Clinical Profile of a New Monoclonal Antibody-Based Immunoassay for Tissue Polypeptide Antigen

Our preliminary evaluation of a new monoclonal antibody-based assay for tissue polypeptide antigen (TPA) has shown it to be clinically equivalent to the polyclonal antibody-based assay for TPA. The new assay (TPA-M) employs three monoclonal antibodies to epitopes on cytokeratins 8, 18 and 19. This multicenter, multinational study included 266 patients with newly diagnosed carcinomas of the lung, breast, large bowel and urinary bladder. TPA values from the two assays were compared with three other cytokeratin markers (TPS, CYFRA 21–1 and TPACyk) and with the established reference markers for these malignancies (CEA and NSE for lung, CA 15–3 for breast, CEA and CA 19–9 for colorectal tumors). Analysis of receiver operating characteristic (ROC) curves in lung, colorectal and bladder cancer showed similar sensitivities for the two assays, ranging from 50% to 80% with a specificity of 95%. In breast cancer all the markers studied showed poor sensitivity. However, TPA determination by either method could discriminate advanced stage (stages III and IV) from early stage disease (stages 0 to II). TPA showed similar discriminating ability in bladder cancer. On the basis of the results obtained in our patient series, it seems that of the cytokeratin markers studied, TPA and TPA-M are the most sensitive and offer a wide range of clinical applications.

Paravertebral schwannoma with high uptake of fluorodeoxyglucose on positron emission tomography

A paravertebral mass was discovered in a 27-year-old woman, while investigating a painful shoulder and arm. CT, MRI and fine needle aspiration cytology (FNAC) pointed in the direction of a benign mass, but positron emission tomography (PET) showed a high uptake of [(18)F]fluorodeoxyglucose (FDG), which was indicative of a malignant lesion. Pathological analysis of the thoracoscopically resected tumour gave us the final diagnosis of a benign schwannoma. This report demonstrates that a high uptake of FDG in a non-malignant mediastinal tumour is possible.

Pseudodystrophy. A conversion disorder mimicking reflex sympathetic dystrophy

The authors suggest some criteria by which pseudodystrophy and reflex sympathetic dystrophy, although sharing some similar clinical features, can be distinguished as two different conditions, each requiring its own approach and management. The most important distinction is found on bone scintigraphy. In reflex sympathetic dystrophy the bone scan shows a typical increased tracer uptake (at least during stages I and II); in pseudodystrophy there is a normal or decreased tracer uptake in the affected region. Moreover the vascularization is increased in reflex sympathetic dystrophy stage I, whereas in pseudodystrophy hypovascularization is found from the beginning. The clinical features, as well as the results of technical investigations, psychological evaluation and treatment of 4 patients with pseudodystrophy are presented. The importance of distinguishing this condition from reflex sympathetic dystrophy is stressed.

The effect of stress on gastric emptying rate measured with a radionuclide tracer

BACKGROUND/AIMS

Stress can delay gastric emptying rate. This phenomenon has not yet been investigated with a physiological solid test meal or a regional analysis.

METHODOLOGY

We investigated the gastric emptying rate in beagle dogs using a radio-labeled solid test meal and a gamma camera. The transport to an unknown environment served as a stress stimulus. This offers the advantage to mimic fairly well the clinical situation just before a diagnostic or therapeutic procedure. Control values were obtained after the third investigation, in which all dogs were accustomed to the environment.

RESULTS

Regional analysis of the emptying curves from the whole gastric region revealed that the length of the lag phase increased with stress, but the post-initial emptying rate remained unchanged. Emptying of the fundus changed hardly, but the antropyloral motor activity decreased during stress.

CONCLUSIONS

Gastric emptying rate is impeded during stress. It is necessary to limit the unnatural stress-stimuli, in order to mimic the clinical situation. Measurement techniques that influence directly gastric emptying or act as a stress-stimulus by themselves are undesirable. A radionuclide solid test meal is preferable and a regional analysis reveals the impairment of the antral motility as the mechanism of the delay of gastric emptying.

Gastric emptying rate for solid and for liquid test meals in patients with dyspeptic symptoms after partial gastrectomy and after vagotomy followed by partial gastrectomy

BACKGROUND/AIMS

Gastric emptying rate for solid and for liquid test meals was investigated retrospectively in patients with longstanding epigastric distress after partial gastrectomy, either as primary treatment or after failure of vagotomy for peptic ulcer in order to find an explanation for the postoperative symptoms.

METHODOLOGY

Radionuclide-labeled liquid and solid test meals were used to evaluate gastric emptying rate, at least one year after surgery.

RESULTS

The lag phase for liquid test meals disappeared in all operated patients. Partial gastrectomy usually lead to fast emptying but this resective procedure, if performed after vagotomy, lead to stasis in a significant number of patients. Gastric emptying rate for solids increased in only a few of these symptomatic patients. In most of them however, there was a normal to decreased emptying rate. If a vagotomy had preceded the resective procedure, gastric emptying rate decreased significantly.

CONCLUSIONS

In all these symptomatic patients, gastric emptying had been disturbed for at least one type of test meal. This makes investigation for both meals necessary, especially since there is a lack of correlation. Furthermore, if vagotomy fails to prevent ulcer recurrence, one should carefully consider all options before performing partial gastrectomy since gastric emptying rate after these consecutive procedures worsens considerably.

Comparison of anterior and geometric mean liquid and solid gastric emptying rates in dogs and in patients after partial gastrectomy

OBJECTIVE

The purpose of this study was to determine if geometrical correction is necessary in the study of gastric emptying rate (GER) for liquids, using a low-energy radionuclide, such as 99mTc. Solid test meals were considered the reference.

METHODS

Both solid and liquid GERs were investigated using regional analysis. Anterior data were compared with geometrically corrected values in 15 dogs and 9 partial gastrectomy patients.

RESULTS

Anterior and geometrically corrected measurements differed significantly for solid food in the whole gastric region and in the antrum. Geometrically corrected values differed slightly from anterior data after partial gastrectomy. No difference was found for liquid food. Liquids redistributed much faster than solids within the stomach.

CONCLUSION

Measurement of GER using a single-phase liquid meal does not require geometrical correction. This is due to the rapid intragastric redistribution of the liquid. Geometrical correction for solid food can be omitted only after partial gastrectomy.

