Identification of malnutrition-related diabetes mellitus among hospitalized patients in Taiwan

A retrospective review of 1,089 diabetes mellitus admitted to the metabolic ward of Chang Gung Memorial Hospital was performed to screen for malnutrition-related diabetes mellitus (MRDM). None of the patients fulfilled the MRDM criteria, although 20 patients with a body mass index < or = 15 kg/m2 were further analyzed. These patients presented with poor glycemic control and most had associated chronic diseases. C-peptide levels were < 0.8 ng/mL in 17 patients and undetectable in six patients. Two patients experienced diabetic ketoacidosis (DKA). Insulin treatment was required by 18 patients with a mean (+/- SD) dosage of 30 +/- 9 U/day. During follow-up of 14 of the patients for 9.8 +/- 4.3 months, HbA1c decreased significantly. Their mean body weight and body mass index increased significantly from 36.6 +/- 4.6 kg to 47.2 +/- 6.2 kg and 13.9 +/- 0.9 to 18.0 +/- 1.9 kg/m2, respectively. Careful attention should be paid to diabetic control and associated chronic illness in patients with severe undernutrition.

Neonatal jaundice and molecular mutations in glucose-6-phosphate dehydrogenase deficient newborn infants

Molecular mutations of the glucose-6-phosphate dehydrogenase (G6PD) gene and clinical manifestations of neonatal jaundice in 112 male and 50 female Chinese neonates with G6PD deficiency were studied. In the 112 males, the nucleotide (nt) 1376 (G-->T) mutation was the dominant type (50.0%), followed by nt 1388 (G-->A) (16.1%), nt 493 (A-->G) (8.0%), nt 1024 (C-->T) (6.2%), nt 95 (A-->G) (5.4%), nt 392 (G-->T) (1.8%), nt 487 (G-->A) (1.8%), nt 871 (G-->A) (0.9%), and nt 1360 (C-->T) (0.9%). The nt 871 variant has not been reported in Taiwan before. The occurrence rates for nt 1376, nt 1388, nt 493, nt 95, and nt 1024 mutations in the 50 females were 44.0%, 18.0%, 12.0%, 6.0%, and 6.0%, respectively. The type of G6PD mutation in 10 male and 7 female neonates has not been identified yet. Although G6PD deficient neonates had higher frequency of phototherapy than G6PD normal neonates in both sexes, a significant difference in the prevalence of hyperbilirubinemia (peak bilirubin > or = 15.0 mg/dl) between G6PD deficient and normal neonates was found only in males. Further analysis showed that duration of phototherapy was longer in G6PD deficient male neonates than in the control group, while the outcome of phototherapy was better in subjects with non-nt 1376 mutations than subjects with the nt 1376 mutation. Most (78.3%) of the 23 G6PD deficient neonates who subsequently suffered from neonatal hyperbilirubinemia carried the nt 1376 mutation. The results of this study indicate that the nucleotide substitution at 1376 is the most common and important mutation for G6PD deficiency in Chinese neonates in Taiwan.

Comparison of the outcome between the calculated dosimetry and the estimated dosimetry of 131I in the treatment of hyperthyroidism

To compare the outcomes of different methods in prescribing the optimal dose of radioactive iodine (131I) for the treatment of hyperthyroidism, we retrospectively analyzed 52 patients with toxic diffuse goiter. They received single dose of 131I for the treatment of hyperthyroidism. In addition, all of them met the following criteria: 1) symptoms and signs of hyperthyroidism; 2) elevated blood triiodothyronine (T3) and thyroxin (T4) by radioimmunoassay (RIA) method; 3) diffuse goiter with increase of uptake proved by thyroid scintiscan; 4) only one dose of 131I was given during the follow-up period; 5) well-documented thyroid function test in the medical chart during the follow-up period (6 months, 1 year, 2 years and 5 years after 131I therapy). The enrolled patients were divided into estimated and calculated group. The dose of 131I in the calculated group was obtained from the measurement of size and 131I uptake of thyroid gland. The dose of 131I in the estimated group was prescribed according to the size of thyroid gland by physical examination, and the association with cardiac arrhythmia, congestive heart failure, or ischemic heart disease. The mean doses of 131I were 4.8 +/- 1.4 mCi and 7.0 +/- 1.1 mCi in the calculated and estimated group respectively. In this study, there were no significant difference in the incidence of euthyroidism, hyperthyroidism, and hypothyroidism between these two groups in thefollow-up period after 131I therapy. In view of simplicity and time-saving, it is a practical choice to prescribe the dose of 131I therapy for toxic diffuse goiter according to the size of thyroid gland and the associated cardiac condition.

