The Impact of Enhanced Triage on the Emergency Service with Special Track Streams

Background

Over sixty percent of emergency department (ED) attendances belonged to the semi-urgent or non-urgent categories. The existing triage system failed to detect those patients in need of emergency service within these groups. It increased the risk to patients and affected the quality of care especially with overcrowding and long waiting time.

Objective

To assess the impact of a special track program in providing medical services to targeted groups and on the overall emergency service.

Method

Four special groups of patients triaged as semi- or non-urgent and required procedural interventions or possible in-hospital treatment were identified. The impact on waiting time, length of stay, rate of left without being seen and re-attendances rate were measured and studied prospectively.

Results

A total of 438 cases were analysed. Special track groups had a shorter mean waiting time and mean disposal time (36.6 minutes and one hour) when compared with all category 4 patients. Special track group had no disappeared case and a smaller re-attendance rate.

Conclusions

Special track program improves the safety and quality of care in patients of fast track streams without compromising care to other semi-urgent or non-urgent categories patients.

Mushroom poisoning in Hong Kong: a ten-year review

INTRODUCTION

Mushroom poisoning is a cause of major mortality and morbidity all over the world. Although Hong Kong people consume a lot of mushrooms, there are only a few clinical studies and reviews of local mushroom poisoning. This study aimed to review the clinical characteristics, source, and outcome of mushroom poisoning incidences in Hong Kong.

METHODS

This descriptive case series review was conducted by the Hong Kong Poison Information Centre and involved all cases of mushroom poisoning reported to the Centre from 1 July 2005 to 30 June 2015.

RESULTS

Overall, 67 cases of mushroom poisoning were reported. Of these, 60 (90%) cases presented with gastrointestinal symptoms of vomiting, diarrhoea, and abdominal pain. Gastrointestinal symptoms were early onset (<6 hours post-ingestion) and not severe in 53 patients and all recovered after symptomatic treatment and a short duration of hospital care. Gastrointestinal symptoms, however, were of late onset (≥6 hours post-ingestion) in seven patients; these were life-threatening cases of amatoxin poisoning. In all cases, the poisonous mushroom had been picked from the wild. Three cases were imported from other countries, and four collected and consumed the amatoxin-containing mushrooms in Hong Kong. Of the seven cases of amatoxin poisoning, six were critically ill, of whom one died and two required liver transplantation. There was one confirmed case of hallucinogenic mushroom poisoning caused by Tylopilus nigerrimus after consumption of a commercial mushroom product. A number of poisoning incidences involved the consumption of wild-harvested dried porcini purchased in the market.

CONCLUSION

Most cases of mushroom poisoning in Hong Kong presented with gastrointestinal symptoms and followed a benign course. Life-threatening cases of amatoxin poisoning are occasionally seen. Doctors should consider this diagnosis in patients who present with gastrointestinal symptoms that begin 6 hours or more after mushroom consumption.

Co-morbidities in psoriasis: a hospital-based case-control study

BACKGROUND

Recent researches show that psoriasis is frequently associated with systemic co-morbidities.

OBJECTIVES

This study aimed to identify possible associated co-morbidities in psoriatic patients stratified by age and sex.

METHODS

In this retrospective hospital-based case-control study, patients diagnosed as psoriasis at the Kaohsiung Veterans General Hospital in Taiwan between January 2008 and December 2009 were enrolled as cases and classified into severe and mild based on their use of systemic therapy. The controls were the patients without psoriasis matched the cases in 1 : 1 ratio with same birth year, sex and calendar date. Odds ratios (ORs) and 95% confidence intervals (CIs) from the conditional logistic regression method were used to assess the risk of co-morbidities between psoriatic and non-psoriatic patients.

RESULTS

A total of 447 cases and 447 matched controls, with mean age of 51.3 ± 18.3 years and male-to-female ratio of 2.17 : 1 were enrolled. The ratio of mild-to-severe was 3.5 : 1. Compared with non-psoriatic patients, psoriatic patients had significantly higher OR of hypertension (1.85), diabetes mellitus (2.88) and obesity (1.66). Among those aged ≥51 years old, there was significant risk in male psoriatic patients with ischaemic and hypertensive heart disease (IHHD) (OR = 2.167) after eliminating female IHHD psoriatic patients (OR = 0.125). Psoriasis was significantly negatively associated with cancers (OR = 0.267). Psoriasis patients often had the usual drinking habit (OR = 2.23) and seldom had an occasional drinking habit (OR = 0.25).

CONCLUSIONS

Psoriasis is strongly associated with hypertension, diabetes mellitus and obesity. The association between psoriasis and IHHD, stroke, cancers, smoking and alcohol habits warrant more investigation.

Newer fluoroquinolones for treating respiratory infection: do they mask tuberculosis?

Possible masking of tuberculosis (TB) in treatment of community-acquired respiratory infection by newer fluoroquinolones has not been examined in randomised controlled trials. We undertook a randomised, open-label controlled trial involving adults with community-acquired pneumonia or infective exacerbation of bronchiectasis encountered in government chest clinics in Hong Kong. 427 participants were assigned by random permutated blocks of 20 to receive either amoxicillin clavulanate (n = 212) or moxifloxacin (n = 215). Participants were followed for 1 yr for active pulmonary TB. Excluding three participants with positive baseline culture, 13 developed active pulmonary TB: 10 (4.8%) out of 210 were given amoxicillin clavulanate, and three (1.4%) out of 214 were given moxifloxacin. The difference was significant by both proportion and time-to-event analysis. Post hoc analysis showed a significant decrease in the proportion with active pulmonary TB from 4.8% to 2.4% and 0% among participants given amoxicillin clavulanate (n = 210), moxifloxacin for predominantly 5 days (n = 127) and 10 days (n = 87), respectively. The log rank test for trend also showed a significant difference between the three subgroups. Regression models reaffirmed the linear effect; the adjusted odds ratio (95% confidence interval) of active pulmonary TB after moxifloxacin exposure up to predominantly 10 days was 0.3 (0.1-0.9). Newer fluoroquinolones appear to mask active pulmonary TB.

