PHOSPHO1 is essential for normal bone fracture healing: An Animal Study.

OBJECTIVES: Bone fracture healing is regulated by a series of complex physicochemical and biochemical processes. One of these processes is bone mineralization, which is vital for normal bone development. Phosphatase, orphan 1 (PHOSPHO1), a skeletal tissue-specific phosphatase, has been shown to be involved in the mineralization of the extracellular matrix and to maintain the structural integrity of bone. In this study, we examined how PHOSPHO1 deficiency might affect the healing and quality of fracture callus in mice. METHODS: Tibial fractures were created and then stabilized in control wild-type (WT) and Phospho1-/- mice (n = 16 for each group; mixed gender, each group carrying equal number of male and female mice) at eight weeks of age. Fractures were allowed to heal for four weeks and then the mice were euthanized and their tibias analyzed using radiographs, micro-CT (µCT), histology, histomorphometry and three-point bending tests. RESULTS: The µCT and radiographic analyses revealed a mild reduction of bone volume in Phospho1-/- callus, although it was not statistically significant. An increase in trabecular number and a decrease in trabecular thickness and separation were observed in Phospho1-/- callus in comparison with the WT callus. Histomorphometric analyses showed that there was a marked increase of osteoid volume over bone volume in the Phospho1-/- callus. The three-point bending test showed that Phospho1-/- fractured bone had more of an elastic characteristic than the WT bone. CONCLUSION: Our work suggests that PHOSPHO1 plays an integral role during bone fracture repair and may be a therapeutic target to improve the fracture healing process.Cite this article: M. W. Morcos, H. Al-Jallad, J. Li, C. Farquharson, J. L. Millán, R. C. Hamdy, M. Murshed. PHOSPHO1 is essential for normal bone fracture healing: An Animal Study. Bone Joint Res 2018;7:397-405. DOI: 10.1302/2046-3758.76.BJR-2017-0140.R2.

Protective Effects of Liraglutide and Linagliptin in C. elegans as a New Model for Glucose-Induced Neurodegeneration.

Liraglutide and linagliptin are novel drugs for the treatment of diabetes. Antioxidative and neuroprotective effects have been described for both compounds. However, it is not yet known, whether these mechanisms are also protective against diabetic retinal neurodegeneration. We assessed the antioxidative and neuroprotective capabilities of liraglutide and linagliptin as well as the signaling pathways involved, by using C. elegans as a model for glucose-induced neurodegeneration. C. elegans were cultivated under conditions, which mimic clinical hyperglycemia, and treated with 160 µmol/l liraglutide or 13 µmol/l linagliptin. Oxidative stress was reduced by 29 or 78% and methylglyoxal-derived advanced glycation endproducts (AGEs) by 33 or 22%, respectively. This resulted in an improved neuronal function by 42 or 60% and an extended mean lifespan by 9 or 11%, respectively. Antioxidative and AGE reducing effects of liraglutide and linagliptin were not dependent on v-akt murine thymoma viral oncogene homologue 1/forkhead box O1 (AKT1/FOXO). Neuroprotection by liraglutide was AKT1/FOXO dependent, yet AKT1/FOXO independent upon linagliptin treatment. Both liraglutide and linagliptin exert neuroprotective effects in an experimental model for glucose-induced neurodegeneration, however, the signaling pathways differ in the present study. Further pharmacological intervention with these pathways may help to delay the clinical onset of diabetic retinopathy by preserving neuronal integrity.

Mesenchymal stem cell therapy promotes corneal allograft survival in rats by local and systemic immunomodulation.

Mesenchymal stem cells (MSCs) are being investigated extensively due to their ability to dampen immune responses. Here, we tested the ability of MSCs from three distinct sources to prolong rat corneal allograft survival. A fully allogeneic rat cornea transplant model (DA to LEW) was used. Recipient rats received 1 × 10(6) MSCs (syn [LEW], allo [DA] or third-party [Wistar Furth]) intravenously 7 days before transplantation and again on the day of transplantation (day 0). A high percentage of untreated and syn-MSC treated allografts were rejected (80% and 100%, respectively). Preactivation of syn-MSCs with interferon gamma also failed to prolong allograft survival. Conversely, corneal allograft survival was significantly prolonged in allo-MSC treated (90%) and third-party MSC treated (80%) allograft recipients. Flow cytometric analysis revealed less infiltrating natural killer T cells in corneas of both allo- and third-party MSC treated animals, coupled with a higher proportion of splenic CD4+Foxp3+ regulatory T cells, compared to controls. In the case of allo- and third-party MSCs, results from a delayed-type hypersensitivity assay clearly showed that hypo-responsiveness was specific for corneal donor-associated allo-antigens. Thus, allo- and third-party MSC treatment prolongs corneal allograft survival by suppressing peripheral immune responses and promoting an intragraft immunoregulatory milieu.