Gastric emptying rate measurement after vertical banded gastroplasty

BACKGROUND

In vertical banded gastroplasty (VBG), a small proximal gastric pouch is created, which is believed to fill rapidly and to empty slowly.

METHODS

In 13 patients who underwent VBG, gastric emptying rate was measured. A radiolabelled solid test meal was used before and 2 weeks after operation. From a region of interest above the whole stomach, the proximal pouch and the distal stomach, half emptying time as well as retention percentage were derived.

RESULTS

All patients experienced early satiety and gastric fullness after ingestion of a small test meal. The proximal pouch emptied rapidly. The evacuation of the test meal from the whole gastric region as well as the distal stomach were not altered significantly by the operation.

CONCLUSION

VBG is a safe operation which reduced weight significantly. Early satiety, however, induced by this technique, cannot be explained alone by slow emptying of the proximal pouch. The nature of the outlet of the pouch as well as the behavior of its wall must be considered.

What is reflex sympathetic dystrophy?

In the literature there is no unanimity with respect to the diagnosis of reflex sympathetic dystrophy (RSD). Frequently, the diagnosis is established on mere clinical grounds. In our opinion, however, bone scintigraphy is of major importance for the diagnosis. Using this examination, true RSD can be clearly differentiated from other conditions which are incorrectly diagnosed and treated as RSD. If the bone scan is not suggestive of RSD, the clinical picture, radiological examination and vascular scan may lead to the correct diagnosis. This may be a pseudodystrophy, in which a hypovascularization is found right from the start, while in true RSD there is initially a hypervascularization. Other conditions which may be confused with RSD are causalgia, neurotic compulsive postures, hysterical conversion, malingering and even self-mutilation. In the spontaneous course of RSD three phases can be distinguished. Stage I is the warm or hypertrophic phase, stage II the cold or atrophic phase. Per definition the third phase corresponds to stabilization or, in rare instances, to healing. By means of the vascular scan the correct stage can be determined, and the results of treatment evaluated. Finally it should be noted that in children the condition is completely different from true RSD, as it concerns a pseudodystrophy or disuse-related dystrophy. This condition may also be seen in adults and adolescents, usually females. The bone scan is always negative. In this way bone scintigraphy constitutes the means to answer the question as to what RSD is and what it is not. An algorithm for the differential diagnosis is presented.

Gastric emptying of liquid meals after anterior gastric stapling and posterior truncal vagotomy in beagle dogs: discrepancy with results for solid food

BACKGROUND/AIMS

Since the development of highly selective vagotomy (HSV), simplified procedures such as posterior truncal vagotomy with anterior gastric wall stapling (PTV-AGS) became available to achieve parietal cell denervation. The purpose of this investigation was to detect possible gastric emptying disturbances due to complete vagotomy of the posterior gastric wall and to stapling of the anterior stomach wall.

METHODOLOGY

Six female dogs, undergoing HSV, were compared with six others, in which PTV-AGS was performed. Radionuclide labeled liquid test meals were used to evaluate gastric emptying rate (GER) and results were compared with solid test meal emptying.

RESULTS

A small, statistically insignificant fastening of liquid gastric emptying was seen early after HSV, as well as after PTV-AGS, and persisted one year after operation. There proved to be a striking lack of correlation between the GER-results after liquid versus solid meals.

CONCLUSION

Just as after HSV, gastric emptying rates of liquid meals after PTV-AGS do not show a statistical difference as compared with preoperative values. Both operations therefore do not induce clinically important gastric motility changes. Separate test meals with liquid and solid food prove to be necessary in order to detect such changes.

Comparison of radionuclide labelled test meals versus endoscopy in the preoperative assessment of the gastric outlet patency

A series of 39 patients with peptic ulcer disease is investigated with respect to gastric outlet obstruction. Two diagnostic tools are compared, namely endoscopy and evaluation of radionuclide meal emptying. Endoscopic obstruction was qualified as non passage of a 14 mm gastroscope. Gastric emptying reduction was considered clinically relevant when half emptying times exceeded 60 minutes for solids and 12 minutes for liquids. Comparison of both techniques of radionuclide meal emptying with endoscopy showed a poor correlation (accuracy 15/28), especially when liquid gastric emptying versus endoscopy was concerned.

Analytical and clinical evaluation of a method to quantify bone alkaline phosphatase, a marker of osteoblastic activity

An immunoradiometric assay (IRMA), involving specific monoclonal antibodies (Ostase, Hybritech) and agarose electrophoresis (Isopal, Beckman), two methods for quantification of serum bone alkaline phosphatase (ALP), a marker for osteoblastic activity, were analytically and clinically compared in 293 patients: 79 with end-stage renal failure treated with hemodialysis and 214 with malignant disease. Acceptable within-assay precision was obtained for the IRMA method: 82.5% of the duplicate determinations had a coefficient of variation (CV) < 5%. Curve fitting characteristics were bad and the sensitivity was better than the one mentioned by the manufacturer. Overall correlation between the two methods was good (r = 0.92), except (a) for low values of bone ALP and (b) in some samples with high total liver ALP activity. Low bone ALP determined with the IRMA (< 5 micrograms/L) was confirmed by electrophoresis (< 22 U/L), but ALP activity determined by electrophoresis to be low (< 22 U/L) was not correlated with the IRMA results. After standardizing our results by computing z-values for bone ALP, delta z (= zostase - zelectrophoresis) was significant correlated with liver ALP activity (r = 0.73, P < 0.0001). We conclude that the IRMA for quantifying bone ALP is acceptable. However, when high values for bone ALP are found with the Ostase method, confirmation by electrophoresis remains mandatory to rule out cross-reactivity with high amounts of liver ALP.

Comparison of one first and three second generation methods for the determination of CA 125

The monoclonal antibody, OC125 (Centocor, Inc, Malvern, Pa) was the basis for the first generation, one step immunoradiometric assays (IRMA) to detect the CA 125 glycoprotein. Recently, two step IRMA's were developed, the CA 125 II generation assays. In these new assays the CA 125 capture antibody is the M11 monoclonal antibody coated on a solid phase and the OC125 monoclonal antibody is used as the tracer. We compared analytically and clinically one first generation radioassay, and three second generation assays (two radioassays and one ELISA). The ELISA method showed the best within-assay precision and the best curve fitting characteristics. In the clinical comparison, none of the correlations between the first and the second generation methods really satisfied, however the cut off level of 35 U/ml was confirmed. The four CA 125 assays do not yield equal results. As a consequence, the evolution of CA 125 serum concentration during disease monitoring is not reliable when different determination methods are used consecutively.