Suppression of choroidal neovascularization by intramuscular polymer-based gene delivery of vasostatin

The purpose of this study was to evaluate the efficacy of gene delivery of angiogenesis inhibitor, vasostatin (VS), in suppressing experimental model of choroidal neovascularization (CNV). A mammalian expression vector carrying VS, pCMV3-VS, was constructed and evaluated for its ability to produce VS in transfected cells using western blot analysis and a cell viability assay. CNV was induced in Brown Norway rats by fundus argon laser photocoagulation and evaluated by fundus fluorescein angiography (FAG). Ten days post-laser treatment, gene delivery was achieved by intramuscular (IM) injection of poly-(N-vinyl pyrrolidone) (PVP) polymer conjugated with pCMV3-VS (PVP-VS) or a control vector (PVP-vector). Systemic VS expression was analysed by western blot analysis and enzyme linked immunosorbent assay (ELISA), and the extent of CNV was monitored by FAG analysis at different time intervals post-PVP treatment. Transfection of pCMV3-VS into muscle cells resulted in increased production and release of exogenous VS, which specifically inhibited the proliferation of endothelial cells. Besides, IM injection of PVP-VS, but not PVP-vector, led to elevated VS level in plasma for 30 days. After laser photocoagulation, rats injected with PVP-VS exhibited significantly lower incidence of CNV comparing with animals of control groups (P < 0.01) for at least 42 days. Moreover, rats treated with PVP-VS also showed a significant reduction in the CNV lesions compared with control groups (P < 0.001) for at least 42 days. Above all, no overt adverse effects were observed in rats received PVP-VS. These results demonstrate the potential of IM VS gene delivery for CNV treatment.

Management of ingested foreign bodies: a retrospective review of 5240 patients

This review was carried out to assess the effectiveness of our protocol designed for the management of ingested foreign bodies. It was a retrospective review of 5240 patients with ingested foreign bodies admitted over a five-year period to the Ear Nose and Throat Unit. These patients were managed according to a standardized protocol which was adopted and modified from our previous study. Under his management protocol, the mean hospital stay was 1.6 days. Flexible oesophagoscopy under local anaesthesia, and rigid oesophagoscopy under general anaesthesia, were performed in 1.5 per cent and 7.7 per cent of cases respectively. Major complications including oesophageal perforation and deep neck abscesses occurred in 0.19 per cent of patients. There was no mortality. This management protocol for ingested foreign bodies was both safe and cost-effective when compared to similar studies reported in the literature.

Internal carotid artery hemorrhage after irradiation and osteoradionecrosis of the skull base

OBJECTIVE

To evaluate the clinical presentation and management of internal carotid artery rupture after irradiation and osteoradionecrosis of the skull base.

STUDY DESIGN AND SETTING

A retrospective review of the patients in an otorhinolaryngology-head and neck secondary and tertiary referral center.

METHODOLOGY

From January 1993 to December 1996, patients with hemorrhage from internal carotid artery as a complication of irradiation and osteoradionecrosis of skull base were reviewed and analyzed.

RESULTS

Four patients with internal carotid arterial rupture were included in this study. Angiography was performed in all cases. Embolization of the aneurysm was performed on 2 patients and the remaining 2 patients underwent occlusion of their internal carotid arteries. Three of the 4 patients did not survive. The fourth is currently alive and well 18 months after embolization of 1 internal carotid artery.

CONCLUSION

Skull base osteoradionecrosis with bleeding from internal carotid artery is a potentially fatal complication of irradiation. Angiography was the mainstay of diagnosis with embolization of the aneurysm and embolization or ligation of the internal carotid artery being the management options. Internal carotid artery occlusion is the definitive treatment provided cross circulation is adequate.

SIGNIFICANCE

The advantages and disadvantages of the treatment options are discussed and a management protocol is proposed.

Prognostic factors of hyperglycemic hyperosmolar nonketotic state

BACKGROUND

To delineate the prognostic factors of patients suffering from hyperglycemic hyperosmolar nonketotic state (HHNK) in Taiwan.

METHODS

We reviewed the charts of patients who had been admitted to the Division of Endocrinology and Metabolism of Kaohsiung Veterans General Hospital from 1992 to 1998 due to HHNK. General and clinical data were collected. The influential factors for prognosis were determined.

RESULTS

One hundred and nineteen patients fulfilling the criteria of HHNK were included in our study. The mean age was 67.8 +/- 11.7 years with male predominance. Twenty-nine patients died which produced a fatality rate of 24.4%. Eighty-six (72.3%) cases occurred in patients with known diabetic history, while another thirty-three (27.7%) occurred in patients with no diabetic history. Most patients received oral antidiabetic drugs before HHNK episodes. The patients who died had shorter length of inpatient stay than did survivors. The leading precipitating factor was infection (57.1%), followed by poor compliance of medication (21.0%) and undiagnosed diabetes (10.9%). Fifty patients (42%) had a history of stroke. The risk factors for death included precipitation of HHNK by infection and low Glasgow coma scale (GCS) on admission. Old age itself did not contribute to death. Severity of hyperglycemia or hyperosmolarity was also not an important prognostic factor. Multiple logistic regression revealed that low GCS on admission was the most influential factor of leading to death. Most of the patients who died did so due to underlying precipitating factors.

CONCLUSIONS

Neither age nor osmolarity, but underlying precipitating factors and state of consciousness were the most influential factors affecting the prognosis of HHNK.

Role of endothelin in diabetic vascular complications

Endothelin-1 (ET-1), a 21 amino acid peptide originally purified from conditioned medium of cultures of porcine aortic endothelial cells, is recognized as a product of many other cells as well. It is now known that there are three endothelin genes in the human genome (ET-1, ET-2, and ET-3). ET-1 and ET-2 are both strong vasoconstrictors, whereas ET-3 is a potentially weaker vasoconstrictor than the other two isoforms. Besides being the most potent vasoconstrictor yet known, ET-1 also acts as a mitogen on the vascular smooth muscle, and, thus, it may play a role in the development of vascular diseases. It is well known that accelerated angiopathy is a major complication in diabetes mellitus. As generalized endothelial cell damage is thought to occur in diabetic patients, ET-1, being released from the damaged endothelial cells, is able to make contact with the underlying vascular smooth muscle cells and thus could be one important cause of diabetic angiopathy. This article summarizes the reported literature of the role of ET-1 in the development of diabetic complications, with particular focus on the possible role of ET-1 in mediating the effects of angiotensin-converting enzyme inhibitors.

Excision of the preauricular sinus: a comparison of two surgical techniques

OBJECTIVES

To compare the long-term recurrence rate of the standard technique (simple sinectomy) and the supra-auricular approach (wide local excision) for the surgical management of preauricular sinuses.

STUDY DESIGN

Retrospective cohort.

METHODS

Fifty-four patients with a preauricular sinus excised between May 1986 and December 1996 were included in this study. All patients were categorized into one of two groups based on the type of surgery performed: the standard technique or the supra-auricular approach. The medical records were then reviewed and the latest information concerning the recurrence of a preauricular sinus were updated by phone interview. The recurrence rate of these two groups was statistically analyzed by the Fisher exact test.

RESULTS

Forty-nine of 54 patients were successfully contacted with data updated and analyzed. The 32% recurrence rate of the standard excision (n = 25) was significantly higher than the 3.7% recurrence rate of the supraauricular approach (n = 27; two-tailed test, P = .01).

CONCLUSION

The supra-auricular approach for excision of a preauricular sinus has a statistically lower recurrence rate in comparison to the standard technique.

