Usefulness and limits of quick intraoperative measurements of intact (1-84) parathyroid hormone in the surgical management of hyperparathyroidism: sequential measurements in patients with multiglandular disease

This study was designed to assess whether reliability of quick intraoperative assay of intact (1-84) immunoreactive parathyroid hormone (iPTH) could allow us to quit after removing one (or several) enlarged parathyroid gland(s) and obtaining a normal iPTH level. Intact iPTH was assayed during surgery before removal of enlarged parathyroid gland(s) and 5, 10, and 20 minutes afterward. Forty-seven patients entered the study: 40 with primary hyperparathyroidism (32 with uniglandular disease and eight with multiglandular disease) and seven with secondary hyperparathyroidism; all underwent bilateral neck exploration. Among 32 patients with uniglandular disease, five had normal basal intraoperative levels, 25 demonstrated a clear-cut drop from supranormal to normal levels, and two had elevated levels. Among the eight patients with multiglandular disease, two had undetectable levels and two had normal levels after removal of the first enlarged gland. The seven patients with secondary hyperparathyroidism demonstrated a decline in PTH levels, suggesting hormone clearance similar to that of patients with primary hyperparathyroidism. In conclusion, quick intraoperative assay with intact (1-84) iPTH (1) is not hampered by renal insufficiency, (2) may overlook a second enlarged gland after removal of a first adenoma and obtaining normal iPTH levels, and (3) should not be used as a substitute for bilateral neck exploration.

[Macroprolactinemia in a child]

An hyperprolactinemia, with basal serum prolactin levels ranging from 41 to 135 ng/ml was found to be coincidentally associated with psychosocial dwarfism in a 11 year-old boy. Sephadex G 100 exclusion chromatography showed that the predominating form of immunoreactive prolactin levels ranging from 41 to 135 ng/ml was found to be weight, differing from the regular occurrence of a 22 kilodalton major variant. Prolactin levels increased under TRH (increments between 29 and 76%) but were not blunted by bromocriptine at a dose of 2.5 mg/day. This so-called macroprolactinemia syndrome should be searched for whenever a discrepancy is noted between clinical symptoms and blood prolactin levels.

[comparison of the effects on phosphocalcic metabolism and bone of 3 protocols of vitamin D administration in the elderly]

According to recent studies, vitamin D deficiency may contribute to the osteoporosis observed in elderly subjects, with reduced intestinal calcium absorption and secondary hyperparathyroidism. Vitamin D deficiency is often present in elderly people, due to inadequate diet and confinement at home. The administration of either oral vitamin D in doses of 4,000 IU per day, or six-monthly intramuscular injections of ergocalciferol 600,000 IU, combined with a daily intake of at least 1 g of calcium brings back to normal both 25 OH D concentrations and parathyroid hormone levels. When pursued for one year, these treatments also maintain the formation of cortical bone, as shown by the metacarpal index. As for the concentration of 25 OH D, it seems that 60 to 75 nmol/l are necessary to restore calcium homeostasis. The dietary habits of elderly people are such that a supplement of medicinal calcium is required. Finally, we regard the parenteral form of ergocalciferol as being preferable to the oral form at that age for better compliance with treatment.

Altered erythrocyte cation permeability in familial pseudohyperkalaemia

1. Erythrocyte cation transport pathways have been investigated in a family with pseudohyperkalaemia. 2. Ouabain- and bumetanide-resistant Na+ and K+ effluxes in three pseudohyperkalaemic patients were not different from those of control subjects when assessed at 37 degrees C. 3. When the temperature was decreased to 20 degrees C and 9 degrees C, K+ passive permeability markedly increased and Na+ permeability remained unchanged in these patients. In contrast, in control subjects a reduction in temperature caused a marked reduction in Na+ and K+ passive permeability. 4. These findings could account for the marked increase in plasma K+ concentration observed at subphysiological temperatures. 5. The Na+-K+ co-transport pathway was reduced in all members of the family, but the Na+-K+ pump was reduced in only two of them. These alterations were independent from the pseudohyperkalaemic state.

