MR spectroscopy of hepatic fat and adiponectin and leptin levels during testosterone therapy in type 2 diabetes: a randomized, double-blinded, placebo-controlled trial

BACKGROUND

Men with type 2 diabetes mellitus (T2D) often have lowered testosterone levels and an increased risk of cardiovascular disease (CVD). Ectopic fat increases the risk of CVD, whereas subcutaneous gluteofemoral fat protects against CVD and has a beneficial adipokine-secreting profile.

HYPOTHESIS

Testosterone replacement therapy (TRT) may reduce the content of ectopic fat and improve the adipokine profile in men with T2D.

DESIGN AND METHODS

A randomized, double-blinded, placebo-controlled study in 39 men aged 50-70 years with T2D and bioavailable testosterone levels <7.3 nmol/L. Patients were randomized to TRT (n = 20) or placebo gel (n = 19) for 24 weeks. Thigh subcutaneous fat area (TFA, %fat of total thigh volume), subcutaneous abdominal adipose tissue (SAT, % fat of total abdominal volume) and visceral adipose tissue (VAT, % fat of total abdominal volume) were measured by magnetic resonance (MR) imaging. Hepatic fat content was estimated by single-voxel MR spectroscopy. Adiponectin and leptin levels were measured by in-house immunofluorometric assay. Coefficients (b) represent the placebo-controlled mean effect of intervention.

RESULTS

TFA (b = -3.3 percentage points (pp), P = 0.009), SAT (b = -3.0 pp, P = 0.006), levels of adiponectin (b = -0.4 mg/L, P = 0.045), leptin (b = -4.3 µg/mL, P < 0.001), leptin:adiponectin ratio (b = -0.53, P = 0.001) and HDL cholesterol (b = -0.11 mmol/L, P = 0.009) decreased during TRT compared with placebo. Hepatic fat content and VAT were unchanged.

CONCLUSIONS

The effects of TRT on cardiovascular risk markers were ambiguous. We observed potentially harmful changes in cardiovascular risk parameters, markedly reduced subcutaneous fat and unchanged ectopic fat during TRT and a reduction in adiponectin levels. On the other hand, the decrease in leptin and leptin:adiponectin ratio assessments could reflect an amelioration of the cardiovascular risk profile linked to hyperleptinaemia in ageing men with T2D.

Identification and Characterization of a Nationwide Danish Adult Common Variable Immunodeficiency Cohort

In this study, we identified all adults living in Denmark diagnosed with common variable immunodeficiency (CVID) and characterized them according to clinical presentation and EUROclass classification. Using a retrospective, cross-sectional design, possible CVID patients were identified in the Danish National Patient Register and Centers in Denmark treating patients with primary immunodeficiencies. The CVID diagnosis was verified by review of medical records. One-hundred-seventy-nine adults with CVID were identified. This corresponds to a prevalence of 1:26,000. The median age at onset of symptoms was 29 years with no sex difference. The median age at diagnosis was 40 years. Males were diagnosed earlier with a peak in the fourth decade of life, whereas females were diagnosed later with a peak in the sixth decade. The median diagnostic delay was seven years. Recurrent sinopulmonary infections were seen in 92.7% of the patients. The prevalence of non-infectious complications was similar to that of previously reported cohorts: bronchiectasis (35.8%), splenomegaly (22.4%), lymphadenopathy (26.3%), granulomatous inflammation (3.9%) and idiopathic thrombocytopenic purpura (14.5%). Non-infectious complications were strongly associated with B cell phenotype, with all having a reduced number of isotype-switched memory B cells. One-hundred-seventy (95%) were treated with immunoglobulin replacement therapy, primarily administered subcutaneously. According to international guidelines, diagnostic evaluation was inadequate in most cases. This study emphasizes the need for improved diagnostic criteria and more awareness of CVID as a differential diagnosis. Diagnosis and management of CVID patients is a challenge requiring specialists with experience in the field of PID.

Peak muscle mass in young men and sarcopenia in the ageing male

SUMMARY

The prevalence of sarcopenia increases with age. The diagnosis of sarcopenia relies in part on normative data on muscle mass, but these data are lacking. This study provides population-based reference data on muscle mass in young men, and these results may be used clinically for the diagnosis of sarcopenia in men.

INTRODUCTION

The ageing population increases the prevalence of sarcopenia. Estimation of normative data on muscle mass in young men during the peak of anabolic hormones is necessary for the diagnosis of sarcopenia in ageing males. The purposes of this study were to provide population-based reference data on lean body mass (LBM) in young men during the time of peak levels of GH/IGF-1 and testosterone and further to apply the reference data on a population-based sample of men aged 60-74 years to estimate the prevalence of sarcopenia.

METHODS

This is a cross-sectional, population-based single-centre study. Our participants are from random selection of 783 men, aged 20-29 years, and 600 men, aged 60-74 years. LBM was assessed by dual-energy X-ray absorptiometry (DXA). LBM T-scores were calculated on the basis of LBM in the young participants. Muscle function in the lower extremities was measured using a leg extension power (LEP) rig in the ageing participants.

RESULTS

Total lean body mass (TLB) was (mean (SD)) 64.7 kg (6.8) in the young and 60.4 kg (6.4) in the ageing men (p<0.001). Lower extremity lean mass (LELB) was 22.0 kg (2.6) in the young and 19.2 kg (2.4) in the ageing men (p<0.001). In the ageing men, TLB and LELB T-scores were -0.64 (0.94) and -1.09 (0.94). A total of 4.8 and 8.5% had a TLB or LELB T-score of less than -2 and a LEP in the lowest quartile.

CONCLUSIONS

This study provides population-based reference data on LBM in men, and these data may be used clinically for the diagnosis of sarcopenia.

Similar reference intervals for total testosterone in healthy young and elderly men: results from the Odense Androgen Study

CONTEXT

Ageing in men is associated with changes in levels of sex hormones.

OBJECTIVE

To evaluate differences in sex hormones in young and elderly men and the significance of comorbidity and fat mass on sex hormones in elderly men.

DESIGN

Cross-sectional.

PATIENTS

Seven hundred and eighty-three men aged 20-29 years and 600 men aged 60-74 years randomly recruited from the background population.

MEASUREMENTS

Sex hormones and sex hormone-binding globulin (SHBG) were measured, and reference intervals were determined in healthy individuals in both groups and in elderly men stratified according to whether they were obese or lean (waist circumference ≥102 cm).

RESULTS

Sex hormones were lower and SHBG higher in elderly men compared with the young cohort. Lower cut-offs for total testosterone (TT) in healthy, young and elderly men were similar [Lower cut-off (95% CI): Young: 11·7 (11·2-12·1) vs elderly: 11·2 (10·3-12·1) nmol/l], but lower and higher cut-offs of bioavailable testosterone (BT) and free testosterone (FT) were higher in young men. Higher levels of androgens were found in healthy elderly men compared with those with a chronic disease or obesity. Androgens were inversely associated with central fat mass (CFM), whereas SHBG was inversely and directly associated with CFM and lower extremity fat mass, respectively, in both young and elderly men.

CONCLUSION

Reference intervals for TT were comparable in healthy young and elderly men, but reference intervals for FT and BT were lower in elderly men due to higher levels of SHBG. Androgens and SHBG were lower in elderly men with chronic disease and inversely associated with CFM.

