Metyrapone induced increase in plasma corticotropin is not associated with changes in peripheral venous arginine vasopressin or corticotropin releasing factor

The responses of the "stress hormones" cortisol, 11-deoxycortisol, ACTH, vasopressin (AVP), and corticotropin releasing factor (CRF) were studied in 6 normal males in response to acute cortisol deficiency induced by the 11-beta-hydroxylase inhibitor, metyrapone. A 750 mg dose was administered orally at 08:00 h on day 1 and at 4 hourly intervals over a 24-h period. A 20 mg tablet of hydrocortisone or placebo was then given at 08:00 h on day 2, according to a randomized cross-over design. Each subject was restudied after an interval of at least one month. Blood samples were taken for all hormones at 08:00 h on day 1 and at 04:00 h on day 2. Thereafter ACTH and AVP were sampled at 10-min intervals, CRF at 20-min intervals, and cortisol and 11-deoxycortisol at hourly intervals until 12:00 h on day 2. Cortisol (mean +/- SE) fell from 628 +/- 218 nmol/l at 08:00 h (day 1) to a minimum of 230 +/- 78 nmol/l at 05:00 h on day 2. Plasma 11-deoxycortisol rose from 14.0 +/- 0.8 nmol/l to a maximum of 622 +/- 36 nmol/l and plasma ACTH rose from 8.71 +/- 1.64 pmol/l to a maximum of 166.2 +/- 57.5 pmol/l. Diurnal rhythmicity of plasma ACTH was maintained. There was no detectable change in plasma levels of AVP or CRF from baseline (AVP 2.5 +/- 0.8 pmol/l, CRF 3.4 +/- 0.5 pmol/l).(ABSTRACT TRUNCATED AT 250 WORDS)

Bone mineral density in patients receiving suppressive doses of thyroxine for thyroid carcinoma

AIMS

Studies of the effect of thyroxine therapy on skeletal integrity have given conflicting results; the reductions in bone mass reported by some have prompted recommendations that the prescribed replacement doses of thyroxine should be reduced. We have examined bone mineral density in a group of patients with differentiated thyroid carcinoma receiving high doses of thyroxine to suppress thyroid stimulating hormone (TSH).

METHODS

The 44 patients (6 male, 38 female) had a median age of 49 years (range 27-75) with median duration of thyroxine therapy of 9.0 years (range 3 to 42) and mean dose of thyroxine 0.167 mg/day (range 0.125-0.3). TSH levels were chronically suppressed in 39 subjects. Bone mineral density (BMD) was measured by dual energy x-ray absorptiometry (DEXA) in all subjects at the femoral neck and lumbar spine and compared with previously established local reference ranges.

RESULTS

There was no reduction in bone mineral density in the thyroxine treated group compared with the local reference population at both lumbar spine and femoral neck, and no correlation with duration of therapy.

CONCLUSIONS

These negative findings, that thyroxine in suppressive doses does not significantly reduce bone mineral density in New Zealand patients suggest that thyroxine therapy alone is not a major risk factor for the development of osteoporosis.

Acute renal failure in a case of paraquat poisoning with relative absence of pulmonary toxicity

A 37 year old male presented after the ingestion of paraquat ('Gramoxone', 20% w/v). Plasma paraquat concentrations indicated that he had a greater than 50% probability of death. The patient survived following a period of acute oliguric renal failure and with only mild pulmonary toxicity.

Hypertension, coronary artery disease and insulin resistance--linked disorders with an impact on treatment

Coronary artery disease is a very common disorder for which hypertension is a well-recognized risk factor. However many trials of antihypertensive therapy have failed to demonstrate a reduction in the incidence of coronary events. One explanation is that hypertension is a disorder associated with hyperinsulinaemia, obesity and non-insulin dependent diabetes. Furthermore certain antihypertensive drugs, notably thiazide diuretics, increase the hyperinsulinaemia and thereby increase one of the other coronary risk factors. In this review the links between hypertension and hyperinsulinaemia are explored and the mechanisms whereby an increased plasma insulin can lead to the more rapid development of coronary artery disease are explained. These observations may influence the choice of drugs used to treat hypertension.

