Influenza A infection enhances antigen-induced airway inflammation and hyperresponsiveness in young but not aged mice.

BACKGROUND: Although morbidity and mortality rates from asthma are highest in patients > 65 years of age, the effect of older age on airway inflammation in asthma is not well established. OBJECTIVE: To investigate age-related differences in the promotion of allergic inflammation after influenza A viral respiratory infection on antigen-specific IgE production, antigen-induced airway inflammation and airway hyperresponsiveness in mice. METHODS: To accomplish this objective, the following model system was used. Young (6 week) and aged (18 months) BALB/c mice were first infected with a non-lethal dose of influenza virus A (H/HKx31). Mice were then ovalbumin (OVA)-sensitized during the acute infection (3-days post inoculation) and then chronically underwent challenge to the airways with OVA. Forty-eight hours after the final OVA challenge, airway hyperresponsiveness (AHR), bronchoalveolar fluid (BALF) cellular and cytokine profile, antigen-specific IgE and IgG1, and lung tissue inflammation were measured. RESULTS: Age-specific differences were noted on the effect of a viral infection, allergic sensitization, airway inflammation and airway hyperresponsiveness. Serum OVA-specific IgE was significantly increased in only the aged mice infected with influenza virus. Despite greater morbidity (e.g. weight loss and sickness scores) during the acute infection in the 18-month old mice that were OVA-sensitized, there was little effect on the AHR and BALF cellular differential. In contrast, BALF neutrophils and AHR increased, but eosinophils decreased in 6-week mice that were OVA-sensitized during an acute influenza infection. CONCLUSION: With increased age in a mouse model, viral infection prior to antigen sensitization affects the airway and systemic allergic response differently. These differences may reflect distinct phenotypic features of allergic inflammation in older patients with asthma.

Management of the patient with diabetic peripheral neuropathy presenting for peripheral regional anesthesia: a European survey and review of literature.

BACKGROUND: Diabetic peripheral neuropathy (DPN) is a frequent complication of longstanding diabetes mellitus. There is no evidence-based consensus whether neuropathic patients undergoing peripheral regional anesthesia are at increased risk of neurologic damage. It is unknown whether these controversial results have been incorporated into clinical practice. We conducted a survey to test the hypothesis that the majority of respondents would consider DPN a potential risk factor for nerve damage in regional anesthesia, and would adapt their technique when performing regional anesthesia. In parallel, we sought to summarize the current knowledge-base regarding regional anesthesia and DPN. METHODS: We therefore performed 1) a literature search to review current literature and 2) an online computer-based survey among members of the European Society of Regional Anesthesia and Pain Therapy (ESRA). RESULTS: The overall response rate was 19% (584 responders/3107 invitations). About a quarter of participants would avoid regional anesthesia in patients with diabetic neuropathy, and 59% of respondents would counsel patients with diabetic neuropathy about increased risk of regional anesthesia. When techniques were modified, most participants would decrease or omit epinephrine, while fewer respondents would decrease dose of local anesthetic or perform other adjustments. More than 80% agreed with the statement that nerve blocks could be performed safely in diabetic neuropathic patients. CONCLUSION: In conclusion, we report the results of the first survey analyzing attitudes and standards of care among European anesthesiologists with regards to regional anesthesia in DPN. While literature is divided on the question whether pre-existing diabetic neuropathy is a risk factor for new neurological deficit after regional anesthesia, most of the responders of this survey take measures to reduce risks, counsel patients on a possible greater risk of neurologic complications, but only a minority of responders would avoid peripheral regional anesthesia altogether.

Effects of intraarticular IL1-Ra for acute anterior cruciate ligament knee injury: a randomized controlled pilot trial (NCT00332254).

