Long-term methimazole therapy in Graves' hyperthyroidism and adverse reactions: a Danish multicenter study.

Purpose: In this prospective multicenter study with patients newly diagnosed with Graves' hyperthyroidism (GH), we studied the timing and characteristics of adverse drug reactions in patients treated with anti-thyroid drugs (ATD) for up to 48 months. Methods: Patients with GH were treated with ATD until remission and hereafter with a low-dose regime to keep the patients in remission. The patients were followed with blood samples and recording of adverse events approximately every second month for the first 2 years and every third month for the following 2 years. Results: We included 208 patients and the patients were treated for a median of 22 (range: 0.5-49) months. Ten percent of the patients experienced adverse drug reactions and 75% of the cases occurred during the first 6 months. After 24 months, the methimazole dose was lowered to 5 mg/day, and after this time point, no further adverse drug reactions were recorded. Skin reactions were the most prominent reaction, comprising 68% of the registered reactions, and no hepatic and bonemarrow affection was recorded. Conclusion: With this study, we report the frequency, timing of occurrence, and characteristics of adverse drug reactions when treating GH with the ATD drug methimazole for up to 48 months. Long-term low-dose methimazole treatment can be a cost-effective and straightforward treatment option if adverse drug reactions such as severe hepatic and bone marrow affection are kept in mind.

Metabolome-based signature of disease pathology in MS.

BACKGROUND: Diagnostic delays are common for multiple sclerosis (MS) since diagnosis typically depends on the presentation of nonspecific clinical symptoms together with radiologically-determined central nervous system (CNS) lesions. It is important to reduce diagnostic delays as earlier initiation of disease modifying therapies mitigates long-term disability. Developing a metabolomic blood-based MS biomarker is attractive, but prior efforts have largely focused on specific subsets of metabolite classes or analytical platforms. Thus, there are opportunities to interrogate metabolite profiles using more expansive and comprehensive approaches for developing MS biomarkers and for advancing our understanding of MS pathogenesis. METHODS: To identify putative blood-based MS biomarkers, we comprehensively interrogated the metabolite profiles in 12 non-Hispanic white, non-smoking, male MS cases who were drug naïve for 3 months prior to biospecimen collection and 13 non-Hispanic white, non-smoking male controls who were frequency matched to cases by age and body mass index. We performed untargeted two-dimensional gas chromatography and time-of-flight mass spectrometry (GCxGC-TOFMS) and targeted lipidomic and amino acid analysis on serum. 325 metabolites met quality control and supervised machine learning was used to identify metabolites most informative for MS status. The discrimination potential of these select metabolites were assessed using receiver operator characteristic curves based on logistic models; top candidate metabolites were defined as having area under the curves (AUC) >80%. The associations between whole-genome expression data and the top candidate metabolites were examined, followed by pathway enrichment analyses. Similar associations were examined for 175 putative MS risk variants and the top candidate metabolites. RESULTS: 12 metabolites were determined to be informative for MS status, of which 6 had AUCs >80%: pyroglutamate, laurate, acylcarnitine C14:1, N-methylmaleimide, and 2 phosphatidylcholines (PC ae 40:5, PC ae 42:5). These metabolites participate in glutathione metabolism, fatty acid metabolism/oxidation, cellular membrane composition, and transient receptor potential channel signaling. Pathway analyses based on the gene expression association for each metabolite suggested enrichment for pathways associated with apoptosis and mitochondrial dysfunction. Interestingly, the predominant MS genetic risk allele HLA-DRB1×15:01 was associated with one of the 6 top metabolites. CONCLUSION: Our analysis represents the most comprehensive description of metabolic changes associated with MS in serum, to date, with the inclusion of genomic and genetic information. We identified atypical metabolic processes that differed between MS patients and controls, which may enable the development of biological targets for diagnosis and treatment.

Predictors of Initial and Sustained Remission in Patients Treated with Antithyroid Drugs for Graves' Hyperthyroidism: The RISG Study.

