Thalidomide is active against advanced myeloma. It can induce marked and durable responses in some patients with multiple myeloma, including those who relapse after high-dose chemotherapy.

Both aging and loss of sex steroids have adverse effects on skeletal homeostasis, but whether and how they may influence each others negative impact on bone remains unknown. We report herein that both female and male C57BL/6 mice progressively lost strength (as determined by load-to-failure measurements) and bone mineral density in the spine and femur between the ages of 4 and 31 months. These changes were temporally associated with decreased rate of remodeling as evidenced by decreased osteoblast and osteoclast numbers and decreased bone formation rate; as well as increased osteoblast and osteocyte apoptosis, increased reactive oxygen species levels, and decreased glutathione reductase activity and a corresponding increase in the phosphorylation of p53 and p66 shc , two key components of a signaling cascade that are activated by reactive oxygen species and influences apoptosis and lifespan. Exactly the same changes in oxidative stress were acutely reproduced by gonadectomy in 5-month-old females or males and reversed by estrogens or androgens in vivo as well as in vitro. We conclude that the oxidative stress that underlies physiologic organismal aging in mice may be a pivotal pathogenetic mechanism of the age-related bone loss and strength. Loss of estrogens or androgens accelerates the effects of aging on bone by decreasing defense against oxidative stress.Age-related loss of bone mass and strength is an invariable feature of human biology, affecting women and men alike. Moreover, population-based studies demonstrate that substantial bone loss begins as early as the 20s in young adult women and men, long before any hormonal changes (1).3 The extent to which estrogen deficiency contributes to age-related bone loss and the slower rate of decline of bone mass and strength during the late postmenopausal years, and the molecular and cellular mechanisms of such putative interactions, are unknown.The universality of age-associated bone loss irrespective of sex steroid status notwithstanding, age is by far a more critical determinant of fracture risk than bone mass in humans indicating that age-related increase in fracture risk reflects a loss of bone strength that is only partly accounted for by loss of bone mass (2). Whereas an increased propensity to fall due to agerelated decline in neuromuscular function is a factor, there are also age-related changes in the bone itself. Such changes include disrupted architecture, altered composition of the bone mineral and matrix, delayed repair of fatigue microdamage, excessive turnover, and inadequate bone size (3-7). The most recently appreciated qualitative factor is loss of osteocytes (8, 9), former osteoblasts entombed into the mineralized matrix. Osteocyte death may influence the signals necessary for mechanical adaptation and repair and also lead to long term changes in bone hydration. The anti-apoptotic effect of sex steroids on osteocytes, which has been well documented in mice, rats, and humans (10 -12), may contribute to their anti-fracture efficacy independently of...

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Glucocorticoid-induced osteoporosis may be due, in part, to increased apoptosis of osteocytes and osteoblasts, and bisphosphonates (BPs) are effective in the management of this condition. We have tested the hypothesis that BPs suppress apoptosis in these cell types. Etidronate, alendronate, pamidronate, olpadronate, or amino-olpadronate (IG9402, a bisphosphonate that lacks antiresorptive activity) at 10 -9 to 10 -6 M prevented apoptosis of murine osteocytic MLO-Y4 cells, whether it was induced by etoposide, TNF-α, or the synthetic glucocorticoid dexamethasone. BPs also inhibited apoptosis of primary murine osteoblastic cells isolated from calvaria. Similar antiapoptotic effects on MLO-Y4 and osteoblastic cells were seen with nanomolar concentrations of the peptide hormone calcitonin. The antiapoptotic effect of BPs and calcitonin was associated with a rapid increase in the phosphorylated fraction of extracellular signal regulated kinases (ERKs) and was blocked by specific inhibitors of ERK activation. Consistent with these in vitro results, alendronate abolished the increased prevalence of apoptosis in vertebral cancellous bone osteocytes and osteoblasts that follows prednisolone administration to mice. These results suggest that the therapeutic efficacy of BPs or calcitonin in diseases such as glucocorticoidinduced osteoporosis may be due, in part, to their ability to prevent osteocyte and osteoblast apoptosis.

