Long-term beneficial effects of adrenal medullary autografts supported by nerve growth factor in Parkinson's disease

Parkinson's disease has been the object of several therapeutic strategies based upon replacement of the degenerating dopaminergic neurons. Adrenal medullary transplants were tried initially, because of the biochemical relationship between chromaffin cells of the medulla and dopaminergic neurons of the substantia nigra. Compared to transplant of fetal neurons, autologous grafts of adrenal medullary tissue has the advantage of using a readily available source of tissue without the problems of immunosuppression. However, these cells have not proven to be as effective as fetal neurons, probably because they do not fully differentiate into neurons. In animal models, brief treatment with nerve growth factor can facilitate such differentiation. This study is a clinical evaluation of the efficacy of adrenal medullary cell transplantation, combined with nerve growth factor infusion. Two patients were selected who were moderately to severely affected (Hoehn-Yahr stage 2 in on-phase and stage 4 in off-phase). After adrenalectomy, small pieces of medulla were prepared and implanted stereotactically into the dorsal putamen on one side of the brain. A catheter filled with mouse beta-nerve growth factor (NGF) was placed close to the grafts. Infusion of NGF was continued for one month. Despite a progressively deteriorating course prior to surgery, both patients showed improvement on the rating scales postoperatively. There was also significant improvement in timed motor tests. Motor readiness evoked potentials showed increased voltage over the operated hemisphere. The study points to methods and feasibility of supplying nerve growth factor intraparenchymally to the human brain. Possible implications with respect to other growth factors, particularly Glial cell-line Derived Neurotrophic factor (GDNF) are discussed.

Operation for primary hyperparathyroidism: the new versus the old order. A randomised controlled trial of preoperative localisation

BACKGROUND AND AIMS

In patients with primary hyperparathyroidism (PHPT), parathyroid imaging is nowadays routinely used for the purpose to perform a focused unilateral minimally invasive operation. The outcome of this new strategy has, however, not been established in randomised trials.

MATERIAL AND METHODS

Patients were randomised to either preoperative localisation with sestamibi scintigraphy and ultrasonography (group I) or no preoperative localisation (group II). In group I, a minimally invasive parathyroidectomy was performed in patients in whom both localisation studies were consistent with a single pathological gland, whereas a conventional bilateral neck exploration was performed in cases with negative localisation findings. In group II all patients underwent conventional bilateral neck exploration. Primary outcome measure was normocalcaemia at 6 months postoperatively.

RESULTS

In the preoperative localisation group (group I) 23/50 (46%) of the patients could be operated on with the focused operation whereas 26/50 (52%) were operated on by bilateral neck exploration. All patients in the no localisation group (group II; n = 50) were operated on with the intended bilateral neck operation. Normocalcaemia was obtained in 96% and 94% in group I and II, respectively. Total (localisation and operative) costs were 21% higher in group I.

CONCLUSIONS

Routine preoperative localisation, with the intention to perform minimally invasive parathyroidectomy, is not cost effective if concordant results of scintigraphy and ultrasonography are a prerequisite for the focused operation. Less than half of the patients were successfully managed with this strategy, at a higher cost and without obtaining a more favourable clinical outcome.

Primary hyperparathyroidism. Update on pathophysiology, clinical presentation and surgical treatment

The most important step in calcium homeostasis is the regulation of parathyroid hormone (PTH) secretion. The discovery and characterization of the calcium sensing receptor (CaR) of the parathyroid cell has led to a better understanding not only of the physiology of the parathyroid glands, but also of the development of hyperparathyroidism. Drugs acting on CaR can now be designed to treat hyperparathyroidism and osteoporosis. The workshop on primary hyperparathyroidism held at the National Institutes of Health in 2002 has recommended new guidelines for the treatment of asymptomatic hyperparathyroidism. Controversy still exists regarding the treatment of patients with non-classical symptoms, such as weakness, fatigue and depression. Primary hyperparathyroidism as a risk factor for cardiovascular disease and mortality is also debated. Improved techniques for the preoperative localization of pathological parathyroid glands have led to a shift in surgical strategy: surgeons abandon the traditional bilateral neck exploration in favor of a more limited approach. This change of strategy has not been based on the results of prospective randomized studies and the long term results are not known.

Heterogeneous expression of receptor mRNAs in parathyroid glands of secondary hyperparathyroidism

BACKGROUND

Secondary hyperparathyroidism (HPT) is characterized by inappropriate control of parathyroid hormone (PTH) secretion and asymmetric hyperplasia of the parathyroid glands. Receptors for calcium and vitamin D are involved in the control of secretion, as well as parathyroid cell proliferation. Defective receptor mechanisms therefore may play a role in the pathogenensis of secondary HPT. Previous studies have shown that the expression of calcium receptor (CaR), calcium-sensing receptor (CAS) and vitamin D receptor (VDR) protein, and mRNA is decreased in hyperplastic parathyroid glands of secondary HPT when compared with normal parathyroid glands.

METHODS

Thirty-six hyperplastic glands from 18 patients with secondary hyperparathyroidism were analyzed with in situ hybridization in order to investigate the expression of CaR, CAS, VDR, and PTH mRNAs in the same specimens. In nine nodular parathyroid glands, it was possible to make a comparison between the expression of these mRNAs in nodular and internodular areas.

RESULTS

The level of CaR was in the same order of magnitude in the hyperplastic glands and in the biopsies of normal parathyroid, whereas the levels of CAS, VDR and PTH were clearly reduced in the hyperplastic glands. There was a positive correlation between the expression of CaR and CAS (P = 0.02). Otherwise, no correlations between CaR, CAS, VDR, and PTH mRNAs were found. The expression of all four genes was highly variable as well between different glands as within individual glands.

CONCLUSION

The expression of mRNAs for receptors of importance in the control of PTH secretion and parathyroid cell proliferation is heterogeneously decreased in parathyroid glands of secondary HPT. The expression pattern corroborates earlier studies in which it has been assumed that each nodule in secondary HPT is of monoclonal origin, but that the monoclonal origin of each nodule is independent.

Homozygous inactivation of the MEN1 gene as a specific somatic event in a case of secondary hyperparathyroidism

BACKGROUND

Most patients who have been surgically treated for secondary hyperparathyroidism (HPT) harbor at least one pathological parathyroid gland with a tumor of monoclonal origin.

OBJECTIVE

To elucidate the underlying genetic mechanisms behind secondary HPT, by studying a panel of such tumors for numerical alterations.

METHODS

Sixteen parathyroid glands from eight patients (median age 58 years, range 31-74 years), were screened for numerical chromosomal imbalances, using comparative genomic hybridization (CGH). Mutation analysis of the multiple endocrine neoplasia type 1 gene (MEN1) was also performed by sequencing of the coding region.