Purpose. To study predictors of attaining (part 1) and sustaining (part 2) remission in patients with Graves' hyperthyroidism (GH) treated with antithyroid drugs (ATD). Methods. In the prospective first part, the included patients were treated with ATD until a prespecified definition of remission (thyrotropin > 0.4 mU/L and TSH-receptor antibodies (TRAb) ≤ 1. 0 IU/L in a patient receiving a methimazole dose ≤ 5 mg/day, on two occasions two months apart) was met, or for 24 months. In the second part, patients attaining remission in part 1 were randomized to treatment or observation and followed until relapse or for 24 months. Results. 173 patients completed study 1 and 53% attained remission. TRAb and age were the only significant predictors of remission. Patients with baseline TRAb below vs above 10 IU/L attained remission in 63% compared to 39%, and 5 months priorly (p<0.001). In study 2, 96.4% of the patients randomized to treatment (n=33) sustained remission compared to 66% in the observation group (n=33). Treatment arm was the only significant parameter (p<0.001) of sustained remission. Conclusion. Baseline TRAb was prognostic for attaining remission in GH. Consecutive TRAb measurements during treatment were not worthwhile, but a single measurement after 6-8 months in patients with initial TRAb < 10 IU/L could substantially shorten the treatment period in a subgroup of patients. Only 3.6% of the patients in remission experienced relapse during follow-up when treated with a combination of fixed low dose methimazole and L-T4. ClinTrial.gov registration number is NCT00796913.

Maternal hypothyroidism in the perinatal period and childhood asthma in the offspring.

BACKGROUND: There is increasing interest in the possible link between maternal hypothyroidism in the perinatal period and childhood asthma risk. We explored this in this study while accounting for the timing of hypothyroidism diagnosis. Further, we evaluated whether the risk was moderated by thyroid hormone treatment during pregnancy. METHODS: We conducted a population-based cohort study using Danish national registers. All live-born singletons in Denmark from 1998 to 2007 were identified. Maternal hypothyroidism and asthma in the children were defined by data from the Patient Register and Prescription Registry. We estimated incidence rate ratios (IRRs) of asthma among children born to hypothyroid mothers versus children born to mothers with no recorded thyroid dysfunction using Poisson regression models. RESULTS: Of 595 669 children, 3524 children were born to mothers with hypothyroidism diagnosed before delivery and 4664 diagnosed after delivery. Overall, 48 990 children received treatment for asthma. The IRRs of asthma was 1.16 (95% confidence interval (CI): 1.03-1.30) and 1.12 (95% CI: 1.02-1.24) for children born to mothers with hypothyroidism diagnosed before and after delivery, compared to children born to mothers with no thyroid dysfunction. The highest risk was observed among children born to mothers with hypothyroidism diagnosed before delivery who did not receive thyroid hormone treatment during pregnancy (IRR=1.37, 95% CI: 1.04-1.80). CONCLUSION: Our findings suggest that maternal hypothyroidism, especially when it is untreated, increases childhood asthma risk. Early detection and appropriate treatment of hypothyroidism in pregnant women may be an area for possible prevention of childhood asthma.

Hypothyroidism incidence in and around pregnancy: a Danish nationwide study.

OBJECTIVE: Immunological changes in and after a pregnancy may influence the onset of autoimmune diseases. An increased incidence of hyperthyroidism has been observed both in early pregnancy and postpartum, but it remains to be studied if the incidence of hypothyroidism varies in a similar way. DESIGN: Population-based cohort study using Danish nationwide registers. METHOD: All women who gave birth to a singleton live-born child in Denmark from 1999 to 2008 (n = 403 958) were identified, and data on hospital diagnosis of hypothyroidism and redeemed prescriptions of thyroid hormone were extracted. The overall incidence rate (IR) of hypothyroidism during 1997-2010 and the IR in three-month intervals before, during and after the woman's first pregnancy in the study period were calculated and compared with the IR of hyperthyroidism. RESULTS: Altogether 5220 women were identified with onset of hypothyroidism from 1997 to 2010 (overall IR 92.3/100 000/year) and 1572 women developed hypothyroidism in the period from 2 years before to 2 years after birth of the first child in the study period. The incidence of hypothyroidism decreased during the pregnancy (incidence rate ratio (IRR) vs overall IR in the rest of the study period: first trimester: 0.89 (95% CI: 0.66-1.19), second trimester: 0.71 (0.52-0.97), third trimester: 0.29 (0.19-0.45)) and increased after birth with the highest level at 4-6 months postpartum (IRR 3.62 (2.85-4.60)). CONCLUSION: These are the first population-based data on the incidence of hypothyroidism in and around pregnancy. The incidence declined during pregnancy followed by a sharp increase postpartum. Notably, hypothyroidism as opposed to hyperthyroidism showed no early pregnancy increase.

