Prolonged successful therapy for hyperinsulinaemic hypoglycaemia after gastric bypass: the pathophysiological role of GLP1 and its response to a somatostatin analogue

BACKGROUND

Spontaneous hyperinsulinaemic hypoglycaemia following gastric bypass surgery (GBS) is increasingly recognised. However, its pathophysiology remains unclear. Some patients require pancreatectomy. Medical therapy with calcium channel blockers, acarbose and diazoxide has been reported to be beneficial but has variable adherence and response.

METHOD

We demonstrate the role of GLP1, counter-regulatory hormones and the subsequent response of GLP1 to somatostatin analogue therapy in a 42-year-old woman with persistent neuroglycopaenia 6 years after GBS. Plasma GLP1, insulin and glucose were measured for 5  h on three settings: i) a 75  g oral glucose tolerance test (OGTT); ii) a standard liquid test meal (LTM); and iii) an OGTT 30  min after a s.c. injection of 100  μg octreotide.

RESULTS

In comparison with obese non-diabetic controls, the patient had an elevated fasting and a markedly enhanced GLP1 response during the OGTT, followed by an exaggerated insulin response and a subsequent low glucose level. The GLP1 response to a LTM was similar but greater. Octreotide given prior to the OGTT attenuated both the GLP1 and insulin responses and abolished hypoglycaemia. Octreotide therapy significantly improved the patient's neuroglycopaenic symptoms. The hormone profile was reassessed after 6 months following the LTM preceded by octreotide injection. Peak GLP1 and insulin responses were less pronounced than pretreatment responses and without hypoglycaemia. The patient was treated with lanreotide and had remained symptom-free and euglycaemic for 4 years.

CONCLUSION

An exaggerated incretin response following altered gastrointestinal anatomy was the likely cause of hypoglycaemia in our GBS patient. Somatostatin successfully suppressed this response acutely and in the long term, thereby avoiding pancreatectomy and its sequelae.

[Dose dependent effects of the combined beta-gamma-emitter 188Rhenium on the growth of human vessel wall cells]

PURPOSE

To evaluate the dose of (188)Re that completely suppresses growth and clonogenic activity of human aortic smooth muscle cells (haSMC) since these cells are mainly responsible for restenosis occurring after PTA. For comparison, growth and clonogenic activity of endothelial cells (EC) were investigated with corresponding doses.

MATERIALS AND METHODS

Two days after plating, haSMC and EC were incubated with (188)Re for five days. The doses applied ranged from 4 to 16 Gy. Cell growth was observed for a period of 20 days (EC) or 30 days (haSMC), respectively. Clonogenic activity was monitored over a period of 20 days for both cell lines.

RESULTS

Irradiation caused dose-depend-ent inhibition of cell growth and clonogenic activity both in haSMC and in EC. HaSMC growth was completely blocked with 8 Gy, while EC still showed some proliferation even with 16 Gy. The clonal activity of haSMC was also completely blocked with 8 Gy while EC still showed little clonal activity even with 16 Gy.

CONCLUSION

Cell growth of both haSMC and EC can be effectively suppressed in a dose-dependent manner. Only haSMC showed a complete growth arrest with 8 Gy while EC were able to proliferate even with 16 Gy. HaSMC colony formation was completely suppressed after application of 8 Gy, while the EC still showed colony formation activity with 16 Gy. (188)Re has some advantageous properties for intravascular irradiation in comparison to other radionuclides making it an interesting radionuclide for stent coating to prevent restenosis.

Psychomotor development in preschool children exposed to antiepileptic drugs in utero

The aim of this study was to assess psychomotor development with the Griffiths' test in preschool children exposed to antiepileptic drugs (AED) in utero. The study sample consisted of 76 children exposed to AED in utero and 71 unexposed children. The children (exposed and unexposed) have since birth been included in a population-based longitudinal follow-up study of children born to women with meticulously treated epilepsy during pregnancy, initiated in 1985. In total, 67 exposed and 66 unexposed children were tested with the Griffiths' test, which consists of 6 subsets: locomotor function, personal and social behaviour, hearing and speech, eye and hand coordination, performance, and practical reasoning. There was no significant difference in the global scores of the Griffiths' test between the two groups of children. Children exposed to phenytoin in utero (n = 16) showed a significant but subtle reduction in the scores for locomotor development compared with the unexposed children (mean scores: 98 vs 106: 95% confidence interval for the difference in mean scores: -14.0 to -0.4). There was no such difference for the children exposed to carbamazepine in utero (n = 35). The exposed children had significantly fewer siblings (p < 0.01). A significant number of the mothers with AED treatment had no higher level of education than compulsory school (p < 0.01). No other differences in socioeconomic status were observed between the groups.