Stimulatory effects of L-5-hydroxytryptophan on postdexamethasone beta-endorphin levels in major depression

Recently it has been shown that acute administration of 200 mg L-5-hydroxytryptophan (L-5-HTP) PO may increase post-dexamethasone (DST) adrenocorticotropic hormone (ACTH) and cortisol levels in major, but not minor, depressed subjects. This study aimed to examine the effects of 200 mg L-5-HTP PO on post-DST beta-endorphin levels in the same depressed subjects. It was found that in major, but not minor, depressed subjects, L-5-HTP significantly increased post-DST beta-endorphin concentrations as compared to placebo. The L-5-HTP-induced post-DST beta-endorphin responses were significantly higher in major than in minor depressed subjects. There was a significant and positive relationship between L-5-HTP-induced post-DST beta-endorphin and ACTH or cortisol responses. There was a significant and positive relationship between L-5-HTP-induced post-DST beta-endorphin values and the Hamilton Depression Rating Scale (HDRS) score. The results show that the acute administration of L-5-HTP may increase the escape of beta-endorphin secretion from suppression by dexamethasone in major, but not minor, depression.

Lower serum transcortin (CBG) in major depressed females: relationships with baseline and postdexamethasone cortisol values

This study has been carried out to examine (i) transcortin or corticosteroid binding globulin (CBG), the major glucocorticoid transport protein, in major depressed versus minor depressed and normal subjects; and (ii) the relationships between CBG and basal and postdexamethasone cortisol or adrenocorticotropic hormone (ACTH) values. Serum CBG was significantly lower in major depressed than in minor depressed subjects and normal controls. The significant decrease in serum CBG was observed in major depressed women but not in major depressed men. In depressed subjects, there was a significant and negative relationship between serum CBG and severity of illness. There were significant positive relationships between serum CBG and basal 8:00 a.m. plasma cortisol in normal volunteers (r = 0.87, P < 10(-4)) and depressed subjects (r = 0.40, P = 0.0002). There was no significant relationship between serum CBG and 24-h urinary cortisol. In depressed patients, there was a positive relationship between serum CBG and postdexamethasone cortisol (r = 0.31, P = 0.003). It is concluded that, in depression, serum CBG levels should be taken into consideration for the interpretation of baseline and postdexamethasone plasma total cortisol levels.

Acute administration of buspirone increases the escape of hypothalamic-pituitary-adrenal-axis hormones from suppression by dexamethasone in depression

Recently, our laboratory found a significant enhancing effect of L-5-hydroxy-tryptophan (L-5-HTP) on post-dexamethasone (DST) plasma adrenocorticotropic hormone (ACTH) and cortisol levels in major-but not in minor-depression. To further elucidate the effects of central serotonin (5-HT) activity on the negative feedback of glucocorticoids on hypothalamic-pituitary-adrenal (HPA)-axis function in depression, this study investigates the effects of buspirone, a 5-HT1A receptor agonist, on post-DST ACTH and cortisol levels in 75 depressed subjects. Plasma post-DST ACTH and cortisol concentrations were significantly increased by the acute administration of buspirone (30 mg PO) compared to placebo. There were no differences in buspirone-induced post-DST ACTH or cortisol responses between minor and major depression. There were significant correlations between post-DST ACTH and cortisol, and between post-DST-buspirone ACTH and cortisol. The buspirone-induced post-DST cortisol responses were significantly higher in depressed women than men. It is concluded that buspirone may augment ACTH and, consequently, cortisol escape from suppression by dexamethasone in major as well as in minor depression.

An augmented escape of androstenedione from suppression by dexamethasone in melancholia: relationships to intact ACTH and cortisol nonsuppression

To further examine the association between basal and postdexamethasone (DST) pituitary and adrenal activity in depression, the authors measured intact adrenocorticotropic hormone (ACTH), androstenedione and cortisol, both in baseline and post-DST conditions, in 63 depressed subjects (14 minor, 33 simple major and 16 melancholic subjects). It was found that post-DST androstenedione, cortisol and ACTH values were significantly higher in melancholic than in minor depressed subjects. There were highly significant correlations between plasma androstenedione and ACTH both in baseline and post-DST conditions. The significant intercategory differences in post-DST androstenedione were determined by differences in post-DST ACTH. Basal and post-DST androstenedione values were significantly higher in men than in women and both values were significantly and negatively related to age. There were highly significant, positive relationships between cortisol and ACTH and between cortisol and androstenedione both in baseline and post-DST conditions. The results corroborate our hypotheses that, in depression, pituitary (ACTH) and adrenal (cortisol and androstenedione) hormonal secretion are tightly coupled in post-DST conditions and that the augmented escape of ACTH-target hormones in melancholia is, in part, related to that of pituitary ACTH.

Anterior gastric wall stapling combined with posterior truncal vagotomy in the treatment of duodenal ulcer

Anterior gastric stapling with posterior truncal vagotomy was examined as an alternative to highly selective vagotomy in the treatment of peptic ulcer disease. A clinical series of 32 patients who underwent the combined procedure is presented; gastric acid output was adequately reduced (basal output by 82 per cent, peak by 64 per cent). Motility changes were temporary and mild. Clinical follow-up, using a modified Visick grading, showed good to excellent results in 21 of 25 patients who could be classified. This procedure is suggested as an appropriate alternative to highly selective vagotomy.