OBJECTIVE: To evaluate the clinical effectiveness of intraarticular IL-1 receptor antagonist (IL-1Ra) for anterior cruciate ligament (ACL) tear. METHODS: Eleven patients with acute ACL tear confirmed by magnetic resonance imaging (MRI) were randomized to receive a single intraarticular injection of IL-1Ra (anakinra 150 mg, n = 6) or equal volume of saline placebo (1 ml, n = 5). The double-blinded treatment was administered a mean 2 weeks after injury. Synovial fluid (SF) (n = 9 patients) and sera (all patients) were available at baseline (prior to injection) and immediately prior to surgery (mean 35 days later) and analyzed for SF IL-1α, IL-1ß, IL-1Ra and serum hyaluronan (HA), an indicator of synovial inflammation. The primary outcome, standardized Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire, was obtained at 0 (baseline), 4, and 14 days after injection. RESULTS: Compared with placebo, the IL-1Ra group had substantially greater improvement in key outcomes over 14 days (KOOS pain P = 0.001; activities of daily living P = 0.0015; KOOS sports function P = 0.0026; KOOS quality of life (QOL) P = 0.0048; and total KOOS P < 0.0001). There were no adverse reactions in either group. SF IL-1α (P = 0.05) and serum HA (P = 0.03), but not IL-1ß, or IL-1Ra, decreased significantly in the IL-1Ra but not the placebo treated patients. Compared with placebo, IL-1α was borderline significantly different in the IL-1Ra treated group (P = 0.06). CONCLUSIONS: Administered within the first month following severe knee injury, IL-1Ra reduced knee pain and improved function over a 2-week interval. This promising proof of concept study provides a new paradigm for studies of acute joint injury and suggests that a larger follow-up study is warranted.

Rapid reversal of hepatic steatosis, and reduction of muscle triglyceride, by rosiglitazone: MRI/S studies in Zucker fatty rats.

AIM: This study aimed to chart the time course and durability of the effects of rosiglitazone, a potent thiazolidinedione-based peroxisome proliferator-activated receptor gamma agonist, on hepatic steatosis and intramyocellular lipid in an animal model of obesity, the Zucker Fatty (ZF) rat. METHODS AND RESULTS: Rosiglitazone (3 mg/kg/day p.o.) significantly reduced both liver fat content (by 59%; p < 0.05) and size (11.5%; p < 0.05) in male ZF rats that received between 3 days and 1 week of treatment, and these reductions were maintained for at least 12 weeks. Liver fat content measured by magnetic resonance spectroscopy (MRS) correlated closely and positively with plasma insulin levels (reduced by 89% within a week, r = 0.8) and with postmortem histological fat fractional volume (r = 0.89). Similarly, liver volume measured by magnetic resonance imaging (MRI) correlated closely with postmortem wet weight (r = 0.99). MRS also showed, and numbers of lipid vacuoles counted in transmission electron micrographs confirmed, that rosiglitazone significantly reduced the elevated intramyocellular lipid seen in ZF rat skeletal muscle by at least 40% (p < 0.05). CONCLUSIONS: Localized MRS and MRI showed that rosiglitazone reversed the hepatic steatosis, hepatomegaly and intramyocellular lipid, characteristic of the ZF rat, an animal model of obesity.

Extended acclimatization is required to eliminate stress effects of periodic blood-sampling procedures on vasoactive hormones and blood volume in beagle dogs.

Important in all experimental animal studies is the need to control stress stimuli associated with environmental change and experimental procedures. As the stress response involves alterations in levels of vasoactive hormones, ensuing changes in cardiovascular parameters may confound experimental outcomes. Accordingly, we evaluated the duration required for dogs (n = 4) to acclimatized to frequent blood sampling that involved different procedures. On each sampling occasion during a 6-week period, dogs were removed from their pen to a laboratory area and blood was collected either by venepuncture (days 2, 15, 34, 41) for plasma renin activity (PRA), epinephrine (EPI), norepinephrine, aldosterone, insulin, and atrial natriuretic peptide, or by cannulation (dogs restrained in slings; days 1, 8, 14, 22, 30, 33, 37, 40) for determination of haematocrit (HCT) alone (days 1 to 22) or HCT with plasma volume (PV; days 30 to 40). PRA was higher on days 2 and 15 compared with days 34 and 41 and had decreased by up to 48% by the end of the study (day 41 vs day 15; mean/SEM: 1.18/0.27 vs 2.88/0.79 ng ANG I/ml/h, respectively). EPI showed a time-related decrease from days 2 to 34, during which mean values had decreased by 51% (mean/SEM: 279/29 vs 134/20.9 pg/ml for days 2 and 34, respectively), but appeared stable from then on. None of the other hormones showed any significant variability throughout the course of the study. HCT was relatively variable between days 1 to 22 but stabilized from day 30, after which all mean values were approximately 6% lower than those between days 1 and 8. We conclude that an acclimatization period of at least 4 weeks is required to eliminate stress-related effects in dogs associated with periodic blood sampling.