Polymorphisms of muscle genes are associated with bone mass and incident osteoporotic fractures in Caucasians

The interaction between muscle and bone is complex. The aim of this study was to investigate if variations in the muscle genes myostatin (MSTN), its receptor (ACVR2B), myogenin (MYOG), and myoD1 (MYOD1) were associated with fracture risk, bone mineral density (BMD), bone mineral content (BMC), and lean body mass. We analyzed two independent cohorts: the Danish Osteoporosis Prevention Study (DOPS), comprising 2,016 perimenopausal women treated with hormone therapy or not and followed for 10 years, and the Odense Androgen Study (OAS), a cross-sectional, population-based study on 783 men aged 20-29 years. Nine tag SNPs in the four genes were investigated. In the DOPS, individuals homozygous for the variant allele of the MSTN SNP rs7570532 had an increased risk of any osteoporotic fracture, with an HR of 1.82 (95 % CI 1.15-2.90, p = 0.01), and of nonvertebral osteoporotic fracture, with an HR of 2.02 (95 % CI 1.20-3.41, p = 0.01). The same allele was associated with increased bone loss (BMC) at the total hip of 4.1 versus 0.5 % in individuals either heterozygous or homozygous for the common allele (p = 0.006), a reduced 10-year growth in bone area at the total hip of 0.4 versus 2.2 and 2.3 % in individuals heterozygous or homozygous for the common allele, respectively (p = 0.01), and a nonsignificantly increased 10-year loss of total-hip BMD of 4.4 versus 2.7 and 2.9 % in individuals heterozygous or homozygous for the common allele, respectively (p = 0.08). This study is the first to demonstrate an association between a variant in MSTN and fracture risk and bone loss. Further studies are needed to confirm the findings.

Positive associations between serum levels of IGF-I and subcutaneous fat depots in young men. The Odense Androgen Study

INTRODUCTION

Serum levels of IGF-I are of growing interest due to the associations with morbidity and mortality. Despite markedly suppressed GH secretion, total IGF-I levels are often within normal range in obese adults.

AIM

To study associations between IGF-I and estimated muscle mass in the Odense Androgen Study population and secondly to investigate associations between serum IGF-I and regional fat depots.

METHOD

The Odense Androgen Study is a population-based, cross-sectional study of 776 randomly selected men aged 20-29 years. Regional lean and fat mass were measured by dual-energy X-ray absorptiometry, whereas regional muscle and fat areas were assessed by magnetic resonance imaging.

RESULTS

Age-adjusted IGF-I levels correlated significantly with different estimates of muscle mass (r-values between 0.15 and 0.19; p<0.001). Using multiple linear regression, serum IGF-I correlated positively with subcutaneous adipose tissue on the abdomen (SAT) after controlling for visceral adipose tissue (VAT) in the whole group and in the subgroup of men with normal waist circumference (r-values between 0.13 and 0.15; p<0.03). In addition, IGF-I correlated positively with subcutaneous thigh fat area (TFA) after controlling for intramyocellular lipid (imcl) r=0.18; p<0.004) and IGF-I correlated negatively with TFAimcl in the whole group and in the subgroup of men with normal waist circumference.

CONCLUSION

SAT and subcutaneous TFAs were positively associated with IGF-I in regression analyses. Conversely, imcl of the thigh was inversely associated with IGF-I levels. These findings emphasize the differential associations between IGF-I and regional fat deposits. Future studies may provide further insight regarding the interplay between circulating IGF-I levels and regional muscle and fat mass.

Vitamin D status and PTH in young men: a cross-sectional study on associations with bone mineral density, body composition and glucose metabolism

OBJECTIVE

Although vitamin D and bone metabolism are closely related, few studies have addressed the effects of vitamin D status on bone in men at time of peak bone mass. The objectives of this study were to evaluate the prevalence of vitamin D inadequacy in a cross-sectional study in young men and the effects of vitamin D and parathyroid hormone (PTH) on bone mass, bone markers and metabolic function.

DESIGN AND PARTICIPANTS

The study population consisted of 783 men aged 20-29 years.

MEASUREMENTS

Bone mineral density (BMD) of the total hip, femoral neck and lumbar spine was measured. dual-energy X-ray absorptiometry was used to evaluate total body fat mass (BFAT). Visceral fat mass and abdominal subcutaneous fat mass (ViFM and ScFM) were assessed using magnetic resonance imaging. A radioimmunoassay was used to measure the level of 25-hydroxy vitamin D (25OHD).

RESULTS

The prevalence of vitamin deficiency (serum 25OHD < 50 nm) was 6·3% during summer and 43·6% during winter. Serum 25OHD was associated with BMD at all sites and inversely associated with bone-specific alkaline phosphatase and directly with carboxyterminal telopeptide of type-1-collagen. 25OHD and PTH were inversely associated with BFAT, whereas 25OHD also was inversely associated with body mass index, waist-hip ratio, ViFM and ScFM after adjustment for confounders. The associations were found only to be present in participants with insufficient levels of 25OHD. 25-Hydroxy vitamin D and PTH were inversely related to insulin resistance in vitamin-insufficient participants only. No associations between PTH or 25OHD and blood pressure were noted.

CONCLUSION

The study showed a high prevalence of 25OHD deficiency in young, northern European men, which was significantly associated with decreased BMD. PTH and 25OHD were found to be inversely related to the markers of insulin resistance.

Polymorphisms in the endocannabinoid receptor 1 in relation to fat mass distribution

OBJECTIVE

Both animal and human studies have associated the endocannabinoid system with obesity and markers of metabolic dysfunction. Blockade of the cannabinoid receptor 1 (CB1) caused weight loss and reduction in waist size in both obese and type II diabetics. Recent studies on common variants of the CB1 receptor gene (CNR1) and the link to obesity have been conflicting. The aim of the present study was to evaluate whether selected common variants of the CNR1 are associated with measures of obesity and fat distribution.

DESIGN AND METHODS

The single nucleotide polymorphisms (SNPs) rs806381, rs10485179 and rs1049353 were genotyped, and body fat and fat distribution were assessed by the use of dual-energy X-ray absorptiometry and magnetic resonance imaging in a population-based study comprising of 783 Danish men, aged 20-29 years.

RESULTS

The rs806381 polymorphism was significantly associated with visceral fat mass (FM) only, whereas the rs1049353 was significantly and directly associated with visceral and intermuscular FM. None of the SNPs analysed were associated with total body FM or subcutaneous FM.

CONCLUSION

The results point towards a link between common variants of the CNR1 and fat distribution in young men.

Adiponectin and peak bone mass in men: a cross-sectional, population-based study

Adiponectin, a protein classically known to be secreted by adipocytes, is also secreted by bone-forming cells. Results of previous studies have been contradictory as to whether serum adiponectin and bone mineral density (BMD) are associated. The aim of this study was to investigate a possible association between serum adiponectin and BMD in young, healthy men at a time of peak bone mass. BMD in the femoral neck, total hip, and lumbar spine were measured in this population-based cross-sectional study of 700 men aged 20-29 years participating in the Odense Androgen Study. Magnetic resonance imaging of femoral cortical thickness and bone marrow size was performed in a subsample of 363 participants. The associations between serum adiponectin and various bone measures were investigated by means of regression analyses with adjustment for potential confounding variables. An inverse association was found between serum adiponectin and total hip BMD and a direct between adiponectin and femoral bone marrow size (r = -0.092; P = 0.036 and r = 0.164; P = 0.003, respectively). Femoral muscle size may, at least in part, explain the association between adiponectin and total hip BMD. Serum adiponectin was inversely associated with total hip BMD in men at the time of peak bone mass, but this association may be explained by factors related to muscle size and function. The observed association between adiponectin and femoral bone marrow size was retained even after adjustment for potential covariates.

Subcutaneous rather than visceral adipose tissue is associated with adiponectin levels and insulin resistance in young men

INTRODUCTION

Studies on the association between adiponectin, body composition, and insulin resistance (IR) have been conflicting.

AIM

Our aim was to evaluate the impact of body composition on adiponectin and IR determined by homeostasis model assessment (HOMA) in a population-based study on relatively healthy young men, minimizing the possible effects of age, obesity, and severe comorbidity. DESIGN, METHODS, AND SUBJECTS: A population-based, cross-sectional study of 783 men aged 20-29 yr, randomly drawn from the Danish Central Personal Registry. Adiponectin was assessed using an in-house assay, and IR was determined using HOMA. Central fat mass (CFM) and lower extremity fat mass (LEFM) was measured by dual-energy x-ray absorptiometry, and visceral adipose tissue (VAT), sc adipose tissue (SAT), and thigh fat area (TFA) were assessed by magnetic resonance imaging.

