Prädiktion der pharmakologischen Wirkung von Octreotid bei Akromegalie mittels 111In-Pentetreotid-Szintigraphie und Berechnung eines hypophysären Uptake-Index

Ziel: Ziel unserer prospektiven Studie war die optimierte Bestimmung des hypophysären Somatostatin-Rezeptorstatus in der 111 -In-Pentetreotid-Szintigraphie und der intraindividuelle Vergleich mit dem pharmakologischen Effekt von Octreotid bei florider Akromegalie. Methoden: Bei n = 22 Patienten mit Wachstumshormon-(GH)-sezernierendem Hypophysenadenom wurde eine 111-In-Pentetreotid-Szintigraphie durchgeführt und die spezifische Nuklidakkumulation in der Hypophysenregion (Auswertung sowohl visuell als auch semiquantitativ mittels ROI-Technik und Berechnung verschiedener Uptake-Indizes) mit dem akuten GH-Abfall nach 100 ug Octreotid s.c. (Octreotid-Akuttest) korreliert. Ergebnisse: Der von uns vorgeschlagene Uptake-Index (Quotient zirkuläre Hypophysen-ROI : irreguläre Zerebrum-ROl, jeweils cts/pixel nach Untergrund-Korrektur im sagittalen SPECT-Schnitt mit der maximalen Hypophysendarstellung 24 h p. i.) korreliert am besten mit dem pharmakologischen Effekt (akuter GH-Abfall) von Octreotid; seine obere Normgrenze liegt im Bereich von 3,5. Schlußfolgerungen: Da sich häufig auch die normale Hypophyse szintigraphisch darstellen läßt, ist die rein visuelle Abgrenzung zum pathologischen Rezeptorstatus manchmal uneindeutig. Ein mittels standardisierter ROI-Technik berechneter, hypophysärer Uptake-Index erleichert diese Abgrenzung und hilft so, mögliche Responder für eine Octreotid-Langzeittherapie zu selektieren.

The influence of testosterone substitution on bone mineral density in patients with Klinefelter's syndrome

The aim of this study was to clarify the extent of bone mineral deficiency in patients with Klinefelter's syndrome on the premise that testosterone substitution could prevent this deficiency. Bone mineral density was measured by single-photon absorptiometry in 42 patients with Klinefelter's syndrome, (21 patients without therapy, 10 with testosterone substitution before the age of 20 and 11 patients with testosterone substitution beginning after the age of 20). We found significantly lower bone mineral density in patients without therapy and in patients when the therapy began later compared to normal individuals. Patients with early therapy showed a high proportion of normal values of bone mineral density. We found a positive correlation between bone mineral density and plasma testosterone and a negative correlation between plasma testosterone and age for patients without therapy. These findings suggest that low testosterone levels before or during puberty cause inadequate bone development and low bone mineral density in Klinefelter's syndrome. Only early testosterone substitution may prevent bone mineral deficiency. Later substitution no longer affects bone mineral density.

Gynaecomastia in a patient with a hCG producing giant cell carcinoma of the lung. Case report

Gynaecomastia, or enlargement of the male breast may result from various endocrine dysfunctions and often reflects ectopic production of substances such as hCG and estradiol. We report on the case of a 30 year old man who presented with gynaecomastia and elevated plasma levels of hCG, estradiol and testosterone. As a result of several diagnostic procedures such as selective venous sampling and magnetic resonance tomography (MRT), a hCG producing tumor of the upper lobe of the left lung was found. This hormonal overproduction induced an enhanced secretion of estradiol and testosterone in the testicular tissue. Histology revealed a giant cell carcinoma with positive immunostaining for hCG. This case report further underlines the necessity of an intensive search for ectopic beta-hCG production due to malignant tumours, in particular in the adult.

Hypergonadotropic hypogonadism in a patient with inv ins (2;4)

We report on a 30-year-old man with azoospermia, primary hypogonadism and minor dysmorphic features who carried a balanced insertional chromosome translocation inv ins (2p24;4q28.3q31.22)de novo. Molecular cytogenetic analyses of the chromosome breakpoints revealed the localization of the breakpoint in 4q28.3 between BACs RP11-143E9 and RP11-285A15, an interval that harbours the PCDH10 gene. In 4q31.22, a breakpoint-spanning clone (RP11-6L6) was identified which contains the genes LSM6 and SLC10A7. On chromosome 2, BACs RP11-531P14 and RP11-360O18 flank the breakpoint in 2p24, a region void of known genes. In conclusion, the chromosome aberration of this patient suggests a gene locus for primary hypogonadism in 2p24, 4q28.3 or 4q31.2, and three possible candidate genes (LSM6, SLC10A7 and PCDH10) were identified by breakpoint analyses.