Effects of stress reduction on cardiovascular risk factors in type 2 diabetes patients with early kidney disease - results of a randomized controlled trial (HEIDIS).

Current guidelines for the treatment of type 2 diabetes focus on pharmacological treatment of glucose and cardio-vascular risk factors. The aim of this prospective randomized controlled intervention study was to examine the effects of a psychosocial intervention on clinical endpoints and risk factors in patients with type 2 diabetes and early diabetic kidney disease.110 patients were randomized to receive an 8-week mindfulness-based stress reduction (MBSR) training (n = 53) compared to standard care (n = 57). The study was carried out open-labelled and randomization was performed computer-generated in a 1:1 ratio. Primary outcome of the study was the change in urinary albumin excretion (albumin-creatinine-ratio, ACR); secondary outcomes were metabolic parameters, intima media thickness (IMT), psychosocial parameters and cardiovascular events.89 patients (42 in control group and 47 in intervention group) were analysed after 3 years of follow-up. After 1 year, the intervention group showed a reduction of ACR from 44 [16/80] to 39 [20/71] mg/g, while controls increased from 47 [16/120] to 59 [19/128] mg/g (p = 0.05). Parallel to the reduction of stress levels after 1 year, the intervention-group additionally showed reduced catecholamine levels (p < 0.05), improved 24 h-mean arterial (p < 0.05) and maximum systolic blood pressure (p < 0.01), as well as a reduction in IMT (p < 0.01). However, these effects were lost after 2 and 3 years of follow-up.This is the first study to show that a psychosocial intervention improves cardiovascular risk factors in high risk type 2 diabetes patients. Trial-Registration: NCT00263419 http://clinicaltrials.gov/ct2/show/NCT00263419 TRIAL REGISTRATION: clinicaltrials.gov-Identifier: NCT00263419.

Understanding diabetic polyneuropathy and longevity: what can we learn from the nematode Caenorhabditis elegans?

Pathogenesis of late diabetic complications is influenced by a complex interplay of multiple exogenous and intrinsic factors. The well characterised nematode Caenorhabditis elegans is an ideal model to study causes of diabetic polyneuropathy because of its easily accessible nervous system. A repertoire of methods allows the assessment of both morphological and functional glucotoxic damages as well as reduction of lifespan, thereby helping to examine the influence of different pathways and mechanisms on neurodegeneration. Its insulin signalling system allows to directly visualize effects of insulin on high glucose induced neuronal damage, leading to a better understanding of diabetic polyneuropathy.

Role of lentivirus-mediated overexpression of programmed death-ligand 1 on corneal allograft survival.

To investigate the role of lentivirus-mediated overexpression of programmed death-ligand 1 (PD-L1) on rat corneal allograft survival. A fully allogeneic rat cornea transplant model was used for in vivo studies. Lentiviral (LV) vectors are efficient tools for ex vivo genetic modification of cultured corneas. LV vector encoding for PD-L1 (LV.PD-L1) and LV vector encoding for eGFP (LV.eGFP, as control) were constructed and tested. PD-L1 or eGFP expression was increased on corneal cells upon LV.PD-L1 and LV.eGFP transduction, respectively. Both allogeneic controls and allogeneic LV.eGFP transduced corneas were uniformly rejected (MST: 13.8 ± 1.7 days and 12.3 ± 1.9 days, respectively). In contrast, allogeneic LV.PD-L1 transduced corneas showed a high percentage (83%) of graft survival (MST > 30 days, n = 5, 15 days, n = 1). Graft opacity of PD-L1 transduced corneas was present but was significantly reduced compared to control or eGFP expressing corneas. Flow cytometric analysis revealed that percentages of CD3(+) CD8(+) CD161(+) and CD3(+) CD8(+) CD161(-) lymphocytes were decreased in animals receiving LV.PD-L1 transduced corneas compared to animals grafted with LV.eGFP transduced corneas. Moreover, reduced expression of proinflammatory cytokines (IFN-γ and IL-6) in PD-L1 transduced corneas compared to allogeneic controls was also observed. Local PD-L1 gene transfer in cultured corneas is a promising approach for the prolongation of corneal allograft survival and attenuation of graft rejection.