Gonadotropic axis and Trypanosoma brucei gambiense infection

A gonad endocrine survey on 46 Congolese patients (15 women and 31 men) with parasitologically confirmed trypanosomiasis found amenorrhoea in 60% of the women and impotence in 70% of the men. The basic gonad endocrine examination showed a decrease in oestradiol levels in about 65% of the women. Both amenorrhoea and low oestrogen levels were observed in the second phase (P2) of the disease, but low oestrogen levels were sometimes noted in the first phase of the disease (P1). In the men, about 50% of the cases (P2) showed a decrease in testosterone. However, as in the women, the variation of testosterone was also observed in the first phase (P1). A static and dynamic examination of the hypothalamic-pituitary-gonadal axis was undertaken in order to investigate the origin of these hypogonadisms. A supra - or extra-hypophyseal origin is discussed.

Adrenocorticotropin and cortisol responses to ovine corticotropin-releasing factor in alcohol dependence disorder. Preliminary report

A 100-micrograms bolus of synthetic ovine corticotropin-releasing factor was administered intravenously to 10 nondepressed inpatients suffering from an alcohol dependence disorder. The test was performed during withdrawal and after 4 weeks of abstinence. During withdrawal, the plasma cortisol responses of alcoholic patients and 7 control subjects were similar, except for an earlier decrease of cortisol in the former group. However, after 4 weeks of abstinence, the cortisol response was significantly lower in alcoholic patients than in controls. These abnormalities observed during discontinuance of alcohol consumption may reflect adaptive mechanisms of the hypothalamic-pituitary-adrenal activity which may be previously altered by chronic alcohol intoxication.

[Hyperreninemic hypoaldosteronism syndrome induced by plasma exchange]

The study was designed to measure sequential changes in plasma renin activity, aldosterone, angiotensin-converting enzyme activity and ionograms, prior to, and after therapeutic plasma exchange. Each measurement was repeated before and after stimulation of renin activity induced by furosemide. The results showed that plasma exchange induces a syndrome of hyperreninemic hypoaldosteronism associated with a depletion in angiotensin-converting enzyme activity which might account for the dissociation between plasma renin activity and aldosterone.

Screening heterozygotes for 21-hydroxylase deficiency among hirsute women: lack of utility of the adrenocorticotropin hormone test

Heterozygosity for 21-hydroxylase deficiency (21-OHD) was investigated in 174 adult hirsute women by using the sum of the incremental responses of serum 17 alpha-hydroxyprogesterone (17 alpha-OHP) and progesterone (P) (delta 17 alpha-OHP + P), 60 minutes after a 0.25 mg intravenous (IV) bolus of synthetic adrenocorticotropic hormone (ACTH). The distribution of 17 alpha-OHP + P in hirsute women was bimodal, allowing two subgroups to be distinguished. In one subgroup including 137 patients, the mode was similar to controls and all values were lower than 3 ng/ml. Thirty-seven (21%) patients constituted another subgroup with values higher than 3 ng/ml and could a priori have been considered as heterozygotes for 21-OHD. However, human leukocyte antigen genotyping provided no conclusive evidence that this subgroup included exclusively heterozygotes for the 21-OHD.

[Phosphocalcium metabolism in the elderly. Study of 101 subjects living in an institution]

Calcium and phosphorus metabolism was studied in 101 institutionalized subjects over 70 years of age (mean: 82.5 years). The study was performed in serum and urine; it included parathyroid hormone and calcidiol (250HD3) assays and radiological examination of bones with determination of Meunier's index and metacarpal cortical index. Calcidiol concentrations did not vary with age but were higher in people who left the institution and in men. In contrast, there was a significant age-group related increase of parathyroid hormone concentrations. This increase was accompanied by an increase of parathyroid hormone activity, as shown by a parallel fall in phosphorus reabsorption rate. These findings are in agreement with current pathogenetic theories on senile osteoporosis. Invalid subjects had higher urinary calcium and serum parathyroid hormone levels and a lower cortical index. Paradoxically, there was less vertebral collapse as evaluated by Meunier's index, which may suggest that very old patients develop progressive cortical bone hyperresorption entirely independent of sequelae from their former trabecular osteoporosis.