GABA enhances transmission at an excitatory glutamatergic synapse.

GABA mediates both presynaptic and postsynaptic inhibition at many synapses. In contrast, we show that GABA enhances transmission at excitatory synapses between the lateral gastric and medial gastric motor neurons and the gastric mill 6a and 9 (gm6a, gm9) muscles and between the lateral pyloric motor neuron and pyloric 1 (p1) muscles in the stomach of the lobster Homarus americanus. Two-electrode current-clamp or voltage-clamp techniques were used to record from muscle fibers. The innervating nerves were stimulated to evoke excitatory junctional potentials (EJPs) or excitatory junctional currents. Bath application of GABA first decreased the amplitude of evoked EJPs in gm6a and gm9 muscles, but not the p1 muscle, by activating a postjunctional conductance increase that was blocked by picrotoxin. After longer GABA applications (5-15 min), the amplitudes of evoked EJPs increased in all three muscles. This increase persisted in the presence of picrotoxin. beta-(Aminomethyl)-4-chlorobenzenepropanoic acid (baclofen) was an effective agonist for the GABA-evoked enhancement but did not increase the postjunctional conductance. Muscimol activated a rapid postsynaptic conductance but did not enhance the amplitude of the nerve-evoked EJPs. GABA had no effect on iontophoretic responses to glutamate and decreased the coefficient of variation of nerve-evoked EJPs. In the presence or absence of tetrodotoxin, GABA increased the frequency but not the amplitude of miniature endplate potentials. These data suggest that GABA acts presynaptically via a GABA(B)-like receptor to increase the release of neurotransmitter.

Increasing sensor flexibility through neuromodulation.

Both biological and man-made motor control networks require input from sensors to allow for modification of the motor program. Real sensory neurons are more flexible than typical robotic sensors because they are dynamic rather than static. The membrane properties of neurons and hence their excitability can be modified by the presence of neuromodulatory substances. In the case of a sensory neuron, this can change, in a functionally significant way, the code used to describe a stimulus. For instance, extension of the neuron's dynamic range or modification of its filtering characteristics can result. This flexibility has an apparent cost. The code used may be situation-dependent and hence difficult to interpret. To address this issue and to understand how neuromodulation is used effectively in a motor control network, I am studying the GPR2 stretch receptor in the crustacean stomatogastric nervous system. Several different neuromodulatory substances can modify its encoding properties. Comparisons of physiological and anatomical evidence suggest that neuromodulation can be effected both by GPR2 itself and by other neurons in the network. These results suggest that the analog of neuromodulation might be useful for improving sensor performance in an artificial motor control system.

Repeated acetaminophen dosing in rats: adaptation of hepatic antioxidant system.

Repeated dosing of acetaminophen (paracetamol) to rats is reported to decrease their sensitivity to its hepatotoxic effects, which are associated with oxidative stress and glutathione depletion. We determined if repeated acetaminophen dosing produced adaptive response of key antioxidant system enzymes. Male rats (Sprague-Dawley, 10 weeks) were given 800, 1200, or 1600 mg/kg/day acetaminophen by oral gavage for 4 days. Liver was assayed for oxidative stress and antioxidant markers: malondialdehyde (MDA), thiobarbituric acid reactive substance (TBARS), total antioxidant status (TAS), glutathione (GSH), glutathione reductase (GR), glutathione peroxidase (GPx), glucose-6-phosphate dehydrogenase (G6PD), catalase (CAT), and superoxide dismutase (SOD), and alanine transaminase (ALT) as a marker of hepatocellular injury. Acetaminophen at 1200/1600 mg/kg decreased GSH 26/47%, GPx 21/26%, CAT 35/28%, SOD 21/12%; and TAS 28/18% (correlated with CAT, r=0.91; SOD, r=0.66; GPx, r=0.45). Despite antioxidant deficiencies, and no TBARS change, MDA decreased 26%/33%/37% at 800/1200/1600 mg/kg, which correlated with increased GR (61%/62%/76%, r=0.77) and G6PD (130%/110%/190%, r=0.78). Both MDA (r=0.68) and G6PD (r=0.71) correlated with hepatic ALT, which decreased 27%/43%/48%, respectively. Resistance to acetaminophen hepatotoxicity produced by repeated exposure is partially attributable to upregulation of hepatic G6PD and GR activity as an adaptive and protective response to oxidative stress and glutathione depletion.