Environmental exposure to endotoxin in rural and urban Egyptian school children and its relation to asthma and atopy.

AIM: The environmental exposure of farm children to micro-organisms in dust has been related to a reduced prevalence of asthma and atopy. The aim of this study was to evaluate the relation between settled dust endotoxin and development of asthma and/or atopy in rural and urban school children. METHODS: A comparative study was conducted on 40 rural and 40 urban school children (6-12 years). Parental self-reported allergic symptoms questionnaires were distributed. Forced expiratory volume in the first second (FEV1), forced vital capacity (FVC) were measured using MIR spirobank and FVE1% was calculated. Skin prick testing with the most common aeroallergens was performed. Limulus amebocyte lysate endotoxin content was measured in settled dust samples. RESULTS: The rural group which has higher exposure to farm animals and feeding on farm milk has less allergic symptoms. Rural students showed highly significant FEV1, FEV1% and significant FVC versus urban students (110.9±19.7, 103.8±12.2, 105.8±24.3 vs. 92.3±24.2, 98.4±18.9, 92.7±23.2, respectively). Rural school dust contains significantly higher level of endotoxin (2-3 EU/mg) than urban school (0-0.1 EU/mg). Urban residence was associated with increase risk of asthma after age and sex adjustments ([ORadj], 5.16; 95% [CI], 0.95-28). CONCLUSION: Our results support the hygiene theory, i.e., endotoxin exposure could be protective to asthma and atopy in school children.

Angiotensin-converting enzyme inhibitors and angiotensin II type 1 receptor blockers after renal transplantation.

Renin-angiotensin system blockade retards the progression of diabetic and non-diabetic chronic kidney disease of the native kidneys. Though most patients suffer from a significant renal insufficiency (chronic kidney disease stage III) and a concomitant heart disease after renal transplantation, there is up to now no evidence supporting the use of inhibitors of the renin-angiotensin system in these patients. We wish to summarize the available evidence on the use of inhibitors of the renin-angiotensin system after renal transplantation. We specifically discuss potential beneficial as well as adverse effects of a renin-angiotensin system blockade. In addition, we review their influence on morphologic and biochemical markers as well as on renal function, graft and patient survival after renal transplantation.

Simultaneous pancreas-kidney transplantation in type 1 diabetes.

The outcome of simultaneous pancreas-kidney (SPK) transplantation in type 1 diabetes has dramatically improved in recent years because of optimized surgical techniques and new immunosuppressive drug regimens. Normoglycemia is followed by stabilization or even regression of diabetic lesions, i.e., of heart and kidneys. However, these effects are only visible after more than five yr of normoglycemia (achieved by a functioning allograft). This is also a likely explanation for the conflicting results of studies that investigated patient or kidney graft survival in SPK transplantation compared to kidney transplantation alone. Most studies had too short follow-up periods, i.e., less than five yr, to compare effectively different transplant strategies in patients with type 1 diabetes and therefore failed to discover a survival benefit in favor of simultaneously transplanted patients. Recent data now indicate that, with a longer follow-up, there is an increasing survival benefit for simultaneously transplanted patients compared to patients who received a single kidney transplant. This is paralleled by the comparison of simultaneously transplanted patients to patients who received a single kidney transplant from a living donor. A survival benefit for the combined procedure was here visible after 10 yr of follow-up. We give a short overview on SPK transplantation, with a focus on the effects of this procedure on diabetic complications as well as patient and kidney graft survival.

[The unsolved problem of diabetes mellitus type 2 and associated complications]. / Diabetes mellitus Typ 2 Ein ungelöstes Problem und seine Komplikationen.

Type 2 diabetes and impaired glucose tolerance are an increasing burden not only for affected patients, but also for the whole health care system. The pathophysiology of diabetes and its late complications are far from being understood with hyperglycaemia being only the last sign of a long lasting and complex metabolic dysfunction. One major problem in finding therapeutic targets is the fact that the cellular disorders responsible for the development of diabetes involve phylogenetically ancient repair mechanisms. This is one of the reasons why therapeutic targeting of these mechanisms is difficult with the exception of life-style interventions which are, however, limited by individual compliance. In addition, the impact of many therapeutic agents on the entire organism is not well understood. Blood glucose control cannot be considered "high tech" medicine and requires non-medical personnel to reach defined blood glucose targets. Non-adherence to treatment and life-style changes, however, facilitate the interaction of patients and medical personnel and individuals with diabetes are therefore often considered themselves to "blame" for being affected by diabetes. Finally, generating treatment guidelines is extremely difficult as clinical studies targeting vascular endpoints need more than 10 years to become informative, partly due to the so-called glycaemic memory.