Immunoradiometric method and electrophoretic system compared for quantifying bone alkaline phosphatase in serum

Agarose electrophoresis (Isopal, Beckman) and an immunoradiometric assay (IRMA) involving specific monoclonal antibodies (Ostase, Hybritech), two methods for the quantification of serum bone alkaline phosphatase (ALP, EC 3.1.3.1), a marker of osteoblastic activity, were compared in 293 patients: 79 with end-stage renal failure treated with hemodialysis and 214 with malignant disease. Overall correlation between the two methods was good (r = 0.92), except (a) for low values of bone ALP and (b) in some samples with high total liver ALP activity--both due to considerable cross-reactivity of the anti-bone ALP antibodies of the Ostase kit with liver ALP. This interference was not constant and was not evenly distributed across all concentrations of bone ALP. Low bone ALP determined with the IRMA (&lt; or = 5 micrograms/L) was confirmed by electrophoresis (&lt; or = 21 U/L), but bone ALP activity determined by electrophoresis to be low (&lt; or = 21 U/L) was not correlated with the IRMA results. After standardizing our results by computing z-values for bone ALP, delta z (= zOstase - zIsopal) was significantly correlated with liver ALP activity (r = 0.73, P &lt; 0.0001). We conclude that the IRMA for quantifying bone ALP is acceptable as a screening method. However, when high values for bone ALP are found with the Ostase method, confirmation by electrophoresis remains mandatory to rule out cross-reactivity with high amounts of liver ALP. For detecting low bone ALP activities, electrophoresis remains the method of choice.

Immunoradiometric method and electrophoretic system compared for quantifying bone alkaline phosphatase in serum

Agarose electrophoresis (Isopal, Beckman) and an immunoradiometric assay (IRMA) involving specific monoclonal antibodies (Ostase, Hybritech), two methods for the quantification of serum bone alkaline phosphatase (ALP, EC 3.1.3.1), a marker of osteoblastic activity, were compared in 293 patients: 79 with end-stage renal failure treated with hemodialysis and 214 with malignant disease. Overall correlation between the two methods was good (r = 0.92), except (a) for low values of bone ALP and (b) in some samples with high total liver ALP activity--both due to considerable cross-reactivity of the anti-bone ALP antibodies of the Ostase kit with liver ALP. This interference was not constant and was not evenly distributed across all concentrations of bone ALP. Low bone ALP determined with the IRMA (< or = 5 micrograms/L) was confirmed by electrophoresis (< or = 21 U/L), but bone ALP activity determined by electrophoresis to be low (< or = 21 U/L) was not correlated with the IRMA results. After standardizing our results by computing z-values for bone ALP, delta z (= zOstase - zIsopal) was significantly correlated with liver ALP activity (r = 0.73, P < 0.0001). We conclude that the IRMA for quantifying bone ALP is acceptable as a screening method. However, when high values for bone ALP are found with the Ostase method, confirmation by electrophoresis remains mandatory to rule out cross-reactivity with high amounts of liver ALP. For detecting low bone ALP activities, electrophoresis remains the method of choice.

Effects of serotonin precursors on the negative feedback effects of glucocorticoids on hypothalamic-pituitary-adrenal axis function in depression

In order to investigate the relationships between brain serotonergic turnover and hypothalamic-pituitary-adrenal (HPA) axis function in unipolar depression, the authors measured intact adrenocorticotropic hormone (ACTH) and cortisol levels in baseline conditions and after combined dexamethasone (1 mg PO) and L-5-hydroxytryptophan (L-5-HTP, 200 mg PO) administration in 13 minor, 17 simple major, and 17 melancholic subjects. L-5-HTP significantly enhanced post-DST ACTH and cortisol secretion in major--but not in minor--depressed subjects. Major depressed subjects with or without melancholia exhibited significantly higher post-DST ACTH and cortisol responses to L-5-HTP than minor depressed subjects. L-5-HTP administration converted some major depressed ACTH or cortisol suppressors into nonsuppressors. L-5-HTP stimulated ACTH or cortisol secretion to the same extent in major depressed HPA-axis suppressors and nonsuppressors. It is concluded that L-5-HTP loading may augment ACTH and, consequently, cortisol escape from suppression by dexamethasone in major but not in minor depressed subjects. The findings show that serotonergic mechanisms modulate the negative feedback of glucocorticoids on central HPA-axis regulation. It is hypothesized that the higher L-5-HTP-induced post-DST HPA-axis hormone responses in major depression reflect upregulated 5-HT2 receptor-driven breakthrough secretion of pituitary ACTH from suppression by dexamethasone.

Adrenocorticotropic hormone, beta-endorphin and cortisol responses to oCRH in unipolar depressed patients pretreated with dexamethasone

1. Corticotropin-releasing hormone (ovine CRH, 100 micrograms intravenous bolus) was given to 63 unipolar depressed inpatients following the 1 mg overnight dexamethasone suppression test (DST). The depressed patients included 18 minor, 24 simple major and 21 melancholic subtypes. 2. Baseline or postdexamethasone plasma levels of intact adrenocorticotropic hormone (ACTH), beta-endorphin/beta-lipotropin (beta END/beta LPH), cortisol, and dexamethasone were measured, as well as the post DST+CRH hormone responses. 3. CRH administration 9.5 hr after dexamethasone resulted in a significant enhancement of ACTH, beta END/beta LPH and cortisol secretion. The post DST+CRH ACTH and beta END/beta LPH- but not cortisol-values exceeded their baseline hormone levels. The post DST+CRH ACTH--but not beta END/beta LPH or cortisol-levels were significantly higher in major depressives compared to minor depressives. The post DST+CRH ACTH and beta END/beta LPH--but not cortisol-levels were significantly higher in DST nonsuppressors than suppressors. The post DST+CRH ACTH levels were significantly and positively related to severity of illness. 4. The results provide evidence that the pathophysiology underlying the abnormal DST+CRH and DST tests in melancholia is localized at the pituitary level and may consist of a CRH-driven breakthrough of corticotropic cell secretion synergized by central and peripheral agents, in conjunction with a decrease in glucocorticoid feedback suppressibility.

A further investigation of basal HPT axis function in unipolar depression: effects of diagnosis, hospitalization, and dexamethasone administration

Hypothalamic-pituitary-thyroid (HPT) axis function was assessed in depressed subjects 1 and 8 days after hospital admission, and after the administration of 1 mg of dexamethasone. Plasma levels of thyroid stimulating hormone (TSH), free triiodothyronine (FT3), and free thyroxine (FT4) were measured by ultrasensitive assays in 16 patients with minor depression, 15 patients with simple major depression, and 13 patients with melancholia. The postdexamethasone adrenocorticotropic hormone (ACTH) (intact 1-39 molecule) and cortisol values were determined. Basal TSH values were significantly lower in melancholic patients than in patients with minor and simple major depression on the day after admission and 1 week later. Basal TSH values determined 1 week after admission were significantly and negatively related to FT4 values and severity of depression. There were no significant differences in basal TSH, FT3, and FT4 values obtained on day 1 and day 8 after hospital admission. Dexamethasone administration had a significant suppressant effect on basal TSH and FT3 values. Patients who failed to suppress cortisol after the dexamethasone suppression test (DST) exhibited significantly less suppression of basal TSH values than did DST cortisol suppressors.