Aberrant expression of tissue-specific proteins in the thymus: a hypothesis for the development of central tolerance

Herein we present the case for the existence of a thymic cortical epithelial cell that possesses an unusual gene transcription. It produces tissue-specific proteins that have their usual physiological functions outside the thymus and presents them, as well as household proteins, to the differentiating thymocytes. We suggest that this specialized cell enforces tolerance to most self-proteins by causing release of a signal for programmed cell death to thymocytes that express receptors for these self-antigens.

Murine thymic nurse cells express ICAM-1 on caveolar and vacuolar membranes

The thymic nurse cell is a unique type of epithelial cell in the thymic cortex. It is in intimate contact with the developing thymocytes by harbouring up to 200 thymocytes in distinct vacuoles, called caveoles. This investigation is concerned with the nurse cell expression of the intercellular adhesion molecule ICAM-1, the ligand for thymocyte LFA-1. Nurse cells from young Balb/c mice were isolated in a density gradient. ICAM-1 expression was studied by using two different immunotechniques: alkaline phosphatase labelled cryosections, and immunogold electron microscopy. The specific antibody was a monoclonal rat anti-mouse ICAM-1. Immunostaining of cryosections demonstrated that ICAM-1 is expressed on the surface membrane and in the internal caveolar membranes of thymic nurse cells. Electron microscopy of immunogold labelled sections revealed ICAM-1 on the surface membrane of thymic nurse cells and on the membranes of the caveoles, the small cytoplasmic vesicles, as well as on the Golgi apparatus.

[Prediction of pharmacological effect of octreotide in acromegaly by means of 111In-pentetreotide scintigraphy and calculation of a pituitary uptake index]

AIM

The aim of our prospective study was to optimize the determination of the pituitary somatostatin receptor status by means of 111-In-pentetreotide scintigraphy and to compare it intraindividually with the pharmacological effect of octreotide in active acromegaly.

METHODS

In n = 22 patients with growth hormone (GH) secreting pituitary adenoma, 111-In-pentetreotide scintigraphy was performed, and the specific radionuclide accumulation in the pituitary area (evaluation visually as well as semiquantitatively by means of ROI technique and calculation of various uptake indices) was correlated with the acute drop of GH after administration of 100 micrograms octreotide s. c. (octreotide acute test).

RESULTS

The uptake index we propose (cts/pixel-ratio circular pituitary ROI: irregular cerebrum ROI after background correction in the sagittal SPECT slice with maximum pituitary uptake 24 h p.i.) correlates best with the pharmacological effect (acute decrease of GH levels) of octreotide; its upper normal limit amounts of 3.5.

CONCLUSION

As often the normal pituitary gland can be visualized scintigraphically, the purely visual differentiation between a normal and a pathological receptor status sometimes is equivocal. A pituitary uptake index, calculated by means of a standardized ROI technique, facilitates this discrimination and so contributes to select possible responders for a treatment with octreotide.

[Quantitative determination of echogenicity of diffuse inflammatory thyroid gland diseases]

Grey level was measured in 93 ultrasonic scans of the thyroid gland in order to quantify hypoechogenicity in diffuse inflammatory thyroid disease. Using a modern ultrasound device (256 grey-scale steps and 7.5-MHz parallel scan), grey levels were measured in normal thyroid glands and euthyreotic goiters as well as in thyroiditis or Graves' disease using a programmed setting of the device. Highly significant differences were found between normal thyroid glands and thyroiditis or Graves' disease. Sensitivity of the method was 65% in discriminating Graves' disease and 91% in discriminating thyroiditis; specificity was 95%. The clinical value of the method for follow-up studies in inflammatory diseases of the thyroid gland still has to be established.

[Sports therapy in Bechterew's disease--presentation of a new treatment concept]

Bechterew's disease is a chronic-inflammatory condition of the spine, with a tendency toward stiffening and relatively frequent involvement also of the hip, knee and shoulder joints. Contrary to most other rheumatic diseases, drug therapy plays a rather minor role. The focus is on movement, in line with the motto that "Bechterew patients need movement". The sports therapy concept of the Münster University Bechterew group as well as initial experience are set out.

Subcutaneous gonadotropin therapy in male patients with hypogonadotropic hypogonadism

OBJECTIVE

The response to subcutaneous (SC) gonadotropin replacement therapy, using human chorionic gonadotropin (hCG) and human menopausal gonadotropin (hMG) or hCG alone, was evaluated in male hypothalamic hypogonadism.

DESIGN

Sixteen patients with hypothalamic hypogonadism were treated with gonadotropins for induction of puberty and normalization of spermatogenesis. The results were analyzed retrospectively.

SETTING

The study was carried out in a clinical endocrinology department providing tertiary care and in private practices of endocrinology.

PATIENTS

Eight patients with idiopathic hypogonadotropic hypogonadism and eight patients with Kallmann's syndrome in prepubertal or early pubertal stages.

INTERVENTIONS

Human chorionic gonadotropin and hMG were administered SC in individual dosages.