The -174G>C IL-6 gene promoter polymorphism and diabetic microvascular complications.

This study examined a possible association of the G>C polymorphism at nucleotide -174 in the promoter region of the interleukin-6 (IL-6) gene (rs1800795) with the prevalence of diabetic complications in 235 patients with type 1 and 498 patients with type 2 diabetes. Genotyping was performed using polymerase chain reaction (PCR) and subsequent cleavage by Nla III restriction endonuclease. Analyzing all diabetic patients together demonstrated that 301 patients (41.1%) carried the GG genotype, 114 (15.6%) the CC genotype, and 318 (43.3%) were heterozygous for the GC genotype. However, there was no correlation of any of the genotypes with the prevalence of diabetic nephropathy or diabetic neuropathy, but subjects with the CC genotype had a significantly higher prevalence of diabetic retinopathy compared to patients with the GC and GG genotype (p=0.016). This association was mainly lost when a logistic regression model was adjusted for diabetes duration (p=0.07). Consistently, a weak but not significant association of the polymorphism with diabetic retinopathy was observed when type 1 and type 2 diabetic patients were analyzed separately (patients with type 1 diabetes: p=0.12; patients with type 2 diabetes: p=0.09). Analogically, no association of the polymorphism was found for diabetic nephropathy or diabetic neuropathy in these groups. In conclusion these data suggest no major influence of the -174G>C variant in the promoter region of the IL-6 gene on the development of microvascular complications in patients with diabetes.

Drug-resistant tuberculosis in Egyptian children using Etest.

AIM: Etest (AB Biodisk, Solna, Sweden) is a new rapid and accurate alternative for susceptibility testing. It also can measure the minimal inhibitory concentration. The aim of this study was to assess the prevalence of drug-resistant Mycobacterium TB (MT) in newly diagnosed tuberculous Egyptian children, and to determine the effectiveness of the Etest to detect drug-resistant MT. METHODS: This prospective study included 150 newly diagnosed pulmonary and extrapulmonary tuberculous children. The organism was isolated and identified after decontamination. Antimicrobial susceptibility testing was performed by proportion method using Lowenstein-Jensen medium (PMLJ) and Etest. Minimal inhibitory concentration for both first and second line anti tuberculous drugs was determined by Etest. Comparison between the two methods was done. RESULTS: Age range was 6 months - 15 years (mean of 7.4+/-3.3). Pulmonary tuberculosis (TB) and extrapulmonary cases were 85/150 (55.3%) and 67/150 (44.7%) respectively. Seventy three isolates of MT were obtained from patients or contacts. Using Etest, the over all drug resistant of MT was 24.7% which is resistance to one drug (any drug). Resistance to first-line drugs; isoniazid, rifampicin, streptomycin and ethambutol was 5.4%, 2.7%, 6.8% and 1.4% respectively. Rifampicin resistance strongly correlated with isoniazid resistance. The prevalence of multi-drug resistance was 2.7%. Resistance to second line was 2.7% for amikacin and 1.4% for ciprofloxacin. Etest showed an overall specificity of 97.89 and sensitivity of 81.8. Overall agreement of Etest with reference proportion method range was 94.5-100%. CONCLUSION: Etest appears to be a good alternative method for testing susceptibility of Mycobacterium tuberculosis.

Rosiglitazone reduces angiotensin II and advanced glycation end product-dependent sustained nuclear factor-kappaB activation in cultured human proximal tubular epithelial cells.

Tubular damage is a major feature in the development of diabetic nephropathy. This study investigates the effects of the thiazolidindione rosiglitazone on angiotensin II and advanced glycation end product-induced tubular activation in human proximal tubular epithelial cells IN VITRO. Angiotensin II and advanced glycation end products, both induced a dose-dependent sustained activation of the redox-sensitive transcription factor, Nuclear Factor KAPPA B (NF-kappaB). Nuclear translocation of NF-kappaB was evident already after one hour and persistent for more than four days. Co-incubation of proximal tubular epithelial cells with rosiglitazone significantly reduced angiotensin II and advanced glycation end product-mediated generation of reactive oxygen species, angiotensin II-dependent advanced glycation end product formation, NF-kappaB activation, and NF-kappaB-dependent pro inflammatory gene expression. Most importantly, rosiglitazone effects on NFkappaB activation were maximal at later time points, indicating that rosiglitazone treatment confers long lasting renoprotective effects.