Crab stomach pyloric muscles display not only excitatory but inhibitory and neuromodulatory nerve terminals.

Movements of the foregut in crustaceans are produced by striated muscles that are innervated by motor neurons in the stomatogastric ganglion (STG). Firing of the STG motor neurons generates excitatory junctional potentials (EJPs) in the stomach muscles. We now provide evidence for the existence of separate inhibitory and neuromodulatory innervations of some pyloric muscles in the foregut of several crabs, Callinectes sapidus, Cancer magister, and Cancer borealis. Electron microscopic examination of several pyloric muscles revealed three distinct types of nerve terminals. Excitatory terminals were readily identified by the spherical shape of their small, clear synaptic vesicles. These terminals also housed a few large dense core vesicles. Inhibitory nerve terminals were recognized by the elliptical shape of their small, clear synaptic vesicles, and contacted the muscles at well-defined synapses equipped with dense bar active zones. Bath application of GABA reduced the amplitudes of EJPs in a pyloric muscle of C. borealis, consistent with the presence of GABAergic inhibitory innervation. Neuromodulatory terminals were characterized by their predominant population of large dense and dense core vesicles. These terminals formed synapses with presynaptic dense bars on the muscle, as well as on the excitatory and inhibitory nerve terminals. The presence of the inhibitory and neuromodulatory terminals creates a functional context for previously described reports of neuromodulatory actions on stomach muscles and suggests that the transfer function from STG motor patterns to pyloric movement may be orchestrated by a complex innervation from sources outside of the STG itself.

Encoding of muscle movement on two time scales by a sensory neuron that switches between spiking and bursting modes.

The gastropyloric receptor (GPR) neurons of the stomatogastric nervous system of the crab Cancer borealis are muscle stretch receptors that can fire in either a spiking or a bursting mode of operation. Our goal is to understand what features of muscle stretch are encoded by these two modes of activity. To this end, we characterized the responses of the GPR neurons in both states to sustained and rapidly varying imposed stretches. The firing rates of spiking GPR neurons in response to rapidly varying stretches were directly related to stretch amplitude. For persistent stretches, spiking-mode firing rates showed marked adaptation indicating a more complex relationship. Interspike intervals of action potentials fired by GPR neurons in the spiking mode were used to construct an accurate estimate of the time-dependent amplitude of stretches in the frequency range of the gastric mill rhythm (0.05-0.2 Hz). Spike trains arising from faster stretches (similar to those of the pyloric rhythm) were decoded using a linear filter to construct an estimate of stretch amplitude. GPR neurons firing in the bursting mode were relatively unaffected by rapidly varying stretches. However, the burst rate was related to the amplitude of long, sustained stretches, and very slowly varying stretches could be reconstructed from burst intervals. In conclusion, the existence of spiking and bursting modes allows a single neuron to encode both rapidly and slowly varying stimuli and thus to report cycle-by-cycle muscle movements as well as average levels of muscle tension.

Safety and efficacy of shed mediastinal blood transfusion after cardiac surgery: a multicenter observational study. Multicenter Study of Perioperative Ischemia Research Group.

OBJECTIVE: To examine the efficacy and safety of shed mediastinal blood (SMB) transfusion in preventing allogenic red blood cell (RBC) transfusion. DESIGN: An observational clinical study. SETTING: Twelve US academic medical centers. PARTICIPANTS: Six hundred seventeen patients undergoing elective primary coronary artery bypass grafting. INTERVENTIONS: Patients were administered SMB transfusion or not, according to institutional and individual practice, without random assignment. MEASUREMENTS AND RESULTS: The independent effect of SMB transfusion on postoperative RBC transfusion was examined by multivariable modeling. Potential complications of SMB transfusion, such as bleeding and infection, were examined. Three hundred twelve of the study patients (51%) received postoperative SMB transfusion (mean volume, 554 +/- 359 mL). Patients transfused with SMB had significantly lower volumes of RBC transfusion than those not receiving SMB (0.86 +/- 1.50 v 1.08 +/- 1.65 units; p < 0.05). However, multivariable analysis showed that SMB transfusion was not predictive of postoperative RBC transfusion. Demographic factors (older age, female sex), institution, and postoperative events (greater chest tube drainage, lower hemoglobin level on arrival to the intensive care unit, and use of inotropes) were significant predictors of RBC transfusion. The volume of chest tube drainage on the operative day (707 +/- 392 v 673 +/- 460 mL; p = 0.30), reoperation for hemorrhage (3.1% v2.5%; p = 0.68), and overall frequency of infection (5.8% v 6.6%; p = 0.81) were similar between patients receiving and not receiving SMB, respectively. However, in patients who did not receive allogenic RBC transfusion, there was a significantly greater frequency of wound infection in the SMB group (3.6% v0%; p = 0.02). CONCLUSION: These data suggest that SMB is ineffective as a blood conservation method and may be associated with a greater frequency of wound infection.