Multiple reciprocal relationships between in vivo cellular immunity and hypothalamic-pituitary-adrenal axis in depression

Major depression is reportedly characterized by increased activity of the hypothalamic-pituitary-adrenal (HPA) axis and by in vivo immune activation. The present study was carried out in order to investigate the relationships between HPA-axis activity and in vivo immune function in depression. Towards this end the following parameters were measured: 24 h urinary cortisol (UC) excretion; basal and post-dexamethasone (DST) plasma cortisol, beta-endorphin/beta-lipotropin (beta END/beta LPH) and dexamethasone concentrations; and leucocyte subsets (i.e. lymphocytes, neutrophils, monocytes, CD4+, CD4+CD45RA+, CD4+CD45RO+, CD8+, CD8+CD57+, CD8+CD57-, HLA-DR+, CD25+ T cells, HLA-DR+, CD19+, CD20+, and CD21+ B cells) both pre- and post-DST. Dexamethasone administration (1 mg orally) induced leucocytosis, lymphocytopaenia, monocytopaenia and neutrophilia. HPA-axis non-suppressors exhibited a relative resistance to the enhancing (e.g. neutrophils) or depressant (e.g. lymphocytes, CD4+ T cells) effects of dexamethasone. There were significant correlations between UC excretion and the number of percentage of lymphocytes, monocytes, CD4+CD45RA+ and CD8+CD57- T cells (negatively) and neutrophils (positively). It is concluded that multiple and complex intertwined relationships between HPA-axis hyperactivity and systemic immune stimulation participate in the pathophysiology or pathogenesis of major depression.

Comparison of the effect of conventional highly selective vagotomy and anterior gastric wall stapling with posterior truncal vagotomy on the gastric emptying rate for solid meals in beagle dogs

Anterior gastric wall stapling combined with posterior truncal vagotomy has been used as a new and adequate gastric acid output-reducing procedure. Severing the posterior vagal trunk as well as stapling the anterior gastric wall could impair gastric emptying. In this study, the gastric emptying rate for solid food, using a radionuclide technique, has been evaluated in 2 series of canine experiments. Compared to the results after conventional highly selective vagotomy, a temporary delay in the gastric emptying rate could be found after this new procedure, however, completely normalizing 1 year later.

Ultrasensitive assay for measuring the intact (1-39) ACTH molecule: an asset in depression research

This study investigates the utility for depression research of an assay for intact (1-39) adrenocorticotropic hormone (ACTH) versus that of a previously employed (i.e., 1-17, 1-24 sequences) ACTH assay. ACTH plasma levels were measured using two different ACTH assays (labeled as intact versus nonintact) in 10 minor and 27 major depressed subjects undergoing the combined dexamethasone suppression (DST) and corticotropin-releasing hormone (CRH) test. Intact--but not nonintact--ACTH values were significantly correlated with the severity of illness. Major depressed subjects exhibited significantly higher post-DST+CRH intact ACTH values than minor depressives, whereas nonintact ACTH values were not significantly different between these groups. Post-DST+CRH intact ACTH values were significantly more closely related to post-DST+CRH cortisol than nonintact ACTH values. It is concluded that the assay of the intact ACTH molecule is an asset in depression research and should replace the previous less specific and sensitive ACTH assays.

Hyperfunctioning unilateral adrenal macronodule in three patients with Cushing's disease: hormonal and imaging characterization

We aimed to investigate the dynamics of adrenocorticotropin (ACTH) and cortisol secretion in pituitary-dependent Cushing's syndrome with bilateral macronodular adrenal hyperplasia presenting as a single adrenal macronodule, and to determine the imaging characteristics of this syndrome. Three female patients were studied. Plasma ACTH and serum cortisol secretion were studied by determining their rhythmicity and pulsatility and their responses to the administration of ovine corticotropin-releasing factor, thyrotropin-releasing hormone, metyrapone, tetracosactrin, insulin and dexamethasone. Techniques used to localize the anatomical lesion were bilateral simultaneous inferior petrosal sinus sampling, magnetic resonance examination of the pituitary, computed tomography (CT) scanning and [75Se]cholesterol scintigraphy of the adrenal glands. Plasma ACTH and serum cortisol levels were measured using a commercial radioimmunoassay and an immunoradiometric assay. The ACTH and cortisol pulse number and amplitude were calculated using established computer software. In all three patients ACTH and cortisol secretory dynamics fulfilled the requirements for diagnosis of pituitary-dependent Cushing's syndrome. A close relationship between ACTH and cortisol pulses also favored a pituitary dependency. Study of the amplitude of cortisol pulses classified two patients in the group of hypopulsatile Cushing's disease. Adrenal CT scanning demonstrated the presence of a large single nodule. [75Se]Cholesterol scintigraphy showed bilateral radionuclide uptake, although mostly localized over the adrenal nodule. All patients underwent successful trans-sphenoidal hypophysectomy. Over a period of 1 year, a slow shrinkage of the adrenal nodule was observed in two patients, while no change in volume was observed in one patient.(ABSTRACT TRUNCATED AT 250 WORDS)

Pituitary and adrenal hormone responsiveness to Synacthen in melancholic subjects versus subjects with minor depression

Increased adrenal cortex responsiveness to adrenocorticotropic hormone (ACTH) has been suggested to contribute to increased cortisol secretion in dexamethasone nonsuppression and melancholia. To further examine this hypothesis, the following variables were examined in 68 patients with unipolar depression (minor, n = 24; simple major, n = 25; melancholic, n = 19): basal or post-Synacthen [ACTH(1-24), 250 micrograms IV] intact ACTH(1-39), beta-endorphin/beta-lipotropin, cortisol, and androstenedione concentrations, as well as the postdexamethasone (DST) plasma ACTH(1-39) and cortisol values. Melancholic subjects showed significantly higher baseline ACTH(1-39), beta-endorphin/beta-lipotropin, and androstenedione values compared with subjects with minor depression. No significant differences in post-Synacthen cortisol or androstenedione secretion between any of the groups or between [ACTH(1-39) or cortisol] DST nonsuppressors and suppressors were found. No significant relationships between DST and ACTH test results were observed. Abnormally increased post-DST cortisol values in melancholic subjects were highly predicted (> 68% of the variance) by post-DST intact ACTH levels. ACTH(1-39) values were significantly lower after Synacthen administration in melancholic subjects than in subjects with minor depression. These results are not consistent with the hypothesis that melancholia is characterized by an increased adrenocortical responsivity to exogenous ACTH compared with minor depression or that DST nonsuppression is due to adrenal hyperresponsiveness.