CONCLUSION

The subtle delay in locomotor development evaluated with the Griffiths' test at 4.5-5 y of age in children exposed to phenytoin may indicate a subtle influence on psychomotor development, which may be more obvious at school age: thus, larger studies and further follow-up are warranted.

[Surgical treatment of diffuse hyperthyroid goiter. Experience at a hospital in Valdivia, Chile]

BACKGROUND

The choice of medical, radiation or surgical therapy for hyperthyroid diffuse goiter is still empirical.

AIM

To report a retrospective analysis of the surgical treatment of hyperthyroid goiter in a Regional Hospital in Chile.

PATIENTS AND METHODS

The charts of 64 patients, 54 female, aged between 15 and 57 years old, operated between 1985 and 1995 were analyzed.

RESULTS

The indication for surgical treatment was failure of medical treatment in 59 patients and a big goiter causing mechanical compression in 3 patients. A subtotal thyroidectomy was done after an abbreviated surgical preparation. The mean weight of the resected glands was 65.9 g. Four patients had transient hypocalcemia and 4 had surgical wound seromas. After a mean follow up of 31 months, 77% of patients remain euthyroid, hyperthyroidism relapsed in 13.1% and 10% became hypothyroid.

CONCLUSIONS

Surgical treatment of hyperthyroid goiter is safe but the percentage of hyperfunction relapse is high.

[Breast hydatid cyst. A case report]

We report the case of a 63 years old woman with a left mammary hydatid cyst. The patient presented with a left painless mammary mass of four months evolution. Mammography showed a dense image of 9 cm phi in the left breast. Ultrasound showed a solid and heterogeneous lesion. The tumor was excised under general anesthesia. The initial macroscopic inspection showed a tumor with a well defined fibrous capsule filled with a grayish material that contained membrane debris. The pathological study confirmed the diagnosis of a hydatid cyst.

Tibial shock measured with bone and skin mounted transducers

The purpose of this study was to assess the value of superficial transducer mounting to measure tibial shock during locomotion. Surface (SMT) and bone mounted transducers (BMT) simultaneously recorded axial tibial acceleration in five subjects who ran at 4.5 m s-1. SMT produced inconsistent recording across the subjects both in the time and frequency domains. In two subjects, SMT signals provided close approximation of BMT signals, some distortion occurred in one subject while severe distortions were observed in the other two subjects. The present results established that SMT could not be used directly to quantify the shock transmitted through the tibia during running. However, frequency transformation of SMT recordings produced encouraging results; the transformed SMT signals mimicked the signals recorded with the bone mounted transducer.

[Cysts of second branchial cleft: review of 32 operated cases]

The aim of this work was to analyze retrospectively the clinical features of 32 patients aged 23.9 years (21 female) with the histological diagnosis of second branchial cleft cyst. In 28 patients, the cyst was localized below the mandibular angle. The presenting symptom was a cervical tumor in 30 patients and pain in eight. Fourteen aspiration punctures was performed obtaining 8 purulent and 6 straw colored aspirates. The preoperative diagnosis was correctly made in only 19 patients; the principal confounding diagnosis was tuberculous adenitis. All patients were operated performing a complete cystectomy in 30 and partial cystectomy in two. Three patients had a surgical wound infection and the cysts recurred 5 months and 4 years after operation in the two patients subjected to partial cystectomy. The histological study revealed squamous epithelial with underlying lymphoid tissue. It is concluded that aspiration puncture is useful for the correct diagnosis and that the cyst must be completely eradicated to avoid recurrences.

[Diffuse hyperthyroid goiter associated with occult papillary carcinoma of the thyroid. Report of 2 cases]

The association of diffuse hyperthyroid goiter and thyroid cancer is rare and interesting, considering that both diseases affect the same organ but have different pathogenesis and prognosis. We report two patients that consulted for diffuse hyperthyroid goiter and were subjected to a subtotal bilateral thyroidectomy due to antithyroid drug failure. Pathological study revealed the coexistence of diffuse gland hyperplasia and a papillary thyroid carcinoma of less than 7 mm phi. In both cases, the thyroid remanent was ablated with radioactive iodine during the postoperative period and thyroid substitution was started.

[Observation in 10 calves with a survival time of more than 100 hours after total heart replacement (author's transl)]

It is reported on 10 calves surviving total artificial heart replacement more than 100 hours. Pneumatically driven double-chambered blood pumps made of silastic were implanted. During the experiments an increase of the right atrial pressure as well as a rise of the perfusion volumes (CO) and of the blood volumes could be found regularly. At autopsy congestion of the organs especially of the liver was a regular finding. The changed hemodynamic is first seen as possible reason for this developments. The influence of anemia and the possible disturbances in the neurohumoral autoregulation of the animals by unphysiologic pressure curves are discussed.