Graves'-Basedow disease in pregnancy. New trends in the management and guidance to reduce the risk of birth defects caused by antithyroid drugs.

Thyroid hormones are essential development factors and maternal thyroid dysfunction may cause pregnancy complications and diseases in the fetus/child. In the present review we discuss new data on the incidence of Graves'-Basedow disease (GBD) in and around pregnancy, and how hyperthyroidism may affect the risk of spontaneous abortion and stillbirth. A special concern in pregnant women is the potential side effects from the use of antithyroid drugs (ATDs). One type of side effects is the allergic/toxic reactions to the drugs, which seem to be similar in and outside pregnancy, and another is that ATDs tend to over treat the fetus when the mother with GBD is made euthyroid. To avoid fetal hypothyroidism, the lowest possible ATD dose should be used to keep maternal thyroid function at the upper limit of normality with low serum TSH. Birth defects after the use of methimazole (MMI) (or its prodrug carbimazole) have been considered to be very rare, and no risk has previously been associated with the use of propylthiouracil (PTU). However, a recent Danish national study found that 1/30 of children exposed to MMI in early pregnancy had birth defects associated with this, and many defects were severe. PTU exposure was associated with defects in 1/40, and these defects were less severe. Proposals are given on how to reduce the risk of ATD associated birth defects.

The spread of injectate during saphenous nerve block at the adductor canal: a cadaver study.

BACKGROUND: The spread of injectate during a saphenous nerve block at the adductor canal has not been clearly described. METHODS: We examined the spread of 15 ml dyed injectate during ultrasound-guided saphenous nerve blocks at the adductor canal in 15 unembalmed cadavers' lower limbs followed by comparative dissections of the same limbs. RESULTS: The spread of the injectates was determined by the fascial limits and the muscles surrounding the adductor canal. The anteromedial limit of the adductor canal (the roof) was found to be a continuous fascia, with a thin proximal part and a thicker distal part (the vastoadductor membrane) covering the canal from the apex of the femoral triangle to the adductor hiatus. The fascial limits of the adductor canal formed a conduit around the femoral neurovascular bundle. The dyed aqueous injectate spread throughout the entire adductor canal to the femoral triangle and reached 1-2 cm into the popliteal fossa. Injections superficial to the adductor canal spread over the femoral artery within the subsartorial fat compartment resembling the injections within the canal but with ultrasonographic distinct features. These injections spread only half the length of the adductor canal. The only nerve observed within the adductor canal was the saphenous nerve. CONCLUSIONS: Injection of 15 ml dye was sufficient to spread throughout the adductor canal and beyond both proximally and distally. Distinct ultrasonographic features could be identified separating a subsartorial injection from an injection within the adductor canal with consequent differences in the spread.

Attention deficit hyperactivity disorder and autism spectrum disorder in children born to mothers with thyroid dysfunction: a Danish nationwide cohort study.

OBJECTIVE: To examine the association between maternal hyper- and hypothyroidism and the risk of attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) in the child. DESIGN: A population-based cohort study. SETTING: Singletons liveborn in Denmark between 1991 and 2004. POPULATION: A total of 857 014 singletons alive and living in Denmark at the age of 3 years. METHODS: Information on the diagnosis and/or treatment of maternal thyroid disease and the neurodevelopmental disorders ADHD and ASD in the child was obtained from Danish nationwide registers. The Cox proportional hazards model was used to estimate the hazard ratio (HR) with 95% confidence interval (95% CI) for risk of ADHD and ASD in children born to mothers with thyroid dysfunction, adjusting for potential confounding factors. MAIN OUTCOME MEASURES: ADHD and ASD in the child. RESULTS: Altogether, 30,295 singletons (3.5%) were born to mothers with thyroid dysfunction. Maternal hyperthyroidism diagnosed and treated for the first time after the birth of the child increased the risk of ADHD in the child (adjusted HR 1.23; 95% CI 1.05-1.44), whereas hypothyroidism increased the risk of ASD (adjusted HR 1.34; 95% CI 1.14-1.59). No significant association was seen for maternal diagnosis and treatment prior to the birth of the child. CONCLUSIONS: Children born to mothers diagnosed and treated for the first time for thyroid dysfunction after their birth may have been exposed to abnormal levels of maternal thyroid hormone already present during the pregnancy, and this untreated condition could increase the risk of specific neurodevelopmental disorders in the child.