RESULTS

Using multiple linear regression analysis, adiponectin correlated negatively with CFM (r = -0.27; P < 0.001) and SAT (r = -0.20; P < 0.001) and positively with LEFM (r = 0.19; P < 0.001) and TFA (r = 0.18; P < 0.001), whereas VAT did not associate significantly. In multiple linear regression analysis, HOMA-IR (dependent variable), correlated significantly with CFM (r = 0.27; P < 0.001) and SAT (r = 0.15; P < 0.001), whereas LEFM, VAT, or TFA did not correlate. Adiponectin was an independent predictor of HOMA-IR in both analyses (r = -0.14; P < 0.001).

CONCLUSION

SAT rather than VAT was inversely associated with adiponectin levels, and, interestingly, fat on the lower extremities was positively associated with adiponectin. Focusing on insulin resistance, SAT rather than VAT and TFA independently predicted a higher HOMA-IR. The observation that adiponectin was independently associated with lower HOMA-IR must be repeated in other populations.

Correction of respiratory acidosis and transient hypomagnesemia

Four elderly patients with established chronic obstructive airways disease were admitted with a days' to weeks' history of increasing dyspnea. Acute respiratory acidosis was diagnosed and mechanical ventilation instituted. A few hours after initiation of treatment, arterial pH was normal in all patients, but serum magnesium concentrations decreased over the next 1-3 days. Thereafter, a spontaneous normalization was seen. It is suggested that the transient hypomagnesemia is due to correction of the acidosis per se.

Polymorphisms in the low-density lipoprotein receptor-related protein 5 (LRP5) gene are associated with peak bone mass in non-sedentary men: results from the Odense androgen study

PURPOSE

To investigate the impact of the Ala1330Val (rs3736228, exon 18) and Val667Met (rs4988321, exon 9) polymorphisms of the low-density lipoprotein receptor-related protein 5 (LRP5) gene on peak bone mass in young men.

METHODS

The Odense Androgen Study (OAS) is a population-based study comprising 783 Caucasian men aged 20-30 years. Genotyping was performed using real-time polymerase chain reaction (PCR) or fluorescence polarization. Bone mineral density (BMD) measurements were performed using dual-energy X-ray absorptiometry.

RESULTS

The CC, CT, and TT genotypes in Ala1330Val were found in 75.6%, 21.8%, and 2.6% of the participants, respectively. Similarly, the GG, GA, and AA genotypes of Val667Met were found in 89.7%, 9.8%, and 0.5%, respectively. For the Ala1330Val polymorphism, no significant differences between the genotypes were found regarding BMD in the overall study population. However, when analysis was restricted to non-sedentary men (n = 589), a significant association between the number of T-alleles and BMD in the spine and whole body were found. Each copy of the T-allele changed the Z-score of the spine by (median and 95% confidence interval) -0.21 [95% CI: -0.40; -0.03] (p < 0.02). Analysis suggested an association between the AA genotype in the Val667Met polymorphism and increased body height and decreased BMD of the femoral neck; however, no significant gene-dose effect of the A-allele could be demonstrated in the whole population. When the analysis was restricted to non-sedentary subjects, however, each number of A-alleles was associated with a change in Z-score of -0.26 [95% CI: -0.51; -0.01] (p = 0.04). No further significant results emerged with haplotype analysis.

CONCLUSION

The Ala1330Val and Val667Met polymorphisms in the LRP5 gene are significantly associated with peak bone mass in physically active men.

Population-based reference values for bone mineral density in young men

Population-based reference values for peak bone mass density in Danish men. BMD of total hip (1.078 +/- 0,14 g/cm2) differed significantly from values from National Health and Nutrition Examination Survey III and of total lumbar spine ((1.073 +/- 0.125 g/cm2) differed significantly from Hologic values.

INTRODUCTION

Geographic, ethnic, and socio-economic factors are known to affect bone mineral density (BMD) and peak bone mass significantly. Reference values for male peak bone mass are scarce, and the diagnosis of male osteoporosis often relies on values provided by producers of dual-energy X-ray absorptiometry (DXA) equipment.

METHODS

The aim of the present study was 1) to establish population-based reference values for BMD in young men and 2) to study subgroups based on variables with suspected impact on bone metabolism. We included 783 young Caucasian men aged 20 to 30 years in the Odense Androgen Study (OAS).

RESULTS

Peak BMD was attained within the third decade. Obesity (BMI > 30 kg/m2) was associated with higher BMD. Abuse of anabolic steroids as well as chronic illness was associated with lower BMD. Our population-based reference values for BMD of the total hip (1.078 +/- 0.14 g/cm2) differed significantly from published values from National Health and Nutrition Examination Survey III for non-Hispanic white men, while BMD of total lumbar spine (1.073 +/- 0.125 g/cm2) differed significantly from Hologic reference values.

CONCLUSIONS

Locally derived reference values are important to avoid false positive or false negative findings during work-up in patients evaluated for osteoporosis.

Prevalence of overweight, obesity and physical inactivity in 20- to 29-year-old, Danish men. Relation to sociodemography, physical dysfunction and low socioeconomic status: the Odense Androgen Study

OBJECTIVE

To assess the prevalence of overweight, obesity and physical inactivity in 20- to 29-year-old men and to analyze whether sociodemography, physical dysfunction and low socioeconomic status are independent correlates of obesity and physical inactivity.

DESIGN

Population-based, cross-sectional study.

SUBJECTS

Seven hundred and eighty-three Caucasian, Danish men, aged 20-29 years recruited from 2042 respondents in a questionnaire survey of 3000 men, randomly drawn from the Danish Civil Registration System.

METHODS

Questionnaire, interview and physical examination.

RESULTS

The 783 included men and the 2042 questionnaire respondents matched the background population demographically. The 783 men matched the questionnaire respondents as regards BMI, physical activity, chronic disease, medication, smoking, sociodemography and socioeconomic status. The prevalence of overweight and obesity was 31.7 and 7.9%, respectively (World Health Organization criteria). Using waist circumference (WC) cutoffs of 94 and 102 cm, the prevalence was 16.2 and 10.6%, respectively; 24.4% were physically inactive. BMI and WC increased significantly from age 20 to 29 years. Physical activity decreased significantly with age and correlated inversely with WC, but not with BMI. Occupation, geography, partner status, fatherhood and tobacco exposure were independently related with obesity and physical inactivity. Obesity was also related to musculoskeletal complaints, whereas chronic diseases and low educational level were associated with physical inactivity. Age was not independently related with either outcome.

CONCLUSION

In affluent societies, sociodemographic changes may partly explain the age-related decrease in physical activity and the parallel increase in WC and BMI.

Morphometric X-ray absorptiometry: reference data for vertebral dimensions in a population-based sample of young Danish men

PURPOSE

To determine reference values for vertebral heights in healthy young Danish males using morphometric X-ray absorptiometry (MXA).

MATERIAL AND METHODS

A population-based study group of 487 males aged between 20 and 30 years (mean 25 years) from the county of Funen, Denmark, were recruited. Using a Hologic QDR 4500 (dual energy X-ray absorptiometry) DXA-scanner, MXA scans covering the vertebrae from T4 to L4 were acquired for each subject. Anterior (Ha), middle (Hm), and posterior (Hp) heights of the thoracic (T4-T12) and lumbar (L1-L4) vertebral bodies were measured. Moreover, wedge, mid-wedge, crush I, and crush II ratios were calculated.

RESULTS

No correlation between vertebral dimensions and crush indices on the one hand and age or weight on the other were found. Body height, however, correlated significantly with the cumulated vertebral heights. Reference data for vertebral dimensions, wedge, mid-wedge, crush I, and crush II are tabulated.

CONCLUSION

The anterior, middle, and posterior heights of the vertebral bodies of T4 to L4 can be measured reproducible with MXA. In young men, the cumulative vertebral heights correlated with body height but not with age. Moreover, the wedge and crush indices were unrelated of both age and height.

Dose-, IGF-I- and sex-dependent changes in lipid profile and body composition during GH replacement therapy in adult onset GH deficiency

OBJECTIVE

Patients with GH deficiency of adult onset (GHDA) exhibit dyslipidaemia and increased cardiovascular morbidity. GH replacement potently reduces body fat and serum lipids in GHDA. In recent years, lower GH doses have been introduced. The purpose of this analysis was to explore the response relationship between GH doses, lipids and body composition.

