogonadism, defined as testosterone 50 ng/dl or less, was identified in 97 men (1.6%) in the large retrospective cohort initially reviewed. The most common etiology was prior anabolic androgenic steroid exposure, which was identified in 42 men (43%). Because of this surprising data, we performed an anonymous followup survey of our current hypogonadal population of 382 men with a mean±SD age of 49.2±13.0 years. This identified 80 patients (20.9%) with a mean age of 40.4±8.4 years who had prior anabolic androgenic steroid exposure. Hypogonadal men younger than 50 years were greater than 10 times more likely to have prior anabolic androgenic steroid exposure than men older than 50 years (OR 10.16, 95% CI 4.90-21.08). Prior anabolic androgenic steroid use significantly correlated negatively with education level (ρ=-0.160, p=0.002) and number of children (ρ=-0.281, p<0.0001).

CONCLUSIONS

Prior anabolic androgenic steroid use is common in young men who seek treatment for symptomatic hypogonadism and anabolic steroid induced hypogonadism is the most common etiology of profound hypogonadism. These findings suggest that it is necessary to refocus the approach to evaluation and treatment paradigms in young hypogonadal men.

'Roid rage in rats? Testosterone effects on aggressive motivation, impulsivity and tyrosine hydroxylase

In humans and animals, anabolic-androgenic steroids (AAS) increase aggression, but the underlying behavioral mechanisms are unclear. AAS may increase the motivation to fight. Alternatively, AAS may increase impulsive behavior, consistent with the popular image of 'roid rage. To test this, adolescent male rats were treated chronically with testosterone (7.5mg/kg) or vehicle and tested for aggressive motivation and impulsivity. Rats were trained to respond on a nose-poke on a 10 min fixed-interval schedule for the opportunity to fight in their home cage with an unfamiliar rat. Although testosterone increased aggression (6.3±1.3 fights/5 min vs 2.4±0.8 for controls, p<0.05), there was no difference in operant responding (28.4±1.6 nose-pokes/10 min for testosterone, 32.4±7.0 for vehicle). This suggests that testosterone does not enhance motivation for aggression. To test for impulsivity, rats were trained to respond for food in a delay-discounting procedure. In an operant chamber, one lever delivered one food pellet immediately, the other lever gave 4 pellets after a delay (0, 15, 30 or 45 s). In testosterone- and vehicle-treated rats, body weights and food intake did not differ. However, testosterone-treated rats chose the larger, delayed reward more often (4.5±0.7 times in 10 trials with 45 s delay) than vehicle controls (2.5±0.5 times, p<0.05), consistent with a reduction in impulsive choice. Thus, although chronic high-dose testosterone enhances aggression, this does not include an increase in impulsive behavior or motivation to fight. This is further supported by measurement of tyrosine hydroxylase (TH) by Western immunoblot analysis in brain regions important for motivation (nucleus accumbens, Acb) and executive function (medial prefrontal cortex, PFC). There were no differences in TH between testosterone- and vehicle-treated rats in Acb or PFC. However, testosterone significantly reduced TH (to 76.9±3.1% of controls, p<0.05) in the caudate-putamen, a brain area important for behavioral inhibition, motor control and habit learning.

Recent developments in bone anabolic therapy for osteoporosis

Osteoporosis is a disorder in which there is a net bone loss and microarchitectural deterioration with an increased risk of bone fracture because of uncoupling of bone formation and bone resorption. The treatment of osteoporosis aims to inhibit bone resorption by osteoclasts and/or promote bone formation by osteoblasts. However, most of the current approaches for treating osteoporosis focus on inhibiting bone resorption. As the only US FDA-approved anabolic agent, the recombinant human parathyroid hormone is recommended for consecutive 2-year period treatment in a clinical setting. Therefore, it is highly desirable to identify novel bone anabolic agents or approaches for osteoporosis treatment. In this review, the authors introduce a new bone anabolic therapy by means of RNAi strategy. Specifically, the authors also discuss the current status and perspectives for RNAi as a novel anabolic approach in the treatment of osteoporosis.