Depth penetration and detection of pH gradients in biofilms by two-photon excitation microscopy.

Deep microbial biofilms are a major problem in many industrial, environmental, and medical settings. Novel approaches are needed to understand the structure and metabolism of these biofilms. Two-photon excitation microscopy (TPE) and conventional confocal laser scanning microscopy (CLSM) were compared quantitatively for the ability to visualize bacteria within deep in vitro biofilms. pH gradients within these biofilms were determined by fluorescence lifetime imaging, together with TPE. A constant-depth film fermentor (CDFF) was inoculated for 8 h at 50 ml. h(-1) with a defined mixed culture of 10 species of bacteria grown in continuous culture. Biofilms of fixed depths were developed in the CDFF for 10 or 11 days. The microbial compositions of the biofilms were determined by using viable counts on selective and nonselective agar media; diverse mixed-culture biofilms developed, including aerobic, facultative, and anaerobic species. TPE was able to record images four times deeper than CLSM. Importantly, in contrast to CLSM images, TPE images recorded deep within the biofilm showed no loss of contrast. The pH within the biofilms was measured directly by means of fluorescence lifetime imaging; the fluorescence decay of carboxyfluorescein was correlated with biofilm pH and was used to construct a calibration curve. pH gradients were detectable, in both the lateral and axial directions, in steady-state biofilms. When biofilms were overlaid with 14 mM sucrose for 1 h, distinct pH gradients developed. Microcolonies with pH values of below pH 3.0 were visible, in some cases adjacent to areas with a much higher pH (>5.0). TPE allowed resolution of images at significantly greater depths (as deep as 140 microm) than were possible with CLSM. Fluorescence lifetime imaging allowed the in situ, real-time imaging of pH and the detection of sharp gradients of pH within microbial biofilms.

Corona plasma discharge for rapid analysis of microorganisms by mass spectrometry.

Corona plasma discharge provides a rapid and reliable tool for release of biomarkers from gram negative and positive bacteria, spores and viruses for characterization by mass spectrometry.

Temporal dynamics of convergent modulation at a crustacean neuromuscular junction.

At least 10 different substances modulate the amplitude of nerve-evoked contractions of the gastric mill 4 (gm4) muscle of the crab, Cancer borealis. Serotonin, dopamine, octopamine, proctolin, red pigment concentrating hormone, crustacean cardioactive peptide, TNRNFLRFamide, and SDRNFLRFamide increased and -allatostatin-3 and histamine decreased the amplitude of nerve-evoked contractions. Modulator efficacy was frequency dependent; TNRNFLRFamide, proctolin, and allatostatin-3 were more effective when the motor neuron was stimulated at 10 Hz than at 40 Hz, whereas the reverse was true for dopamine and serotonin. The modulators that were most effective at high stimulus frequencies produced a significant decrease in muscle relaxation time; those that were most effective at low stimulus frequencies produced modest increases in relaxation time. Thus modulator actions that appear redundant when examined only at one stimulus frequency are differentiated when a range of stimulus dynamics is studied. The effects of TNRNFLRFamide, serotonin, proctolin, dopamine, and -allatostatin-3 on the amplitude and facilitation of nerve-evoked excitatory junctional potentials (EJPs) in the gm4 and gastric mill 6 (gm6) muscles were compared. The EJPs in gm4 have a large initial amplitude and show relatively little facilitation, whereas the EJPs in gm6 have a small initial amplitude and show considerable facilitation. Modulators that enhanced contractions also enhanced EJP amplitude; -allatostatin-3 reduced EJP amplitude. The effects of these modulators on EJP amplitude were modest and showed no significant frequency dependence. This suggests that the frequency dependence of modulator action on contraction results from effects on excitation-contraction coupling. The modulators affected facilitation at these junctions in a manner consistent with a change in release probability. They produced a change in facilitation that is inversely related to their action on EJP amplitude.