DESIGN

Two consecutive, randomized 12-month GH replacement studies covering placebo and three different doses of GH (0.5, 1.0 and 1.7 IU/m(2) per day). Low and intermediate doses were IGF-I titrated.

PATIENTS

Fifty-eight patients with severe GHDA, not previously treated with GH and stably substituted for other endocrine deficiencies, were included in the study.

METHODS

Serum lipoproteins, serum IGF-I and body composition analysis by dual energy X-ray absorptiometry (DXA) were used.

RESULTS

Fifty-seven percent of patients exhibited low density lipoprotein (LDL) cholesterol levels above 4.16 mmol/l, corresponding to the American Heart Association threshold of 160 mg/dl. GH treatment resulted in significant decreases in total and LDL cholesterol, with no significant change in high density lipoprotein cholesterol or triglycerides. The low dose induced no significant changes in lipid levels, whereas the medium dose reduced LDL cholesterol and the high dose decreased both LDL and total cholesterol. The effects depended significantly on the GH dose and the level of IGF-I obtained, but not on gender. GH replacement induced dose-dependent reductions in fat mass and sex-dependent increases in lean mass.

CONCLUSIONS

GH given for 1 year at a dosage between 0.5 and 1.7 IU/m(2) per day reduced fat mass in a dose-dependent manner, increased lean body mass and lowered total and LDL cholesterol in patients with severe GHDA. Low dose GH treatment with normal IGF-I levels induced smaller changes compared with high dose therapy, and may need a longer treatment time.

Meiotic crossing-over in the regions of homology between homologous chromosomes V

Homologous chromosomes V of Saccharomyces cerevisiae and S. carlsbergensis virtually do not recombine in meiosis. Artificially created short regions of homology were found to induce meiotic crossing-over if they contained sequences located upstream of the S. carlsbergensis ILVI gene. Heterozygous restriction site markers were introduced within the 1.1 kb region of homology to monitor conversion events associated with the crossovers. In the presence of five heterozygosities, 85% of crossovers showed associated conversion. Crossovers with no detected conversion were found in the two largest (0.34 and 0.29 kb) intervals, into which the 1.1 kb region was divided by the introduction of the five markers, whereas the shortest conversion tracts observed did not exceed 0.26 kb. Several lines of evidence suggest that each crossover required a formation of heteroduplex DNA with the considerable minimal length of approximately 200-260 bp.

Pneumocystis carinii pneumonia in HIV-infected patients: effect of steroid therapy on surfactant level

Previous studies have suggested alterations in pulmonary surfactant lipid in the setting of Pneumocystis carinii pneumonia in HIV-infected patients. Because pulmonary surfactant lipid is composed of a variety of lipid products and because other phospholipids might be present in bronchoalveolar lavage (BAL) lipid determinations, a single molecular species of phospholipid which comprises a substantial portion of the surfactant lipid fraction, dipalmitoyl phosphatidylcholine (DPPC), was measured by capillary column gas chromatography in BAL samples taken at the time of the diagnosis of P. carinii pneumonia, and 10 days after treatment for P. carinii pneumonia. DPPC was measured at day 0 and day 10 in seven patients who had been randomized to receive methylprednisolone adjuvant therapy for P. carinii pneumonia and in six patients who had been randomized to not receive methylprednisolone therapy. The level of DPPC in BAL from all patients at day 0 was 0.49 +/- 0.06 microgram ml-1 BAL. This level is significantly lower that the level of DPPC determined in BAL from five normal volunteers 2.48 +/- 0.40 micrograms ml-1. At day 0, the BAL level of DPPC in patients treated with methylprednisolone was not different from the BAL level of DPPC in patients not treated with methylprednisolone. By day 10 of therapy for P. carinii pneumonia, BAL levels of DPPC in all patients had increased to 1.05 +/- 0.19 micrograms ml-1 BAL. At day 10 DPPC levels in the methylprednisolone treated group were not different from the group not treated with methylprednisolone. We conclude that in HIV-infected patients, lung surfactant lipid is reduced in the setting of P. carinii pneumonia. The lipid levels return toward normal levels with treatment. Adjuvant therapy with corticosteroids does not alter the rate of recovery of surfactant lipid levels at least after 10 days of therapy.

In vitro metabolism of quinidine: the (3S)-3-hydroxylation of quinidine is a specific marker reaction for cytochrome P-4503A4 activity in human liver microsomes

The aim of this study was to evaluate the (3S)-3-hydroxylation and the N-oxidation of quinidine as biomarkers for cytochrome P-450 (CYP)3A4 activity in human liver microsome preparations. An HPLC method was developed to assay the metabolites (3S)-3-hydroxyquinidine (3-OH-Q) and quinidine N-oxide (Q-N-OX) formed during incubation with microsomes from human liver and from Saccharomyces cerevisiae strains expressing 10 human CYPs. 3-OH-Q formation complied with Michaelis-Menten kinetics (mean values of Vmax and Km: 74.4 nmol/mg/h and 74.2 microM, respectively). Q-N-OX formation followed two-site kinetics with mean values of Vmax, Km and Vmax/Km for the low affinity isozyme of 15.9 nmol/mg/h, 76.1 microM and 0.03 ml/mg/h, respectively. 3-OH-Q and Q-N-OX formations were potently inhibited by ketoconazole, itraconazole, and triacetyloleandomycin. Isozyme specific inhibitors of CYP1A2, -2C9, -2C19, -2D6, and -2E1 did not inhibit 3-OH-Q or Q-N-OX formation, with Ki values comparable with previously reported values. Statistically significant correlations were observed between CYP3A4 content and formations of 3-OH-Q and Q-N-OX in 12 human liver microsome preparations. Studies with yeast-expressed isozymes revealed that only CYP3A4 actively catalyzed the (3S)-3-hydroxylation. CYP3A4 was the most active enzyme in Q-N-OX formation, but CYP2C9 and 2E1 also catalyzed minor proportions of the N-oxidation. In conclusion, our studies demonstrate that only CYP3A4 is actively involved in the formation of 3-OH-Q. Hence, the (3S)-3-hydroxylation of quinidine is a specific probe for CYP3A4 activity in human liver microsome preparations, whereas the N-oxidation of quinidine is a somewhat less specific marker reaction for CYP3A4 activity, because the presence of a low affinity enzyme is demonstrated by different approaches.

[Anesthesiologic aspects in patients with HIV infections]

A review of anaesthesia for patients with HIV-infection is given. The use of new antiretroviral drug combinations to treat HIV-infection may result in longer survival, and therefore more cases of HIV-positive patients who undergo surgery and require anaesthetic services. Clinical manifestations of the HIV infection in humans can be seen in almost every organ. The anaesthetist must have an understanding of the many manifestations of the syndrome. Physical examination and preoperative preparation is essential. Considerations for the anaesthetist include: the effects of medications and possible drug interactions, organ dysfunction, altered metabolism and choice of anaesthetic technique for the HIV-positive patient. Anaesthetists and other health care professionals must know about the manifestations of HIV-infection in order to provide competent and compassionate care.

Fluvoxamine is a potent inhibitor of the metabolism of caffeine in vitro

The selective serotonin re-uptake inhibitor, fluvoxamine, is a very potent inhibitor of CYP1A2, and accordingly causes pharmacokinetic interactions with drugs metabolised by CYP1A2, such as caffeine, theophylline, imipramine, tacrine and clozapine. Interaction between caffeine and fluvoxamine has been described in vivo, leading to lowering of total clearance of caffeine by 80% during fluvoxamine intake. The main purpose of the present study was to evaluate this interaction in vitro in human liver microsomes. A high-performance liquid chromatography method was developed in order to assay 1,3-dimethylxanthine, 1,7-dimethylxanthine, 3,7-dimethylxanthine and 1,3,7-trimethyluric acid formed from caffeine by human liver microsomes. The limit of detection was 0.06 nmol.mg protein-1.hr-1. As expected, fluvoxamine was a very potent inhibitor of the formation of the N-demethylated caffeine metabolites, displaying Ki values of 0.08-0.28 microM. The formation of 1,7-dimethylxanthine was virtually abolished by 10 microM of fluvoxamine, indicating that the N3-demethylation of caffeine is almost exclusively catalysed by CYP1A2. The CYP3A4 inhibitors, ketoconazole and bromocriptine, inhibited 1,3,7-trimethyluric acid formation with Kis of 0.75 microM and 5 microM, respectively, thus further supporting the involvement of CYP3A4 in the 8-hydroxylation of caffeine. The study shows that fluvoxamine, as expected, is a potent inhibitor of the metabolism of caffeine in vitro.