Use of Aripiprazole in treatment resistant schizophrenia.

For various reasons large numbers of patients treated with Clozapine end up discontinuing the treatment. The authors present the results of switching to Aripiprazole in patients who had to discontinue Clozapine because of neutropenia below the acceptable level for treatment with Clozapine. To summarize and present three cases of individuals with treatment resistant schizophrenia based on the ICD-10 diagnosti criteria. In all cases Clozapine was discontinued and treatment changed to Aripiprazole. Favorable clinical results were noticed in all three patients. The findings from this case series suggest that there is scope for a trial of Aripiprazole for patients with treatment resistant schizophrenia and an invitation for further research of this area.

A M55V polymorphism in the SUMO4 gene is associated with a reduced prevalence of diabetic retinopathy in patients with Type 1 diabetes.

AIMS: We studied the association between a functionally relevant M55V polymorphism in the SUMO4 gene with microvascular diabetic complications in patients with type 1 diabetes. METHODS: 223 patients with type 1 diabetes were studied using polymerase chain reaction and subsequent cleavage by restriction endonucleases for the M55V SUMO4 gene variant. RESULTS: No effect of the polymorphism on diabetic neuropathy or diabetic nephropathy was found, but heterozygous or homozygous patients for the M55V polymorphism in the SUMO4 gene had a markedly reduced prevalence of diabetic retinopathy (odds ratio 0.37, 95%-confidence interval (CI) [0.32;0.43]; p=0.004). Furthermore, a multiple logistic regression model showed an age and diabetes duration independent effect of the M55V polymorphisms on the prevalence of diabetic retinopathy (p=0.03), but not of diabetic neuropathy or nephropathy. CONCLUSIONS: Our data indicate that the M55V polymorphism in the SUMO4 gene is associated with a reduced risk of diabetic retinopathy in type 1 diabetes. Thus, the results of our study suggest that posttranslational modification of proteins via SUMO4 could contribute to the development of certain diabetic complications.

Pleiotrophic and anti-inflammatory effects of pioglitazone precede the metabolic activity in type 2 diabetic patients with coronary artery disease.

We investigated MMP-9 levels and inflammatory markers during pioglitazone treatment in type 2 diabetic patients with cardiovascular disease. In this randomized multicenter, double blinded, placebo controlled study, 92 type 2 diabetic patients with angiographically proven CHD were randomly assigned to pioglitazone or placebo treatment. At baseline and during a 28 days observational period MMP-9, MCP1, hsCRP, IL-6, sCD40, and P-selectin were monitored. During Pioglitazone treatment, a 12% reduction in MMP-9 and a 18% reduction in hsCRP levels (p<0.05, respectively) could be observed already after 3 days. MCP-1 levels were reduced by 14% after 10 days of treatment (p<0.0001). At the end of the study, these parameters were significantly lower in the pioglitazone group as compared to the placebo group (MMP-9: 392+/-286 versus 427+/-166 ng/ml; hsCRP: 1.9+/-1.7 versus 3.1+/-2.3 ng/L; MCP-1: 413+/-115 versus 471+/-146 pg/ml; p<0.05, respectively). sCD40 levels decreased by 32.5% (p<0.05) and P-selectin decreased by 3.2% (p=0.053) in the pioglitazone group. No change could be found with regard to the other study endpoints. No changes in these parameters could be observed during placebo treatment. Even before effects on glucose metabolism could be obtained, pioglitazone exerts immediate effects on plasma markers of plaque vulnerability and inflammation.

sRAGE and esRAGE are not associated with peripheral or autonomic neuropathy in type 2 diabetes.