Plasma endothelin levels are unaltered by thyroid hormone status in humans

Endothelin is a novel potent vasoconstrictor peptide produced by a wide variety of cell types and which has diverse biological activities. Previously we have reported that thyroid hormone status alters tissue levels of immunoreactive endothelin (irET) in rats. In order to study whether plasma irET levels in humans are affected by thyroid hormone status, we measured irET concentrations by means of radioimmunoassay in plasma samples from euthyroid controls as well as from patients with either hypothyroidism or hyperthyroidism. Plasma samples from the above-mentioned three groups of subjects were collected. After extraction with Sep-Pak C18 cartridges, plasma irET levels were measured by radioimmunoassay. The plasma irET levels in the three groups of subjects did not show any significant difference. Also, no correlations were found between plasma irET levels, thyroid hormones and the thyroid-stimulating hormone thyrotropin (TSH) in euthyroid, hypothyroid and hyperthyroid subjects. These results suggest that thyroid function per se is not a major determinant of plasma irET levels in humans.

Detection and characterization of endothelin in transformed human osteoblast cell culture medium

Endothelin-1 (ET-1), a 21 amino acid peptide originally purified from conditioned medium of cultures of porcine aortic endothelial cells, is recognized also as a product of many other cells such as epithelial cells, glial cells, and neurons. It is now recognized that at least ET-1 plays an important role in bone metabolism. It has been shown that ET-1 inhibits osteoclast bone resorption by a direct effect on cell motility and it can also activate phospholipase C in the osteoblast. Furthermore, several studies have shown that ET-1 stimulates the formation of inositol phosphates, the synthesis of DNA, the mobilization of calcium from extra- and intracellular pools, the activation of phospholipase D, and the stimulation of tyrosine phosphorylation in osteoblast-like (MC3T3-E1 and UMR-106) cells. The aim of the present study was to detect and characterize the presence of endothelin in transformed human osteoblast cell culture medium (HTb96) by radioimmunoassay and chromatography methods. Immunoreactive endothelin (IR-ET) was undetectable in the medium incubated at 0.5 and 1 h and was 3.2 +/- 0.2 fmol/10(5) cells (mean +/- SEM, n = 6) at 2 h, 9.5 +/- 0.5 fmol/10(5) cells at 6 h, 19.8 +/- 2.1 fmol/10(5) cells at 24 h, and 23.7 +/- 2.0 fmol/10(5) cells at 48 h, respectively. Sephadex G-25 superfine chromatography and fast protein liquid chromatography studies showed that >90% of IR-ET in the culture medium coeluted with synthetic ET-1. These results show that ET-1 could be formed by transformed human osteoblasts. Further studies should be conducted to elucidate the physiological role of endothelins as possible autocrine, paracrine, or endocrine factors in calcium and bone metabolism.

Hypertrophic cranial pachymeningitis and lymphocytic hypophysitis in Sjögren's syndrome

The authors describe a patient with primary Sjögren's syndrome who developed pachymeningitis, hypopituitarism, and central diabetes insipidus. The patient improved with corticosteroid pulse therapy.

Serum endothelin and atrial natriuretic peptide in cirrhotic patients with ascites and hepatorenal syndrome

BACKGROUND

The pathogenesis of cirrhotic ascites and hepatorenal syndrome remains unresolved. The involvement of both endothelin-1 and atrial natriuretic peptide have recently been suggested. This study investigated the concentrations of serum endothelin and atrial natriuretic peptide in cirrhotic patients.

METHODS

Seven healthy subjects and 31 cirrhotic patients were studied. Cirrhotic patients were divided into three groups: Group I, 16 cirrhotic patients without ascites; Group II, 10 cirrhotic patients with ascites, but without hepatorenal syndrome; and Group III, five cirrhotic patients with hepatorenal syndrome and ascites. Their sera were analyzed for endothelin-1 and atrial natriuretic peptide concentrations.

RESULTS

Cirrhotic patients with ascites, Group II and Group III, had higher plasma endothelin-1 concentrations (15.9 +/- 2.3 pg/ml and 24 +/- 2.1 pg/ml, respectively) than normal subjects and compensated cirrhotics (3.8 +/- 0.7 pg/ml and 6.4 +/- 1.1 pg/ml, respectively); p < 0.001). Atrial natriuretic peptide concentrations were also significantly higher in cirrhotic patients than in normal subjects (p < 0.025). Plasma endothelin-1 concentration had a negative correlation with creatinine clearance (r = -0.65, p < 0.001), as did atrial natriuretic peptide concentrations (r = -0.44, p = 0.012). Plasma endothelin-1 correlated significantly with atrial natriuretic peptide concentrations (r = 0.38, p = 0.035).

CONCLUSIONS

Both endothelin-1 and atrial natriuretic peptide concentrations were elevated in cirrhotic patients with ascites and hepatorenal syndrome. Endothelin-1 may have a negative impact on renal function. Our data also suggested that impaired responsiveness rather than impaired secretion of atrial natriuretic peptide is responsible for sodium retention in cirrhotic patients with ascites.

Is captopril-induced improvement of insulin sensitivity mediated via endothelin?

Angiotensin-converting enzyme (ACE) inhibitors have been reported to improve insulin sensitivity during either short-term or long-term administration. Recent studies indicate that endothelin-1 (ET-1) has potent glycogenolytic effects in rat hepatocytes and may cause insulin resistance in rat adipocytes. In addition, ET may also have a role in stimulation of the hypothalamic-pituitary-adrenal axis. To test the hypothesis that part of the effect of captopril in enhancing insulin sensitivity may be mediated via ET and/or by glucocorticoids, we measured 24-h urinary excretion of ET and free cortisol before and after short-term treatment with captopril. The 24-h urinary immunoreactive endothelin (IR-ET) excretion decreased significantly (p < 0.05) from 65 +/- 4 ng at baseline to 42 +/- 3 ng after captopril treatment, whereas no significant change in the 24-h urinary free cortisol excretion was observed. Moreover, no significant change in the 24-h urinary IR-ET and free cortisol excretions was noted in the placebo-treated group. We speculate that ACE inhibitors may exert their effect on insulin sensitivity not only by blocking the renin-angiotensin and kinin systems but also by inhibiting production and/or release of ET.