MAIN OUTCOME MEASURES

Increase of serum testosterone (T), testicular volume, semen volume, and sperm count were evaluated.

RESULTS

Normalization of serum T and complete sexual maturation was achieved in all patients. Spermatogenesis was induced in all but two patients. Seven patients showed normal findings in semen volume and sperm count, and two patients had semen quality close to normal. In five patients sperm count remained less than 10 x 10(6)/mL.

CONCLUSIONS

The results obtained by SC gonadotropin replacement prove this mode of administration to be effective in stimulating steroidogenesis and spermatogenesis in hypogonadotropic males.

The influence of penbutolol and placebo on blood sugar levels and insulin consumption in the glucose-controlled insulin infusion system ("artificial endocrine pancreas")

The aim of the study was to investigate the influence of 40 mg of the beta-blocker penbutolol (Betapressin TM; Hoechst Ltd., Frankfurt/Main) in comparison to placebo on the insulin consumption on the blood sugar profile in twelve insulin-dependent diabetes (IDDM) patients. The patients were treated with penbutolol and placebo for a period of three days, and then were examined with the help of the glucose-controlled insulin infusion system. The blood sugar profile and insulin consumption over a 24 hour period was not affected by either penbutolol or placebo, nor could any changes be measured in these parameters when measured after food intake. After a submaximal exercise load on the bicycle ergometer (1 watt per kg body weight) following an evening meal, no difference could be observed between penbutolol and placebo in the above-mentioned parameters. The same was also true for hormonal parameters as STH, ACTH, cortisol, and catecholamines. These findings demonstrated that medication of penbutolol over a three-day period has no influence on the baseline blood sugar profile and insulin consumption or on insulin consumption after food intake during rest and physical exercise.

[Long-term study of endocrine ophthalmopathy and retrospective assessment of therapeutic measures]

The follow-up of Graves' ophthalmopathy was analysed regarding to clinical and chemical data on the one hand and to dependence on different therapeutic alternatives on the other. 297 patients (44 +/- 14 years, 249 female, 48 men) were observed with inclusion of data from the history and clinical data as well (computer tomography and orbital sonography). At the onset of therapy 253 patients were hyperthyroid, 36 euthyroid and eight showed hypothyroidism. The staging was: I 13, II 54, III 113, IV 95, V five, VI eight patients. The HLA-typing in 89 patients showed the following results: B8 in 32%, DR3 in 42%, B8 as well as DR3 in 24% of the patients. In about 50% of the cases there were raised microsomal and in about 18% there were raised thyroglobuline antibodies. 63% of the patients received immunosuppressive medication: corticosteroids in 100% (more than one time in 43%), cyclosporine A in 11%, ciamexone in 10%, other non-steroid immunosuppressants in 5% of the cases. The retrobulbar irradiation was performed in 9%, and total thyroidectomy in 7%. During therapy the inflammatory process was clearly ameliorated, however exophthalmos and diplopia were more resistant to treatment. In the group of patients with combined cyclosporine and prednisone therapy and in the group of patients with total thyroidectomy and partly retrobulbar radiotherapy, significant differences were observed regarding to visual acuity and Hertel values. None of the therapies applied constitutes an optimal treatment with the regard to the long-term course. Under therapy an improvement can be reached, but no complete healing.

Evaluation of the clonidine-suppression test in the diagnosis of pheochromocytoma

In this study we examined the preoperative value of the clonidine-suppression test in 15 patients with surgically proved pheochromocytomas. The result of the clonidine-suppression test was pathological (epinephrine plus norepinephrine above 500 ng/l 3 h after clonidine) in 10 of 15 patients (66%). These patients had relatively large tumors and higher basal norepinephrine plasma levels. Out of the 5 cases without a pathological clonidine test 4 had normal basal plasma catecholamine levels with the result that the clonidine test could not be properly applied and 1 case produced a false negative result. These 5 cases generally had smaller tumors and lower plasma catecholamine levels. Two of these cases had basally raised epinephrine values. The other three cases had either a paradoxical increase or a suspiciously low fall (less than 25%) in norepinephrine within the normal range. We conclude that the clonidine-suppression test is only reliable for the diagnosis of relatively large pheochromocytomas.

[Type II multiple endocrine neoplasms. Diagnosis, therapy and prognosis]

From 1979 to 1986, seven patients with multiple endocrine neoplasia (MEN) type IIa and three with type IIb were treated. Nine had a C-cell carcinoma, one had C-cell hyperplasia. None had hyperparathyroidism. Three patients had multiple mucous neuromas. Six patients had proven pheochromocytoma: adrenalectomy was performed in these six (unilateral or bilateral depending on whether the tumor was uni- or bilateral). All ten patients had a total thyroidectomy--three later required neck dissection for regional lymphnode metastases. One patient died from the consequences of diffuse liver metastases of a C-cell carcinoma. Extensive family screening is necessary with patients who have MEN type II, in order to discover early any occult disease carriers. In addition, MEN type II should be excluded in all patients who have C-cell carcinoma, pheochromocytoma or hyperparathyroidism.