Decrease of angiotensin-converting enzyme activity after plasma exchange

We measured sequential changes in serum angiotensin-converting enzyme (ACE) in 12 ICU patients undergoing plasma exchange (PE) with plasma substitutes (albumin-Polygelin). A dramatic decrease in serum ACE activity was observed after each of the 51 PE procedures. Repeated PE procedures resulted in almost a total depletion of serum ACE, which returned to normal ranges in 4 to 10 days. No ACE change was observed during hemodialysis or hemofiltration. ACE activity increased after PE with fresh frozen plasma replacement. ACE changes were compared with IgG, antithrombin III, and fibronectin changes. Extraction ratio comparisons were consistent, with a loss in removed plasma accounting for 50% to 70% of the observed ACE decrease. Plasma zinc levels were not modified after PE. Mixing experiments with increasing volumes of plasma substitutes showed ACE inhibition by Polygelin. In vivo infusion of Polygelin had the same effect. The renin-induced aldosterone response studied in six exchanged patients was consistent with a relative hyperreninemic hypoaldosteronism after repeated PE. These findings may be of clinical relevance during acute hypovolemia and dehydration after PE or Polygelin infusion and in patients with impaired lung endothelial function.

Clinical and biological phenotypes in late-onset 21-hydroxylase deficiency

We analyzed data from 20 patients with late-onset 21-hydroxylase deficiency (LOHD). Three clinical phenotypes could be distinguished among the 18 women. Seven (39%) presented with clinical features suggesting polycystic ovarian disease (PCOD). However, despite androgen levels similar to those of patients with typical PCOD, high serum LH to FSH ratios were not consistently found. Seven other women (39%) presented with isolated hirsutism, suggesting idiopathic hirsutism. The remaining 4 women (22%) had no manifestations of androgen excess and were considered to have the cryptic form of LOHD. Serum 17-hydroxyprogesterone (17-OHP) and androgen levels were similar in the 3 phenotypes, suggesting that the clinical expression of LOHD in women is modulated by individual factors, such as androgen sensitivity. The 2 men were detected by family study and were clinically normal. Since clinical diagnosis of LOHD is impossible, we concentrated on hormonal data with the aim of providing guidelines for the biological diagnosis of LOHD. Assay of basal serum 17-OHD at 0800 h in both sexes and in the early follicular phase in women was sufficient to establish the diagnosis of LOHD in most patients. If doubtful results are obtained, i.e. serum 17-OHP levels between 2 and 5 ng/ml, an ACTH test must be performed. Post-ACTH serum 17-OHP levels exceeding 10 ng/ml confirm the diagnosis of LOHD. Such results should avoid confusion with heterozygotes for 21-hydroxylase deficiency, whose frequency is high within the general population and may be even higher in patients with idiopathic hirsutism or PCOD.

A double blind controlled study of the hormonal and clinical effects of bromocriptine in the polycystic ovary syndrome

Previous studies on the efficacy of bromocriptine for the treatment of patients with the polycystic ovary syndrome failed to include control groups. This study, therefore, was undertaken to determine the clinical and endocrine effects of bromocriptine and a placebo (given in a random double blind fashion) in 55 patients with PCOS. The plasma levels of estrone, estradiol, testosterone, androstenedione, dehydroepiandrosterone, dehydroepiandrosterone sulfate, 17-hydroxyprogesterone, and serum PRL and gonadotropins (LH and FSH) were measured before treatment. In addition the serum PRL response to TRH and the serum LH and FSH response to GnRH were determined. The effects of acute administration of bromocriptine (2 X 2.5 mg at 12-h intervals) on serum gonadotropins and their response to GnRH were studied to explore the possibility that this test might predict the response to chronic bromocriptine treatment. Bromocriptine then was given at an initial dose of 1.25 mg twice daily. If no clinical improvement occurred 2.5 mg were given twice daily for at least 6 months. Hormonal measurements and dynamic tests were repeated after 3 and 6 months of therapy. The endocrine profile of the two groups was not different before treatment. The clinical results were not better in the treatment group than in the placebo-treated patients: therapy was successful (restoration of ovulatory cycles of less than 35 days duration) in 12 of 28 patients taking bromocriptine vs. 8 of 27 taking placebo. Slight improvement (1 or 2 ovulations) occurred in 3 of 28 vs. 3 of 27, and failure (no clinical change) in 13 of 28 taking bromocriptine vs. 16 of 27 taking placebo, respectively. Serum PRL fell significantly in the bromocriptine group, and there was a significant fall in the serum LH response to GnRH in both groups. No hormonal measurement or response predicted the clinical response to treatment. The only significant effect of chronic bromocriptine therapy (5 mg/day) in patients with the polycystic ovary syndrome was to lower the serum PRL concentration.