Parathyroid hormone and parathyroid hormone related protein assays in the investigation of hypercalcemic patients in hospital in a Chinese population

There are many pathological causes and potential mechanisms for hypercalcemia. We measured intact parathyroid hormone (PTH) and parathyroid hormone related protein (PTHrP) in the hypercalcemic in-patients and attempted to evaluate the roles of PTH and PTHrP in hypercalcemia due to malignancy. We performed a prospective study of 178 patients with corrected serum calcium concentrations greater than 2.74 mmol/l in a hospital over a 3-year period. We measured calcium and albumin using a Hitachi 747 autoanalyzer, and we measured PTH and PTHrP by two-site immunoradiometric assays (IRMA). Hypercalcemia was attributed to malignancy alone in 93 patients (52.3%), primary hyperparathyroidism (HPT) alone in 28 patients (15.7%), uremia with hemodialysis in 23 patients (12.9%), unknown in 16 patients (9%), primary HPT coexisting with malignancy in 7 patients (3.9%) and other rare causes (6.2%). Plasma PTHrP levels were elevated in 71/93 (76.3%) patients with hypercalcemia due to malignancy, but the elevated PTHrP percentage differed for each kind of tumor. PTHrP levels were elevated in 100% of patients with squamous carcinomas (CA) in the lung, esophagus, skin, cholangiocarcinoma of liver, and breast CA. The positive bony metastatic rate was 44.1% (41/93). There was no correlation between high PTHrP and bony metastasis. There was a good correlation between the corrected serum calcium and PTHrP levels (r = 0.476, p < 0.001), but no correlation between survival time and serum calcium level or PTHrP level. There was no significant difference in life expectancy after cancer diagnosis between the high PTHrP group and normal PTHrP group, and there was no significant difference in life expectancy after the first occurrence of hypercalcemia between the two groups. Measurement of both PTH and PTHrP levels led to a change in the initial diagnosis in 7 patients. In routine practice, measurement of serum PTH alone is not enough. This study suggests that the appropriate combination of PTH and PTHrP assays results in a more accurate diagnosis of the hypercalcemic causes. In addition, especially high PTHrP levels should be screened for malignancy. However, the prognosis in cancer patients after hypercalcemia with high PTHrP group, as compared to those with the normal PTHrP group is not significantly different.

Thoracoscopic lobectomy for an infected intrapulmonary bronchogenic cyst

A 19-year-old male who presented with cough and fever was found to have an 8-cm cyst in his left lung. Video-assisted thoracoscopic left lower lobectomy was performed. The cyst had to be decompressed by needle aspiration prior to retrieval through a 5-cm minithoracotomy. The patient was discharged on postoperative day 4 in good condition. The technical aspects form the basis of this report.

Late-onset idiopathic hypoparathyroidism with thymoma: a case report

A 62-year-old male was admitted because of numbness and twitching of both hands. Hypocalcemia with positive Trousseau's sign was noted. Chest X-ray and computed tomography (CT) showed an anterior mediastinal mass. Skull X-ray and whole body bone scan could not rule out bony metastasis to the left parietal bone, causing an anterior mediastinal tumor with bony metastasis to be suspected initially. Median sternotomy and extended thymectomy were done, and Stage II thymoma with negative calcitonin staining was noted. However, hypocalcemia persisted after thymectomy and the results of pre-operative and post-operative intact-parathyroid hormone (intact-PTH) were less than the detection limit (<13.3 pg/ml). Tumor markers and gallium tumor scan were all negative. Brain CT disclosed calcification over the bilateral basal ganglia and bilateral dentate nuclei of the cerebellum; the supposed metastatic osteolytic lesions of parietal bone were considered to result from pacchionion arachnoid granulation tissues. The coexistence of late-onset idiopathic hypoparathyroidism and thymoma has not been reported before. Long-term replacement therapy with vitamin D and calcium was necessary for this case.

MELAS syndrome associated with diabetes mellitus and hyperthyroidism: a case report from Taiwan

MELAS syndrome is a form of mitochondrial myopathy with manifestations of seizure, stroke-like syndrome, lactic acidosis, ragged red muscle fibres and mitochondrial encephalopathy. The syndrome has been reported in association with a variety of endocrine and metabolic disorders including diabetes mellitus (DM), hypothalamo-pituitary hypofunction, hypothalamic growth hormone deficiency and delayed puberty. Mitochondrial DNA (mtDNA) point mutation may be the major pathological defect. However, association of MELAS syndrome with hyperthyroidism has not previously been reported. A case is reported from Taiwan of a 32-year-old woman suffering from MELAS syndrome with associated DM and hyperthyroidism. When the latter was diagnosed in April 1988, the patient underwent subtotal thyroidectomy. There was no family history of thyroid disease. Because of repeated seizures, she had computed tomography (CT) and magnetic resonance imaging (MRI) of the brain which showed focal, low-density lesions over the cerebral hemispheres. Both serum and cerebral spinal fluid lactic acid levels were elevated. Mild elevations of serum T4 and T3 and a high titre of TSH receptor antibody were still present. Hyperglycaemia was noted during hospitalization and DM confirmed by oral glucose tolerance test. Muscle biopsy showed ragged red fibres. DNA analysis showed an A-to-G transition at the 3243rd nucleotide position of the tRNA(Leu(UUR)) gene of the mtDNA from the patient. Quantitative polymerase chain reaction (PCR) and restriction analysis revealed that about 60% of the blood mtDNA was of mutant type. The patient received antithyroid drugs for hyperthyroidism, diet control for DM and anti-epileptic drugs for seizure.

Insulin autoimmune syndrome in a patient with methimazole and carbimazole-treated Graves' disease: a case report

Insulin autoimmune syndrome (IAS) includes fasting or reactive hypoglycemia, hyperinsulinemia and the presence of insulin-binding antibodies in patients who have never been exposed to exogenous insulin. The report concerns a 34-year-old male patient with Graves' disease who had history of having taken methimazole for two months, without any consequence, 4 years previously. However, when methimazole was again administered for three weeks followed by a week of carbimazole, the patient suffered hypoglycemia 4 times during the next 4 weeks. He denied history of diabetes mellitus (DM), of taking any oral hypoglycemic agent or of having received insulin injection. Laboratory data showed total serum insulin level > 320 microU/mL, free insulin 55 microU/mL and insulin antibody 88.3%. Oral glucose tolerance test (OGTT) revealed DM pattern. Since the patient had history of allergy to anti-thyroid drugs before this event, so he was treated with radioiodine (131I). There was no episode of hypoglycemic attack during 15 months of follow-up.

Factors affecting the labor efficiency of hospital-based blood bank laboratories

BACKGROUND

A variety of financing mechanisms and managerial innovations have been developed in the past decade to control hospital costs. Some evidence suggests that those changes have not produced substantial improvements in labor efficiency among employees in the hospital's technical level, such as in the blood bank laboratories.

STUDY DESIGN AND METHODS

This study measured labor efficiency in 40 hospital-based blood bank laboratories in Southern California during the year from July 1989 to June 1990 and explored the impact of financial, managerial, and operational factors on labor efficiency.

RESULTS

With standardized output measures used in all blood bank laboratories, a wide variation of labor efficiency was found. Multivariate analyses indicate that the labor efficiency of blood bank employees was not influenced by organizational financial incentives, but was affected by the managerial styles of blood bank managers.