Decision matrix for selection of patients for a home infusion therapy program.

Managed care and escalating healthcare costs have affected all aspects of clinical practice. Today's practitioners must evaluate each patient and clinical situation to select the appropriate intravenous delivery venue to improve the chances of producing a satisfactory outcome. The IV venue discussed in this article will focus on the key elements of identifying patients who will benefit from receiving pharmacomedical services in a home infusion therapy program.

Certification for child protective services staff members: the Texas initiative.

Cases coming to the attention of child protective service agencies are increasingly complex and difficult, while the number of trained staff members has decreased substantially over the last 10 years. Some states are attempting to improve the situation by implementing a certification process for staff members in child welfare service. This article describes the Texas initiative to do so, identifies problems in planning and implementation, and discusses implications for practice.

Diffusion and binding measurements within oral biofilms using fluorescence photobleaching recovery methods.

Numerous studies have postulated that bacteria which reside in a biofilm differ from planktonic bacteria. These differences are thought to affect biofilm permeability and, indirectly, the susceptibility of biofilm bacteria to antibacterial agents. In this study fluorescence recovery after photobleaching (FRAP) was used to monitor the diffusion and binding characteristics of a set of size fractionated fluorescein isothiocyanate (FTTC)-conjugated dextrans over small areas (ca. 10 micron) in bacterial biofilms. From these measurements it was straightforward to calculate apparent diffusion rates. Initial studies on the concentration dependence of dextran interaction with planktonic bacteria showed that no irreversible interaction was occurring, however, anomalous faster than free solution diffusion rates were obtained. This phenomenon was modelled using novel analytical and numerical methods which incorporate reversible binding with associated fluorescence changes. Apparent diffusion rates measured in biofilms were highly dependent on biofilm preparation. Sucrose starved biofilms produced an apparent slow-down of two- to fivefold depending on dextran molecular mass and location within the biofilm, indicating that diffusion within the biofilm is hindered. Sucrose supplemented biofilms produced apparent diffusion rates close to those in free solution, suggesting less hindered diffusion. Ex vivo plaque showed diffusion and binding similar to the sucrose supplemented biofilms. The FRAP approach provides a fast and convenient method for determining diffusion rates over small areas within bacterial biofilms. This study reinforces the importance of considering the influence of reversible binding and associated fluorescence changes, as these may have a marked effect on the measured apparent diffusion rate.

Prevention of corticosteroid osteoporosis. A comparison of calcium, calcitriol, and calcitonin.

BACKGROUND: Prolonged corticosteroid therapy increases the risk of osteoporosis and fracture. We studied whether corticosteroid-induced osteoporosis could be prevented by treatment with calcium, calcitriol (1,25-dihydroxyvitamin D3), and calcitonin. METHODS: One hundred three patients starting long-term corticosteroid therapy were randomly assigned to receive 1000 mg of calcium per day orally and either calcitriol (0.5 to 1.0 microgram per day orally) plus salmon calcitonin (400 IU per day intranasally), calcitriol plus a placebo nasal spray, or double placebo for one year. Data on treatment efficacy were available for 92 of these patients. Bone density was measured every four months for two years by photon absorptiometry. There were no significant differences between groups with respect to age, underlying disease, initial bone density, or corticosteroid dose during the first year. RESULTS: Calcitriol (mean dose, 0.6 microgram per day), with or without calcitonin, prevented more bone loss from the lumbar spine (mean rates of change, -0.2 and -1.3 percent per year, respectively) than calcium alone (-4.3 percent per year, P = 0.0035). Bone loss at the femoral neck and distal radius was not significantly affected by any treatment. In the second year, lumbar bone loss did not occur in the group previously treated with calcitonin plus calcitriol (+0.7 percent per year), but it did occur in the group given calcium alone (-2.3 percent per year). The calcitriol group also lost lumbar bone (-3.6 percent per year) but received more corticosteroid in the second year than the other two groups. CONCLUSIONS: Calcitriol and calcium, used prophylactically with or without calcitonin, prevent corticosteroid-induced bone loss in the lumbar spine.