Comparison of 131I-metaiodobenzylguanidine scintigraphy with urinary and plasma catecholamine determinations in the diagnosis of pheochromocytoma

In a retrospective study of 31 patients with suspected pheochromocytoma we examined the preoperative results of 131I-metaiodobenzylguanidine (131-I-MIBG) scintigraphy and a fluorimetric urine catecholamine determination test. An additional radioenzymatic plasma catecholamine determination test was performed in 25 patients. In 14 of the 31 patients the diagnosis of pheochromocytoma was later histologically confirmed. In the remaining 17 patients the suspected diagnosis was finally rejected after a clinical decision had been made on the basis of clinical history, symptoms, laboratory and imaging tests. 131-I-MIBG scintigraphy apparently had a very high specificity (no false-positive results among the patients with rejected diagnosis), but showed the least sensitivity (3 of 14 tumours were not detected). Urine catecholamines showed two false-negative and three false-positive results. Plasma catecholamines had the highest sensitivity and gave only one false-positive result. Because of its high pathognomonic value 131-MIBG scintigraphy can be helpful not only for localization, but also for confirmation of diagnosis when catecholamine determination tests are contradictory. On the basis of our experience with false-positive results after interfering medication therapy, urine and plasma catecholamine determination tests should only be carried out after purification with thin layer chromatography or high performance liquid chromatography.

Selective blood sampling in adrenal hypertension

Selective venous blood sampling was performed in 89 patients with hypertension (14 pheochromocytoma, 10 Conn's syndrome, 8 Cushing's disease, 57 essential hypertension). We looked for diagnostic criteria and the valuability of blood sampling from the adrenal veins in such diseases. Defining a norepinephrine concentration of more than 8,000 ng/l as pathological, we had an accuracy of 94.6%. Defining an aldosterone concentration of more than 1,400 pg/ml as pathological, we had an accuracy of 97.4%. In Cushing's disease this method was not very helpful due to overlapping results.

Developmental and application of insulin infusion profiles for therapy of type-I diabetics with portable insulin infusion systems

We studied the insulin requirements of seven insulin-dependent diabetics applying a glucose controlled insulin infusion system. The data were transformed into individually programmed and rectangular profiles. The MAGE, a measure of blood sugar fluctuations, was significantly lower when individually programmed step profiles were used (P less than 0.005) than it was when rectangular profiles were applied: 57.7 +/- 24.8 mg/dl vs 89.0 +/- 42.9 mg/dl. The average of measured blood glucose levels was significantly lower in individually programmed infusion profiles (P less than 0.025). The combination of individually programmed profiles and preprandial insulin bolus significantly reduced the postprandial blood glucose level and increase (P less than 0.001). Our investigations suggest that individually programmed insulin infusion profiles are able to smooth blood glucose fluctuations. When combined with an initial insulin bolus they may lead to a reduced insulin consumption after meals.

A comparison of the activity of the sympathoadrenal and adrenocortical system under inhalation anesthesia techniques

Epinephrine, norepinephrine, ACTH and cortisol plasma levels as well as heart rate and blood pressure were studied in 32 patients undergoing ophthalmic surgery. Epinephrine levels rose significantly during nitrous oxide anesthesia and also during enflurane-nitrous oxide anesthesia, whereas they fell slightly during halothane-nitrous oxide anesthesia. Norepinephrine levels remained unchanged. ACTH and cortisol levels increased during all three types of anesthesia. During nitrous oxide and enflurane-nitrous oxide anesthesia, heart rate and blood pressure were elevated, halothane nitrous oxide anesthesia was associated with an increased heart rate but not with increased blood pressure.

Islet-cell tumors: detection of small lesions with computed tomography and ultrasound

Fifteen patients with a total of 16 islet-cell tumors 7-20 mm in diameter (average, 12 mm) were examined preoperatively by computed tomography (CT) and ultrasound. Seven out of 16 tumors were detected by CT and 9 out of 15 by ultrasound. Marked contrast enhancement was seen on dynamic CT scans following a bolus injection, while a circumscribed, hypoechoic mass was seen on ultrasound. Tumors of the tail of the pancreas and those outside the pancreas were difficult to detect. Ultrasound is recommended as the initial step for locating islet-cell tumors, followed by CT; angiography and transhepatic venous sampling should be restricted to tumors which are not detectable by other methods. Intraoperative ultrasound was successful in 3 patients and may facilitate the operative search.