Fluvoxamine inhibits the CYP2C19-catalysed metabolism of proguanil in vitro

OBJECTIVE

The potent CYP1A2 inhibitor fluvoxamine has recently been shown also to be an effective inhibitor of the CYP2C19-mediated metabolism of the antimalarial drug proguanil in vivo. The purpose of the present study was to confirm this interaction in vitro.

METHODS

A high-performance liquid chromatography (HPLC) method was developed to assay 4-chlorophenylbiguanide (4-CPBG) and cycloguanil formed from proguanil by microsomes prepared from human liver. The limit of detection was 0.08 nmol mg-'. h-I.

RESULTS

The formation of 4-CPBG and cycloguanil could be described by one-enzyme kinetics, indicating that the formation of the two metabolites is almost exclusively catalysed by a single enzyme, i.e. CYP2C19 within the concentration range used, or that the contribution of an alternative low-affinity enzyme, probably CYP3A4, is very low. This notion was confirmed by the lack of potent inhibition by four CYP3A4 inhibitors: ketoconazole, bromocriptine, midazolam and dihydroergotamine. Fluvoxamine was a very effective inhibitor of the oxidation of proguanil, displaying Ki values of 0.69 micromol x l(-1) for the inhibition of cycloguanil formation and 4.7 micromol x l(-1) for the inhibition of 4-CPBG formation. As expected, the CYP2C19 substrate omeprazole inhibited the formation of both metabolites with an IC50 of 10 micromol x l(-1). Norfluoxetine and sulfaphenazole inhibited proguanil oxidation with Ki values of 7.3-16 micromol x l(-1), suggesting that the two compounds are moderate inhibitors of CYP2C19.

CONCLUSIONS

Fluvoxamine is a fairly potent inhibitor of CYP2C19 and it has the potential for causing drug-drug interactions with substrates for CYP2C19 such as imipramine, clomipramine, amitriptyline and diazepam. The combination of fluvoxamine and proguanil can not be recommended.

[Hepatitis B vaccination status among Danish physicians]

As part of a nation-wide questionnaire survey among Danish doctors, the incidence of hepatitis B vaccination was studied. For each specialty the findings were related to the risk of hepatitis B exposure assessed by the incidence of percutaneous and mucocutaneous blood exposure (PCE and MCE). A total of 6256 of 9375 doctors (67%) responded and 6005 (64%) questionnaires were eligible for analysis. Only 34.3% of the doctors had been vaccinated against hepatitis B, ranging from 8.9% in Psychiatry to 56.9% in Obstetrics-Gynaecology. The annual incidence of PCE and MCE was high in surgical as well as non-surgical specialties with an average of 3.0 PCE and 3.9 MCE per person. In conclusion all doctors must be considered at risk of exposure to hepatitis B during part of or the entire career. The current level of hepatitis B vaccination is insufficient. Hepatitis B vaccination of all doctors before entering clinical work seems to be indicated.

[Percutaneous blood exposure among Danish physicians. Mechanisms and prevention]

The study describes the mechanisms of percutaneous blood exposure (PCE) among Danish doctors and discusses rational strategies for prevention. Data were obtained as part of a nation-wide survey of occupational blood exposure. The most recent percutaneous or mucocutaneous exposure within the previous three months was described. Of 9375 doctors, 6005 (64%) participated. A total of 971 PCE were described. Inattentiveness contributed to 30.5%. Use of fingers rather than instruments was a contributing cause of 36.9% of 483 PCE on suture needles. Common concomitant causes in such cases (n = 199) were poor space in (30.2%) or view of (18.6%) the operation field. Of 689 PCE in surgical specialties, 17.4% were inflicted by colleagues. Up to 53.3% of PCE on hollow-bore needles could be attributed to unsafe routines only. In conclusion, education in safer working routines are needed in all specialties. Introduction of safer devices should have a high priority in surgical specialties, and should be considered in non-surgical specialties too.

[Poor compliance with universal precautions among Danish physicians]

In a nation-wide survey among Danish doctors, the compliance and reasons for non-compliance with universal precautions (UP) and the associated circumstances of mucocutaneous blood exposure (MCE) were studied. Of 9384 questionnaires, 6256 (67%) were returned and 6005 were eligible for analysis. Only 35% complied with the basic principles of UP. Compliance with protective barrier use in surgical versus non-surgical specialties was: Gloves 63.0% and 23.4%, masks 55.2% and 17.6% and protective eyewear 11.5% and 4.0% respectively. Common given reasons for non-compliance were: "Interferes with working skills", "forget", "wear spectacles", "not available", "too much trouble to get" or "gloves do not fit". Of 741 MCE described in detail, an estimated 84-98% were potentially preventable if appropriate barriers had been worn. More than half of MCE were preventable by two interventions only: Compulsory use of protective eyewear during operations and of gloves during insertion of peripheral i.v.-catheters. In conclusion compliance with UP is unacceptably low and the majority of MCE were potentially preventable if appropriate barriers had been worn.

[Underreporting and follow up of exposure to blood among Danish physicians]

In a nation-wide questionnaire survey concerning percutaneous (PCE) and mucocutaneous (MCE) blood exposure among Danish doctors, the frequency of and reasons for underreporting and compliance with initial follow-up were studied. Of 9384 doctors, 6256 (67%) responded and 6005 questionnaires were included. Only 3.5% of 3755 PCE and 0.4% of 4847 MCE had been reported. Major reasons for underreporting were "considered unnecessary" (37.1%) or "too time-consuming" (19.3%). Of 1712 PCE and MCE that were described in detail, the doctors were tested for anti-Hbs in 4.8%, anti-HIV in 5.0%, and received hepatitis B vaccination in 3.7%. Major reasons to refrain from anti-HIV test was "felt that there was no risk of HIV-transmission" (49.1%), "the risk so low that testing was unnecessary" (48.8%) or "too time-consuming" (18.9%). In conclusion, only a few percent of the exposures are reported, and the reports do not give a valid impression of the problem. The importance of initial serological follow-up and vaccination should be emphasized.

[Occupational blood exposure among Danish physicians--incidence and risk factors]

In a nation-wide questionnaire survey, the incidence and risk factors of percutaneous (PCE) and mucocutaneous (MCE) blood exposure among doctors in Denmark were studied. Of 9375 doctors, 6256 (67%) responded and 6005 were included for analysis. The highest incidence per person-risk-year (pry) was found in General Surgery, Neurosurgery, Obstetrics-Gynaecology and Orthopaedic Surgery (6.2-8.5 PCE/pry and 7.3-8.8 MCE/pry) followed by Anaesthesiology and Oto-rhinolaryngology (2.6-3.1 PCE/pry and 6.0-6.9 MCE/pry) and Pathology, Internal medicine, Radiology and Paediatrics (0.8-1.3 PCE/pry and 1.3-2.9 MCE/pry). Employment as senior as compared to junior doctor was associated with a higher risk of PCE and MCE among surgeons and a higher risk of PCE in anaesthetists, but a lower risk of PCE and MCE in Internal Medicine, Radiology and Paediatrics. Only 35% adhered to the basic principles of universal precautions and non-compliance was associated with a considerably increased risk of exposures, especially in non-surgical specialties. In conclusion, we found an unacceptably high incidence of occupational blood exposures among Danish doctors and preventive measures to reduce the incidence are strongly needed.

Noncompliance with universal precautions and the associated risk of mucocutaneous blood exposure among Danish physicians

OBJECTIVE

To study the compliance, and reasons for noncompliance, with Universal Precautions and the associated circumstances of mucocutaneous blood exposure (MCE) among Danish physicians.