Testosterone and sport: current perspectives

Testosterone and other anabolic-androgenic steroids enhance athletic performance in men and women. As a result, exogenous androgen is banned from most competitive sports. However, due to variability in endogenous secretion, and similarities with exogenous testosterone, it has been challenging to establish allowable limits for testosterone in competition. Endogenous androgen production is dynamically regulated by both exercise and winning in competition. Furthermore, testosterone may promote athletic performance, not only through its long-term anabolic actions, but also through rapid effects on behavior. In women, excess production of endogenous testosterone due to inborn disorders of sexual development (DSD) may convey a competitive advantage. For many years, female competitors have been subject to tests of sexual genotype and phenotype known as gender verification. Although gender verification has not identified any normal man competing as a woman, this process has identified women athletes with DSD. As understanding of DSD has expanded in recent years, women with DSD are increasingly able to continue athletic competition.

Testosterone as a discriminative stimulus in male rats

Testosterone and other anabolic-androgenic steroids (AAS) are reinforcing in animals, as determined by conditioned place preference or self-administration. Most drugs of abuse produce subjective effects on mood and perception that initiate and maintain drug taking. Whether AAS have similar effects is not known. Food-restricted male Sprague-Dawley rats (n=9) were tested for their ability to discriminate an injection of testosterone from the β-cyclodextrin vehicle using a standard two-lever operant paradigm. In drug discrimination, animals use the subjective effects of drug or vehicle to select the appropriate lever to obtain food pellets under an FR10 schedule of reinforcement. All rats demonstrated vigorous responding for food (1415.1±76.1 responses/20 min) with 94.9% of responses on the active lever. For the first 30 days, rats received 1mg/kg testosterone sc 30 min before testing. On Day 14, one rat achieved the discrimination criteria of 9/10 consecutive days with >90% responses on the active lever and ≤5 responses on the inactive lever before the first reinforcement. Subsequently, rats were tested with testosterone at different doses (2, 7.5, 15 mg/kg at 30 min before testing) and times (2mg/kg at 30 or 60 min before testing), each for 20 days. One additional rat demonstrated successful discrimination at Day 54 with 2mg/kg testosterone 60 min before testing. The remaining 7 rats failed to discriminate testosterone within 110 days. When analyzed according to less-stringent standards, 4 additional rats met criteria for testosterone discrimination. However, continued performance was not stable. Thus, testosterone was unable to consistently support drug discrimination. We conclude that testosterone does not produce rapid interoceptive effects (NIH DA12843 to RIW).

Rhabdomyolysis of the deltoid muscle in a bodybuilder using anabolic-androgenic steroids: a case report

OBJECTIVE

Rhabdomyolysis (breakdown of skeletal muscle tissue) may be caused by mechanical, physical, chemical, or biological factors. We present the unique case of a bodybuilder who developed localized rhabdomyolysis of the deltoid muscle after injection of steroids into the shoulder region.

BACKGROUND

A 39-year-old amateur bodybuilder presented to the emergency department with excruciating pain and inability to move his right shoulder after injecting stanozolol, an anabolic-androgenic steroid (AAS), into his right deltoid muscle on the same day. On physical examination, the right deltoid muscle was swollen and tense and the surrounding skin red, tender, and warm. He had no fluctuation or systemic fever and no sensory or motor deficit. His distal pulsations were distinct. Laboratory test results suggested massive rhabdomyolysis. The major magnetic resonance imaging finding was diffuse hyperintensity signals on T2-weighted images of the deltoid muscle, which was consistent with edema.

DIFFERENTIAL DIAGNOSIS

Polymyositis and dermatomyositis, mild injury, infectious myositis without phlegmon or abscess formation, radiation therapy, subacute denervation, compartment syndrome, early myositis ossificans, rhabdomyolysis, and sickle cell crisis.

TREATMENT

The patient was treated with intravenous fluid replacement and sodium bicarbonate to alkalinize the urine. Four days after admission, his pain had decreased, he had regained range of motion, and his renal function remained unaffected.

UNIQUENESS

Anabolic-androgenic steroid use is associated with various side effects that are generally systemic and dose related. We could not find reports of localized side effects of AAS use, as this case presented, elsewhere in the English-language literature.

CONCLUSIONS

"Doping" among amateur athletes occurs frequently. It can cause acute and chronic health problems, most of which are systemic. This is the first description of localized rhabdomyolysis in the area of an AAS injection.

Gene expression in hair follicle dermal papilla cells after treatment with stanozolol

Doping with anabolic agents is a topic in sports where strength is crucial, e.g. sprinting, weight lifting and many more. Testosterone and its functional analogs are the drugs of choice taken as pills, creams, tape or injections to increase muscle mass and body performance, and to reduce body fat. Stanozolol (17β-hydroxy-17α-methyl-5α-androst-2-eno[3,2c]pyrazol) is a testosterone analogue with the same anabolic effect like testosterone but its ring structure makes it possible to take it orally. Therefore, stanozolol is one of the most frequently used anabolic steroids.