CONCLUSION

Interpretation of the findings suggests that labor efficiency is affected by operational designs intended to improve responses to variable workloads and reduce slack time.

The lung contents of endothelin are altered by thyroid hormone status in rat

Endothelin-1 (ET-1) is a 21-residue peptide isolated from the conditioned medium of cultured porcine endothelial cells and is widely distributed throughout the body, with relatively high levels in the kidney and lung. Animal studies have revealed that the lung appears to have the largest capacity for ET-1 removal from the blood stream. In this study we have examined the possible influence of thyroid status on immunoreactive endothelin (IR-ET) levels in the plasma and lung of the male rats. 3 weeks after the surgical removal of the thyroid gland from male rats, the IR-ET levels in the lung were reduced by 39%. Similarly, IR-ET levels were decreased 46% in the lung of rats rendered hypothyroid by treatment with 0.1% (w/w) PTU in the drinking water for 30 days, and replacement with daily L-thyroxine (T4) injections (5 micrograms/100 g) prevented this decrease. However, thyrotoxicosis induced by daily L-T4 injections (10 micrograms/100 g) also caused a decrease of the lung IR-ET levels by 49%. Nevertheless, the plasma IR-ET levels are similar in each group. Fast protein liquid chromatography study verified the presence of ET-1 immunoreactivity in both rat plasma and lung tissue extracts. This study demonstrates that euthyroid status is required for the maintenance of physiological concentrations of IR-ET in the lung of male rats.

Tissue contents of endothelin vary according to thyroid hormone status in rat

Endothelin-1 (ET-1) is a 21-residue peptide isolated from the conditioned medium of cultured porcine endothelial cells and is widely distributed throughout the body, with relatively high levels in the kidney and lung. In this study we examined the influence of thyroid hormone status on immunoreactive endothelin (ir-ET) levels in the plasma, lung, and kidney tissues of rats. Three weeks after surgical removal of the thyroid gland from male rats, the ir-ET levels in the lung and kidney were reduced by 39% and 42%, respectively. Similarly, ir-ET levels were decreased by 46% in the lung and 45% in the kidney of rats rendered hypothyroid by treatment with 0.1% (wt/wt) n-propylthiouracil (PTU) in the drinking water for 30 days. Replacement with daily L-thyroxine (T4) injections (5 micrograms/100 g) prevented this decrease. However, thyrotoxicosis induced by daily L-T4 injections (10 micrograms/100 g) also caused a decrease of the lung ir-ET levels by 49%, but had no significant effect on the renal ir-ET levels. However, the plasma ir-ET levels were similar in each group. Fast protein liquid chromatography study verified the presence of ir-ET-1 in the plasma and tissue extracts. This study demonstrates that thyroid hormone status affects tissue levels of ir-ET differently and that a euthyroid status is required for the maintenance of physiologic concentrations of ir-ET in the lung of male rats.

Endothelin-like immunoreactivity in rat models of diabetes mellitus

The factors associated with high concentrations of circulating plasma immunoreactive endothelin in patients with diabetes mellitus are unknown. Plasma and tissue (lung and kidney) immunoreactive endothelin levels were therefore measured by radioimmunoassay in three animal models of diabetes mellitus: dexamethasone-treated rats (2 mg/kg per day for 12 days), streptozotocin-treated rats (100 mg/kg, 4 days before being killed) and rats treated with both dexamethasone and streptozotocin. Plasma concentrations of immunoreactive endothelin in the dexamethasone-treated rats (3.13 +/- 0.28 pmol/l, mean +/- S.E.M., n = 15) were significantly (P less than 0.005) higher than those in controls (1.33 +/- 0.18 pmol/l, n = 15), while plasma concentrations of immunoreactive endothelin in streptozotocin-treated rats (n = 8) and rats treated with both dexamethasone and streptozotocin (n = 14) were undetectable (less than 0.5 pmol/l). Fast protein liquid chromatographic analysis of the plasma immunoreactive endothelin of dexamethasone-treated rats showed four peaks: one in the void volume, one eluting before endothelin-3, one eluting after endothelin-3 and before endothelin-1 and one eluting in a position identical with that of endothelin-1. Pulmonary concentrations of immunoreactive endothelin in the three groups of rats with diabetes mellitus were lower (P less than 0.005) but no significant change was found in renal immunoreactive endothelin. These findings indicate that short-term dexamethasone treatment increases plasma levels of immunoreactive endothelin while streptozotocin treatment decreases them. Thus, multiple factors may influence plasma concentrations of immunoreactive endothelin in diabetes mellitus.

Presence of immunoreactive endothelin in human saliva and rat parotid gland

The presence of immunoreactive endothelin (IR-ET) in human saliva and rat parotid gland was investigated by radioimmunoassay. The IR-ET concentration (mean +/- SEM) in saliva taken from normal volunteers was 2.0 +/- 0.2 pmol/l (n = 15). The IR-ET concentration in rat parotid gland was 19.2 +/- 2.2 fmol/g wet weight (n = 10). Fast protein liquid chromatography (FPLC) of human saliva extract revealed 6 peaks; one peak eluting in the void volume, one in a position between ET-1 and -3, and the other four in the positions of synthetic ET-1, -2, -3 and big ET(1-38), respectively. A similar pattern of rat parotid gland extract was noted with FPLC, except that there was no peak after the void volume. Presence of endothelin, a potent growth factor, in saliva and salivary gland points to a role in maintaining the integrity of the oral and gastrointestinal tract mucosa.

A twelve month double-blind randomized study of the efficacy and immunogenicity of human and porcine insulins in non-insulin-dependent diabetics

This study aims to compare the effectiveness and immunogenicity of semisynthetic human insulin (NOVO) and highly purified (monocomponent) porcine insulin over a 12 month period in 16 non-insulin-dependent diabetic subjects not previously exposed to insulin. Sixteen patients were randomly allocated for treatment with either human (n = 9) or monocomponent porcine (n = 7) insulin in a double-blind trial. Both groups were identical with respect to age, sex and measures of metabolic control. Significant insulin antibody was detected in seven of the nine patients (78%) 3 months after the commencement of human insulin therapy whereas it was detected in all patients (100%) in the group treated with monocomponent porcine insulin as early as 2 months after insulin therapy. Besides the delayed rise of insulin antibodies during the first 3 months of human insulin therapy, it tended to have a lower mean insulin antibody titer, though statistically insignificant, at the end of the study. No adverse reaction to either type of insulins was noted. It is concluded that both semisynthetic human and monocomponent porcine insulin were safe and effective. Although human insulin showed a slightly lower immunogenicity than monocomponent porcine insulin of the same formulation and purities, it was not non-immunogenic. Hence, there is no reason to treat all insulin-requiring diabetic subjects with human insulin except those who have developed insulin allergy or those at risk or with a history of allergy.