The receptor for glycation end-products RAGE was previously shown to play a central role in the development of diabetic neuropathy. The present study was aimed to investigate, whether plasma levels of the soluble forms of RAGE are associated with neuropathy in type 2 diabetes. One-hundred and eight patients were screened for peripheral and autonomic diabetic neuropathy using standardized screening tests. No differences in the levels of soluble RAGE or the more defined endogenous secretory RAGE were observed in patients categorized into having no, mild, moderate, or severe deficits in the neuropathy disability or symptom score. In bivariate analysis, neither soluble RAGE nor endogenous secretory RAGE correlated with the expiration to inspiration ratio of heart rate variability. In multivariate models, the neuropathy disability score was independently associated with age (beta=0.38, p<0.01), glomerular filtration rate (beta=0.28, p<0.01) and the presence of retinopathy (beta=0.27, p<0.01), while the neuropathy symptom score was associated with age (beta=0.31, p<0.01) and fasting glucose (beta=0.24, p<0.05). The expiration to inspiration ratio of heart rate variability was associated with age (beta=-0.42, p<0.01), the body-mass-index (beta=-0.28, p<0.01) and presence of retinopathy (beta=-0.19, p<0.05). In contrast to classical risk factors, plasma soluble RAGE and endogenous secretory RAGE are not associated with measures of diabetic neuropathy in type 2 diabetes patients.

Improved vascular function upon pioglitazone treatment in type 2 diabetes is not associated with changes in mononuclear NF-kappaB binding activity.

Thiazolidinediones such as pioglitazone have been shown to exert anti-inflammatory effects independent of their insulin sensitizing effects by reducing activation of the proinflammatory transcription factor NF-kappaB in animal models of experimental diabetes. Furthermore, short-term pioglitazone treatment ameliorates endothelial dysfunction in conduit arteries of patients with type 2 diabetes. Since inflammation is supposed to impair flow-mediated vasodilatation, we studied the effects of an 8-week pioglitazone intervention on endothelial function and mononuclear NF-kappaB activation in patients with type 2 diabetes. Twenty patients were included in a randomized, double-blind, placebo-controlled study receiving 30 mg pioglitazone or placebo, respectively. Flow-mediated endothelium dependent vasodilatation (FMD) of the brachial artery, NF-kappaB binding activity in peripheral blood mononuclear cells [pBMC, determined by electrophoretic mobility shift assay (EMSA)] and interleukin-6 (IL-6)-transcription rates (determined by real-time PCR) were measured at study entry and after eight weeks of intervention. Pioglitazone treatment resulted in a significant improvement of FMD (4.3%+/-3.3; p=0.003), while no effect was seen under placebo medication (2.0%+/-2.7; p=0.71). The correction of FMD was neither paralleled by a pioglitazone-dependent reduction in mononuclear NF-kappaB binding activity (DeltaNF-kappaB activity: pioglitazone: 9.2%+/-6.7, p=0.24; placebo: 5.7%+/-19.6; p=0.82) nor in NF-kappaB dependent gene transcription as determined for IL-6 (DeltaIL-6 pioglitazone: +1.8%+/-12.0, p=0.93; placebo: -0.2%+/-9.7; p=0.92). These data demonstrate for the first time that pioglitazone treatment improves endothelial dysfunction in patients with type 2 diabetes without affecting NF-kappaB binding activity and NF-kappaB dependent proinflammatory gene expression in pBMC.

Long-term treatment of central Cushing's syndrome with rosiglitazone.

CONTEXT: Central Cushing's syndrome is not always curable by surgery or radiation of the pituitary. Medical treatment is often not possible or effective. Some studies revealed beneficial effects of the PPARgamma (Peroxisome-Proliferator-Activator- Receptor-gamma)-agonist rosiglitazone (RG) in in vitro studies, animal models and short term clinical studies. OBJECTIVE: of this study was to observe the long-term effects of RG-treatment on cortisol- and ACTH -secretion, clinical outcomes and morphological changes of the pituitary in patients with persistent ACTH-overproduction despite previous operation and radiation. DESIGN, SETTING AND PATIENTS: 14 patients with persistent central ACTH -production were included and monitored over a period up to 12 months. RG was administered daily and increased to a maximum dosage of 24 mg daily, according to the response of ACTH and cortisol secretion. ACTH and cortisol were measured at least every 4 weeks during RG treatment. RESULTS: Patients were treated between 4 and 12 months with RG (mean 6.8 months). Compared to baseline, ACTH- and cortisol levels dropped significantly (p<0.01) after 12, 16, 20, 24 and 28 weeks but thereafter rose again during the study period, despite continuous RG- treatment and dose increase up to the maximum dosage. This was paralleled by reocurrence of clinical symptoms. MRI-scans were performed in 6 patients because of persisting visible adenoma, but showed no morphological changes. CONCLUSION: RG seems not to be a long-term treatment option for patients with persistent central ACTH-evcess. Though, in order to reduce perioperative complications, short term treatment of patients could be an alternative.