TSH responses to TRH as a function of basal serum TSH: relevance for unipolar depression in females--a multivariate study

Baseline thyroid-secreting-hormone (TSH)-assessed by means of ultrasensitive assays (IRMA)-and free-thyroid-hormone (FT4) levels were determined in 84 depressed females, and the TSH responses to 200 micrograms thyrotropin-releasing hormone (TRH) (IV) measured. It was found that TRH-induced TSH responses were linearly and positively related to basal TSH-IRMA; lower TRH-stimulated TSH secretion in melancholic patients was attributable to lowered basal TSH-IRMA values. A progression was found-within the euthyroid range-of basal TSH-IRMA values towards lower levels along the diagnostic spectrum: the highest basal TSH-IRMA levels were witnessed in minor depressives and the lowest in melancholics, while simple major-depressed females occupied an intermediate position. This shift appears to be indicative of severity of illness. Basal TSH-IRMA data can roughly be used as a clinical tool separating melancholia from minor depression: at a threshold value of less than or equal to 1 microUI/ml, sensitivity was 56% and specificity 92%. It is concluded that basal TSH-IRMA provides a more accurate representation of melancholia than peak TSH responses, which appear to constitute little more than a magnified, but biased signal of basal TSH-IRMA. In future, the assay of basal TSH-IRMA could replace TRH testing.

Adrenocorticotropin hormone, beta-endorphin and cortisol responses to oCRF in melancholic patients

Several authors have reported attenuated adrenocorticotropin hormone (ACTH) responses to corticotropin releasing factor (CRF) administration in melancholic patients as compared with healthy controls. In order to explore the integrity of the hypothalamic-pituitary-adrenal (HPA)-axis in melancholics, we examined the following parameters in 98 subjects: the ACTH; beta-endorphin; and cortisol responses to ovine CRF (oCRF) (100 micrograms/i.v.); and the postdexamethasone cortisol values. We found significant lower CRF-induced ACTH responses in melancholic patients as opposed to healthy controls and minor depressives, while major depressives occupied an intermediate position. The psychopathological correlates of the blunted CRF-induced ACTH responses were feelings of worthlessness, self-reproach, or excessive guilt. The CRF-stimulated beta-endorphin and cortisol response did not differ between the study samples. Higher baseline plasma cortisol was associated with attenuated CRF-induced ACTH responses, but these effects were not pertinent to melancholia. There were no relationships between the disordered oCRF test results, and postdexamethasone cortisol values, age, body size, sex and severity of illness. The diagnostic power of the oCRF and the dexamethasone suppression test for melancholia is enhanced when both test results are combined.

The use of 99Tcm-HSA dynamic vascular examination in the staging and therapy monitoring of reflex sympathetic dystrophy

Evaluation of the local haemodynamic changes was performed in 93 patients with untreated reflex sympathetic dystrophy, based upon a simple dynamic vascular examination technique, using 99Tcm-HSA. According to the disease stage, opposite observations were made: in stage I (n = 72) an increase in both blood flow and blood volume was found, in stage II (n = 21) in contrast, both blood flow and blood volume decreased. These findings show that reflex sympathetic dystrophy can be staged according to haemodynamic changes. It is obvious, moreover, that a careful haemodynamic staging is most important for the choice of the right vasoactive treatment; e.g. calcitonin (vasoconstrictive) versus guanethidine (vasodilating).

L-5-hydroxytryptophan stimulated cortisol escape from dexamethasone suppression in melancholic patients

The dexamethasone suppression test (DST) was carried out in 62 depressed patients. At 0800 the postdexamethasone cortisol values were determined and 125 mg L-5-hydroxytryptophan (L-5-HTP) was administered. The second cortisol sample at 0930 revealed a significant enhancing effect for L-5-HTP on the postdexamethasone cortisol values in melancholic patients, whereas no effects were detected in minor depressives. Our results show that L-5-HTP converts some DST suppressors into nonsuppressors, whereas the escape from dexamethasone in some nonsuppressors is markedly stimulated. The L-5-HTP-stimulated 0930 postdexamethasone cortisol values performed markedly better than the 0800 DST results: at a cut-off value of greater than or equal to 5 micrograms/dl the sensitivity for melancholia increased from 46% to 68%, and the specificity remained unchanged (96%).

Calculation of half-life of carcinoembryonic antigen after lung tumour resection: a case report

Since little is known about carcinoembryonic antigen (CEA) half-life in humans, we followed changes in CEA levels after curative resection of a small bronchial adenocarcinoma in a 54 yr old man with an unusually high preoperative serum CEA level of 1,199 ng.ml-1. Serum CEA followed a four phase curve with an initial increase, attributed to release of CEA from the tumour, a rapid fall during four days (CEA half-life 3.2 days), a slower exponential decay to normal levels during almost three months (CEA half-life 11 days) and eventually maintenance of normal levels for 14 months. These results are consistent with data from animal experiments and a single report on CEA half-life in humans, but CEA half-life seems longer in man than in animals. This observation also suggests that a very high serum CEA level should not in itself preclude curative surgical resection of a primary bronchogenic carcinoma.

Calculation of half-life of carcinoembryonic antigen after lung tumour resection: a case report

Since little is known about carcinoembryonic antigen (CEA) half-life in humans, we followed changes in CEA levels after curative resection of a small bronchial adenocarcinoma in a 54 yr old man with an unusually high preoperative serum CEA level of 1,199 ng.ml-1. Serum CEA followed a four phase curve with an initial increase, attributed to release of CEA from the tumour, a rapid fall during four days (CEA half-life 3.2 days), a slower exponential decay to normal levels during almost three months (CEA half-life 11 days) and eventually maintenance of normal levels for 14 months. These results are consistent with data from animal experiments and a single report on CEA half-life in humans, but CEA half-life seems longer in man than in animals. This observation also suggests that a very high serum CEA level should not in itself preclude curative surgical resection of a primary bronchogenic carcinoma.