[CEA determination to differentiate between pheochromocytoma with ectopic calcitonin formation and type-II multiple endocrine neoplasms]

Plasma levels of calcitonin and carcinoembryonic antigen (CEA) were determined pre-operatively and two months postoperatively in ten patients with C-cell carcinoma as part of multiple endocrine neoplasia type II. In addition, CEA was measured in extracts from 20 different phaeochromocytomas (five from patients with multiple endocrine neoplasia type II, 15 from patients with sporadic phaeochromocytoma). In comparison, CEA concentration was determined in extracts from five C-cell carcinomas of patients with multiple endocrine neoplasia type II. When correlating pre- and postoperative calcitonin and CEA levels, there was a significant linear relationship (P less than 0.001). CEA concentration in extracts from phaeochromocytomas was at the lower level of sensitivity (4.7 +/- 12.2 pg/mg tumour wet-weight). In extracts from C-cell carcinomas they were much higher (6402 +/- 4570 pg/mg tumour wet-weight). The results suggest that it is possible, in patients with phaeochromocytoma and high calcitonin levels, to differentiate by additional CEA determination between C-cell carcinoma in the course of multiple endocrine neoplasia type II and sporadic phaeochromocytoma with ectopic calcitonin liberation.

Treatment with human insulin (recombinant DNA) in diabetic subjects pretreated with pork or beef insulin: first results of a multicenter study

In two double-blind studies 66 insulin-dependent diabetic subjects pretreated with pork insulin were changed to human insulin (recombinant DNA) or a purified pork insulin preparation (regular and NPH insulin). Sixty-five patients previously pretreated with beef insulin were transferred, in a randomized, double-blind fashion, to human insulin and purified beef insulin of the same preparations (regular and NPH insulin). Patients' metabolic control, as demonstrated by fasting and 1-h postprandial blood glucose, HbA1c, and daily insulin dosage, over 4 mo was unchanged in our four groups compared with the values before changing insulin preparation. No severe hypoglycemic attacks or skin reactions were reported.

[Imaging adrenergic tumours with 131J-meta-benzylguanidine]

Pheochromocytoma scanning using 131J-meta-benzylguanidine was done in one patient with metastasizing paraganglioma, one patient with multiple endocrine neoplasia type IIb. No activity of tumour tissue could be demonstrated in the patient with metastasizing paraganglioma, whereas the pheochromocytoma could be clearly defined in the patient with multiple endocrine neoplasia type IIa. The female with multiple endocrine neoplasia type IIb showed a suspect space-occupying lesion of the left adrenal using computed tomography. Pheochromocytoma could be excluded by 131J-benzylguanidine scanning, selective estimation of catecholamines in adrenal venous blood as well as the glucagon stimulation and clonidine suppression.

[Ectopic hormone formation in multiple endocrine type IIa neoplasia (author's transl)]

A patient with high-grade osteoporosis had elevated levels of ACTH, cortisol and carcinoembryonic antigen (CEA). Computed tomography demonstrated enlarged adrenal glands. Despite intensive search no ACTH-producing tumour was found. A central Cushing's syndrome was thus possible, and a radiologically normal sella turcica made a microadenoma of the hypophysis a possibility. However, a one-time hypertensive crisis with elevated catecholamines raised the suspicion of an additional phaeochromocytoma and thus provided the first pointer to a multiple endocrine neoplasia. Bilateral phaeochromocytomas, discovered at adrenalectomy, as well as raised serum-calcitonin levels, strongly suggested coexistence of a C-cell carcinoma, which previously had not been demonstrated either by thyroid scanning or fine-needle biopsy. A total thyroidectomy revealed a multifocal and metastasizing C-cell carcinoma. On extraction it contained a high concentration of calcitonin, typical for a C-cell carcinoma. An unusual finding was of ACTH in extracts of both the C-cell carcinoma and the phaeochromocytoma. It was immunologically identical with the synthetic ACTH used as a standard.

[Diagnosis of the site of insulinomas: percutaneous transhepatic portal vein catheterisations with selective blood sampling for hormone determination (author's transl)]

Percutaneous transhepatic portal vein catheterisation with blood sampling from the various areas of drainage, especially the pancreatic veins, was undertaken in seven patients with insulinoma to diagnose its site. In six patients measurement of serum-insulin levels revealed an abrupt rise in the vascular area later found to drain the area of the insulinoma. Insulin measurement in one patient with insulinoma in the head of the pancreas falsely indicated an islet-cell tumour in the region of the tail of the pancreas. C-peptide concentration in serum followed the concentration of insulin, but did not show such a marked rise. The method of percutaneous transhepatic portal vein catheterisation with selective blood sampling for the measurement of hormonal concentration was superior to ultrasound, computer tomography or coeliacography for determining the site of the tumour.