Preparation, characterization, and anesthetic properties of 2-hydroxypropyl-beta-cyclodextrin complexes of pregnanolone and pregnenolone in rat and mouse

Prototype formulations of the progesterone derivatives pregnanolone and pregnenolone were prepared by solubilizing the steroids in 2-hydroxypropyl-beta-cyclodextrin (HP beta CD). The aqueous solubility of the steroids was increased as a function of HP beta CD concentration generating linear (AL) or curvilinear (AP) phase-solubility profiles. While the solubility of pregnanolone could not be increased with the addition of water-soluble pharmaceutical polymers, the concentration of pregnenolone in HP beta CD was increased more than 60% by the addition of small amounts (0.10%) of (hydroxypropyl)methylcellulose. Mice studies found that while pregnanolone was highly potent in an HP beta CD vehicle, pregnenolone was devoid of activity. Since pregnenolone and pregnanolone differ marginally in structure and physicochemical profile, the data suggest that these derivatives interact via a specific receptor and not via nonspecific membrane perturbations. Sex differences in the action of the pregnanolone complex was observed in that parenteral (i.v. and i.p.) drug administration was more effective in males than females. These data are in contrast to observations made in the case of alfaxalone, a related steroid anesthetic, in which the sex difference favored female animals. On the other hand, females appeared to be more sensitive to the effects of the pregnanolone complex when administered orally. Finally, parenteral pregnanolone was more toxic to males than females with LD50 (i.v.) values of 355 and 548 micromol/kg, respectively.

Expression of vascular cell adhesion molecule-1 by follicular dendritic cells

Follicular dendritic cells are the major supporting cell of the germinal center microenvironment. The major function of follicular dendritic cells is to present antigen to B cells in secondary lymphoid tissues. Through cell-cell interactions, FDCs are hypothesized to be central to the regulation of normal B cell growth and differentiation. The major receptor-ligand pair which mediates B cell-FDC adhesion is the beta 1 integrin VLA-4, present on B cells and VCAM-1 expressed on FDCs. Follicular non-Hodgkin's lymphomas similarly employ this mechanism to bind to neoplastic germinal centers. The VCAM-1 molecule can exist as a 6 or 7 immunoglobulin domain form. The major form of VCAM-1 on activated endothelium is the 7 domain form. In this report we have determined by polymerase chain reaction of purified FDCs that they express predominantly mRNA for 7 domain VCAM-1. It is likely that the two forms of VCAM-1 are associated with distinct functions, therefore the expression of 7 domain VCAM-1 may be important in normal and neoplastic B cell-FDC interactions.