Serum postdexamethasone prolactin measures in depressive patients and control subjects

Recently, some researchers noted significant positive relationships between postdexamethasone serum cortisol and prolactin levels, whilst endogenous depressives exhibited a significantly lower suppression of prolactin by dexamethasone than non-endogenous patients or normal controls. To ascertain the extent of prolactin responses to dexamethasone in severely depressed patients, we measured 8 a.m. pre- and postdexamethasone prolactin levels in 104 depressed and 42 normal subjects. Serum cortisol levels were also determined in depressed patients before and after dexamethasone administration. We found a significant suppressive effect of dexamethasone on prolactin levels. There were no significant differences either in pre- or postdexamethasone prolactin, or in actual dexamethasone-induced decrements in prolactin between normal controls, melancholics, simple major or minor depressed subjects. We have not found any significant relationships between cortisol and prolactin, either under baseline or postdexamethasone conditions.

Changes in serum thyroid hormone autoantibody concentrations during pregnancy: a case report

A 29-year-old female patient with Graves' disease who developed thyroid hormone autoantibodies (THAA) under treatment with methimazole is presented. THAA were identified as IgG-kappa. During a first pregnancy that ended by miscarriage in the 3rd month, the titer of anti-thyroxine autoantibodies decreased by about 30%. Relapse of Graves' disease occurred 2 months later and an increase in serum THAA concentration to the initial titer was observed. THAA titer remained unchanged during treatment with methimazole and afterwards during thyroxine supplementation for radioiodine-induced hypothyroidism. During a second pregnancy, a decrease in anti-thyroxine autoantibody titer reached 45% at the time of delivery and an increase by 20% was noted 5 months later. A similar decline in THAA concentration was shown during a third pregnancy. The changes in THAA concentrations observed during pregnancy suggest an immunological influence of pregnancy on the THAA production, as previously demonstrated in other autoimmune diseases, like Hashimoto's thyroiditis.

A revised interpretation of postdexamethasone ACTH and cortisol findings in unipolar depressed females

Baseline 8 a.m. adrenocorticotropic hormone (ACTH) and cortisol levels and the postdexamethasone ACTH/cortisol values at 8 a.m. and 4 p.m. were determined in 86 depressed females diagnosed using DSM-III criteria. Postdexamethasone ACTH and cortisol values were significantly correlated with their baseline levels. We have shown that regression analysis should be used to assess dexamethasone-induced changes as the residual ACTH and cortisol responses, with the relative effects of the baseline data on the hormone responses being partialed out. The residual ACTH and cortisol values were significantly increased in the most severely depressed females as compared to minor depressives. The residual ACTH responses were markedly correlated with the residual cortisol responses. Cortisol nonsuppression during a depressive episode appeared to be determined by an augmented ACTH escape from dexamethasone suppression. The residual ACTH and cortisol responses could prove to be the most sensitive reflection of the disorder in the negative feedback by dexamethasone on the pituitary. In clinical practice, the ratio ln (postdexamethasone ACTH): ln (basal ACTH) can be used, since this ratio is linearly correlated with the residual ACTH responses.

Clinical subtypes of unipolar depression: Part III. Quantitative differences in various biological markers between the cluster-analytically generated nonvital and vital depression classes

The hypothalamic-pituitary-adrenal (HPA) axis, the hypothalamic-pituitary-thyroid (HPT) axis, and the availability of L-tryptophan (L-TRP) to the brain were studied in their relationships to (1) 14 depressive symptoms measured by the Structured Clinical Interview for DSM-III-R--Patient Version (SCID) and (2) the cluster-analytically generated vital/nonvital classes. The following biological parameters were measured in 100 depressed females: free thyroxine (FT4), baseline thyroid stimulating hormone (TSH), predexamethasone and postdexamethasone cortisol and adrenocorticotropic hormone (ACTH) values, the circulating levels of total L-TRP, and the L-TRP/sum of competing amino acids ratio. We found that the psychopathological correlates of disorders in the HPA/HPT axis and of a decreased availability of L-TRP were vital symptoms, i.e., distinct quality of mood, nonreactivity, early morning awakening, anorexia-weight loss, and psychomotor disorders. There was no significant relationship between those biological markers and the nonvital symptoms of the SCID inventory for depressive symptoms. However, we did not validate our SCID clustering in vital and nonvital classes by qualitative differences in the biological variables. It was concluded that our nonvital/vital clusters should be regarded as continuous categories with regard to the biological markers studied; these clusters constitute relevant stages in the continuum of progressing biological dysfunction.

Suppressive effects of dexamethasone on hypothalamic-pituitary-thyroid axis function in depressed patients

This study investigated the effects of dexamethasone (1 mg orally) on the function of the hypothalamic-pituitary-thyroid (HPT) axis. We determined pre- and post-dexamethasone thyroid-secreting hormone (TSH), free thyroxine (FT4), free triiodothyronine (FT3), reverse T3 and cortisol levels in 61 depressed inpatients. Dexamethasone had a pronounced suppressive effect on basal TSH and FT3 levels. It had a significant stimulating effect on rT3 levels. No differences were found between melancholic and minor depressives in the effects of dexamethasone on basal TSH, FT3 and rT3. Cortisol non-suppressors were characterized by less suppression of basal TSH values.

Positive relationship between the catecholaminergic turnover and the DST results in depression

In the past some workers have reported positive relationships between indices of noradrenaline activity and measures of hypothalamic-pituitary-adrenal (HPA)-axis function. In order to investigate these relations, the authors measured noradrenaline, adrenaline and vanillylmandelic acid (VMA) in 24 h urine samples of 72 depressed females. Serum adrenocorticotrophic hormone (ACTH) and cortisol concentrations were determined before and after administration of 1 mg of dexamethasone. Cortisol non-suppressors exhibited a significantly higher noradrenaline, adrenaline and VMA excretion as compared to cortisol suppressors. We determined significantly positive correlations between the postdexamethasone cortisol values and the excretion rates of noradrenaline and VMA. These indices of noradrenaline activity correlated neither with the baseline cortisol and ACTH nor with the postdexamethasone ACTH values.