Influence of norepinephrine on vessel geometry of the intact femoral artery in juvenile insulin-dependent diabetics-evidence of early diabetic angiopathy in central arteries

A modified M-mode ultrasound echo system had been employed to study blood-vessel geometry of the intact femoral artery before and after Norepinephrine (NE) infusion. 14 patients with juvenile IDDM aged below 35 years and 11 healthy subjects participated in the study. In the diabetic group, wall distensibility (delta D/delta P) was reduced (p less than 0.01) at control conditions. After NE infusion, wall distensibility decreased in both groups (p less than 0.01). The decrease of wall distensibility is due to an increase in pulse pressure (delta P) (p less than 0.002) in the diabetic group and a reduction of pulsatile diameter (delta D) (p less than 0.02) in the normal group. Increased stiffening of the arteriaL wall after NE infusion with progressive reduction of wall strain (delta D/Dd) is the typical finding in the normal group. No change of wall strain was observed in the diabetic group. The functional alteration of the diabetic femoral artery may be described as diminished resistance of the arterial wall to the distending force of rising blood pressure.

[Blood-sugar-controlled insulin infusion systems for rapid adjustment of insulin-dependent diabetics (author's transl)]

Empirically obtained data could be verified and the basis for assessment of total insulin requirement, circadian distribution of insulin doses and contents of single insulin portions of old and delayed-action insulin could be established in a prospective study in 13 insulin-dependent diabetics. Assessment of insulin requirements was done after a 36-hour investigation period with the artificial endocrine pancreas using standardised conditions. Readjustment was complemented by dietary advice and rearrangement of total calory input and distribution of carbohydrates during the day. Therapeutic success in 55 patients justifies this procedure. Adjustment of insulin-dependent diabetics was thus obtained more rapidly, better and at less cost.

[Localization of islet cell tumors using sonography, computed tomography, arteriography and selective transhepatic venous sampling for hormone assay (author's transl)]

Of 29 patients examined operation revealed a malignant tumor in 9 and a benign insulinoma in 18, 2 insulinomas were not found. The problems of preoperative tumor localization were limited to small insulinomas (size 7-35 mm). Ultrasound detected all of 3 insulinomas as low echogenic structures (size 7, 8, 17 mm). Computed tomography demonstrated 4 of 5 insulinomas (size 7, 8, 15, 17 mm) due to contrast enhancement following bolus injection. Arteriography localized 12 of 18 insulinomas preoperatively and 14 of 18 retrospectively. Selective transhepatic venous sampling for insulin assay identified 7 of 8 tumors. Real-time ultrasound and dynamic CT are promising in the diagnostics of insulinomas over 7 mm and should precede arteriography. Selective transhepatic venous sampling as the last diagnostic step is a major procedure and most specific, but not always without problems in interpretation.

[The effect of enflurane anaesthesia and operation on the sympathoadrenal and adrenocortical system (author's transl)]

The effect of enflurane anaesthesia on the sympathoadrenal system, the hypothalamic-hypophyseal-adrenocortical system, and on the circulatory system was investigated in patients undergoing ophthalmic surgery. Blood concentrations of adrenaline, noradrenaline, ACTH, cortisol, and arterial blood pressure and heart rate were measured in 10 patients 30 min after premedication (I), 3-5 min after surgical incision (II), 20 or 45 min after surgical incision (III) and in 7 of 10 patients 10-15 min after extubation (IV). After conventional induction anaesthesia was maintained with enflurane (1.5-2.0%), combined with N2O/O2 2:1, and intermittent relaxation. Plasma adrenaline, ACTH, cortisol and heart rate increased significantly during operation, while plasma noradrenaline and blood pressure did not change significantly. Thus enflurane anaesthesia could not completely inhibit the increased activity of sympathoadrenal and hypothalamic-hypophyseal-adrenocortical system caused by surgical stress.

[Sympathetic activity and blood pressure in normotensive and hypertensive patients undergoing ophthalmic surgery under electrostimulation anaesthesia (author's transl)]

Plasma adrenaline, noradrenaline, blood pressure and heart rate were determined in 10 normotensive and 10 hypertensive patients undergoing ophthalmic surgery under electrostimulation anaesthesia. Venous blood samples for the determination of the catecholamines by a spectrofluorometric method were taken 30 min after premedication and 45 min after surgical incision. The catecholamine concentrations showed no significant differences neither by comparing the normotensive patients with the hypertensive patients nor by comparing the values during operation with them after premedication in each group. However, in the hypertensive patients blood pressure showed a higher increase during operation than in the normotensive patients.

The effects of equal caloric amounts of xylitol, sucrose and starch on insulin requirements and blood glucose levels in insulin-dependent diabetics

Xylitol has been suggested as a potentially useful sweetener in the diabetic diet. In 14 insulin-dependent diabetics a standard diabetic diet regimen was compared with diets in which starch was isocalorically exchanged in the breakfast meal by either 30 g xylitol or 30 g sucrose. Insulin requirement and blood glucose were measured using a glucose-controlled insulin infusion system. The results following breakfast with xylitol were similar to those after starch breakfasts. Sucrose, in contrast, induced a greater post-prandial rise in blood glucose levels despite counter-regulation by the glucose-controlled insulin infusion system. Insulin requirement after sucrose significantly exceeded (p less than 0.01) that after xylitol or starch during the first 60 min and 2 h respectively. No short-term side effects of xylitol were found.