Endothelin in human brain and pituitary gland: presence of immunoreactive endothelin, endothelin messenger ribonucleic acid, and endothelin receptors

The presence of immunoreactive (IR) endothelin, endothelin mRNA, and endothelin receptors in human brain and pituitary gland has been studied by RIA, Northern blot hybridization, and receptor assay. IR endothelin was detected in all five brain regions examined (cerebral cortex, cerebellum, brain stem, basal ganglia, and hypothalamus) (6-10 fmol/g wet wt) and spinal cord (22 +/- 6 fmol/g wet wt, n = 7, mean +/- SEM). Higher concentrations of IR endothelin were found in the pituitary gland (147 +/- 30 fmol/g wet wt). Fast protein liquid chromatographic analysis of the IR endothelin in pituitary gland showed a large IR peak in the position of endothelin-3 and a smaller peak in the position of endothelin-1, whereas IR endothelin in the hypothalamus and brain stem was mainly endothelin-1. Endothelin messenger RNA was detected by Northern blot hybridization in the pituitary but not in hypothalamus. The receptor assay showed that 125I-endothelin-1 binding sites were present in large numbers in all five brain regions but were much less abundant in the pituitary gland. Binding capacity and dissociation constant were 5052 +/- 740 fmol/mg protein and 0.045 +/- 0.007 nM in brain stem and 963 +/- 181 fmol/mg protein and 0.034 +/- 0.009 nM in hypothalamus. In the pituitary gland, there were two classes of binding sites for endothelin with dissociation constants of 0.059 +/- 0.002 nM (binding capacity = 418 +/- 63 fmol/mg protein) and 0.652 +/- 0.103 nM (binding capacity = 1717 +/- 200 fmol/mg protein). Endothelin-1, -2 and -3 were almost equipotent in displacing the binding (IC50 approximately 0.04 nM). These findings are in accord with the possibility that endothelin acts as a neurotransmitter, neuromodulator or neurohormone in man.

Cytokine stimulated endothelin release from endothelial cells

Endothelin release from bovine endothelial cells of the aorta, pulmonary artery, and retinal microvessels was measured in response to various cytokines. Transforming growth factor beta (0.05-5 ng/ml) was found to be a potent stimulator (3-4 fold increase) of endothelin secretion in all three cell types. Tumour necrosis factor alpha (0.1-10 ng/ml) and interferon gamma (8-800 U/ml) had a small (1.5-2 fold increase) but significant effect on endothelin secretion from endothelial cells of large vessels but not the retinal microvessels. Interleukin-1 beta, Interleukin-6 and interleukin-8 at various doses did not affect endothelin secretion. These effects were observed at various time points from 6-24 hrs and indicate that of the cytokines tested, only transforming growth factor beta has a potent effect on endothelin release from endothelial cells of different organs.

Immunoreactive endothelin in human plasma, urine, milk, and saliva

Using a highly sensitive radioimmunoassay, elevated plasma immunoreactive endothelin (ir-ET) levels were found in patients with diabetes mellitus (1.88 +/- 0.12 pmol/L, mean +/- SEM, n = 100), patients undergoing maintenance hemodialysis (4.28 +/- 0.76 pmol/L, n = 14), patients with acute myocardial infarction (3.43 +/- 1.03 pmol/L, n = 6), and patients with subarachnoid hemorrhage (4.92 +/- 0.64 pmol/L, n = 14) (normal controls: 0.54 +/- 0.05 pmol/L, n = 19). ir-ET was also present in urine (2.1 +/- 0.3 pmol/L, n = 12), breast milk (6.8 +/- 1.6 pmol/L, n = 16), and saliva (2.0 +/- 0.2 pmol/L, n = 15) obtained from healthy subjects. Chromatography studies verify the identity of endothelin. Fast protein liquid chromatography (FPLC) showed one peak in the normal plasma extract, three peaks in the plasma extracts from diabetic patients and patients undergoing maintenance hemodialysis, three peaks in the urine extract, four peaks in the milk extract, and five peaks in the saliva extract. When the materials eluting in the void volume on FPLC of urine and saliva extracts were loaded onto a Sephadex G-25 column, the ir-ET was eluted in a higher molecular weight region. Incubation of endothelin-1, endothelin-2, and endothelin-3 in urine for 5 h showed that the total amount of ir-ET decreased to less than 30% of the initial levels, suggesting that endothelins are very unstable in urine.

Endothelin in human brain and pituitary gland: comparison with rat

To investigate the physiological roles of endothelin (ET) in the brain and pituitary gland, the presence of immunoreactive (ir) ET and ET receptors was studied by radioimmunoassay and receptor assay in humans and rats. ir-ET concentrations in human brain (6-10 fmol/g of wet weight) were comparable with the levels in the rat brain (5-9 fmol/g of wet weight). Higher concentrations of ir-ET were found in human pituitary glands (147 +/- 30 fmol/g of wet weight, mean +/- SEM) and rat posterior pituitary lobes (88 +/- 26 fmol/g of wet weight). Fast protein liquid chromatography (FPLC) showed that the ir-ET in human hypothalamus and brainstem was mainly ET-1, while the ir-ET in human pituitary was mainly ET-3. FPLC of the whole rat brain extract showed a larger peak in the position of ET-3 and a smaller peak in the position of ET-1. Receptor assay showed that [125I]ET-1 binding sites were present in very large numbers in all five human brain regions and four rat brain regions examined but were much less abundant in the human pituitary. ET mRNA was detected by Northern blot hybridization in human pituitary but not in human hypothalamus. These findings are in accord with the possibility that ET acts as a neurotransmitter, neuromodulator, or neurohormone.

Endothelin immunoreactivity in mice with gram-negative bacteraemia: relationship to tumour necrosis factor-alpha

1. To investigate the role of endothelin in Gram-negative bacteraemia and the possible involvement of tumour necrosis factor-alpha in its pathophysiology, we measured plasma and tissue (lung, kidney and spleen) immunoreactive endothelin levels in Gram-negative bacteraemic mice, with and without passive immunization by anti-(tumour necrosis factor-alpha) antibody. 2. Plasma immunoreactive endothelin levels were greatly increased after the Escherichia coli injection. Pretreatment with anti-(tumour necrosis factor-alpha) antibody did not suppress elevated plasma immunoreactive endothelin levels (P greater than 0.1). 3. Lung tissue immunoreactive endothelin levels in mice were increased 16 h after the E. coli injection and were not affected by prior passive immunization with anti-(tumour necrosis factor-alpha) antibody. Immunoreactive endothelin in spleen and kidney was undetectable (less than 34 fmol/g wet weight). 4. Injection of rMu tumour necrosis factor-alpha into mice did not increase plasma immunoreactive endothelin levels. 5. Antibody to endothelin given 30 min after a 90% lethal dose challenge with E. coli did not affect mortality. 6. We conclude that the rise in plasma and tissue endothelin that occurs in Gram-negative bacteraemia is independent of tumour necrosis factor-alpha.