Common verification methods for anabolic drugs exist, identifying the chemicals in tissues, like hair or blood samples. The idea of this feasibility study was to search for specific gene expression regulations induced by stanozolol to identify the possible influence of the synthetically hormone on different metabolic pathways. Finding biomarkers for anabolic drugs could be supportive of the existing methods and an additional proof for illegal drug abuse.

In two separate cell cultures, human HFDPC (hair follicle dermal papilla cells) from a female and a male donor were treated with stanozolol. In the female cell culture treatment concentrations of 0 nM (control), 1 nM, 10 nM and 100 nM were chosen. Cells were taken 0 h, 6 h, 24 h and 48 h after stimulation and totalRNA was extracted. Learning from the results of the pilot experiment, the male cell culture was treated in 10 nM and 100 nM concentrations and taken after 0 h, 6 h, 24 h and 72 h. Using quantitative real-time RT-PCR expression of characteristics of different target genes were analysed.

Totally 13 genes were selected according to their functionality by screening the actual literature and composed to functional groups: factors of apoptosis regulation were Fas Ligand (FasL), its receptor (FasR), Caspase 8 and Bcl-2. Androgen receptor (AR) and both estrogen receptors (ERα, ERβ) were summarized in the steroid receptor group. The growth factor group included the insulin like growth factor receptor (IGF1R) and growth hormone receptor (GHR). Fibroblast growth factor 2 (FGF2) and keratinocyte growth factor (FGF7) were summarized in the hair cycle factor group. 5α-Steroidreductases (SRD5A1, SRD5A2) represented the enzyme group. Three reference genes were taken for relative quantification: ubiquitin (UBQ), glycerinaldehyde-3-phsophate-dehydrogenase (GAPDH), and β-actin (ACTB).

In cell culture 1 AR, FasR, FGF2 showed significant regulations within one treatment time, significant gene expressions over time were analysed for Caspase 8. In cell culture 2 AR, FasR and SRD5A2 were significantly regulated within one treatment time.

In this feasibility study first biomarker for a screening pattern of anabolic agents could be identified providing the rationality to investigate modified, metabolic pathways in the whole hair follicle.

Anabolic-androgenic steroid dependence? Insights from animals and humans

Anabolic-androgenic steroids (AAS) are drugs of abuse. They are taken in large quantities by athletes and others to increase performance, with negative health consequences. As a result, in 1991 testosterone and related AAS were declared controlled substances. However, the relative abuse and dependence liability of AAS have not been fully characterized. In humans, it is difficult to separate the direct psychoactive effects of AAS from reinforcement due to their systemic anabolic effects. However, using conditioned place preference and self-administration, studies in animals have demonstrated that AAS are reinforcing in a context where athletic performance is irrelevant. Furthermore, AAS share brain sites of action and neurotransmitter systems in common with other drugs of abuse. In particular, recent evidence links AAS with opioids. In humans, AAS abuse is associated with prescription opioid use. In animals, AAS overdose produces symptoms resembling opioid overdose, and AAS modify the activity of the endogenous opioid system.

Impact of nutritional status on body functioning in chronic obstructive pulmonary disease and how to intervene

PURPOSE OF REVIEW

Chronic obstructive pulmonary disease is the fifth leading cause of mortality in the world. This study reviews diet as a risk or protective factor for chronic obstructive pulmonary disease, mechanisms of malnutrition, undernutrition consequences on body functioning and how to modulate nutritional status of patients with chronic obstructive pulmonary disease.

RECENT FINDINGS

Different dietary factors (dietary pattern, foods, nutrients) have been associated with chronic obstructive pulmonary disease and the course of the disease. Mechanical disadvantage, energy imbalance, disuse muscle atrophy, hypoxemia, systemic inflammation and oxidative stress have been reported to cause systemic consequences such as cachexia and compromise whole body functioning. Nutritional intervention makes it possible to modify the natural course of the disease provided that it is included in respiratory rehabilitation combining bronchodilators optimization, infection control, exercise and, in some patients, correction of hypogonadism.

SUMMARY

Diet, as a modifiable risk factor, appears more as an option to prevent and modify the course of chronic obstructive pulmonary disease. Reduction of mechanical disadvantage, physical training and anabolic agents should be used conjointly with oral nutrition supplements to overcome undernutrition and might change the prognosis of the disease in some cases. Major research challenges address the role of systemic inflammation and the best interventions for controlling it besides smoking cessation.