Clinical associations between thyroid and liver diseases

The liver has an important role in thyroid hormone metabolism and the level of thyroid hormones is also important to normal hepatic function and bilirubin metabolism. Besides the associations between thyroid and liver diseases of an autoimmune nature, such as that between primary biliary cirrhosis and hypothyroidism, thyroid diseases are frequently associated with liver injuries or biochemical test abnormalities. For example, thyroid diseases may be associated with elevation of alanine aminotransferase and alkaline phosphatase, which is mainly of bone origin, in hyperthyroidism and aspartate aminotransferase in hypothyroidism. Liver diseases are also frequently associated with thyroid test abnormalities or dysfunctions, particularly elevation of thyroxine-binding globulin and thyroxine. Hepatitis C virus infection has been connected with thyroid abnormalities. In addition, antithyroid drug therapy may result in hepatitis, cholestasis or transient subclinical hepatotoxicity, whereas interferon (IFN) therapy in liver diseases may also induce thyroid dysfunctions. These thyroid-liver associations may cause diagnostic confusions. Neglect of these facts may result in over of under diagnosis of associated liver or thyroid diseases and thereby cause errors in patient care. It is suggested to measure free thyroxine (FT4) and thyroid-stimulating hormone (TSH) which are usually normal in euthyroid patients with liver disease, to rule out or rule in coexistent thyroid dysfunctions, and consider the possibility of thyroid dysfunctions in any patients with unexplained liver biochemical test abnormalities. It is also advisable to monitor patients with autoimmune liver disease or those receiving IFN therapy for the development of thyroid dysfunctions, and patients receiving antithyroid therapy for the development of hepatic injuries.

Theoretical studies on the structures of natural and alkylated cyclodextrins

A series of semiempirical molecular orbital calculations using the AM1 method have been performed on isolated natural and alkylated alpha- and beta-cyclodextrins. For natural cyclodextrins, three geometries were considered: (i) molecular mechanics (MM2); (ii) AM1 fully optimized geometry; (iii) X-ray structures based on the experimental coordinates for heavy atoms with positions of hydrogen atoms optimized by AM1. Large differences between AM1 calculated properties of geometries i-iii were found. The differences between ii and iii are smaller and reflect the intermolecular, crystal packing forces. Comparisons are made between ii and iii and properties determined therefrom, such as cavity diameter, outer diameter, and height. In addition, AM1 semiempirical calculations were performed on the mixed (2,3,6) (hydroxyprophyl)-beta-cyclodextrin, 2,6-dimethyl-beta-cyclodextrin, and 2,6-bis(hydroxypropyl)-beta-cyclodextrin. The results were compared with the substituent effects on monoglucose. It was found that the alkylation and methyl and 2-(hydroxypropyl) functions on beta-cyclodextrin does not introduce significant steric hindrance.

Efficacy of a 3-substituted versus 17-substituted chemical delivery system for estradiol brain targeting

Brain-targeted delivery of estrogens has been achieved by a chemical delivery system (CDS) in which a molecular targetor (1-methyl-1,4-dihydronicotinate) was attached to the 17-alcohol of estradiol. Optimization of this effect was attempted with the isomeric 3-phenol ester. Estradiol 3-nicotinate was prepared with nicotinic anhydride, which selectively acylated the phenol position. Methylation and reduction gave estradiol 3-(1-methyl-1,4-dihydronicotinate) of the 3-E2-CDS. Theoretical and electrochemical investigation indicated that the 3-E2-CDS was more stable to oxidation than was the prototype 17-ester (17-E2-CDS). Systemic administration of the 17-E2-CDS produced high levels of the corresponding quaternary salt in the brain of rats, which disappeared with an estimated half-life of > 2 days, but 3-E2-CDS dosing resulted in no significant quaternary salt trapping. Pharmacological activity was potent and sustained after 17-E2-CDS dosing but transient after 3-E2-CDS administration. Thus, the 3-E2-CDS reduced the rate of weight gain in male rats but to a lesser extent and for a shorter duration than did the 17-E2-CDS. Similar effects were seen on pituitary hypertrophy, reduction in serum androgen concentrations, and involution of prostate and seminal vesicles. The results of these studies suggest that placement of the targeting ester at the phenol position increases dihydropyridine stability but, at the same time, reduces brain sequestration.