DESIGN

A nationwide questionnaire survey.

SETTING

All Danish hospitals.

PARTICIPANTS

All hospital-employed physicians.

RESULTS

Of 9,384 questionnaires, 6,256 (67%) were returned, and 6,005 were eligible for analysis. Only 35% of respondents were compliant with the basic principle of Universal Precautions. Compliance with specific barriers in the preceding week among "surgeons and pathologists" and "other physicians" was as follows: gloves, 63.0% and 23.4%; masks, 55.2% and 17.6%; and protective eyewear, 11.5% and 4.0%, respectively. Common arguments for non-compliance were "interferes with working skills," "forget," "wear spectacles," "not available," "too much trouble to get," or "gloves do not fit." Detailed descriptions of 741 MCEs were obtained. Blood splashes in the eyes (n = 320) was the most common MCE in surgical specialties and pathology, whereas blood on the hands (n = 290) was most common in other specialties. In 20% of MCEs of the eyes, the exposure occurred despite the use of spectacles. An estimated 84% to 98% of MCEs potentially would have been preventable had appropriate barriers been worn. More than one half of MCEs were preventable by two interventions only: compulsory use of protective eyewear during operations and use of gloves during insertion of peripheral intravenous catheters.

CONCLUSION

Compliance with Universal Precautions is unacceptably low, as reflected by the circumstances of MCE. Increased efforts to ensure education in Universal Precautions, easy accessibility of protective barriers, and improved design of the barriers are necessary to improve compliance and reduce the risk of MCE.

Percutaneous blood exposure among Danish doctors: exposure mechanisms and strategies for prevention

The objective of this study was to describe the mechanisms of percutaneous blood exposure (PCE) among doctors and discuss rational strategies for prevention. Data were obtained as part of a nation-wide questionnaire survey of occupational blood exposure among hospital employed doctors in Denmark. The doctors were asked to describe their most recent PCE, if any, within the previous 3 months. Detailed information on the instruments, procedures, circumstances and mechanisms that caused the PCE was obtained. Of 9375 doctors, 6256 (67%) responded, and 6005 questionnaires were eligible for analysis. Of 971 described PCE the majority were caused by suture needles (n = 483), i.v.-catheter-stylets (n = 94), injection needles (n = 75), phlebotomy needles (n = 53), scalpels (n = 45), arterial blood sample needles (n = 41) and bone fragments (n = 23). Inattentiveness was the most common cause, contributing to 30.5% of all PCE. Use of fingers rather than instruments was a major cause of injury in surgical specialities and was a contributing cause of 36.9% PCE on suture needles. Common contributing causes when fingers were used (n = 199) were poor space in (30.2%) or view of (18.6%) the operation field. It was often argued that instruments were not practical to use or might harm the tissue. Of 689 PCE in surgical specialties, 17.4% were inflicted by colleagues. Up to 53.3% of PCE on hollow-bore needles could be attributed to unsafe routines like recapping only, but other mechanisms like sudden patient movements and 'acute situation' were common, especially in the case of PCE on i.v.-catheter-stylets. It is concluded that the exposure mechanisms of PCE reflect both unsafe routines, difficult working conditions and unsafe devices. Education in safer working routines are needed in all specialties. Introduction of safer devices should have a high priority in surgical specialties, and should be considered in non-surgical specialties too.

Examination of virus shedding in semen from vaccinated and from previously infected boars after experimental challenge with porcine reproductive and respiratory syndrome virus

Danish artificial insemination (AI) centres house several boars antibody positive to porcine reproductive and respiratory syndrome virus as well as PRRSV-naive boars which may become acutely infected. The risk of transmission of PRRSV by semen may therefore constitute a serious problem to the Danish pig industry. The use of a vaccination-program may be a way to avoid or reduce the problem. This study evaluates the use of two vaccines: One live, attenuated vaccine and one inactivated vaccine. A pronounced reduction in viremia and shedding of virus in semen was demonstrated by use of the live vaccine compared to the non-vaccinated control animals. In contrast, no changes in onset, level and duration of viremia and shedding of virus in semen were observed using the inactivated vaccine. Neither viremia nor seminal shedding of virus was detected in previously PRRSV-infected, PRRSV-antibody positive boars after challenge with a Danish field strain of PRRSV.

Incidence and risk factors of occupational blood exposure: a nation-wide survey among Danish doctors

Occupational blood exposures involves a risk of transmission of serious infections. We performed a nation-wide survey, to describe the incidence and risk factors of percutaneous (PCE) and mucocutaneous (MCE) blood exposures among hospital employed doctors in Denmark. Of 9,374 questionnaires, 6,256 (67%) were returned and 6,005 were eligible for analysis. The highest risk per person-risk-year (pry) was found in General surgery, Neurosurgery, Obstetrics-Gynaecology and Orthopaedic surgery (6.2-8.5 PCE/pry and 7.3-8.8 MCE/pry). The second risk group Anaesthesiology and Oto-rhino-laryngology (2.6-3.1 PCE/pry and 6.0-6.9 MCE/pry). Finally Pathology, Internal medicine, Radiology and Paediatrics had a considerable risk (0.8-1.3 PCE/pry and 1.3-2.9 MCE/pry). Potential risk factors were examined by Poisson regression. Employment as senior as compared to junior doctor was associated with a higher risk of PCE (RR 2.2) and MCE (RR up to 2.7 depending on experience) among surgeons and an increased risk of PCE in anaesthetists (RR 1.7). In contrast, senior physicians in Internal medicine, Radiology and Paediatrics had a several fold lower risk of PCE (RR 0.6) and MCE (RR 0.6 in males, 0.3 in females). Only 35% adhered to the basic principles of universal precautions (UP) and non-compliance was associated with a considerably increased risk of both MCE and PCE, especially in non-surgical specialties. In conclusion, we found an unacceptably high incidence of occupational blood exposures among Danish doctors. Non-compliance with UP was associated with an increased risk of exposure and efforts to improve compliance with UP as well as implementation and evaluation of other preventive measures are needed.

[Prognostic value of interleukin-8 in AIDS-related Pneumocystis carinii pneumonia]

We evaluated the significance of interleukin-8 (IL-8) in Pneumocystis carinii pneumonia (PCP). Bronchoalveolar lavage (BAL) fluid and serum was prospectively collected in 76 consecutive HIV-infected patients with a primary episode of PCP, as well as in ten healthy control subjects. Patients were found to have elevated levels of IL-8 in BAL fluid compared to control subjects (p < 0.01). Nine patients died during the course of PCP. Non-survivors had significantly higher IL-8 levels in BAL fluid than survivors (p < 0.05). Furthermore patients with levels of IL-8 in BAL greater then 90 pg/ml (i.e. greater than control subjects) had significantly worse vital prognosis (log rank test, p < 0.05). Thirteen patients required mechanical ventilation (MV), and these patients had significantly elevated levels of IL-8 compared with patients not requiring MV (p < 0.05).

IN CONCLUSION

i) IL-8 in BAL fluid correlates to the clinical severity of the pneumonia, and ii) is a predictor of mortality and severe respiratory compromise.

Does cytomegalovirus predict a poor prognosis in Pneumocystis carinii pneumonia treated with corticosteroids? A note for caution

OBJECTIVE

To examine the importance of cytomegalovirus (CMV) in bronchoalveolar lavage (BAL) fluid of patients with HIV-associated Pneumocystis carinii pneumonia (PCP) treated with adjunctive corticosteroids (CS).

DESIGN

Analysis of clinical data during a 5-year period.

SETTING

Department of infectious diseases where clinical and paraclinical data on patients suspected of having PCP have been sampled prospectively.

PATIENTS

148 consecutive patients with a first episode of PCP in a 5-year period.

MAIN OUTCOME MEASURE

Vital status 3 months after diagnosis of PCP.

RESULTS

Patients with PCP treated with adjunctive CS who had CMV cultured from BAL fluid had a two times higher mortality within 3 months from bronchoscopy than others (p = 0.08). This difference could not be explained by differences in CD4 count, PO2 or PCO2 at time of bronchoscopy.