Acute effects of bromocriptine on gonadotropin secretion in polycystic ovary syndrome

Thirty-two women presenting with polycystic ovary syndrome (PCO) were studied on 3 consecutive days. On day 1, plasma androstenedione, testosterone, dehydroepiandrosterone (DHEA), DHEA sulfate (DHEA-S), 17-hydroxyprogesterone (17-OHP), estrone (E1), estradiol, serum prolactin (PRL), and PRL response to thyrotropin-releasing hormone were determined. On day 2 the patients were given two placebos at 1-hour intervals; then serum PRL, luteinizing hormone (LH), and follicle-stimulating hormone (FSH) and the LH and FSH responses to LH-releasing hormone (LH-RH) were determined. On day 3 the patients were given two 2.5-mg tablets of bromocriptine (BRCR) at 12-hour intervals; then serum PRL, LH, and FSH and the LH and FSH responses to LH-RH were again determined. After BRCR, mean values of basal serum PRL (P less than 0.001), LH (P less than 0.05), and FSH (P less than 0.001) and the FSH response to LH-RH (P less than 0.01) fell with respect to the values determined on day 2. Our group of patients was heterogeneous regarding the effects of BRCR upon the LH response to LH-RH. Of 32 women undergoing the trial, 17 did not respond to BRCR (change of the LH response to LH-RH less than 33% with respect to day 2). They were called "nonresponders." Among the 15 who responded to BRCR, 10 decreased their LH response greater than or equal to 33% ("decreasers") and 5 increased their LH response greater than or equal to 33% ("increasers"). Decreasers had mean values of serum PRL, plasma E1, DHEA-S, and 17-OHP higher than nonresponders (P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Hyperprolactinemia and sexual function in men

Male hyperprolactinemia (HPRL) is known to induce different types of sexual dysfunctions. In order to determine the incidence of HPRL among patients referred for sexual dysfunction, serum prolactin (PRL) was assayed in 1053 clinically idiopathic cases. Among 850 cases complaining of erectile impotence, 10 with marked HPRL (1.1%, PRL above 35 ng/ml) were found, of whom 6 cases were associated with a pituitary adenoma. 17 mild HPRL (2%, PRL 20-35 ng/ml) were also found. Among 124 cases with premature ejaculation, 13 (10%) mild HPRL were found. Serum PRL was normal in 51 cases complaining of an ejaculation without orgasm, and 27 patients exclusively complaining of reduced sexual desire. Our results lay stress on the fact that serum PRL must be assayed in every case of clinically idiopathic erectile impotence. Indeed, 5 of the 10 marked HPRL patients would have been misdiagnosed if we had only assayed this hormone when plasma testosterone was below the normal range. Moreover, in order to shed some light on the mechanisms by which HPRL disturbs male sexual function, the sexual behaviour of 17 markedly HPRL males was compared to their serum levels of PRL and testosterone, first before treatment, then at regular intervals during treatment. Our main conclusion is that impotence cannot be totally explained by a decrease in plasma testosterone, because this steroid hormone was within the normal range 7 of the 16 impotent patients. Moreover, when serum PRL was lowered by bromocriptine, 6 patients recovered their potency before plasma testosterone clearly increased, and in 3 of those patients before it reached the normal range.(ABSTRACT TRUNCATED AT 250 WORDS)

[Posttraumatic neurogenic hyponatremia with late onset]

Ten months following a severe head injury, a 26-year-old man developed a syndrome of inappropriate secretion of antidiuretic hormone (ADH) with a grand mal seizure occurring after an increased intake of non alcoholic beverages. The water loading test was negative but the sorbitol infusion test was positive. In the basal state, plasma concentration of ADH was inappropriate to plasma osmolality. ADH has also been measured during dynamic tests (infusions of sorbitol and of normal saline; complete and partial water restriction; propranolol and diphenylhydantoin treatments). In spite of the poor sensitivity of these measurements when ADH concentrations are low, our results indicate that the plasma osmolality threshold at which ADH secretion is inhibited was probably reset at a level lower than normal.