Thyroid cancer treated in Chang Gung Memorial Hospital (northern Taiwan) during the period 1979-1992: clinical presentation, pathological finding, analysis of prognostic variables, and results of treatment

This study is a retrospective analysis of 248 thyroid cancer patients who received their primary treatment in the Chang Gung Memorial Hospital during the period January 1979 to December 1992. Among these cases, there were 173 papillary thyroid cancers (69.8%), 52 cases of follicular thyroid cancer (21%), 7 cases of medullary thyroid cancer (2.8%), and 16 cases of anaplastic thyroid cancer (6.5%). The subjects included 184 female patients with a mean age of 40.7 +/- 14.3 years and 64 males patients with a mean age of 49.2 +/- 14.3 years. Most of the cases had a nearly total thyroidectomy after the diagnosis was confirmed by frozen section during the operation. During the follow-up period, 19 (8.2%) patients diagnosed with well-differentiated thyroid cancer died of thyroid cancer in contrast to 12 patients (75%) with anaplastic thyroid cancer. The 1-year Greenwood survival probabilities after the disease is diagnosed in papillary, follicular, and anaplastic thyroid cancer are 0.98, 0.86, and 0.25, respectively. For the analysis of prognostic variables in well-differentiated thyroid cancer patients, 16 factors were entered for univariate and multivariate analysis. Using a log-rank univariate analysis, survival was significantly associated with the cell type of the primary tumor, age, clinical staging, postoperative 131I pattern, tumor size, postoperative thyroglobulin (Tg) level and postoperative x-ray results. In the Cox multivariate regression analysis the combination factors that gave the best prognostic value were the association of x-ray finding (P = .004), age (P = .017), and Tg level (P = 0.19). In conclusion, thyroid cancer is not an unusual disease in Taiwan. As previously reported anaplastic thyroid cancer has a poor prognosis. In this limited period of follow-up study, the patients' age with postoperative first positive x-ray finding and Tg level may provide the prognostic factors for patients with well-differentiated thyroid cancer.

Sequential liver and bone biochemical changes in hyperthyroidism: prospective controlled follow-up study

OBJECTIVE

To reexamine the prevalence and sequential changes of liver and bone biochemical abnormalities in patients with hyperthyroidism.

METHODS

A consecutive series of 95 patients with hyperthyroidism and 66 controls with euthyroid goiter seen during same period were studied. The patients were treated with propylthiouracil (PTU) 300 mg/day for 2 months, followed by 100-150 mg/day for 3 months and a subsequent maintenance dose of 100 mg/day. Serum aspartate amino-transferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP), gamma-glutamyl transpeptidase (GGT), bilirubin, ALP isoenzymes, and hepatitis markers were studied before therapy and at 2 and 5 months after PTU therapy was begun.

RESULTS

Seventy-two [75.8%, confidence interval (CI) 67.2-84.4%] of the 95 patients had at least one biochemical abnormality. AST, ALT, ALP, GGT, and bilirubin were elevated in 27.4%, 36.8%, 64.2%, 16.8%, and 5.3%, respectively. Of the 34 patients with ALT elevation, 62% showed gradual normalization of ALT, whereas 38% (CI 21.9-54.5%) showed transient, asymptomatic, but significant (p < 0.025) further elevation of ALT during PTU therapy. Overt hepatitis developed in one patient. None of these changes was due to hepatitis A, B, C, or delta virus infection or autoimmune hepatitis. Changes of serum GGT parallel those of ALT. In contrast, serum ALP (primarily bone isoenzyme) rose significantly (p < 0.01) as T4 and T3 levels declined at 2 months after therapy.

CONCLUSIONS

The results suggest that hyperthyroidism is often associated with abnormal biochemical tests, particularly ALP elevation, and thus may pose diagnostic confusion. The increase of bone isoenzyme accounts for the elevations in total ALP level before and during therapy. Serum ALT and GGT abnormalities usually subside during PTU therapy, but transient asymptomatic PTU hepatotoxicity occurs in one-third of the patients. Discontinuation of PTU is not required unless overt hepatitis develops.