RESULTS

The results show that gross chromosomal alterations occur rarely in secondary HPT. In one of the three glands analyzed from one patient, a complete loss of chromosome 11 was detected. This gland also had an inactivating nonsense mutation, E469X, of the MEN1 gene. The mutation was present neither in the other two glands, nor in the constitutional tissue of the same patient, thus confirming its somatic origin.

CONCLUSIONS

The relative lack of numerical chromosomal alterations would suggest that more discrete genetic alterations are responsible for the monoclonal growth in the majority of cases of secondary HPT. Furthermore, somatic inactivation of the MEN1 tumor suppressor gene contributes to the tumorigenesis in a small proportion of the cases.

In vitro release of aldosterone and cortisol in human adrenal adenomas correlates to mRNA expression of steroidogenic enzymes for genes CYP11B2 and CYP17

Adenomas of the adrenal cortex cause different disorders depending on the main steroid synthesized and released. The aim of this research is to increase our understanding of the pathophysiology of steroidogenesis in adrenocortical disorders by comparing the release of steroids from adrenocortical adenomas in vitro with the messenger RNA (mRNA) expression of steroid synthesizing enzymes. Fourteen patients with adrenal tumors were included in the present study; nine were diagnosed with primary aldosteronism and three with Cushing's syndrome. Two patients had an adrenal tumor discovered on computed tomography (CT) during workup for an unrelated disease. Serum cortisol, plasma aldosterone, and urinary catecholamines were normal. Tissue was taken for in vitro steroid release, and aldosterone and cortisol in the medium after a 1-hour incubation were determined. Oligonucleotide probes with sequences complementary to mRNAs encoding for the steroid synthesizing enzymes 11 beta-hydroxylase (CYP11B1), 18-hydroxylase (CYP11B2), 17 alpha-hydroxylase (CYP17), and 21-hydroxylase (CYP21) were synthesized (Genset, Paris, France) and in situ hybridization was performed. Moderate expression of CYP11B2 and low expression of CYP11B1 were seen in the zona glomerulosa. The zona fasciculata of the control adrenals expressed a high signal of CYP11B1, whereas the expression of CYP11B2 was very low. There was considerable variation in aldosterone release from the aldosteronomas, whereas the tumors from the Cushing patients showed no detectable release of aldosterone. In contrast, tumors from patients with primary aldosteronism, Cushing's syndrome, and no hyperfunction all had the ability to synthesize and release cortisol in vitro. The highest cortisol release was found in tumors from patients with Cushing's syndrome, but also the nonhyperfunctioning tumors and some of the aldosteronomas released significant amounts of cortisol. The two patients with highest release of aldosterone in vitro showed the highest expression of CYP11B2 and the lowest expression of CYP11B1 and CYP17. The remaining aldosteronomas had low expression of CYP11B2, similar to the two other groups. Expression of CYP11B1 was high as expected in the Cushing adenomas, but also the two nonhyperfunctioning tumors and some of the aldosteronomas showed a moderate expression. Adenomas from Cushing's syndrome, nonhyperfunctioning adenomas, and some of the aldosterone-producing adenomas had moderate to high expression of CYP17. This paper presents new means for functional characterization of adrenocortical tumors. Diagnosis of an aldosteronoma is often difficult, and with the advent of these methods it is possible to determine the functional capacity of a tumor, once it is removed. This is of special interest if the patient remains hypertensive postoperatively, and it is not clear whether the patient indeed had a functioning tumor.

[Hereditary thyroid cancer can be cured by prophylactic surgery]

Multiple endocrine neoplasia type 2 (MEN 2) is a rare syndrome in which the consequences for the patient and family members are considerable. Mutation analysis of the RET proto-oncogene is crucial for decision-making regarding each patient. Today, carriers of MEN 2 mutations should be offered prophylactic thyroidectomy with the potential to eliminate the risk for potentially lethal medullary thyroid carcinoma (MTC). Here, we present the first Swedish experience of such operations performed mainly on the basis of genetic analysis. Twenty patients underwent total thyroidectomy at a mean age of 13.5 (6-43) years. In all cases, either manifest MTC (n = 11) or C-cell hyperplasia was found. So far, no patient has any sign of recurrence or developmental insufficiency at 1-5 years follow-up. As the medical and ethical problems in this group of patients are substantial, and as the operations are performed in otherwise healthy children, they should be treated at centers with adequate multidisciplinary expertise and competence.

Expression of cellular retinol- and retinoic acid-binding proteins in normal and pathologic human parathyroid glands

We have previously reported data establishing the human parathyroid gland as a target organ for vitamin A. In the present study, we identified Ito-like cells in parathyroid glands, suggesting local stores of vitamin A. Furthermore, we used immunohistochemistry to investigate the expression of the cellular retinol-binding protein type 1 and the cellular retinoic acid-binding protein type 1 (CRABP I) in histologically normal glands, in remnants of "normal" glandular tissue adjacent to adenoma, in adenomas, and in hyperplastic glands of chief cell type. All normal and abnormal glands displayed immunoreactivity to the two antibodies. CRABP I appeared in the cytoplasm, cell membranes, and nuclear membranes in normal glands, but only exceptionally in the nuclear membranes in abnormal glands. Since retinoic acid inhibits the secretion of parathyroid hormone and CRABP I is thought to play a key role in regulating the amount of retinoic acid available to interact with specific nuclear receptors, these data may suggest impaired transport of retinoic acid to cell nuclei, thus contributing to the development of hyperparathyroidism.

Balanced translocation (3;7)(p25;q34): another mechanism of tumorigenesis in follicular thyroid carcinoma?

Alterations of 3p are the most frequently observed changes in follicular thyroid carcinomas. Loss of 3p25-pter has been speculated to be a critical event in the malignant transformation of a subset of thyroid follicular neoplasms. The present report describes a minimally invasive follicular thyroid carcinoma (FTC) with a balanced t(3;7)(p25;q34) and dic(15;22)(p11;p11) as the only abnormalities. The alterations were present in all metaphases analyzed and were demonstrated by G-banding, spectral karyotyping (SKY), and fluorescence in situ hybridization (FISH). This study represents the second case of FTC where 3p25 is involved in a balanced translocation. The findings support the existence of a gene locus in this region which is involved in the tumorigenesis of thyroid carcinoma.

Expression of matrix metalloproteinase gelatinase A messenger ribonucleic acid in parathyroid carcinomas

BACKGROUND

The incidence of parathyroid cancer in patients with hyperparathyroidism is less than 1%. However, these few cases cause diagnostic problems in the absence of clear-cut invasion of adjacent organs or metastasis. New markers are needed to increase diagnostic accuracy.

METHODS

Thirty-one parathyroid tumors from patients with primary hyperparathyroidism were collected worldwide. Eighteen tumors were classified as unequivocal cancers, whereas 13 tumors were considered equivocal because of a lack of infiltrative growth or evidence of recurrence. Paraffin sections were hybridized with a 35S-labeled riboprobe complementary to gelatinase A mRNA, dipped in photographic emulsion, developed, counterstained, and then evaluated by light- and dark-field microscopy.