It is unknown why sustained elevation of parathyroid hormone (PTH) stimulates bone resorption, whereas intermittent administration stimulates bone formation. We show in mice that daily injections of PTH attenuate osteoblast apoptosis, thereby increasing osteoblast number, bone formation rate, and bone mass, but do not affect osteoclast number. In contrast, sustained elevation of PTH, achieved either by infusion or by raising endogenous hormone secretion with a calcium-deficient diet, does not affect osteoblast apoptosis but increases osteoclast number. Attenuation of apoptosis by PTH in cultured osteoblastic cells requires protein kinase A-mediated phosphorylation and inactivation of the pro-apoptotic protein Bad as well as transcription of survival genes, like Bcl-2, mediated by CREB (cAMP response element-binding protein) and Runx2. But, PTH also increases proteasomal proteolysis of Runx2. Moreover, the anti-apoptotic effect of PTH is prolonged by inhibition of proteasomal activity, by overexpressing a dominant negative form of the E3 ligase (ubiquitin-protein isopeptide ligase) that targets Runx2 for degradation (Smurf1), or by overexpressing Runx2 itself. The duration of the anti-apoptotic effect of PTH, thus, depends on the level of Runx2, which in turn is decreased by PTH via Smurf1-mediated proteasomal proteolysis. The selflimiting nature of PTH-induced survival signaling might explain why intermittent administration of the hormone is required for bone anabolism.Cyclic activation of cell surface receptors often leads to a different biologic response than sustained activation. A classic example is the stimulation of luteinizing hormone and follicle stimulating hormone production by pituitary gonadotroph cells in response to pulsatile gonadotropin releasing hormone (GnRH) versus the inhibition of hormone production by continuous GnRH treatment (1). The differential response of the skeleton to intermittent versus continuous elevation of parathyroid hormone (PTH) 1 is another long known example with important clinical and therapeutic implications. Indeed, chronic elevation of the hormone as in primary or secondary hyperparathyroidism stimulates bone resorption leading to bone loss (2, 3). In contrast, intermittent administration of PTH stimulates new bone formation by increasing osteoblast number (4). Heretofore, a mechanistic explanation for the dependence of this effect on repeated transient increases in PTH has remained unknown. Albeit, intermittent PTH administration by daily injections was recently approved by the United States Food and Drug Administration as the first form of osteoporosis therapy that increases bone mass de novo, reverses the bone deficit, and dramatically reduces the incidence of fractures (5).We had previously shown that daily injections of PTH to mice for 28 days reduces the prevalence of osteoblast apoptosis and increases the number of osteoblasts (6), providing an explanation for the increase in bone formation rate and bone mineral density (BMD) seen with intermittent PTH adminis...

The results of this study offer additional support for the use of the PCPC and POPC. These brief and easily completed measures can provide useful information regarding probable outcomes for pediatric intensive care patients when more extensive psychometric testing is not feasible or desirable.

SummaryAging or glucocorticoid excess decrease bone strength more than bone mass in humans and mice, but an explanation for this mismatch remains elusive. We report that aging in C57BL ⁄ 6 mice was associated with an increase in adrenal production of glucocorticoids as well as bone expression of 11b-hydroxysteroid dehydrogenase (11b-HSD) type 1, the enzyme that activates glucocorticoids. Aging also decreased the volume of the bone vasculature and solute transport from the peripheral circulation to the lacunar-canalicular system. The same changes were reproduced by pharmacologic hyperglucocorticoidism. Furthermore, mice in which osteoblasts and osteocytes were shielded from glucocorticoids via cell-specific transgenic expression of 11b-HSD type 2, the enzyme that inactivates glucocorticoids, were protected from the adverse effects of aging on osteoblast and osteocyte apoptosis, bone formation rate and microarchitecture, crystallinity, vasculature volume, interstitial fluid, and strength. In addition, glucocorticoids suppressed angiogenesis in fetal metatarsals and hypoxia inducible factor-1a transcription and vascular endothelial growth factor production in osteoblasts and osteocytes. These results, together with the evidence that dehydration of bone decreases strength, reveal that endogenous glucocorticoids increase skeletal fragility in old age as a result of cell autonomous effects on osteoblasts and osteocytes leading to interconnected decrements in bone angiogenesis, vasculature volume, and osteocyte-lacunar-canalicular fluid.

BACKGROUND Bisphosphonates decrease bone resorption and are commonly used to treat or prevent osteoporosis. However, the effect of bisphosphonates on their target cells remains enigmatic, since in patients benefiting from therapy, little change, if any, has been observed in the number of osteoclasts, which are the cells responsible for bone resorption. METHODS We examined 51 bone-biopsy specimens obtained after a 3-year, double-blind, randomized, placebo-controlled, dose-ranging trial of oral alendronate to prevent bone resorption among healthy postmenopausal women 40 through 59 years of age. The patients were assigned to one of five groups: those receiving placebo for 3 years; alendronate at a dose of 1, 5, or 10 mg per day for 3 years; or alendronate at a dose of 20 mg per day for 2 years, followed by placebo for 1 year. Formalin-fixed, undecalcified planar sections were assessed by bone histomorphometric methods. RESULTS The number of osteoclasts was increased by a factor of 2.6 in patients receiving 10 mg of alendronate per day for 3 years as compared with the placebo group (P<0.01). Moreover, the number of osteoclasts increased as the cumulative dose of the drug increased (r = 0.50, P<0.001). Twenty-seven percent of these osteoclasts were giant cells with pyknotic nuclei that were adjacent to superficial resorption cavities. Furthermore, giant, hypernucleated, detached osteoclasts with 20 to 40 nuclei were found after alendronate treatment had been discontinued for 1 year. Of these large cells, 20 to 37% were apoptotic, according to both their morphologic features and positive findings from in situ end labeling. CONCLUSIONS Long-term alendronate treatment is associated with an increase in the number of osteoclasts, which include distinctive giant, hypernucleated, detached osteoclasts that are undergoing protracted apoptosis.