Approaches to the management of hypercholesterolaemia

Patients with hypercholesterolaemia need to be carefully evaluated for underlying secondary or genetic causes. All such subjects require dietary advice. Those with total cholesterol levels persistently in excess of 6.5 mmol/l despite diet, and in the presence of multiple cardiac risk factors may need drug therapy. Drug therapy is likely to be life-long and the potential benefits need to be carefully assessed against the long-term safety of the agents employed.

Rhabdomyolysis and acute renal failure following carbon monoxide poisoning: two case reports with muscle histopathology and enzyme activities

Two patients with carbon monoxide poisoning are presented, both of whom suffered rhabdomyolysis complicated by acute renal failure. One patient, an attempted suicide, developed a compartment syndrome of the right thigh that required fasciotomy and recovered after a period of hemofiltration and hemodialysis. Muscle biopsy appearances were consistent with partial muscle infarction. The other patient, rescued from a smoke filled room, exhibited raised creatine kinase but no evidence of muscle swelling. He developed anuric renal failure and adult respiratory distress syndrome and died despite maximum intensive care. Muscle biopsy showed early evidence of muscle necrosis. In both cases there was a marked reduction of enzyme activities in the muscle biopsy consistent with metabolic derangement. Although there was a clinical compartment syndrome in the first case, there was no muscle swelling at the time of biopsy or subsequently in the second case. A direct toxic effect of carbon monoxide may thus have been an important mechanism contributing to the muscle necrosis in the second case, although local ischemia may have been an exacerbating factor in the first case.

Urinary transferrin excretion in type 1 (insulin-dependent) diabetes mellitus

Urinary excretion of transferrin and albumin was studied by radioimmunoassay in 47 adult patients with Type 1 diabetes and 28 control subjects. Median (range) urinary transferrin excretion rate was significantly elevated in the diabetic group 0.58 (0.02-2663.3) micrograms min-1 compared with the control group 0.04 (0.01-0.28) micrograms min-1, p less than 0.001. Urinary transferrin:creatinine ratios (x 10(2)) were different in diabetic 47 (0.6-958.0) micrograms mmol-1 and control groups 0.7 (0.06-2.3) micrograms mmol-1, p less than 0.001). There were correlations between urinary transferrin and albumin excretion rates in diabetic (r = 0.78, p less than 0.001) and control groups (r = 0.81, p less than 0.05). Forty (85%) diabetic patients had elevated transferrin excretion rates, 18 (38.3%) had elevated albumin excretion rates. All diabetic patients with elevated albumin excretion rates had elevated transferrin excretion rates. Twenty-one (77.8%) of the patients with normal albumin excretion rates had elevated transferrin excretion rates. Urinary excretion of N-acetyl-beta-D-glucosaminidase was greater in diabetic patients than control subjects (142 vs 58 mumol h-1 l-1, p less than 0.001). There were correlation between transferrin and N-acetyl-beta-D-glucosaminidase excretion (r = 0.67, p less than 0.01) and albumin and N-acetyl-beta-D-glucosaminidase excretion (r = 0.63, p less than 0.01) in the diabetic group. Elevated urinary transferrin excretion rate may be a marker for renal dysfunction in diabetes mellitus.

Pathophysiology of hypertension in diabetes mellitus--implications for management

A variety of mechanisms may lead to the initiation and progression of hypertension in patients with diabetes mellitus; an understanding of their nature may provide a rational basis for the choice of management. Nevertheless, a decision on the management of an individual patient remains a matter of clinical skill and judgement.

Clinical and neurophysiological studies of aldose reductase inhibitor ponalrestat in chronic symptomatic diabetic peripheral neuropathy

Increased flux through the polyol pathway mediated by the enzyme aldose reductase may be associated with the development of diabetic neuropathy. Fifty-four diabetic patients (median age 56 yr, range 25-65 yr) with chronic neuropathic symptoms were randomly allocated to placebo or aldose reductase inhibition (300 or 600 mg ponalrestat ICI 128436) groups for 24 wk. Patients with vibration perception thresholds (VPTs) greater than 35 V at the great toe or thermal difference thresholds (TTs) greater than 10 degrees C on the dorsum of the foot were excluded from the trial. No significant changes were observed in symptoms of pain, numbness, or paresthesia between ponalrestat and placebo groups, and there were no improvements in VPT or TT at several sites. Posterior tibial nerve conduction velocity changed from 35.3 +/- 4.9 m/s at baseline to 33.4 +/- 4.0 m/s at 24 wk (NS) with placebo compared with 37.6 +/- 5.6 vs. 37.2 +/- 8.7 m/s (NS) with 300 mg ponalrestat and 34.5 +/- 6.1 vs. 36.2 +/- 6.8 m/s (NS) with 600 mg ponalrestat. Further studies are indicated with intervention at an earlier stage in the evolution of neuropathy and for longer periods.