RESULTS

Fourteen of the 18 unequivocal parathyroid cancers expressed gelatinase A, as compared with the equivocal tumors, of which only 4 of 13 showed expression. The strongest hybridization signal was seen in stromal cells at the tumor border, most likely fibroblasts and macrophages. No expression was detected in tumor cells.

CONCLUSIONS

Invasive growth of many tumors is facilitated by proteolytic enzymes, such as gelatinase A. The presence of gelatinase A mRNA in parathyroid tumors strengthens the suspicion of malignancy but cannot be used as a definitive marker of malignancy.

Alternative genetic pathways in parathyroid tumorigenesis

In this study 44 parathyroid tumors from 26 sporadic cases, 10 cases previously given irradiation to the neck, and 8 familial cases were screened for sequence copy number alterations by comparative genomic hybridization. In the sporadic adenomas, commonly occurring minimal regions of loss could be defined to chromosome 11 (38%), 15q15-qter (27%), and 1p34-pter (19%), whereas gains preferentially involved 19p13.2-pter (15%) and 7pter-qter (12%). Multiple aberrations were found in sporadic tumors with a somatic mutation and/or loss of heterozygosity of the MEN1 gene. The irradiation-associated tumors also showed multiple comparative genomic hybridization alterations and frequent losses of 11q (50%), and subsequent analysis of the MEN1 gene demonstrated mutations in 4 of 8 cases (50%). The adenomas from familial cases showed few alterations, and in 3 of these tumors a gain of 19p13.2-pter was seen as the only aberration. In this study numerical copy number alterations were frequently detected in sporadic and irradiation-associated parathyroid adenomas, although these tumors are benign. The majority of these alterations were found in tumors with confirmed involvement of the MEN1 gene locus in agreement with a role of the MEN1 gene in genomic stability. Furthermore, the frequent occurrence of MEN1 mutations (50%) in irradiation-associated parathyroid tumors suggests that inactivation of the MEN1 gene is an important genetic alteration involved in the development of parathyroid tumors in postirradiation patients.

[A Scandinavian multicenter study will investigate the question: surgery or not in mild primary hyperparathyroidism?]

Primary hyperparathyroidism is a common endocrine disease particularly prevalent among elderly women. A majority of these patients diagnosed today are mildly hypercalcaemic, and many seem to lack manifest symptoms or complications. In such cases, conservative follow-up rather than parathyroid surgery may be suggested. However, long-term follow-up may entail costly investigations and be difficult to accomplish. Moreover, conservative follow-up is associated with a risk of subsequent complications or even premature death due to cardiovascular disorders. A Scandinavian multicentre study has been initiated to assess survival, morbidity and quality of life in surgically vs. conservatively treated patients.

No overrepresentation of congenital adrenal hyperplasia in patients with adrenocortical tumours

OBJECTIVE

The development and progression of sporadic adrenocortical tumours are poorly understood. In autopsy studies adrenocortical tumours are found in between 2 and 9% of the general population. In congenital adrenal hyperplasia (CAH), decreased production of cortisol leads to increased secretion of ACTH from the pituitary, resulting in hyperplasia of the adrenals. More than 95% of all cases of CAH are due to steroid 21-hydroxylase deficiency, resulting from mutations in the CYP21 gene. In subjects homozygous and heterozygous for CYP21 mutations, adrenocortical tumours have been found in a high frequency compared to the general population, suggesting that chronic ACTH stimulation may play a role in the development of this tumour form. In order to test whether mild undiagnosed CAH is a common predisposing factor, we screened 27 patients with sporadic adrenocortical tumours for CYP21 mutations.

DESIGN

A retrospective study.

PATIENTS

We screened 27 patients with sporadic adrenocortical tumours, representing both benign and malignant as well as hormonally active and silent lesions.

MEASUREMENTS

Mutation analyses of the CYP21 gene was performed by allele-specific PCR on high molecular weight DNA. The method used detects the nine CYP21 mutations that are responsible for 95% of all disease-causing alleles in CAH.

RESULTS

No mutations were detected in any of the 23 DNA samples that were prepared from leucocytes. In 4 cases where no leucocyte DNA was available, tumour tissue was analysed. In one of these tumours, two CYP21 mutations, V281 L and L307insT, were found in heterozygous form.

CONCLUSION

Our data indicate that mild undiagnosed congenital adrenal hyperplasia is not a common underlying factor predisposing to adrenocortical tumours, at least not in the Swedish population.

Gelatinase A and membrane-type 1 matrix metalloproteinase mRNA: expressed in adrenocortical cancers but not in adenomas

In an attempt to understand the mechanism behind the invasion and metastasis in adrenocortical cancer we performed mRNA in situ hybridization on 30 tumors for three matrix metalloproteinases (MMPs): gelatinase A, membrane type 1 matrix metalloproteinase (MT1-MMP), and collagenase-3. All are known to participate in the invasion and metastasis of other tumor forms by degrading the extracellular matrix. Thirteen of sixteen cancers, but only one of fourteen benign lesions showed expression of gelatinase A, which was localized in stromal cells. MT1-MMP is thought to assist in tumor invasion and metastasis by activating the zymogen gelatinase A. Of 14 malignant tumors analyzed, 12 showed MT1-MMP mRNA expression, which in 7 cases was detected in both neoplastic and stromal cells. The benign tumors showed MT1-MMP expression in only 3 of 11 cases, and it was restricted to tumor cells. Fourteen tumors (11 cancers, 3 adenomas) were also analyzed for collagenase-3 mRNA, but no expression was detected. In conclusion, our data show that gelatinase A mRNA is expressed in most malignant adrenocortical tumors but not in the benign tumors. Gelatinase A mRNA expression is restricted to stromal cells, whereas its activator, MT1-MMP, is expressed in both stromal and neoplastic cells. Inhibition of gelatinase A and other proteinases may in the future become important as a form of cancer treatment.