[Mechanomyography - results in a normal population and in patients with thyroid dysfunction (author's transl)]

Isometric contraction of the adductor pollicis by stimulating the ulnar nerve was determined in 20 normal adult subjects. We measured mechanical latency, electro-mechanical latency, contraction time, time to half relaxation and isometric twitch force. Besides that we registered the compound muscle action potential and the nerve conduction velocity. The median nerve was used to elicit the nerve action potential and to determine conduction velocity and relative refractory period. In 6 pat. with hypothyroidism and in 7 pat. with hyperthyroidism the above mentioned parameters were measured. There was a significant change concerning contractile properties, i.e. muscular contraction became slower in hypothyroidism and faster in hyperthyroidism as compared to values obtained in the control group. The isometric twitch force was reduced in both conditions. To assure the close relationship between thyroid hormone (L-thyroxin) and muscle contraction a group of patients who have undergone thyroidectomy was investigated in the same way. Muscle and nerve parameters were determined during a levothyroxin-therapy and in a period without any treatment. The same phenomenon was observed, i.e. reduction of twitch velocity in the hypothyroid state. The twitch force was not reduced in this group. The close relationship between thyroid hormone and contractile properties allows a discrimination between hypo-and hyperthyroid state and a control of thyroxin substitution.

Comparison of biosynthetic human insulin and pork insulin during rest, food ingestion, and physical work in insulin-dependent diabetic subjects using a glucose controlled insulin infusion system

In six insulin-dependent diabetic subjects, we investigated whether differences between biosynthetic human insulin (BHI) and pork insulin are present as measured by an automatic glucose controlled insulin infusion system (GCIIS) (Biostator). The parameters measured were basal insulin requirement and food-dependent insulin requirement, as well as the blood sugar-lowering and insulin-saving effect of standardized physical work. The results show that BHI does not reveal any differences with regard to the basal food-independent and food-dependent insulin requirement compared to pork insulin in insulin-requiring diabetic subjects. Delayed food-dependent initial rise in blood sugar and insulin during physical work, which was observed with BHI, does not show any differences in the integral over 180 min. These investigations confirm the results found in vitro and in animal experiments. At the same time, they indicate discrete differences in the activity spectrum.

[Effect of calcium dobesilate on permeation of plasma proteins in diabetic patients]

The effect of six months of treatment with 750 mg calcium dobesilate on sedimentation rate blood count, cholesterol, triglycerides, platelet aggregation factor, total protein, electrophoretic distribution of serum protein concentrations, and kinetics of intravenous albumin marked with 131I was established in 35 diabetics with a mean duration of diabetes of 9.8 years. There was significant intravascular retention of 131I albumin and significant increase of serum albumin, beta-globulins and total protein after treatment. The other parameters remained unchanged. The results are interpreted as evidence of lowering of the increased transcapillary permeability within the vascular system seen in diabetics.

Glucagon secretion in four duodenopancreatectomized patients after arginine and glucose load

It is well established that in sera of totally duodenopancreatectomized dogs after complete insulin deprivation an immunoreactive glucagon can be found, which is indistinguishable from the pancreatic glucagon, and which can be stimulated by oral glucose and i.v. arginine as well. In four duodenopancreatectomized patients we found, after 26 h insulin deprivation, normal and elevated basal levels of IRG which were not stimulated by intravenous arginine but by oral glucose. Dilution tests of the sera before glucose stimulation showed immunological properties different from pancreatic standard glucagon, whereas in sera after stimulation immunoidentity with pancreatic standard glucagon could be demonstrated. Gel chromatography of the sera after stimulation yielded at least three immunoreactive peaks, the first over 30 000 daltons, a second eluting in the region of insulin, and a third of about 2000 daltons. True glucagon (3500 MW) could not be clearly demonstrated.

[Surgery of the adrenals: result of 154 operations (author's transl)]

Biochemical and radiological results, surgical technique and its results were critically analysed in a retrospective study of 154 operations on the adrenals in 127 patients, operated on between 1957 and 1980. There were no complications in 95 patients. In the remaining 32, both intra- and postoperative complication rate was greater after extraperitoneal than transabdominal approach to the adrenals. Postoperative mortality was 6%, but since 1967 only two patients have died in the postoperative period. Thromboembolic phenomena were the main cause of death, patients with Cushing's disease most commonly having this complication.