Comparison of estrogen priming effects with body weight restoration effects on the gonadotropin pattern of patients with anorexia nervosa

Plasma estradiol (E2), serum LH and FSH, and the gonadotropin response to two consecutive LHRH administrations (10 and 100 micrograms with an interval of 2 h) were determined in 19 patients with anorexia nervosa (AN) at the emaciation phase, before and after estradiol benzoate (E2B) injections (3 micrograms/kg/day for 7 days). The same investigations were repeated after weight restoration in 9 AN patients who remained amenorrheic. Both at the emaciation phase and after weight restoration, E2B enhanced the second LH response to LHRH and decreased serum FSH, suggesting that the functional capacities of the pituitary gonadotrophs are normal in AN. Unlike E2B injections, weight restoration increased all the hormone values, suggesting that the weight restoration effects on the abnormal gonadotropin secretory pattern of AN depend on another mechanism than the E2 lowering. That mechanism is probably a disorder of the hypothalamic LHRH secretion, the consequences of which could be reinforced by the low E2 levels.

[Hormone levels, celioscopy and ovarian histology in the hirsutism-anovulation syndrome]

Among 50 women with hirsutism, spanio- or amenorrhoea and anovulation, coelioscopy and histological examination of ovarian biopsies showed that 26 had typically polycystic ovaries (PCO), 17 had "borderline ovaries" (BO)--i.e. apparently normal or subnormal but with histological abnormalities identical to those of PCO--and 7 had normal ovaries. The hormonal profiles of BO and PCO were very similar. An increase in LH or in LH response to LHRH, which is regarded as characteristic of polycystic ovarian disease, was only observed in 75% of women with PCO or BO. The PCO and BO detection value of simple basal LH determination was slightly enhanced by the LHRH test, and no further enhancement was observed after repeated LHRH injections. 38% of PCO's and 75% of BO's were associated with adrenal hyperandrogenism, as evidenced by a rise in dehydroepiandrosterone values. Thus, more than one half of hirsute and non-ovulating women have polycystic ovaries. Most of these can be diagnosed by hormonal investigations without having recourse to coelioscopy. However, some do not display, at least permanently, the hormonal profile characteristic of polycystic ovarian disease.

[Antidiuretic hormone levels (arginine-vasopressin) in cases of peripheral hypothyroidism. 26 cases]

Plasma arginine-vasopressin (AVP) levels were measured by radioimmunoassay in 26 untreated myxoedematous patients and 27 healthy subjects. In 22 patients, in spite low osmolality AVP values were not significantly different from those found in controls, but they were considerably increased in 4 patients with severe myxoedema and very low osmolality. Statistical analysis showed negative correlation between AVP values and osmolality in the patients. On the other hand, no correlation was found between AVP values and aldosterone or plasma renin activity values. These results suggest inappropriate secretion of antidiuretic hormone in myxoedema.

Investigative strategy of hyperandrogenism in women

Investigative procedures in the assessment of female hyperandrogenism are reviewed. Based on their experience, the authors suggest an inexpensive investigative strategy in hyperandrogenic females consisting of the following: the first step depends upon the clinical symptoms--in cases of hirsutism with regular menstrual cycles, plasma testosterone (T) and plasma dehydroepiandrosterone sulfate (DHA-S) are assayed, and the basal body temperature chart is recorded. In cases of hirsutism with irregular or anovulatory menstrual cycles, in addition to T and DHA-S, plasma 17-hydroxyprogesterone and urinary-free cortisol are assayed. In case of anovulation without hirsutism, T and DHA-S are assayed, and the LHRH test is performed. The results of this first investigation allow to attribute to the woman one of the six following hormone profiles: (1) metabolic hyperadrenalism; (2) tumoral hyperandrogenism; (3) 21-hydroxylase defect; (4) nontumoral DHA-S increase; (5) nontumoral ovarian hyperandrogenism; (6) idiopathic hirsutism. The additional investigative procedures required in each of these groups are detailed.