Genotyping of adrenocortical tumors: very frequent deletions of the MEN1 locus in 11q13 and of a 1-centimorgan region in 2p16

To identify chromosomal regions that may contain loci for tumor suppressor genes involved in adrenocortical tumor development, a panel of 60 tumors (39 carcinomas and 21 adenomas) were screened for loss of heterozygosity. Although the vast majority of loss of heterozygosity (LOH) were detected in the carcinomas and involved chromosomes 2, 4, 11, and 18, only few were found in the adenomas. Therefore, 2 loci that harbor the familial cancer syndromes Carney complex in 2p16 and the multiple endocrine neoplasia type 1 gene in 11q13 were further studied in 27 (13 carcinomas and 14 adenomas) of the 60 tumors. Detailed analysis of the 2p16 region mapped a minimal area of overlapping deletions to a 1-centimorgan region, which is separate from the Carney complex locus. LOH for a microsatellite marker (PYGM), very close to the MEN1 gene, was detected in all 8 informative carcinomas (100%) and in 2 of 14 adenomas. Of the 27 cases analyzed in detail, 13 cases (11 carcinomas and 2 adenomas) showed LOH on chromosome 11 and was therefore selected for MEN1 gene mutation analysis. In 6 cases a common polymorphism (Asp418Asp) was found, but no mutation was detected. In conclusion, our data indicate the existence of tumor suppressor genes at multiple chromosomal locations, whose inactivations are involved in the development of adrenocortical carcinomas. Loss of genetic material from 2p16 was strongly associated with the malignant phenotype, as it was seen in almost all carcinomas but not in any of the adenomas. LOH in 11q13 also occurred frequently in the carcinomas, but was not associated with a MEN1 mutation, suggesting the involvement of a different tumor suppressor gene on this chromosome.

Evaluation of retinoblastoma and Ki-67 immunostaining as diagnostic markers of benign and malignant parathyroid disease

Assessment of the malignant potential of parathyroid tumors in the absence of metastases can be difficult using morphologic criteria alone. In this study we have examined a total of 58 parathyroid tumors (31 benign, 15 malignant, and 12 equivocal) from 54 patients using immunohistochemistry with monoclonal antibodies directed against the retinoblastoma (RB) protein and the cell cycle-associated antigen Ki-67 to evaluate their role as diagnostic markers. RB protein immunoreactivity was not useful for distinguishing between benign and malignant parathyroid tumors. Analysis of the proliferation marker Ki-67 showed that there was a trend toward more intense staining in the malignant cases. The Ki-67 labeling index was highest in the parathyroid cancers (median 33) and lowest in the sporadic primary adenomas (median 2). An observation that might have clinical implications is that tumors from patients with familial hyperparathyroidism linked to chromosome 1q showed a high Ki-67 index, indicating strong proliferative activity (median 25). This correlates well with the clinical observation of tumors with malignant potential in this syndrome. Because of the considerable overlap between groups of tumors, Ki-67 is not suitable for definitive differentiation between benign and malignant tumors. However, Ki-67 may give valuable information about which patients should be followed more closely.;1999>

Decreased expression of calcium-sensing receptor messenger ribonucleic acids in parathyroid adenomas

BACKGROUND

The set point for parathyroid hormone (PTH) secretion is increased in patients with primary hyperparathyroidism, possibly because of receptor defect(s). A decreased expression of calcium receptor (CaR) messenger ribonucleic acid (mRNA) and protein and a decreased expression of the putative calcium-sensing CAS (gp330/megalin) protein have been demonstrated in parathyroid adenomas.

METHODS

Expression of CAS mRNA was studied in matched pairs of adenomas and adenoma-associated biopsy specimens from normal parathyroid glands from 15 patients with sporadic primary hyperparathyroidism. Cryostat sections were hybridized with an oligonucleotide complementary to CAS mRNA, rinsed, air dried, and exposed to x-ray film for semiquantification of radioactivity.

RESULTS

Expression of CAS mRNA in the adenomas was lowered significantly to 25% (median; range 9% to 80%) of that of the corresponding biopsy specimens of normal parathyroid glands. No correlation was seen between CAS mRNA in the adenoma and preoperative serum calcium levels, PTH level, or weight of the adenoma. The levels of CAS mRNA were significantly lower than those observed previously for CaR mRNA. There was no significant correlation between the levels of CAS and CaR mRNA.

CONCLUSIONS

Lowered levels of receptors sensing extracellular calcium (CaR and CAS) probably contribute to the increased set point for PTH secretion in primary hyperparathyroidism.

Alterations of the MEN1 gene in sporadic parathyroid tumors

Primary hyperparathyroidism is a common endocrine disease that also occurs in a number of inherited disorders, including multiple endocrine neoplasia type 1 (MEN1). Loss of heterozygosity (LOH) in the MEN1 region on chromosome 11q13 has been found in 30% of sporadic parathyroid tumors, making the recently cloned MEN1 gene a prime candidate for involvement in parathyroid tumorigenesis. Using LOH and single strand conformation analysis, we screened 45 sporadic tumors from 40 patients for alterations involving the MEN1 gene. Thirteen tumors showed LOH at 11q13, and in 6 of these cases, somatic mutation of the MEN1 gene was detected. In tumors without LOH, no mutations were detected. The mutations consisted of 3 small deletions, 1 insertion, and 2 missense mutations that had not been reported in MEN1 patients or parathyroid tumors previously. Using messenger ribonucleic acid in situ hybridization, the expression of the MEN1 gene was studied. There was no difference in expression between normal and tumor tissue. In conclusion, the findings of inactivating mutation in tumors with LOH at 11q13 confirm the role of the MEN1 tumor suppressor gene in a subset of sporadic parathyroid tumors.

Familial isolated hyperparathyroidism maps to the hyperparathyroidism-jaw tumor locus in 1q21-q32 in a subset of families

Approximately 70 families with familial isolated hyperparathyroidism (FIHP) have been reported. Whether it is a separate entity or a variant of multiple endocrine neoplasia type 1 (MEN1 at 11q13) or hyperparathyroidism-jaw tumor (HPT-JT or HRPT2 at 1q21-32) syndrome is not known. We describe here 3 unreported families with familial primary hyperparathyroidism and evaluate their clinical, pathological, and genetic profiles. Biochemical and radiological screenings for MEN1 were negative for all families. In 2 families with a total of 10 affected cases and 3 female obligate carriers, there is no evidence of jaw or renal lesions despite careful radiological investigations. In both families the disease was linked to the 1q21-q32 region with the maximum logarithm of the odds (lod) scores of 3.10 and 3.43 for markers D1S222 and D1S249 respectively, at recombination fraction of 0. In 1 family 2 types of parathyroid pathology were found: 3 of chief cell type and 1 of oxyphil/oncocytic cell type. Two chief cell tumors and 1 oxyphil tumor were found to have loss of heterozygosity (LOH) involving loss of the wild-type alleles for chromosome 1q markers. In the third family, with 4 affected siblings, a parathyroid carcinoma and 2 cases of polycystic kidney disease were found. The parathyroid carcinoma also showed loss of heterozygosity in the 1q region. In conclusion, we found that the hyperparathyroidism traits in a subset of FIHP families are linked to the 1q21-32 markers in the HRPT2 region. We describe the spectrum of parathyroid disease in 1q-linked families involving 3 different types of pathology and demonstrate for the first time loss of wild-type alleles in these parathyroid tumors. Taken together, the results suggest that some of the FIHP are a variant of HPT-JT and that the gene involved is a tumor suppressor gene.