Windows of vulnerability: maternal separation, age, and fluoxetine on adolescent depressive-like behavior in rats.

Early exposure to stressful life events plays a significant role in adolescent depression. Clinical studies have identified a number of factors that increase the risk of depression, including sex of the subject, duration of the stressor, and genetic polymorphisms that elevate serotonin levels. In this study we used the maternal separation (MS) model to investigate to what extent these factors interacted during development to manifest in depressive-like behavior in male and female rats. The triadic model of learned helplessness parses depressive-like behavior into aspects of controllable, uncontrollable, and motivational behaviors. This model was used to investigate how the timing of MS between the ages of postnatal day (P) 2-9 and P9-16 interacted with either simultaneous vehicle (saline; 1ml/kg; i.p.) or fluoxetine (10mg/kg) exposure, which was used to enhance serotonin levels; these experiments also compared the effect of a vehicle injection during these developmental periods to a no injection control. Vehicle injections alone increased helplessness in the controllable condition in male rats when injected between P9-16 only, and did not interact further with MS. MS at both ages decreased controllability in male adolescents; females demonstrated an increase in controllability after MS. Elevated serotonin at P2-9 increased escape latencies in male and female control and MS subjects. Fluoxetine exposure at P9-16 increased helplessness in controls. Fluoxetine decreased helplessness in MS males independent of age, but increases helplessness in MS females. This study highlights the importance of age of MS (MS between P2-9 increases helplessness in males more than females), the duration of the stressor (previous results show females are effected by longer MS [P2-20], but not shorter [this study]), and that elevated serotonin increases escape latencies to a greater extent in females.

Enhancing the salience of dullness: behavioral and pharmacological strategies to facilitate extinction of drug-cue associations in adolescent rats.

Extinction of drug-seeking is an integral part of addiction treatment, and can profoundly reverse or ameliorate the harmful consequences of drug use. These consequences may be the most deleterious during adolescence. The studies presented here build from recent evidence that adolescent rats are more resistant to extinction training than adults, and therefore may require unique treatment strategies. We used unbiased place-conditioning in male rats to show that passive, un-explicit extinction pairings resulted in delayed extinction in 40-day-old adolescents relative to 80-day-old adults. However, explicit-pairing of a previously cocaine-associated context with the absence of drug produces extinction in adolescents as rapidly as in adults. These data suggest that successful extinction of drug-paired associations in adolescents may be facilitated by stronger acquisition of a new (extinction) memory. Drug-paired associations are largely controlled by the prelimbic prefrontal cortex (plPFC) and its influence on the nucleus accumbens (NAc). This pathway mediates the motivational salience attributed to incoming stimuli through the D1 dopamine receptor. D1 receptors on plPFC outputs to the accumbens are transiently overproduced during adolescence. Since D1 receptors are selectively responsive to potent stimuli, we hypothesized that the adolescent plPFC hinders competition between potent drug-paired associations and the subtler, drug-free information necessary for extinction. To harness this unique profile of the adolescent plPFC, we aimed to increase the salience of unrewarded extinction memories by activating plPFC D1 receptors during extinction training. In a second study, extinction of drug-cue associations was facilitated in adolescents by elevating dopamine and norepinephrine in the PFC during extinction training with atomoxetine. In a third study, direct microinjection of the D1 receptor agonist SKF38393 mimicked this effect, also facilitating extinction in adolescent subjects. Furthermore, pharmacological intervention attenuated subsequent drug-primed reinstatement of cocaine-conditioned preferences. We establish a potential direction for distinct strategies to treat this vulnerable population.

Dopamine receptor pruning during the peripubertal period is not attenuated by NMDA receptor antagonism in rat.