Expression and biochemical characterization of human glucose-6-phosphate dehydrogenase in Escherichia coli: a system to analyze normal and mutant enzymes

We have developed a system to characterize normal and mutated glucose-6-phosphate dehydrogenase (G6PD) enzymes in vitro. Normal or mutant G6PD cDNA was subcloned into a pGEX-3X vector, which allowed production of a functional fusion protein in Escherichia coli. When we compared the recombinant normal enzyme with authentic human G6PD, indistinguishable Km values for glucose-6-phosphate (G6P) and NADP were obtained, and the utilization rates for two substrate analogues (2-deoxy G6P and deamino NADP) also showed no difference between the enzymes. This system was used to assay a biochemically uncharacterized variant, G6PD Taipei (493 A-->G; 165 Asn-->Asp), plus two other known mutations (487 G-->A; 163 Gly-->Ser and 592 C-->T; 198 Arg-->Cys) that are located close to or within the putative G6P binding domain. Our results show that the G6PD activities of these three mutants were greatly reduced. No significant alteration in G6PD kinetics was observed for both 487 and 493 mutations. However, a drastic reduction in the Km for G6P (4-fold decrease) and tremendous increases in utilization rates of 2-deoxy G6P (32-fold increase) and deamino NADP (6-fold increase) were associated with the 592 mutation. This results suggests that arginine 198 in human G6PD, possibly located within the putative G6P binding domain, may play an important role in binding the substrate G6P. In addition, we and others have recently identified that at least nine different types of mutations are responsible for G6PD deficiency in Chinese. In this report, we also present the occurrence rate of each mutation present in the population of Taiwan.

Insulinoma--clinical experience in ten cases

During the period between January 1981 and December 1992, a total of ten patients with pathologically confirmed insulinoma were studied. All patients presented with variable degrees of neuroglycopenic symptoms and Whipple's triad. The ratio of insulin to glucose after an overnight fast was greater than 0.3 in 90% (9/10) of patients. Eight patients who received supervised fasting developed neuroglycopenia with relative hyperinsulinemia within 48 hours of fasting. Four of 8 patients developed hypoglycemia during a 5-hour oral glucose tolerance test (OGTT). Calcium infusion test was more sensitive in patients with an initially higher plasma glucose. The detection rates of various localization studies were 12.5% (1/8) by abdominal ultrasonography, 37.5% (3/8) by abdominal CT scan, 50% (5/10) by selective superior mesenteric and celiac arteriography. Transhepatic portal venous sampling (THPVS) detected insulinomas in 4 of 4 cases. Endoscopic ultrasonography and intraoperative ultrasonography were performed on 1 and 2 cases respectively, and were able to localize the lesions successfully. All patients received surgical treatment including enucleation (n = 2), subtotal pancreatectomy (n = 3) and distal pancreatectomy (n = 5). All patients had single tumors which were all benign islet cell adenomas. The mean size of the tumors was 15.5 +/- 2.0 mm in diameter (range: 8 to 30 mm) and mainly located in the body (50%) and tail (40%), only 1 in the pancreatic head. All symptoms of hypoglycemia subsided after operation. Hyperglycemia was observed in all patients immediately after operation, and most of them resumed normoglycemia within 8 days. However, the 2 patients who had impaired OGTT preoperatively had persistent hyperglycemia after operation and therefore were diagnosed as having diabetes (NIDDM).

Value of serum alkaline phosphatase in evaluating hyperplasia of parathyroid glands in chronic hemodialysis patients

To investigate the value of serum alkaline phosphatase in evaluating hyperplasia of parathyroid glands in hemodialysis patients, 28 hemodialysis patients who had parathyroid sonography examinations for secondary hyperparathyroidism were studied retrospectively. There were significant elevations of serum alkaline phosphatase, parathyroid hormone (PTH), serum total calcium, and dialysis duration in patients with sonography-detectable parathyroid (N = 17) as compared with those of sonography-undetectable (N = 11) parathyroid. Hemodialysis patients who have both higher serum alkaline phosphatase (> 94 IU/L) and considerably elevated serum PTH (9 x or higher) are likely to have sonography-detectable parathyroids (positive predictive value of 93%). Patients with mildly or moderately elevated serum PTH but normal serum alkaline phosphatase are less likely to have sonography-detectable parathyroids (negative predictive value is 100%). These findings suggest that the elevation of serum alkaline phosphatase could be a valuable parameter in addition to the high serum PTH level in predicting hyperplasia of parathyroid glands in chronic hemodialysis patients.