Tumor-specific decreased expression of calcium sensing receptor messenger ribonucleic acid in sporadic primary hyperparathyroidism

Secretion of PTH is regulated by extracellular calcium via calcium receptors (CaR) on the parathyroid cell surface. Recent studies have shown a decreased expression of CaR messenger RNA (mRNA) and CaR protein in pathological parathyroids. We studied the expression of CaR mRNA in pairs of adenoma and adenoma-associated normal gland from the same patients (n = 17) and in biopsies of normal parathyroid glands of normocalcemic subjects (n = 4) using in situ hybridization with oligonucleotide probes on frozen sections. No down-regulation of CaR mRNA caused by hypercalcemia could be demonstrated in the normal adenoma-associated parathyroids when compared with the normal parathyroids of normocalcemic subjects. In contrast, CaR mRNA in the adenomas was significantly reduced to 64% (median; range 41-98) of the corresponding normal adenoma-associated glands. No correlation was seen between CaR mRNA in the adenoma and preoperative serum calcium, PTH, or weight of the adenoma. Loss of heterozygosity studies were performed on adenomas using markers for the locus of the CaR gene on chromosome 3q. No allelic loss was demonstrated, excluding allelic loss as the cause for decreased CaR mRNA expression in the adenomas. It is concluded that the lowered levels of CaR mRNA in parathyroid adenomas may contribute to the increased set point of PTH secretion. In large adenomas the increased cell mass seems to be more important for the increased secretion of PTH.

Allelic loss on chromosome 11 is uncommon in parathyroid glands of patients with hypercalcaemic secondary hyperparathyroidism

OBJECTIVE

To test the hypothesis that progression of secondary hyperparathyroidism from normocalcaemia to hypercalcaemia occurs because of development of monoclonal parathyroid tumours after the inactivation of a tumour suppressor gene on chromosome 11q13.

DESIGN

Experimental study.

SETTING

University hospital, Sweden.

SUBJECTS

13 Patients with secondary hypercalcaemic hyperparathyroidism.

INTERVENTIONS

48 Parathyroid glands were removed, 39 of which were analysed using Southern blot hybridisation and polymerase chain reaction.

MAIN OUTCOME MEASURES

Loss of heterozygosity on several loci on chromosome 11, including 11q13, which carries the presumed gene for multiple endocrine neoplasia type 1 (MEN1).

RESULTS

Monosomy for chromosome 11 was found in one tumour.

CONCLUSIONS

It seems unlikely that the MEN1 gene is of importance in the progression of secondary hyperparathyroidism.

Differential loss of heterozygosity in familial, sporadic, and uremic hyperparathyroidism

Various genetic loci harboring oncogenes, tumor suppressor genes, and genes for calcium receptors have been implicated in the development of parathyroid tumors. We have carried out loss of heterozygosity (LOH) studies in chromosomes 1p, 1q, 3q, 6q, 11q, 13q, 15q, and X in a total of 89 benign parathyroid tumors. Of these, 28 were sporadic parathyroid adenomas from patients with no family history of the disease, 41 were secondary parathyroid tumors, 5 were from patients with a history of previous irradiation to the neck, 12 were from patients with a family history of hyperparathyroidism, and 3 were parathyroid tumors related to multiple endocrine neoplasia type 1 (MEN1). In addition, we determined the chromosomal localization of a second putative calcium-sensing receptor, CaS, for inclusion in the LOH studies. Based on analysis of somatic cell hybrids and fluorescent in situ hybridization to metaphase chromsomes, the gene for CaS was mapped to chromosomal region 2q21-q22. The following results were obtained from the LOH studies: (1) out of the 24 tumors that showed LOH, only 4 had more than one chromosomal region involved, (2) in the tumors from uremic patients, LOH of chromosome 3q was detected in a subset of the tumors, (3) LOH of the MEN1 region at 11q13 was the most common abnormality found in both MEN1-related and sporadic parathyroid tumours but was not a feature of the other forms of parathyroid tumors, (4) LOH in 1p and 6q was not as frequent as previously reported, and (5) tumor suppressor genes in 1q and X might have played a role, particularly on the X chromosome, in the case of familial parathyroid adenomas. We therefore conclude that the tumorigenesis of familial, sporadic, and uremic hyperparathyroidism involves different genetic triggers in a non-progressive pattern.

Multiple endocrine neoplasia type 1 and the search for the genetic trigger

Multiple endocrine neoplasia type 1 (MEN-1) is characterized by primary hyperparathyroidism, endocrine pancreatic-duodenal and anterior pituitary tumors. The diagnosis is challenging and involves the exclusion of other endocrine neoplasia syndromes with overlapping features. The predisposing genetic defect was assigned to chromosomal region 11q13 based on linkage analysis. Combined tumor and pedigree genotype analysis showed that allele losses in pancreatic, parathyroid and pituitary tumors eliminated the wild-type allele at the 11q13 loci, suggesting inactivation of a tumor suppressor gene in this region. A 5-Mb integrated map of the region has been established by the European consortium on MEN-1. Based on this mapping the critical interval was restricted to 2 Mb, a region within which eight candidate genes are located.

Detection of apoptotic cells and expression of Ki-67 antigen, Bcl-2, p53 oncoproteins in human parathyroid adenoma

Presence of apoptotic cells and immunoreactivity to Ki-67, bcl-2 and p53 were studied in 20 cases of parathyroid adenoma. To determine apoptosis, the DNA nick end labeling method was used. 85% of the parathyroid adenomas were found to harbor apoptotic cells. All of the 20 adenomas contained Ki-67 immunoreactive cells. Proliferative activity was not more confined to nodular than to diffuse areas, but there was a highly significant difference in Ki-67 immunoreactivity between adenomatous tissue and the residual rim of normal tissue outside the adenoma. No Ki-67 immunoreactive cells were found in two normal parathyroid glands used as controls. All but one of the adenomas (95%) demonstrated immunoreactivity to bcl-2, but expression of p53 was detected in only a few adenomas (15%). There was a significant relationship between the adenoma weights and both Ki-67 and bcl-2. This study suggests that parathyroid adenomas contain cell populations with proliferative activity (clonal proliferation), but the weak immunoreactive expression of p53 combined with the relatively strong expression of bcl-2 might contribute to a slow glandular growth.

Genetic aberrations in adrenocortical tumors detected using comparative genomic hybridization correlate with tumor size and malignancy

The differentiation between malignant and benign adrenocortical tumors is often difficult, and better markers are required. Because the genetic background of adrenocortical tumors is poorly characterized, we used comparative genomic hybridization (CGH) to screen for DNA sequence copy number changes in 8 sporadic primary adrenocortical cancers and 14 adenomas. There was a strong relationship between the number of genetic aberrations detected using CGH and both tumor size and malignancy. No alterations were seen in the smaller adenomas (< 5 cm), whereas the two largest adenomas (5 cm each) and seven of the eight cancers (7-20 cm) showed an increased number of genetic alterations. The presence of genetic aberrations detected using CGH was associated with an aneuploid DNA pattern. In the cancers, losses most often involved the chromosomal regions 2, 11q, and 17p (four of eight tumors), whereas gains took place at chromosomes 4 and 5 (four of eight tumors). In conclusion, our data indicate that genetic changes may help to define the malignant potential of adrenocortical tumors. Furthermore, the CGH results implicate several chromosomal regions that may contain genes with an important role in the development of adrenocortical cancers.