Adolescents and androgens, receptors and rewards

Adolescence is associated with increases in pleasure-seeking behaviors, which, in turn, are shaped by the pubertal activation of the hypothalamo-pituitary-gonadal axis. In animal models of naturally rewarding behaviors, such as sex, testicular androgens contribute to the development and expression of the behavior in males. To effect behavioral maturation, the brain undergoes significant remodeling during adolescence, and many of the changes are likewise sensitive to androgens, presumably acting through androgen receptors (AR). Given the delicate interaction of gonadal hormones and brain development, it is no surprise that disruption of hormone levels during this sensitive period significantly alters adolescent and adult behaviors. In male hamsters, exposure to testosterone during adolescence is required for normal expression of adult sexual behavior. Males deprived of androgens during puberty display sustained deficits in mating. Conversely, androgens alone are not sufficient to induce mating in prepubertal males, even though brain AR are present before puberty. In this context, wide-spread use of anabolic-androgenic steroids (AAS) during adolescence is a significant concern. AAS abuse has the potential to alter both the timing and the levels of androgens in adolescent males. In hamsters, adolescent AAS exposure increases aggression, and causes lasting changes in neurotransmitter systems. In addition, AAS are themselves reinforcing, as demonstrated by self-administration of testosterone and other AAS. However, recent evidence suggests that the reinforcing effects of androgens may not require classical AR. Therefore, further examination of interactions between androgens and rewarding behaviors in the adolescent brain is required for a better understanding of AAS abuse.

Lactoferrin--a novel bone growth factor

Lactoferrin is an iron-binding glycoprotein that belongs to the transferrin family. It is present in breast milk, in epithelial secretions, and in the secondary granules of neutrophils. In healthy subjects lactoferrin circulates at concentrations of 2-7 x 10(-6) g/ml. Lactoferrin is a pleiotropic factor with potent antimicrobial and immunomodulatory activities. Recently, we have shown that lactoferrin can also promote bone growth. At physiological concentrations, lactoferrin potently stimulates the proliferation and differentiation of primary osteoblasts and also acts as a survival factor inhibiting apoptosis induced by serum withdrawal. Lactoferrin also affects osteoclast formation and, in murine bone marrow culture, lactoferrin potently inhibits osteoclastogenesis. In vivo, local injection of lactoferrin above the hemicalvaria of adult mice results in substantial increases in the dynamic histomorphometric indices of bone formation and bone area. The mitogenic effect of lactoferrin in osteoblast-like cells is mediated mainly through LRP1, a member of the family of low-density lipoprotein receptor-related proteins that are primarily known as endocytic receptors. Using confocal laser scanning microscopy, we demonstrated that fluorescently labeled lactoferrin is endocytosed and can be visualized in the cytoplasm of primary osteoblastic cells. Lactoferrin also induces activation of p42/44 MAPK signaling in primary osteoblasts, but the two pathways seem to operate independently as activation of MAPK signaling, but not endocytosis, is necessary for the mitogenic effect of lactoferrin. We conclude that lactoferrin may have a physiological role in bone growth and healing, and a potential therapeutic role as an anabolic factor in osteoporosis.

Advances in therapy for osteoporosis

The current status of detection and treatment of osteoporosis is reviewed. Despite substantial advances in the past ten years, most patients with osteoporotic fractures are still not being treated for the underlying bony cause of the fracture, and most people at risk for fracture are not being offered known protective regimens. The foundation of any therapeutic program is adequate nutrition--specifically protein, calcium, phosphorus and vitamin D. Current anti-resorptive agents reduce vertebral fracture risk by 30% to 50% and teriparatide, a newly approved anabolic agent, reduces risk by up to 80+%. Effective treatments for chronic bony pain that occurs in some patients with spine fractures is affored by two minimally invasive procedures, kyphoplasty and vertebroplasty. Some of these chronically painful fractures represent instances of previously unrecognized non-union, and in them low-pressure vertebroplasty produces prompt and lasting relief. Fracture risk reductions with current anti-resorptive agents are at least twice as great as can be explained by drug effects on bone mass. Moreover, risk is reduced within a few months of starting therapy. These observations focus attention on bone remodeling and point to the need for improvement of biomarker technology, since it seems likely that reduction in remodeling activity underlies much of the fracture risk reduction and can therefore be used to monitor therapy.