Endothelin in the gastrointestinal tract. Presence of endothelinlike immunoreactivity, endothelin-1 messenger RNA, endothelin receptors, and pharmacological effect

The possible production and role of endothelin in the gastrointestinal tract was investigated in rats by radioimmunoassay, Northern-blot hybridization, receptor assay using membrane preparations, and pharmacological study using gut strips. Endothelinlike immunoreactivity was detected in all regions (from stomach to colon) of the rat gastrointestinal tract (13-48 fmol/g wet tissue) including the mucosal layer of the ileum and colon (8.4 +/- 2.0 fmol/g wet tissue and 18.4 +/- 2.1 fmol/g wet tissue, respectively, mean +/- SEM; n = 5). Fast protein liquid chromatographic analysis of the endothelinlike immunoreactivity in jejunum, ileum, colon, and colon mucosa extracts showed peaks in the positions of endothelin-1 and endothelin-3. The presence of endothelin-1 messenger RNA was demonstrated by Northern-blot hybridization in the whole colon and pooled ileal and colonic mucosa, but not in the whole jejunum. Specific binding in the rat gastrointestinal tract was particularly high in the fundus of stomach, jejunum, ileum, and colon. In the ileum, many binding sites were found in the circular and longitudinal muscle layers, but few in the mucosal layer. Endothelin-1 and endothelin-3 caused contraction of rat stomach strips, rat colon, and guinea pig ileum. These findings indicate that endothelin is present in the rat gastrointestinal tract, perhaps produced by both vascular endothelial cells and mucosal epithelial cells, and can cause contraction of gastrointestinal smooth muscle. Thus, endothelin may have a physiological role in the control of gastrointestinal function.

Binding sites of a novel neuropeptide pituitary-adenylate-cyclase-activating polypeptide in the rat brain and lung

Pituitary-adenylate-cyclase-activating polypeptide (PACAP) is a novel 38-amino-acid neuropeptide isolated from ovine hypothalamic tissues based on its activity of stimulating adenylate cyclase of rat pituitary cells. Binding sites for PACAP were studied in rat tissue membranes using a 27-amino-acid N-terminal derivative of PACAP [PACAP(1-27)] labelled with 125I. Particularly high specific binding sites of 125I-PACAP(1-27) were noted in the hypothalamus, brain stem, cerebellum and lung. Specific binding sites are also present in the pituitary gland, but at a lower concentration, and mainly in the anterior lobe. Very low concentration of 125I-PACAP(1-27)-binding sites were found in the colon, aorta and kidney membranes and no binding sites were detected in the pancreas and testis. Maximal binding of 125I-PACAP(1-27) was observed at pH 7.4. Interaction of 125I-PACAP(1-27) with its binding site was rapid, specific and saturable as well as time, pH and temperature dependent. PACAP(1-27) is more potent than PACAP in displacing the binding of 125I-PACAP(1-27) with brain membranes [concentration that inhibits 50% of the binding (IC50) = 7.45 +/- 1.52 nM and 11.45 +/- 3.65 nM, respectively; mean +/- SEM, n = 4] and lung membranes (IC50 = 4.41 +/- 0.87 nM and 10.68 +/- 3.09 nM, respectively). Vasoactive intestinal peptide displaced the binding of 125I-PACAP(1-27) in lung membrane (IC50 = 16.88 +/- 5.14 nM) but not in brain membranes. The equilibrium binding of 125I-PACAP(1-27) at 4 degrees C was characterized by a single class of binding site for the brain membrane with a dissociation constant (Kd) of 2.46 +/- 0.53 nM and a maximal binding capacity (Bmax) of 8.44 +/- 3.13 pmol/mg protein, but there were two classes of binding site for lung membranes with Kd of 1.02 +/- 0.51 nM and 5.19 +/- 0.99 nM, and Bmax of 2.84 +/- 0.72 pmol/mg protein and 9.13 +/- 1.89 pmol/mg protein, respectively. These findings suggest that subtypes of PACAP-binding sites exist and PACAP may have a physiological role in the hypothalamus/pituitary axis as well as in other regions of the brain and lung.

Comparison of insulin secretion and insulin sensitivity between normal and impaired glucose tolerance subjects with normal fasting plasma glucose

To examine glucose-stimulated insulin secretion and insulin sensitivity in the normal subjects and patients with impaired glucose tolerance, we performed the oral glucose tolerance test (OGTT) and modified insulin suppression test in 34 non-obese subjects. The plasma glucose and insulin concentrations were measured during fasting and every 30 min up to 120 min following 75 g of oral glucose loading. Ten subjects were classified as impaired glucose tolerance (IGT), and 24 subjects were as having normal glucose tolerance. In addition, the insulin-stimulated glucose uptake was estimated in all subjects by measuring the final 30 min steady-state plasma glucose (SSPG) of a continuous infusion of somatostatin, insulin and glucose for 4 hours (modified insulin suppression test). The mean plasma glucose concentrations of fasting and 60, 90, 120 min during OGTT study were significantly higher in the IGT subjects than in the normals. In addition, the mean incremental glucose areas under the curve during OGTT study were also greater in the IGT subjects than in the normals. The mean serum insulin concentrations were significantly higher at 90 and 120 minutes in the IGT patients than in the normals. During the modified insulin suppression test, the mean SSPG concentrations were significantly higher in the IGT patients than in the normals under the similar steady-state plasma insulin in both groups. There was a good correlation between the incremental insulin areas under the curve (OGTT) and the SSPG in the normal subjects (p less than 0.0001).(ABSTRACT TRUNCATED AT 250 WORDS)

Elevated plasma endothelin in patients with diabetes mellitus

Plasma concentrations of endothelin, a vasoconstrictor peptide released from vascular endothelial cells, have been measured by radioimmunoassay in 100 patients with diabetes mellitus and 19 healthy subjects. The plasma immunoreactive-endothelin concentrations were found to be greatly raised in the patients with diabetes (1,880 +/- 120 fmol/l, mean +/- SEM) compared with the healthy subjects (540 +/- 50 fmol/l, p less than 0.005). The elevation of immunoreactive-endothelin could not be explained by secondary changes in blood pressure or renal disease and did not correlate with the presence of diabetic retinopathy, duration of diabetes mellitus, fasting blood glucose or serum fructosamine. Fast protein liquid chromatographic analysis of the diabetic plasma immunoreactive-endothelin showed three forms, one in a very big molecular weight position, one intermediate and one in the position of endothelin-1 itself. No material appeared in the positions of endothelin-2 and 3. Chromatographic analysis of normal plasma showed only the big molecular weight peak while material in the endothelin-1, 2 or 3 positions was below detection. The elevation of endothelin in diabetic patients may be a marker of, and further exacerbate, their vascular disease.