Sweat glands accumulate Tc-99m MIBI

Tc-99m MIBI, which was originally developed for myocardial perfusion studies, may also be used for depiction and characterization of tumors. Forty-one patients with suspected hyperparathyroidism were examined with Tc-99m MIBI to localize a parathyroid adenoma or hyperplasia. In 19 of these patients (46%), bilateral symmetrical activity corresponding to the large deep apocrine sweat glands of the axillae was present. Sweat gland activity was not correlated with serum calcium levels. Although these patients may represent a selected group, the observation is clinically relevant regardless of its reason or mechanism. It is important also to be aware of this cause for activity in the axilla when assessing lymph node involvement in breast cancer patients using Tc-99m MIBI.

[MIBI-scintigraphy. A simple and reliable method for localization of pathological parathyroid glands]

99Tcm-sestamibi scintigraphy was used to localise enlarged parathyroid glands in 25 patients with primary hyperparathyroidism previously operated in the neck, 20 of whom had recurrent disease and five had previously undergone surgery for thyroid disorders. Of the 18 patients for whom positive scans were obtained, nine were operated on the scan findings being confirmed. Crucial information was provided in two cases of intrathyroidal and one case of intramediastinal localisation of the pathological gland were not operated on as the hypercalcaemia was only marginal or the symptoms were vague. Though preoperative localisation of pathological parathyroid glands is a prerequisite for neck exploration in patients with persistent or recurrent hypercalcaemia due to primary (or secondary) hyperparathyroidism, the procedure is not cost-effective before the initial operation.

Cardiac function in primary hyperparathyroidism before and after operation. An echocardiographic study

OBJECTIVE

To identify possible causes for the increased cardiovascular morbidity and mortality seen in patients with primary hyperparathyroidism.

DESIGN

Prospective, blind study.

SETTING

University hospital, Sweden.

SUBJECTS

44 Patients with primary hyperparathyroidism and 23 (sex and age matched) control patients with atoxic nodular goitres.

INTERVENTIONS

Exploration of the neck with removal of pathological parathyroid glands or thyroid resection. Echocardiography before, and one year after, the operation.

MAIN OUTCOME MEASURES

Blood pressure and echocardiographic findings.

RESULTS

Hyperparathyroid patients had higher blood pressure and greater left atrial diameter than control patients preoperatively. They also had a significantly lower E:A ratio (mitral flow velocity pattern) than the controls (p = 0.02) indicating a disturbance in early diastolic filling of the left ventricle. The E:A ratio correlated negatively with the systolic blood pressure. 19 of the hyperparathyroid patients (43%) had cardiac calcifications as did 14 (61%) of the controls. Most of calcifications were located in the aortic and mitral valves; only a few patients had calcifications in the myocardium. No significant changes had occurred one year after parathyroidectomy, except for a reduction in systolic blood pressure, in the hyperparathyroid patients.

CONCLUSION

Echocardiographic investigation of patients with primary hyperparathyroidism shows early signs of left ventricular dysfunction that may be of clinical importance.

Clinical course of metastatic parathyroid cancer

In a retrospective study the clinical course of 40 patients with symptomatic persistent or recurrent parathyroid cancer was analyzed in order to assess the value of aggressive surgical intervention. Recurrence was diagnosed after a median period of 33 months (1-228 months). Twenty-two patients had locoregional disease, whereas 14 patients had both local and distant spread. The remaining four patients had distant spread. Patients with just locoregional disease were subject to one to nine reoperative procedures. The median survival time from the last operation was 39 months (1-204 months). Eight patients then had no evidence of disease, three were hypercalcemic and 9 of 11 had died of parathyroid cancer. Distant spread was demonstrated in 17 of 40 patients. Pulmonary metastases predominated (14 of 17). Surgical excision was performed in 9 of 14 cases. Of these nine, two patients had a subsequent disease-free interval of 36+ and 72+ months, respectively. One patient was reported hypercalcemic after 84 months, whereas five patients died of cancer between 4 and 60 months after their last surgical exploration. One patient was lost to follow-up. In all, 21 patients (53%) died of parathyroid cancer. Conspicuous nuclear atypia and frequent mitoses predominated. Image cytometric DNA analysis showed high rates for all three groups (median p90 = 80%, range 21-98%).

Primary hyperparathyroidism. Low surgical morbidity supports liberal attitude to operation

OBJECTIVE

To evaluate the results of a modern surgical approach in patients with primary hyperparathyroidism.

DESIGN

Retrospective analysis.

SETTING

University hospital, tertiary care center.

PATIENTS

One hundred patients consecutively operated on for suspected primary hyperparathyroidism. Patients were available for follow-up 1 month (n = 100) and 1 year (n = 96) after surgery.

INTERVENTION

Cervical exploration. Surgical strategy was to remove enlarged parathyroid glands only and perform a biopsy on no more than one normal gland.

MAIN OUTCOME MEASURES

Surgical morbidity and normocalcemia.

RESULTS

No operative mortality or wound infection occurred in any patient. Postoperative vocal cord paralysis was recorded in two patients; both recovered fully. Two patients underwent a second operation. (One patient experienced subcutaneous bleeding and the second patient, previously operated on for toxic goiter, experienced persistent hypercalcemia and was operated on 5 days after the initial operation. A second abnormal gland was then found on the contralateral side, not initially surgically explored.) At follow-up, 97 patients were normocalcemic; three patients had hypoparathyroidism: two of these patients, with multiglandular disease, were normocalcemic and received a low dose of vitamin D (1 alpha [OH]D3), and one patient, who had had a single adenoma removed, was slightly hypocalcemic, however, asymptomatic.

CONCLUSIONS

More than 90% of patients with primary hyperparathyroidism can be operated on without complications occurring. This supports a liberal attitude to operation.