[Experience with CT and adrenal venography in the diagnosis of adrenal disease with endocrine activity (author's transl)]

Report of the result of CT and venography in 12 patients with suspected adrenal disease, venography being combined with selective blood sampling for hormone analysis. In one patient CT showed a 1.6 cm big pheochromocytome in the left adrenal gland, not demonstrated by venography, but proven by analysis of the blood sample. Both methods showed hyperplasia of both adrenals in one patient with Cushing Syndrome with elevated Cortisol levels found in the analysis of the blood smples. Of 3 patients with hyperaldosteronism, venography was able to demonstrate 2 Conn adenomas, not seen on CT; whereas CT showed the third 2 X 1.5 cm big Conn adenoma hidden in an enlarged adrenal gland. Hormone analysis was helpful in 2 of these cases, while in the third it was misleading. The authors believe that both methods should be employed to localise over adrenal disease with endocrine activity.

[Modern methods in localization of pheochromocytomas (author's transl)]

In six patients with adrenal pheochromocytoma the tumors were localized by ultrasonography, phlebography of the adrenal glands and by estimation of plasma catecholamines selectively obtained from the vena cava and the adrenal gland veins. All tumors were localized by selective catecholamine estimation, five by ultrasonography, and four by phlebography. The smallest pheochromocytoma of 1.5 g weight was only localized by selective catecholamine estimation but not by ultrasonography or phlebography. This tumor, however, had been visualized by computed tomography. To avoid diagnostic errors by selective catecholamine estimation, it is important to withdraw blood from the adrenal gland veins prior to the injection of any radiographic contrast media, since this may result in an extremely enhanced secretion of catecholamines from the adrenal medulla.

[The effect of premedication with thalamonal on the plasma catecholamine levels (author's transl)]

The sympathetic suppressant properties of Thalamonal as a premedication is reported in both normotensive and hypertensive patients. The investigations were carried out in 27 patients altogether, of whom 7 were previously treated hypertensives. The plasma catecholamines noradrenaline and adrenaline, the blood pressure and heart rate were monitored before and after premedication.

[The diagnosis of phaeochromocytoma: sensitivity of vanillylmandelic acid and urinary catecholamine determination and the Katecult test (author's transl)]

Tumour weight was compared with maximal vanillylmandelic acid and catecholamine excretion in 24-hour urine in 21 patients with phaeochromocytoma. The tumour weight correlated both with vanillylmandelic acid (r = 0.805, P less than 0.001) as well as urinary catecholamine levels (r = 0.725, P less than 0.001). Normal vanillylmandelic acid excretion was found in seven patients; urinary catecholamine levels were abnormal in all patients. The Katecult test was additionally performed in ten patients, with nine positive results.

[Plasma-catecholamines under electrostimulation and neurolept anaesthesia for retina and vitreous body operations (author's transl)]

We determined in two groups of patients with normal circulation and metabolism during operations on the retina and vitreous body the concentration of plasma catecholamines. The intensity of stress was compared between electrostimulation anaesthesia and neuroleptanaesthesia. Venous blood was sampled 1) before premedication, 2) 30' after premedication, 3) at the start of surgery, 4) 45' after the start of surgery, 5) 30' after extubation. Plasma catecholamines (adrenaline and noradrenaline) were determined using a modified trihydroxyindol-spectrofluoremetric method (combined "Batch-technique"). There was no relevant difference between the two techniques of anaesthesia when using the concentrations of plasmacatecholamines as an indicator of stress resulting from operation and anaesthesia.

Secretory B-cell activity in insulin dependent maturity-onset diabetic

In 10 insulin dependent maturity onset diabetics we found elevated basal C-Peptide levels (4.78 +/- 0.5 ng/ml. Normal range 1.1--3.6 ng/ml), which could be suppressed by insulin injection to the same extent as in sulfonylurea treated diabetics could be demonstrated. C-Peptide immunoreactivity in these patients therefore seems to be newly secreted rather than accumulated material. Since adrenalectomized patients could be suppressed in the same way, it is likely, that catecholamines are not the major factor in the mechanism of suppression. Therefore only decrease of bloodsugar levels seems to be accountable for the decrease of C-Petide levels. High C-Petide levels in insulin dependent maturity onset diabetics which cannot be stimulated but suppressed may be explained by a loss of glucoreceptor molecules.

[Adrenal and extra-adrenal phaeochromocytoma: diagnostic features and localisation by determining plasma catecholamines (author's transl)]

Urinary catecholamines and urinary excretion of vanillylmandelic acid confirmed the diagnosis of phaeochromocytoma in ten patients. In two of seven a modified glucagon test significantly aided confirmation of the diagnosis. In all patients the tumour was localised both by catecholamine determination in blood from the vein draining into the inferior vena cava (IVC) and by adrenal phlebography. Site of the adrenal tumour was definitively determined by the high catecholamine level in the adrenal veins and by phlebography. Three extra-adrenal tumours, a thoracic and two abdominal ones, were localised by high catecholamine levels in blood from other veins draining into the IVC. Vanillylmandelic acid determinaion was unreliable in the diagnosis of small phaeochromocytomas.