The relationships between the cortisol responses to dexamethasone and to L-5-HTP, and the availability of L-tryptophan in depressed females

In order to investigate the relationships between the hypothalamic-pituitary-adrenal (HPA)-axis activity, the central serotonergic neurotransmission, and the peripheral metabolism of l-tryptophan (L-TRP), the authors measured the following: the postdexamethasone cortisol values, the cortisol responses to 125 mg 5-hydroxy-L-tryptophan (L-5-HTP) orally, and the total L-TRP/competing amino acids (CAA) ratio in 64 depressed females. Severely depressed females showed significantly lower values for L-TRP/CAA, significantly higher postdexamethasone cortisol values, and cortisol responses to L-5-HTP as compared with minor depressives. Dexamethasone nonsuppressors showed significantly lower L-TRP/CAA values as compared with suppressors. The cortisol responses to dexamethasone were significantly and negatively correlated with the availability of L-TRP. The cortisol responses to L-5-HTP were not related to either the availability of L-TRP or to the postdexamethasone cortisol values.

Gastric emptying for solids in patients with duodenal ulcer before and after highly selective vagotomy

In a series of 31 duodenal ulcer patients (23 males and 8 females), who underwent a highly selective vagotomy, gastric emptying characteristics of a solid meal, labeled with [99mTc]stannous colloid, were assessed before, two weeks and six months after operation. The clinical diagnosis was confirmed by endoscopy and x-ray; failure of treatment with H2 antagonists or antacids during 1-18 (mean 5) years was the direct indication for operative treatment. A temporary delay in gastric emptying is noted two weeks after operation (T1/2: 124 vs 57 min). After six months, gastric emptying time has practically normalized. It appears that this is the result of the preservation of the antropyloric vagal nerve supply. In these patients, a 10% recurrence rate is noted, comparable to the results in the literature. Highly selective vagotomy proves to be a safe and effective procedure with few side effects. It does not impair gastric motility.

Hypoglycemia owing to inappropriate glucagon secretion treated with a continuous subcutaneous glucagon infusion system

A selective glucagon deficiency was documented in a 36-year-old female patient suffering from severe hypoglycemic attacks. The extremely low fasting plasma glucagon levels could not be stimulated by hypoglycemia. The increase in plasma glucagon during stimulation with arginine did not prevent hypoglycemia provoked by the simultaneous insulin secretion. Treatment consisting of a continuous sc glucagon infusion system resulted in correction of both postabsorptive and postprandial hypoglycemia. Further lowering of the glucose level during an arginine test could be the hallmark of this hypoglycemic syndrome characterized by an inappropriate glucagon secretion. This case report would indicate that epinephrine cannot prevent hypoglycemia when glucagon release is completely deficient.

The effects of glucocorticoids on the availability of L-tryptophan and tyrosine in the plasma of depressed patients

There is evidence that a functional deficit of serotonin/noradrenaline and/or of their precursors L-tryptophan (L-TRP)/tyrosine and disorders in the hypothalamic-pituitary-adrenal (HPA) axis are linked to the pathophysiology of severe depressions. Several reports suggest a reciprocal relationship between these neurotransmitters and HPA axis activity. In order to investigate the effect of glucocorticoid excess on the availability of L-TRP and tyrosine to the brain, we measured urinary cortisol (UC) excretion in 24-h urine, and the availability of both amino acids before and after treatment with 1 mg dexamethasone in 26 depressed patients. We found no relationship between UC excretion and the availability of either amino acid. Dexamethasone significantly suppressed the availability of L-TRP (P less than 10(-5] and of tyrosine (P = 0.005). Major depressed patients with melancholia exhibited a significantly lower availability of L-TRP than minor depressives (P = 0.007).

The decreased availability of L-tryptophan in depressed females: clinical and biological correlates

1. The plasma levels of L-tryptophan (L-TRP) and the sum of five competing amino acids (CAA) namely tyrosine, phenylalanine, valine, leucine, isoleucine, were determined in 79 depressed females categorized according to the DSM-III. 2. In these patients the authors measured several parameters known to affect the availability of the above amino acids, i.e. triidothyronine (FT3) and thyroxine (FT4), vanilylmandelic acid (VMA), noradrenaline and adrenaline in 24 hr urine, the sex hormonal and nutritional state. 3. The 1 mg dexamethasone suppression test was performed and the pre and postdexamethasone cortisol and adrenocorticotropic hormone (ACTH) levels were determined at 8 a.m. 4. L-TRP and the ratio L-TRP/CAA were significantly lower in severely depressed females (296.X3, 296.X4) as compared with minor (300.40, 309.00) and simple major depressives (296.X2). The ratio L-TRP/CAA performed well as a clinical tool separating melancholic from minor depression. 5. FT3, FT4, VMA and noradrenaline were significantly increased in the severely depressed females, but these data did not correlate with the availability of L-TRP. Neither baseline cortisol nor the sex hormonal, nor the nutritional state related to the L-TRP data. The ratio L-TRP/CAA was significantly and negatively correlated with the postdexamethasone cortisol and ACTH values.

Sex-linked differences in cortisol, ACTH and prolactin responses to 5-hydroxy-tryptophan in healthy controls and minor and major depressed patients

Some researchers have found that the administration of 5-hydroxytryptophan (5-HTP) results in increased cortisol secretion in major depressives but not in healthy controls. Other authors observed gender-related differences in cortisol responses to 5-HTP in major depressives. In order to investigate the pituitary/adrenal responsivity to 5-HTP, the authors measured cortisol, adrenocorticotropic hormone (ACTH) and prolactin (PRL) in 30 healthy controls and in 90 depressed patients; the hormone levels were determined in baseline conditions and 60, 90 and 120 min after 125 mg L-5-HTP (orally, non-enteric coated). We found that healthy men had significantly higher cortisol responses to L-5-HTP than healthy women. In the major depressives with melancholia and/or psychotic features these differences were reversed: women exhibited significantly higher cortisol and PRL responses than men. In the female group the most severely depressed patients had increased cortisol and PRL responses to L-5-HTP. The amplitudes of the cortisol, ACTH and PRL responses to L-5-HTP were significantly and positively correlated. It was concluded that the central serotonergic regulation of ACTH and PRL is significantly different between the sexes and between healthy controls, minor depressives and severely depressed patients.