Acute effects of smoking during modified sham feeding in duodenal ulcer patients. An analysis of nicotine, acid secretion, gastrin, catecholamines, epidermal growth factor, prostaglandin E2, and bile acids

Smoking is associated with an increased incidence of duodenal ulcer with a high relapse rate, and smokers tend to be slow healers. The etiology responsible for this remains unknown, and there is general disagreement as to whether smoking affects gastric secretion. The aim of the present study was to investigate both aggressive and protective factors in response to vagal stimulation induced by modified sham feeding (MSF) in duodenal ulcer patients when smoking versus not smoking. On smoking days, nicotine concentrations in plasma averaged about 15 ng/ml and were extremely high in saliva and gastric juice (> 1300 and > 800 ng/ml, respectively). MSF induced a significant decrease in intragastric pH during non-smoking (p = 0.01) but not during smoking. Acid output 1 h after MSF was lower on smoking than on non-smoking days (p = 0.02), as was volume secretion (p = 0.02). Plasma gastrin concentrations were significantly increased during MSF on non-smoking days (p = 0.04) but not on smoking days, the concentrations during the whole day being lower on smoking days (p = 0.002). Plasma catecholamine levels were unaffected by MSF, whether smoking or not. However, plasma concentrations of noradrenaline decreased during the smoking of a single cigarette (p = 0.03), whereas those of adrenaline were increased on smoking days (p = 0.02). Epidermal growth factor concentrations were decreased in gastric juice after MSF during non-smoking (p = 0.01) but not during smoking. Although prostaglandin E2 (PGE2) concentrations in gastric juice were unaffected by MSF, PGE2 output increased after MSF whether smoking or not, the increment being non-significantly less during smoking (p = 0.09).(ABSTRACT TRUNCATED AT 250 WORDS)

Oestrogen, progesterone, and glucocorticoid receptors in normal and neoplastic parathyroid glands

OBJECTIVE

To verify the presence or absence of steroid receptors in the parathyroid glands of patients undergoing operations on the parathyroid and thyroid glands.

DESIGN

Open experimental study.

SETTING

Karolinska Hospital, Stockholm, Sweden.

MATERIAL

165 parathyroid glands from 137 patients, 108 of whom underwent operations on the parathyroid glands and 29 on the thyroid gland.

INTERVENTIONS

Normal and neoplastic parathyroid tissue was analysed for its content of oestrogen and progesterone and glucocorticoid receptors using either ligand binding or antibodies raised against oestrogen and progesterone receptors.

RESULTS

Positive reactions to female sex steroid receptors (defined as > 0.05 fmol/microgram DNA) were uncommon (9%) regardless of the morphological classification of the glands or the age, sex, and menopausal status of the patients. Glucocorticoid receptors were detected in 107/163 (66%) of all glands analysed (mean value 0.43 fmol/micrograms DNA, range 0-44). Seventy of the 96 diseased glands (73%) contained receptors, as did 27/67 normal glands from patients with primary hyperparathyroidism or those undergoing thyroid operations. The difference was again not associated with age, sex, and menopausal status.

CONCLUSIONS

It seems unlikely that sex steroid hormones play a physiological part in the secretion of parathyroid hormone, but our finding of glucocorticoid receptors in normal as well as diseased parathyroid tissue suggests that they may have a role in the regulation of parathyroid function.

Prognostic factors in parathyroid cancer: a review of 95 cases

The clinical course, histopathology, and tumor DNA distribution patterns were analyzed in 95 patients with parathyroid cancer. The median follow-up was 6 years (range 1-25 years). Eighteen patients received a benign diagnosis at their first operation. The initial procedure was tumor resection in 42 patients and tumor resection plus partial or total thyroidectomy in 40 patients. Forty patients developed recurrent disease and 36 patients underwent 1 to 9 re-operations. Cervical recurrence and lung metastases were most commonly encountered. The median time from the first operation to recurrence was 33 months (range 1-228 month). Twenty-one patients died of parathyroid cancer a median of 28 months following discovery of their first recurrence. The histopathological reevaluation confirmed unequivocal parathyroid cancer, i.e., infiltration and/or metastases, in 41 cases. Fifty-four cases lacked these criteria but showed various forms of atypia. Image cytometry demonstrated tumor aneuploidy in 26 of 39 cases with definite cancer by histological criteria, compared to the 13 of the 52 with equivocal histological diagnosis. Twelve patients with aneuploid tumors and 7 patients with euploid tumors died of parathyroid cancer. In a multivariate analysis, patients treated with extensive surgery, i.e., tumor resection and unilateral or bilateral thyroidectomy, had a longer survival and a longer relapse-free period. Other factors of importance for survival were age and histopathology. Histopathology and an aberrant nuclear DNA content were important factors for the time to recurrence. We conclude that histopathology alone is unable to confirm a cancer diagnosis in the absence of infiltration and/or metastases. Because recurrence may occur late, patients should be followed closely. Even repeated surgical interventions have proven beneficial.

Morphology, DNA ploidy and allele losses on chromosome 11 in sporadic hyperparathyroidism and that associated with multiple neoplasia, type 1

OBJECTIVE

To analyse different forms of hyperparathyroidism (for example, sporadic and multiple endocrine neoplasia type 1 (MEN 1)) by histopathology, DNA cytometry and by the presence of allele losses on chromosome 11, thereby identifying common characteristics.

MATERIAL

Enlarged glands from 26 patients with hyperparathyroidism (23 sporadic and 3 MEN 1). Cytometric assessment was made of 28 glands.

RESULTS

Nine patients had multiple gland disease and 15 had single gland disease (14 sporadic and 1 MEN 1). DNA cytometry showed that 18 (15 sporadic and all 3 MEN 1) were diploid, seven tetraploid, and two aneuploid. Two glands from one sporadic case showed different ploidy patterns. Seven patients with sporadic and all three with MEN 1 hyperparathyroidism had allele losses for chromosome 11 in the analysed glands.

CONCLUSION

There were no significant differences in histopathological appearances, ploidy, or allele losses among abnormal glands from a variety of forms of hyperparathyroidism.

Decreased liberation of noradrenaline from the heart following cold crystalloid cardioplegia

Exogenous catecholamine support is often needed soon after termination of cardiopulmonary bypass even when appropriate cardioplegia has been used. To study the effect of hypothermic cardioplegic ischemia and reperfusion on the activity of the cardiac sympathetic nervous system, plasma noradrenaline concentration in the coronary sinus and general circulation was measured in six patients undergoing valve replacement for nonischemic mitral disease. Before cardiopulmonary bypass and cardioplegia the release of noradrenaline from the heart was greater than the mean systemic release. After ischemia, during reperfusion, the heart tended to extract noradrenaline, and 10 min after termination of bypass the plasma noradrenaline gradient over the heart remained less than pre-bypass. The results indicated decreased activity of the cardiac sympathetic nervous system, which may explain the frequent need for catecholamine support.

Effects of physiological increases in plasma noradrenaline on the human endocrine pancreas

The effect of plasma noradrenaline concentrations within the physiological range (less than 5-6 nM) on the endocrine pancreas was investigated in 9 nondiabetic volunteers. Noradrenaline significantly inhibited plasma insulin levels but did not change plasma glucagon and somatostatin concentrations.