D(1) and D(2) receptors are overproduced and pruned in the mammalian striatum during the periadolescent period. The mechanism that underlies this process in striatum is unknown. However, previous research has shown that the activity-dependent pruning of dendrites and synapses in somatosensory cortex and the visual fields is mediated by glutamatergic actions via N-methyl-D- aspartate (NMDA) receptor and is prevented by pretreatment with the NMDA antagonist MK-801. In order to test the hypothesis that the pruning of dopamine D(1) and D(2) receptors that occurs in the striatum after puberty (which occurs at approximately 40 days of age; P40), male and female rats were treated with saline vehicle or MK-801 (0.3 mg/kg) for 20 or 40 days and sacrificed immediately after the 20 day treatment (P60), 40 day treatment (P80), or 40 day treatment with 40 day recovery (P120). Analyses of the data reveal that none of these three treatment regimens altered striatal D(1) or D(2) receptor density in males or females relative to vehicle controls. At P60, MK-801 treatment failed to alter either D(1) (F1,16=0.06, P>0.5) or D(2) receptors (F1,16=0.39, P>0.5) for either sex. Similarly, MK-801 treatment did not affect D(1) or D(2) receptors at P80 (P>0.3) or at P120 (P>0.7). These data suggest that the normal 40% reduction in striatal dopamine receptor density that occurs between puberty and adulthood is not dependent on post-pubertal glutamatergic transmission through NMDA receptors.

[Five cases of gastroenteritis with multiresistant Salmonella enterica serovar Typhimurium DT104 related to farm animals in Denmark]. / Fem tilfaelde af gastroenteritis med multiresistent Salmonella enterica serovar Typhimurium DT104 relateret til husdyrbrug i Danmark.

Whereas the overall incidence of human Salmonella infections in Denmark has fallen during the past three years, the number of infections with multidrug-resistant Salmonella Typhimurium definitive type 104 (DT104) has risen. We report five cases of human infection with DT104 in patients living on farms, in which cattle and mixed herds of cattle and pigs were infected with DT104. Transmission from the animals to the patients in the cases described is likely to have occurred. These cases emphasize the risky of infection through contact with animals infected with DT104.

Maturational increases in c-fos expression in the ascending dopamine systems.

The unique maturational period of adolescence is replete with numerous changes in anatomy and function that may yield clues as to why drug abuse emerges at this stage. The behavioral effects of amphetamine are diminished during periadolescence (35 days) relative to younger (21 days) and older (>60 days) rats, prompting us to examine amphetamine effects on neuronal activation with the immediate early gene, c-fos. Amphetamine (1 and 5 mg/kg, i.p.) increased c-fos immunoreactivity in rats 21, 35, and 60 days of age in a dose-dependent manner. When expressed as a percentage of vehicle for each age, amphetamine-induced effects on c-fos immunoreactivity were higher at 21 days of age compared with the effects at 35 and 60 days of age in the nucleus accumbens core and shell, striatum, and prefrontal cortex. These data provide a possible reason as to why stimulants produce dysphoria in children, before transitioning to euphoria during adolescence. Implications of these results are discussed for stimulant use in a pediatric population and the development of drug abuse.

Synthesis and antimalarial activity of sixteen dispiro-1,2,4, 5-tetraoxanes: alkyl-substituted 7,8,15,16-tetraoxadispiro[5.2.5. 2]hexadecanes.