Cushing's syndrome: analysis of 188 cases

From January 1962 through April 1988, 188 patients with Cushing's syndrome were hospitalized at the Veterans General Hospital. Iatrogenic Cushing's syndrome was found in 123 (65.4%) of the patients. The other 43 patients (22.9%) had excess secretion of adrenocorticotropin (ACTH) and 22 patients (11.7%) had benign or malignant adrenocortical tumors. The clinical features and the functional reserve of the adrenal glands in those patients with iatrogenic Cushing's syndrome were evaluated. A retrospective analysis of the diagnostic rate of the various endocrine evaluations and the radiological examinations was also carried out. Four approaches were used in the management of Cushing's syndrome: (1) pituitary surgery, (2) pituitary irradiation, (3) adrenal surgery, and (4) drug therapy. Both the clinical and hormonal responses to these four management types were evaluated. The endocrinological, radiological, surgical and pathological experiences of 25 patients with Cushing's disease treated with pituitary surgery are presented. Five patients (20%) had an atypical endocrine pattern (20% false-negative). Twenty-four patients received a pituitary CT scan and 16 patients (66.7%) had positive CT findings. Of these 25 patients, 19 had pathology-proven microadenomas (less than 1cm), one had macroadenoma (greater than 1cm) and 5 had no evidence of adenomatous tissue. Among the 22 patients with adrenal Cushing's syndrome, 4 (18%) were suffering from adrenocortical carcinoma and 18 (82%) with benign adrenal tumors. The incidence of left adrenal adenoma was approximately twice that of right adrenal adenoma. The cure rate of adrenocortical adenoma by surgical treatment with unilateral adrenalectomy was excellent, but for adrenocortical carcinoma was poor.

Immunogenicity of highly purified porcine and human insulins in diabetic patients with high titers of insulin antibody

Twenty-nine non-insulin-dependent diabetic Chinese subjects previously treated with conventional porcine isophane insulin (NPH) for a period of time, whose titer of serum insulin antibody was greater than 40% were changed to either highly purified pork insulin (Nordisk, Denmark) or human insulin of recombinant DNA origin (Eli Lilly, USA) for 1 year in a double-blind and randomized trial. The human (n = 16) and pork insulin (n = 13) groups were carefully matched for age, sex and measures of metabolic control. In highly purified pork-insulin-treated patients, the glycated hemoglobin and fasting blood sugar values began to fall significantly from a mean of 13.2% to 12.3% (p less than 0.05) and 228 mg/dl to 183 mg/dl (p less than 0.005), respectively, 2 months after the commencement of this study, whereas insulin antibody levels began to fall significantly from a mean of 61.8% to 49.5% (p less than 0.01) 6 months after the start of the study. Also, daily insulin doses increased significantly from a mean of 58 units to 70 units (p less than 0.005) 6 months after the start of the study. In human-insulin-treated patients, there were no significant changes in the glycated hemoglobin values. The fasting blood sugar levels fell significantly (p = 0.0515) at the end of the study period but the insulin antibody levels did not show any significant change during the same study period. Daily insulin dose increased significantly from a mean of 51 units to 57 units (p less than 0.01) 4 months after beginning the study.(ABSTRACT TRUNCATED AT 250 WORDS)

Quantitation of fetal-maternal hemorrhage by flow cytometry. A simple and accurate method

A simple and objective assay was developed for the detection and quantitation of fetal-maternal hemorrhage with the use of flow cytometry. In vitro prepared control mixtures of 10%, 2%, 1%, 0.5%, 0.25%, 0.125%, and 0.06% D+ RBCs in D- RBCs were tested (8-11) different times by flow cytometry and gave mean % D+ results of 11.10%, 1.90%, 0.92%, 0.45%, 0.24%, 0.11%, and 0.05%. The coefficient of variation of preparing and testing these mixtures ranged from 11.0 to 15.9% for the 10-0.125% mixtures. Thus, flow cytometry was accurate, reproducible, and sensitive. Flow cytometry was compared with Du tests, rosette tests, and acid elution. The Du test was highly variable because it was not sensitive enough to detect a significant bleed (approximately 0.6%) in some cases and too sensitive (necessitating quantitation of an insignificant bleed) in others. The rosette test was too sensitive. Acid elution and flow cytometry results did not always agree; acid elution results were approximately twice as high as flow cytometry. The authors believe flow cytometric detection of D+ red blood cells to be more accurate than the detection of fetal hemoglobin by acid elution techniques, which is known to have poor reproducibility. Postpartum samples from 56 D- women who delivered D+ babies were tested. Fifty-two had fetal bleeds less than 0.3% by acid elution and flow cytometry; all had negative Du test results, but there were two false positive results with the use of the rosette technique. Four had significant bleeds (greater than or equal to 0.6%); in all four cases the flow cytometry results were lower than the acid elution results. The authors were able to quantitate a bleed of fetal RBCs, which were D+ only by the Du test, in a D- mother with the use of flow cytometry, and D+ RBCs in a mother whose RBCs were of the rare DVI mosaic phenotype. This would not have been possible with the use of the standard Du or rosette techniques.

Primary hyperparathyroidism and coexisting hyperthyroidism--review of the literature

Concomitance of hyperthyroidism and hyperparathyroidism is rare and only forty-nine well documented cases could be found in the literature. In the present study, only forty-three patients with adequate available clinical and laboratory data are reported. Hypercalcemia was found in all the patients and five of them (12%) had acute hyperparathyroidism. Two patients were also pregnant and had pancreatitis. Hypercalcuria was found in 73% and hypophosphatemia in 55% of the patients. Eleven patients (26%) had renal concretions. Skeletal roentgenograms showed abnormalities in 63% of the patients. Elevated serum level of alkaline phosphatase was present in 64% of the patients. However, there seemed to be no correlation with the severity of the skeletal lesions. Thyrotoxicosis commenced before that of Hyperparathyroidism in twenty-three patients (53%) whereas in the remaining twenty patients it was impossible to determine which disease began first. The etiologies of hyperparathyroidism as well as the differential diagnosis of parathyroid-related and nonparathyroid-related hypercalcemia are discussed. Microscopically, 74% of the patients had a single adenoma; 16% had hyperplasia of one to three parathyroid glands. One patient had an adenoma in combination with hyperplasia of one parathyroid gland, one had an adenoma and three hyperplastic glands, one had adenomas of two parathyroid glands in combination with hyperplasia of one parathyroid gland, and the other one had carcinoma of a parathyroid gland.2+ Finally, if a thyrotoxic patient still has hypercalcemia when becoming euthyroid after antithyroid therapy, coexisting hyperthyroidism should be considered and an operation should be performed as surgical treatment cured both diseases.(ABSTRACT TRUNCATED AT 250 WORDS)