Raised dopamine metabolites in a case of malignant paraganglioma

This paper describes the case of a malignant retroperitoneal paraganglioma with extensive metastases. The patient presented with a supraclavicular mass and an absence of hypertension. Exclusively raised dopamine metabolites were detected which may be a marker of a malignant process and account for the lack of hypertension.

The human red blood cell glyoxalase system in diabetes mellitus

Methylglyoxal and other alpha-oxoaldehydes are formed from glycolytic intermediates and may be involved in the development of diabetic microangiopathy. Glyoxalase I and glyoxalase II metabolise methylglyoxal to D-lactic acid, via the intermediate S-D-lactoylglutathione. The activities of the glyoxalase enzymes and the concentrations of methylglyoxal and S-D-lactoylglutathione were measured in erythrocytes of 45 control and 85 diabetic subjects (41 with retinopathy and 44 uncomplicated). The concentration of S-D-lactoylglutathione was increased in diabetic patients vs. controls (21.4 +/- 9.3 vs. 12.4 +/- 4.8 mumol/l, P less than 0.001), as was methylglyoxal (3.6 +/- 2.3 vs. 1.4 +/- 0.2 mumol/l, P less than 0.001). There were no significant differences in the activities of glyoxalase I and glyoxalase II between diabetic patients and controls. For insulin-dependent patients only, those without retinopathy had a higher activity of glyoxalase II than those with retinopathy (P less than 0.05). A group of age- and duration-matched insulin-dependent diabetic patients with retinopathy also had a higher activity of glyoxalase I compared with a group of diabetic patients without retinopathy (P less than 0.025). This study provides evidence for elevated concentrations of oxoaldehydes in diabetes mellitus which might have pathogenic significance.

Effect of gliclazide on thromboxane B2, parameters of haemostasis, fluorescent IgG and lipid peroxides in non-insulin dependent diabetes mellitus

Abnormalities of platelet aggregation, and increased levels of lipid peroxides and denatured proteins have been implicated in the pathogenesis of diabetic microangiopathy. Seventeen non-insulin dependent diabetics (mean age 65.7) on established sulphonylurea therapy were converted to an equivalent dose of gliclazide. They were studied at baseline and intervals to 36 weeks. Thromboxane B2 (TXB2) and beta thromboglobulin (beta TG) were measured by radioimmunoassay. Lipid peroxides were measured as total diene conjugates (DC) by scanning UV spectrophotometry and thiobarbituric acid reactivity (TBA) by absorbance at 532 nm. Oxidation products of proteins were represented by fluorescence/UV ratio of immunoglobulin G (*IgG) separated from serum by HPLC. Glycaemic control remained stable throughout the study. TXB2 fell from 734 +/- 233 ng/l at 0 weeks to 488 +/- 155 at 36 weeks, p less than 0.001 and beta TG from 120 +/- 70 ng/ml to 48 +/- 18 at 24 weeks, p less than 0.005. Lipid peroxides fell between 0 and 36 weeks; DC from 0.71 +/- 0.28 to 0.32 +/- 0.09, p less than 0.001 and TBA from 29.6 +/- 22.4 to 4.0 +/- 2.2, p less than 0.001. Fluorescent IgG ratio fell from 1.44 +/- 0.36 to 0.32 +/- 0.07, p less than 0.001. This data provides evidence for a specific action of gliclazide on thromboxane synthesis and platelet aggregation. This is independent of glycaemic control and may in part be mediated by the observed fall in lipid peroxides.