Effect of gliclazide on plasma lipids and pancreatic beta cell function in non-insulin-dependent diabetes mellitus

Eighteen patients with non-insulin-dependent diabetes mellitus (NIDDM), who were newly diagnosed or had their oral hypoglycemic agents discontinued for more than 3 months, were studied to evaluate the effect of gliclazide on glycemic control, plasma lipids and beta cell function. The mean fasting plasma glucose (249 +/- 11 vs 170 +/- 10 mg/dl, p < 0.001), postprandial plasma glucose (353 +/- 16 vs 237 +/- 16 mg/dl, p < 0.001) and HbA1C (9.6 +/- 0.4 vs 6.5 +/- 0.3% p < 0.001) decreased significantly after 3-months of gliclazide treatment. The beta cell function showed a significant increase in fasting serum C-peptide (1.8 +/- 0.2 vs 2.1 +/- 0.3 ng/ml, p < 0.05) and an insignificant increment in serum C-peptide after glucagon stimulation (2.2 +/- 0.3 vs 2.2 +/- 0.4 ng/ml, p < 0.1). In 8 cases with an initial serum cholesterol above 200 mg/dl, the serum cholesterol decreased significantly (236 +/- 8 vs 200 +/- 12 mg/dl, p < 0.05). However, LDL-cholesterol (164 +/- 8 vs 145 +/- 13 mg, p > 0.05) and HDL-cholesterol (66 +/- 5 vs 54 +/- 9 mg, p > 0.05) showed insignificant decrease after gliclazide therapy. In 4 patients with hypertriglyceridemia, the serum triglyceride decreased (441 +/- 161 vs 239 +/- 73 mg/dl, p > 0.1), but this was not statistically significant. These findings suggest that hyperglycemia, fasting serum C-peptide levels and hypercholesteremia are significantly improved after a 3-month period of gliclazide therapy in NIDDM patients.

Technetium-99m pertechnetate scan for ectopic gastric mucosa in children with gastrointestinal bleeding

The detectability of ectopic gastric mucosa by Technetium (Tc)-99m pertechnetate abdominal scanning was investigated by reviewing 62 such scans in 52 pediatric patients with gastrointestinal hemorrhage. The histologic diagnoses and clinical conditions were correlated to the findings of the scans. There were 21 true-positives, 35 true-negatives, one false-positive and five false-negative studies. The overall sensitivity of this scan for the detection of ectopic gastric mucosa was 81%, the specificity was 97% and the accuracy was 90%.

Abnormalities of sodium transport in non-insulin-dependent diabetes: association with renal disease

We investigated both sodium-lithium countertransport (Na-Li CT) and ouabain-sensitive sodium transport (Na pump) of erythrocytes in healthy subjects (group A), patients with non-insulin-dependent diabetes (NIDDM) without nephropathy (group B), patients in the proteinuric stage (group C), and those in the renal insufficiency stage (group D). Erythrocytes from all four groups had a similar initial water and ionic content and were loaded with similar degrees of Li and Na for efflux studies. There were no significant differences in erythrocyte Na-Li CT or Na pump among the four groups. However, the maximal rate of Na-Li CT was significantly higher in a group of subjects with essential hypertension when compared with groups A, B and C, consistent with the view that there is a genetic marker for essential hypertension. Ouabain-insensitive Na efflux (Na leak) of erythrocytes was found to be significantly higher in group D than in groups A or B. Also, a significant positive correlation existed between Na leak and urine protein levels of the subjects studied. Our results thus indicate that in contrast with insulin-dependent diabetic patients (IDDM) where an elevated Na-Li CT is observed, with diabetic nephropathy, Na-Li CT in NIDDM is apparently not associated with nephropathy; rather the ouabain-insensitive Na efflux appears to be correlated with the stages of nephropathy in NIDDM. The association suggests that the rate of ouabain-insensitive Na efflux may provide an index for assessing the degree of nephropathy in NIDDM patients.