CONCLUSION

With the accepted usage of adjunctive CS in severe PCP, the role of CMV as a pulmonary copathogen may have changed. Active CMV infection may be an important cause of failing treatment of severe PCP in those treated with adjunctive CS.

Efficacy and toxicity of two doses of trimethoprim-sulfamethoxazole as primary prophylaxis against Pneumocystis carinii pneumonia in patients with human immunodeficiency virus. Dutch AIDS Treatment Group

The efficacy and toxicity of trimethoprim-sulfamethoxazole (TMP-SMZ) as primary prophylaxis against Pneumocystis carinii pneumonia (PCP) for patients with human immunodeficiency virus (HIV) infection was assessed by comparing the effects of two dosages (480 or 960 mg once a day) of the drug. The multicenter trial involved 260 HIV-infected patients with CD4 cell counts < 0.2 x 10(9)/L and no history of PCP. Patients were randomly assigned to the treatment groups. After a median follow-up of 376 days (range, 1-1219), none of the patients developed PCP. Most adverse reactions that required discontinuation were seen within the first month of TMP-SMZ use and were seen more frequently and earlier in the 960-mg group (hazard ratio, 1.4; 95% confidence interval, 0.95-2.02; P = .007). For patients with HIV infection, 480 mg of TMP-SMZ is as efficacious as but less toxic than 960 mg of the drug for primary prophylaxis against PCP.

Prognostic value of interleukin-8 in AIDS-associated Pneumocystis carinii pneumonia

Interleukin-8 (IL-8) is a potent neutrophil chemoattractant and activator. Pneumocystis carinii pneumonia is associated with an accumulation of neutrophils in bronchoalveolar lavage (BAL) fluid. Thus, we hypothesized that IL-8 is involved in the pathogenesis of P. carinii pneumonia. BAL fluid and serum were prospectively collected in 76 consecutive HIV-infected patients with a primary episode of P. carinii pneumonia, as well as in 10 healthy control subjects. Patients were found to have elevated levels of IL-8 in BAL fluid compared with control subjects (p < 0.01). Nine patients died during the course of P. carinii pneumonia. Comparing survivors with nonsurvivors, the median IL-8 level in BAL fluid was 127 (0 to 3,900) versus 584 (127 to 6,100) pg/ml (p < 0.05). Furthermore, patients with levels of IL-8 in BAL fluid greater than 90 pg/ml (i.e., greater than control subjects) had significantly worse vital prognosis (log rank test, p < 0.05). Thirteen percent required mechanical ventilation (MV). Patients requiring MV had a median IL-8 level of 396 (25 to 6,100) versus 129 (0 to 3,900) pg/ml for patients not requiring MV (p < 0.05).

IN CONCLUSION

i) IL-8 in BAL fluid correlates to the clinical severity of the pneumonia, and ii) is a predictor of mortality and severe respiratory compromise.

Interleukin-8 and eicosanoid production in the lung during moderate to severe Pneumocystis carinii pneumonia in AIDS: a role of interleukin-8 in the pathogenesis of P. carinii pneumonia

Pneumocystis carinii pneumonia (PCP) may cause severe respiratory distress. This is believed to be partly caused by the accumulation of neutrophils in the lung. Interleukin-8 (IL-8) and leukotriene B4 (LTB4) are potent neutrophil chemo-attractants and activators. Eicosanoids [i.e. prostaglandins (PG) and leukotrienes (LT)] are pro-inflammatory mediators released from arachidonic acid by action of phospholipase A2 (PLA2) and have been implicated in the host response to micro-organisms. Bronchoalveolar lavage (BAL) was performed on patients with PCP as part of a randomized study of adjuvant corticosteroids vs. placebo, in addition to standard antimicrobial therapy. Re-bronchoscopy was offered at day 10. BAL fluid was available for 26 patients who had follow-up bronchoscopy performed. At diagnosis, IL-8 levels were elevated in patients with PCP, compared to healthy controls, and correlated with relative BAL neutrophilia and P(A-a)O2. LTB4 was also elevated in PCP, but failed to correlate with either BAL neutrophilia or P(A-a)O2. PLA2 activity in patients correlated with IL-8 levels and BAL neutrophilia, but not with P(A-a)O2. A trend towards a decrease in IL-8 levels in BAL fluid was detected in the corticosteroid-treated patients from days 0-10, whereas no change was detected in the placebo group. No change in levels of LTB4, LTC4, PGE2, PGF2a and PLA2 were detected cover time in either treatment group. This study establishes a correlation between IL-8, BAL neutrophilia and P(A-a)O2, and suggests a role of IL-8 as a mediator in the pathogenesis of PCP, whereas the role of eicosanoids seems less clear.

[AIDS in Denmark. 1. Opportunistic infections and malignant diseases. Danish Study Group for HIV infection]

To examine the distribution of AIDS-defining illnesses among Danish AIDS patients, data on 687 AIDS patients diagnosed in the period from 1980 to 1990 (93% of all reported cases in the period) were collected. The most frequent AIDS-defining illness was Pneumocystis carinii pneumonia followed by candida oesophagitis and Kaposis sarcoma. The proportion of homo/bisexual men presenting with Kaposis sarcoma as the initial AIDS-defining illness declined over time. Patients with extrapulmonary tuberculosis had higher CD4 cell counts than patients presenting with other illnesses. Cytomegalovirus chorioretinitis and atypical mycobacteriosis were seen more frequently after the time of the AIDS diagnosis, and a low CD4 cell count at time of the AIDS diagnosis was a significant predictor for the development of these opportunistic infections during follow-up. Danish AIDS patients present with a wide spectrum of HIV-related illnesses, reflecting their exposure to opportunistic microorganisms and the degree of immune deficiency. The pattern of HIV-related illnesses is changing over time, and therefore continuous surveillance is needed to optimize therapeutic and prophylactic regimens.

[AIDS in Denmark. 2. Survival after the diagnosis of AIDS. Danish Study Group for HIV infection]

The survival pattern was studied for 687 Danish AIDS patients (93% of notified cases in the study period) who were diagnosed with AIDS during the period from 1980 to 1990. The median survival was 17 months. Factors significantly associated with a shortened survival were transfusion-acquired HIV infection, age > 40 years, year of diagnosis before 1987, and the presence of either disseminated infection with Mycobacterium avium-complex, Cytomegalovirus chorioretinitis or malignant lymphoma at time of the AIDS diagnosis. There was also a significant association between survival and CD4 cell count at time of AIDS diagnosis. Patients who had CD4 cell counts above 200 x 10(6)/l had twice as long a survival as patients who had CD4 cell counts less than 50 x 10(6)/l. The prognosis of Danish AIDS patients remains poor. The most important determinant of survival time appears to be the degree of immune deficiency at time of diagnosis.

The seroprevalence of hepatitis B and C in hospitalized Danish patients

Health care workers are at risk of acquiring blood-borne infections. To assess the risk of exposure to hepatitis B or C in the case of occupational blood exposure, we determined the seroprevalence of these infections in 466 patients admitted to a Copenhagen university hospital. Serological markers for hepatitis B or C were detected in 56 patients (12.0%). The seroprevalence of HBsAg and anti-HCV was 0.9% and 1.5% respectively. HCV RNA, indicating ongoing hepatitis C, was found in five of seven anti-HCV-positive patients by polymerase chain reaction. The serological findings had not previously been diagnosed in 4 of 10 potentially infectious patients and only 6 of 10 patients belonged to high-risk groups. In conclusion, health care workers should be aware of the potential the occupational risk of hepatitis B and C even in a low-prevalence country like Denmark. Management of health care workers after blood exposure should include serological testing for both hepatitis B and C. Strict adherence to universal precautions is recommended and vaccination against hepatitis B should be encouraged.