Effects of physiological increases of plasma noradrenaline on gastric acid secretion and gastrointestinal hormones

It is not known if the increased plasma concentration of noradrenaline in patients with chronic duodenal ulcer disease is a pathogenetic factor or not. The aim of the present study was to investigate if physiologic changes of noradrenaline would evoke any alterations in gastric acid secretion or in the plasma concentration of some gastrointestinal hormones (gastrin, secretin, PP, PYY, and GIP) known to affect gastric physiology. The results show that basal plasma noradrenaline concentration was 1.8 nM and after infusion with noradrenaline at 0.04 or 0.2 nmol/kg/min plasma levels of 2.5 and 4.4 nM were obtained. No appreciable changes could be found in basal or pentagastrin stimulated acid secretion or in any of the gastrointestinal peptides studied. If the elevated plasma noradrenaline concentration observed in duodenal ulcer patients is a pathogenetic factor; it is probable that it interferes with other variables such as blood flow, bicarbonate secretion, or prostaglandin synthesis.

No effect of naloxone or morphine on plasma catecholamines during hemorrhage in rat

Awake rats were bled 2.5 per cent of their body weight during 15 min. This caused a 50-fold increase of plasma adrenaline and a 15-fold increase of plasma noradrenaline after 90 min. Treatment with naloxone or morphine did not significantly affect blood pressure or plasma catecholamine levels. The results suggest that the action of naloxone in hemorrhagic hypotension is not mediated via the sympatho-adrenal system.

Is there a relationship between gastric acid secretion and plasma catecholamines in duodenal ulcer disease?

Plasma adrenaline, noradrenaline and dopamine concentrations have been analyzed in three different groups of duodenal ulcer (DU) patients under various regimens of acid reduction in an attempt to find out if acidity per se has any influence on plasma catecholamine concentrations. Treatment with cimetidine in patients with asymptomatic chronic DU disease, reduced gastric acidity to the same level as after highly selective vagotomy (HSV), but increased plasma noradrenaline concentrations insignificantly. In a group of DU patients subjected to HSV, plasma noradrenaline levels were significantly higher 1 year after surgery than 6 weeks thereafter despite the fact that the basal acid output was the same. In a third group of DU patients, plasma noradrenaline and dopamine levels were found to be 20% higher during the active, untreated ulceration than after 4 weeks of ranitidine treatment when the ulcer had healed. It is concluded that the elevated plasma noradrenaline levels found in DU patients are not caused by the hypersecretion of acid per se, nor does there seem to be any general correlation between acidity and the catecholamine levels in peripheral plasma.

Metabolic and hormonal adjustments during hemorrhage in cats after interference with the sympatho-adrenal system

The relative contribution of the splanchnic sympathetic innervation and the adrenal medulla for metabolism and hormone secretion during two different levels of hemorrhagic hypotension was investigated in 3 groups of anesthetized cats, viz, intact, adrenalectomized and splanchnicotomized (adrenalectomy + cutting of splanchnic nerves). In intact cats, hemorrhage caused very marked elevations of arterial plasma glucose, adrenaline, noradrenaline, dopamine, lactate, cAMP, glycerol and glucagon concentrations whereas plasma insulin fell to only 20% of control values. Adrenalectomy attenuated the glucose, adrenaline, noradrenaline and cAMP responses whereas the normal insulin inhibition was abolished. Splanchnicotomy further reduced the hemorrhagic glucose and glycerol responses and, possibly, also that of glucagon. It is concluded that the adrenergic system as a whole is important for the adjustments of the release of glucose, cAMP, glycerol, insulin and glucagon that occur during hemorrhage in cats. The adrenal medulla seems to be of particular importance for the regulation of cAMP release.

Effects of food on plasma catecholamine and gastrin levels in patients with duodenal ulcer and normal volunteers

Changes in plasma concentrations of adrenaline, noradrenaline, dopamine and gastrin in response to a standard meal were studied in 6 normal volunteers and 8 patients with chronic duodenal ulcer (DU) disease. Before the meal plasma gastrin and noradrenaline, but not adrenaline or dopamine, were higher in DU patients than in the controls. Food induced significant increments in plasma gastrin and noradrenaline concentration in both groups, whereas plasma adrenaline and dopamine levels remained unchanged. Plasma gastrin and noradrenaline concentrations were higher in DU patients than in the normal controls both during and after the meal. The results do not support the hypothesis that adrenaline is involved in the pathogenesis of duodenal ulcer disease, whereas the role of the increased plasma noradrenaline concentrations in this disease remains unclear.

The relation between catecholamines, glucagon and pancreatic polypeptide during hypoglycaemia in man

The effects of insulin hypoglycaemia (0.15 IU/kg) on plasma adrenaline, noradrenaline, dopamine, glucagon and pancreatic polypeptide (PP) concentrations were investigated in 6 adrenalectomized subjects and 6 healthy controls. Both the rise in mean plasma insulin and the fall in mean blood glucose concentration were closely similar in the two groups. Mean plasma adrenaline concentration rose by about 3 nmol/l in the normal subjects, but remained unchanged in adrenalectomized subjects. Mean plasma noradrenaline concentration increased by about 2 nmol/l in both groups. Despite the large difference in adrenaline concentrations during hypoglycaemia, there was no significant difference between the responses of the endocrine pancreas of the normal and adrenalectomized subjects. Thus, mean plasma glucagon concentration rose by about 30 pmol/l and mean plasma PP concentration by about 150 pmol/l in each group. We conclude that the release of glucagon and PP during hypoglycaemia does not depend upon changes in plasma adrenaline concentration in man.

Cyclic AMP and metabolic substrates following hemorrhage in awake and anesthetized rats

The levels of several metabolites in plasma were studied during a period of 4 h in awake and barbiturate anesthetized rats after a blood volume loss of approximately 3% of b.w. Blood pressure was 70 mmHg (9.3 kPa) in the awake and 35 mmHg (4.7 kPa) in the anesthetized rats. Resting levels of plasma glucose, blood lactate and pyruvate and plasma cyclic AMP were higher in the awake rats than in the anesthetized rats. Bleeding caused an increase of plasma glucose in both groups. There was a more rapid increase in blood lactate and pyruvate as well as in plasma cyclic AMP levels in the awake rats than in the anesthetized rats. By contrast, plasma glycerol levels were unaltered by bleeding, and plasma FFA levels were decreased in both groups. At the end of the 4-h bleeding period plasma glucose was higher and blood lactate levels were lower in the awake rats. The initial changes in plasma metabolite levels appeared to be directly related to changes in plasma catecholamine levels. There were no differences in the relationship between the adrenaline level and cyclic AMP or glucose increase, suggesting that anesthesia did not alter beta-adrenoceptor sensitivity, but only catecholamine concentrations. The results also indicate that awake rats tolerate long-lasting blood volume loss better than anesthetized rats, because the sympatho-adrenal activation is more short-lasting.