Microalbuminuria in diabetic subjects with chronic peripheral neuropathy

Fifty-five patients with chronic peripheral neuropathy, 31 with and 24 without retinopathy, had albumin excretion rates determined on 2-h supine urine collections on three occasions by a radioimmunoassay method. Four patients with retinopathy had albustix-positive proteinuria and were excluded from subsequent analysis. Microalbuminuria was found in 20 of the 27 patients with retinopathy compared with 10 of the 24 patients with neuropathy alone. The mean albumin excretion rate (AER) was higher in neuropathic patients with retinopathy than in those patients with neuropathy alone (41.2 +/- 40.3 vs 18.8 +/- 33.2 micrograms/min, P less than 0.01). Multivariate analysis of the data was performed and this revealed a correlation coefficient of R2 = 0.33 (P less than 0.01) for AER as the dependent variable with respect to the independent variables HbA1, systolic blood pressure and known duration of diabetes. There was, however, no significant contribution separately of these individual variables to the regression equation. Microalbuminuria was significantly associated with retinopathy although almost half of the patients with neuropathy alone had microalbuminuria. The association between microalbuminuria and neuropathy even in the absence of retinopathy provides support for a microvascular element in the pathogenesis of diabetic neuropathy.

Serum antioxidant activity in diabetes mellitus

Free radical medicated oxidative damage has previously been implicated in the pathogenesis of diabetic microangiopathy. Caeruloplasmin and transferrin act as antioxidants in serum by oxidizing and chelating ferrous iron which could otherwise act as a catalyst in free radical reactions. We have measured the serum anti-oxidant activity in 67 diabetics, 25 of whom had retinopathy and in 37 controls. Serum iron concentrations were normal in diabetics in comparison with controls (21.5 +/- 10 v 19.5 +/- 6.7 mumol/L) although transferrin and iron binding capacity were increased in the diabetics (3.7 +/- 0.8 v 2.9 +/- 0.9 g/L, p less than 0.001 and 69.9 +/- 10.8 v 59.0 +/- 14 mumol/L, p less than 0.002 respectively). Caeruloplasmin, measured by its ferroxidase activity, was increased in both male (46 +/- 11 v 36 +/- 9 mu/mL, p less than 0.002) and female diabetics (57 +/- 13 v 47 +/- 11 mu/mL, p less than 0.002). Ferritin was also increased in both male (124 +/- 113 v 44 +/- 38 ng/mL, p less than 0.001) and female diabetics (132 +/- 118 v 25 +/- 12 ng/mL, p less than 0.001). The presence of retinopathy, the degree of glycaemic control and duration of diabetes had no effect on these findings. We conclude that increased concentrations of iron-oxidizing and iron-binding proteins occur in diabetic serum, and that the increased serum antioxidant activity may be a response to oxidative stress.

Increased diene conjugates in diabetic subjects with microangiopathy

Free radicals are highly reactive unstable chemical species which have been implicated in the vascular damage associated with several disease states. Diene conjugates, probable products of free radical activity on lipids, were measured spectrophotometrically in 26 diabetic patients with microangiopathy, 36 uncomplicated diabetic patients, and 36 healthy controls. Total diene conjugates and diene conjugate to triglyceride ratios were significantly elevated in diabetic patients with microangiopathy (0.57 +/- 0.08 and 0.31 +/- 0.14 OD units/ml respectively; mean +/- SD) when compared with patients without complications (0.32 +/- 0.10, p less than 0.001, and 0.17 +/- 0.06, OD units/ml, p less than 0.011). There was no difference in total diene conjugation and their ratio to triglycerides between healthy controls and uncomplicated diabetic patients and the results were not influenced by the type of diabetes or level of diabetic control. Diene conjugate ratios repeated in 14 patients on two occasions, 6 weeks apart, with stable metabolic control were consistent. Increased diene conjugation suggesting increased free radical activity is associated with microangiopathy and this may have pathogenetic implications.

Campylobacter jejuni myocarditis

A case of Campylobacter jejuni (C. jejuni) myocarditis in a young man is described. C. jejuni was isolated from the patient's stools and he developed specific antibodies to this organism. Tests for other etiological agents (Salmonella, Shigella, Brucella abortus, beta-hemolytic streptococcus Group A, Treponema pallidum and coxsackievirus B) proved negative.