Randomized study of sulfamethoxazole-trimethoprim versus aerosolized pentamidine for secondary prophylaxis of Pneumocystis carinii pneumonia in patients with AIDS

In a prospective, randomized open-label trial, the efficacy of sulfamethoxazole-trimethoprim (SMX-TMP) 400/80 mg b.i.d. was compared with the efficacy of aerosolized pentamidine (AP) 60 mg every 2nd week as secondary prophylaxis (SP) against recurrence of Pneumocystis carinii pneumonia (PCP) in AIDS patients. 94 patients participated in the study, 47 in each group. The patients were observed for a mean period of 17.2 months. PCP recurred in the AP group in 8 cases, while 1 relapse occurred in the SMX-TMP group. The one-year cumulative relapse rate was 9.0% (95% CI 0-19%) in the AP group compared with 2.4% (95% CI 0-8%) in the SMX-TMP group (p < 0.05). The odds ratio was 4.2 (95% CI 0.5-39.8) in favour of SMX-TMP. Furthermore, we found a tendency towards a protective effect against toxoplasmosis in the SMX-TMP group, though there was no difference in survival between the two groups. There was no statistical difference in frequency of crossover from one therapy form to the other. Based on these data we recommend SMX-TMP for secondary PCP prophylaxis.

[Pneumocystis carinii pneumonia in HIV-infected patients examined by bronchoscopy during the period 1989-1991]

We analyzed prospectively collected data from 211 HIV-infected patients who underwent bronchoscopy because of pulmonary symptoms during the period 1989-1991. We found an improvement in survival for patients diagnosed with Pneumocystis carinii pneumonia (PCP) in 1991 as compared to 1989 and 1990 (log rank test: p = 0.07). A significant decline in PO2 and CD4 cell count was observed in patients with PCP in the same period (p < 0.05 and 0.005 respectively). We suggest that the decline in CD4 cell count and in PO2 may reflect a change in Pneumocystis carinii transmission, and that the improved survival may be a result of altered treatment strategy of PCP.

Differential effect on serum neopterin and serum beta 2-microglobulin is induced by treatment in Pneumocystis carinii pneumonia

Forty-three human immunodeficiency virus-infected patients with Pneumocystis carinii pneumonia (PCP) were enrolled in a study of adjunctive corticosteroid treatment for 10 days versus placebo, in addition to antimicrobial treatment. Levels of neopterin and beta 2-microglobulin (beta 2M) were determined in consecutive serum samples. Initiation of antimicrobial treatment resulted in significantly increased neopterin levels, whereas beta 2M levels slightly decreased from pretreatment levels. In patients treated with corticosteroid, both neopterin and beta 2M decreased, by approximately 50% and approximately 30%, respectively, and returned to baseline after discontinuation of corticosteroid treatment. Antimicrobial treatment alone did not affect either neopterin or beta 2M in healthy controls. Results indicate that treatment has a differential effect on the immune response: increased macrophage activation leading to neopterin production and decreased production of beta 2M by lymphocytes. Further, addition of corticosteroids modified and decreased this immune activation and may explain the earlier demonstrated beneficial effect of corticosteroids in PCP treatment.

Admission to Danish hospitals after suspected ingestion of corrosives. A nationwide survey (1984-1988) comprising children aged 0-14 years

A search was made in The National Board Hospital Register of all admissions to Danish hospitals caused by ingestion of corrosives or suspected ingestion of corrosives during 1984-1988 among children aged 0-14 years. Discharge information on each child was collected. The study comprised 224 children. Six children developed a stricture of the esophagus, and in 11 children, the epiglottis was affected. In nearly all cases, these serious complications were due to ingestion of lye or dishwash detergent. Among children without symptoms or signs at the initial examination, none developed a stricture of the esophagus or epiglottic oedema. We conclude that during a period of five years, serious etching after ingestion of corrosives was seen only after ingestion of lye (four cases), dishwash detergent (one case) and an unidentified caustic agent (one case). In all serious cases, symptoms or signs of etching of the skin, mouth or pharynx were observed at first examination.

[AIDS and heart disease]

This article reviews cardiac manifestations of AIDS in terms of etiology, pathogenesis, pathoanatomic lesions and heart function. Hypothetically the prevalence of myocarditis and disperse fibrosis of the myocardium are correlated to increasing rates of dilated cardiomyopathy and cardiac insufficiency. Echocardiography has proved to be of value in detecting early abnormalities and should be recommended on broad indications, though aggressive therapy of cardiac abnormalities is of importance to ensure quality of life and surveillance for the patients.

Serum type III procollagen peptide in patients with Pneumocystis carinii infection. The Copenhagen-Amsterdam PCP-Prednisolone Study Group

Inflammation may play a central role in the pathogenesis of HIV-related Pneumocystis carinii pneumonia (PCP). Serum levels of the amino-terminal propeptide of Type III procollagen (PIIINP) reflect inflammatory activity in granulation tissue and in chronic rheumatic and liver disorders. To investigate changes in PIIINP serum levels during an episode of HIV-related PCP, consecutive serum samples were taken from 48 HIV-infected patients with PCP in a randomized, placebo-controlled study of the effect of adjunctive methylprednisolone therapy (26 in corticosteroid [CS] group and 22 in control group). All patients were treated with co-trimoxazole. In the control group, PIIINP serum levels at day of initiation of therapy (Day 0) were significantly higher in patients requiring mechanical ventilation and/or dying during the course of the pneumonia, and serum levels of PIIINP higher than 5 ng/ml were associated with a higher mortality than levels below 5 ng/ml. The level of PIIINP increased from Day 0 to Day 5. There was a significant correlation between changes in PIIINP levels and changes in the alveolar-arterial oxygen gradient from Day 0 to Day 5. In the CS group, the PIIINP levels decreased while steroid was administered. At Days 21 to 28 there were no difference in the levels of PIIINP between the two groups. PIIINP serum levels may predict the clinical outcome of PCP. The antimicrobial therapy may exacerbate the inflammatory reaction in HIV-related PCP, leading to respiratory failure. CS prevents this increased inflammatory activity.

[Occupational blood exposure among personnel employed in a department of infectious diseases. 1. Frequency and reporting]

We investigated the frequency and reporting rate of occupational blood exposure among formerly and presently employed medical staff in a Department of Infectious Diseases (DID) from 1987-1991, the department has a high prevalence of HIV-positive patients. Subjects were asked to complete an anonymous questionnaire describing occupational percutaneous (PCE) and mucocutaneous (MCE) blood exposure experienced during their employment at the DID. One hundred and thirty-five out of 168 (80%) subjects responded. Forty-five subjects described 37 PCE and 15 MCE. Forty-four (85%) of the exposures involved HIV-positive blood and six (11.5%) involved blood from a patient with hepatitis B. Incidence rates of PCE and MCE per year (PY) were: A) Interns and residents: 0.51 PCE/PY and 0.17 MCE/PY. B): Senior residents and senior physicians 0.13 PCE/PY and 0.21 MCE/PY. C) Registered nurses 0.11 PCE/PY and 0.03 MCE/PY. D) Nursing assistants 0.09 PCE/PY and 0.11 MCE/PY. Sixty-five percent of PCE and 13% of MCE were reported to the security representative. The major reason for not reporting was that the subject found it unnecessary. We conclude that medical personnel, especially interns and residents, employed at clinics of infectious diseases have a real and serious risk of being exposed to infectious blood. The importance of reporting needs to be stressed.

[Occupational exposure to blood among personnel employed in a department of infectious diseases. 2. Accidental mechanisms and protective devices]

We investigated exposure mechanisms of mucocutaneous (MCE) and percutaneous (PCE) blood exposures and compliance with universal precautions among all formerly and presently employed medical staff from 1987 to 1991 in a Danish Department of Infectious Diseases. All subjects were asked to complete an anonymous questionnaire. One hundred and thirty-five out of 168 (80%) subjects responded. Thirty-seven PCE and 15 MCE were described. More than 50% of PCE happened during procedures without specific reasons or were caused by unexpected patient movement, while only one PCE was caused by recapping. Thirty-five percent of PCE happened during drawing of venous blood samples. Compliance with usage of gloves was high (70-100%), depending on the procedure, and 72% of the subjects claimed to have sufficient knowledge of the risk of blood exposures and how to prevent it. Still, 11 (73%) out of 15 MCE might have been prevented by appropriate use of protective barriers. To reduce the frequency of blood exposure further the development of safer instruments and continuous education in safer techniques and usage of protective barriers are of major importance.