Sixteen alkyl-substituted dispiro-1,2,4,5-tetraoxanes (7,8,15, 16-tetraoxadispiro[5.2.5.2]hexadecanes) were synthesized to explore dispiro-1,2,4,5-tetraoxane SAR and to identify tetraoxanes with better oral antimalarial activity than prototype tetraoxane 1 (WR 148999). The tetraoxanes were prepared either by peroxidation of the corresponding cyclohexanone derivatives in H(2)SO(4)/CH(3)CN or by ozonolysis of the corresponding cyclohexanone methyl oximes. Those tetraoxanes with alkyl substituents at the 1 and 10 positions were formed as single stereoisomers, whereas the five tetraoxanes formed without the stereochemical control provided by alkyl groups at the 1 and 10 positions were isolated as mixtures of diastereomers. Three of the sixteen tetraoxanes were inactive (IC(50)'s > 1000 nM), but five (2, 6, 10, 11, 12) had IC(50)'s between 10 and 30 nM against the chloroquine-sensitive D6 and chloroquine-resistant W2 clones of Plasmodium falciparum compared to corresponding IC(50)'s of 55 and 32 nM for 1 and 8.4 and 7.3 nM for artemisinin. We suggest that tetraoxanes 13, 16, and 17 were inactive and tetraoxanes 4 and 7 were weakly active due to steric effects preventing or hindering peroxide bond access to parasite heme. Tetraoxanes 1, 10, 11, and 14, along with artemisinin and arteether as controls, were administered po b.i.d. (128 mg/kg/day) to P. berghei-infected mice on days 3, 4, and 5 post-infection. At this dose, tetraoxanes 10, 11, and 14 cured between 40% and 60% of the infected animals. In comparison, artemisinin and tetraoxane 1 produced no cures, whereas arteether cured 100% of the infected animals. There was no apparent relationship between tetraoxane structure and in vitro neurotoxicity, nor was there any correlation between antimalarial activity and neurotoxicity for these seventeen tetraoxanes.

Sex differences in dopamine receptors and their relevance to ADHD.

Gender differences in ADHD may be attributable to gender differences in dopamine receptor density. Striatal male D2 receptor density increases 144+/-26% between 25 and 40 days (the onset of puberty), while female D2 receptor density increases only 31+/-7%. Male receptor density is then sharply eliminated by 55% by adulthood. Periadolescent females show little overproduction and pruning of striatal D1 and D2 receptors, though adult density is similar to males. The rise of male, but not female, striatal dopamine receptors parallels the early developmental appearance of motor symptoms of ADHD and may explain why prevalence rates are 2-4 fold higher in men than women. Pruning of striatal dopamine receptors coincides with the estimated 50-70% remission rate by adulthood. Transient lateralized D2, dopamine receptors (left > right) in male striatum may increase vulnerability to ADHD. More persistent attentional problems may be associated with the overproduction and delayed pruning of dopamine receptors in prefrontal cortex. Differences in D1 receptor density in nucleus accumbens may have implications for increased substance abuse in males.

Assessment of the antimalarial potential of tetraoxane WR 148999.

The antimalarial peroxide, dispiro-1,2,4,5-tetraoxane WR 148999, was synergistic with chloroquine, quinine, mefloquine, and artemisinin against both D6 and W2 clones of Plasmodium falciparum. In consideration of the contrasting antagonism between artemisinin and chloroquine, these drug combination data imply that WR 148999 and artemisinin may not share a common mechanism of action. For Plasmodium berghei-infected mice given oral, subcutaneous, and intraperitoneal doses of WR 148999 ranging from 2 to 1024 mg/kg in the Thompson test, median survival times were 8.8, 11.8, and 27.5 days, respectively, compared to 8 days for control animals. Using subcutaneous administration, WR 148999 had a considerably longer duration of action than did artemisinin against P. berghei. WR 148999 did not significantly inhibit cytochrome P450 isozymes CYP 2C9, 2C19, 2D6, 2E1, or 3A4 (IC50 >500 microM) but did inhibit CYP 1A2 with an IC50 value of 36 microM, suggesting that WR 148999 may be metabolized by the latter CYP isozyme. These results combined with previous observations that formulation strategies and incorporation of polar functional groups in a series of WR 148999 analogs both failed to enhance tetraoxane oral antimalarial activity suggest that oral bioavailability of tetraoxane WR 148999 is more likely a function of extensive first-pass metabolism rather than solubility-limited dissolution.

Degree of neuronal activation following FG-7142 changes across regions during development.

We report that FG-7142 (20 mg/kg) differentially increased c-fos in the prefrontal cortex, nucleus accumbens, and striatum of rats 10, 18, 45, and 100 days of age. FG-7142 selectively activated the cortex in adults (70.7+/-3.0%), but the pattern was stronger in nucleus accumbens (83.4+/-9.8%) in younger subjects. These results are consistent with the delayed maturation of the cortex, and show that stress produces more diffuse effects early in life.