Improvement of diabetes after treatment with somatostatin analogue SMS 201-995 in an acromegalic patient

The beneficial effects of long acting somatostatin analogue SMS 201-995 in an acromegalic patient affected by severe diabetes mellitus are reported. Neither human insulin alone nor human insulin plus bromocriptine allowed satisfactory metabolic control though, with the latter treatment, virtually normal plasma GH levels were reached. Conversely, addition of SMS 201-995 to insulin treatment led to normalization of blood glucose. This result was obtained with a dose of SMS 201-995 of 400 micrograms/day and only after 3 weeks of therapy.

Cushing's syndrome due to unilateral adrenal nodular hyperplasia with incomplete inhibition of the contralateral gland

A 57-year-old woman was demonstrated to be affected by adrenocorticotropic hormone (ACTH)-independent Cushing's syndrome. Computed-axial tomography of the abdomen demonstrated an expansion of the left adrenal. In apparent contrast with these findings, adrenal scintigraphy demonstrated radiocholesterol uptake also by the right gland. At surgery, the left adrenal was found to be hard and enlarged and was excised, while the right gland was found of normal appearance and left in place. Histologic examination of the excised gland demonstrated nodular hyperplasia. Early after surgery, plasma cortisol returned to normal values with a normal circadian rhythm and complete inhibition by low dose dexamethasone; the response of plasma cortisol to ACTH was normal. The patient represents a rare case of unilateral adrenal nodular hyperplasia. Radiocholesterol uptake by the contralateral gland and early recovery from adrenal atrophy after surgery are exceptional findings and suggest incomplete inhibition of endogenous ACTH.

Thyroid cancer: surgical experience with 322 cases

From November 1970 to July 1983, a total of 322 thyroid cancers were treated surgically in our clinic. Total thyroidectomy was the treatment of choice. In 131 patients, modified neck dissection (unilaterally in 23 and bilaterally in 108) was added. Of the latter patients, 33 also required upper mediastinal lymph node dissection. There were no operative deaths. No recurrent laryngeal nerve iatrogenic palsy was observed. Permanent parathyroid insufficiency developed in only about 4% of patients. The low morbidity and good long-term results justify the use of this procedure in all patients with thyroid malignancies. Despite conservative arguments in the controversial issue of lobectomy versus total thyroidectomy, skilled surgeons should be able to perform total thyroidectomy safely. It is recommended as the treatment of choice because of the well-documented multicentricity of thyroid cancers and the good prognosis of differentiated cancers associated with a near-normal life expectancy, to permit radioactive iodine therapy of possibly functioning metastases and the easier control of hypothyroidism with thyroid supplement medication.

Evidence for differing dopaminergic activity in childhood- or adult-onset obesity

In order to investigate dopaminergic activity in two types of human obesity, childhood- and adult-onset, we have studied the responses of plasma TSH and prolactin to domperidone, a dopamine receptor antagonist, in 12 patients obese since early childhood, 12 patients with adult-onset obesity, and in 12 lean controls. All subjects were females. In childhood-onset obese patients the responses of plasma prolactin and TSH to antidopaminergic stimulation were lower than those of adult-onset obese patients and lean controls. Conversely, the stimulus elicited a normal response of plasma prolactin and an exaggerated response of plasma TSH in adult-onset obese patients. These data indicate the presence of differing dopaminergic tone in the two types of human obesity.

Gonadotropin releasing hormone elicits abnormal hormone responses in schizophrenia

We studied the non-specific responses of GH and PRL to gonadotropin releasing hormone (GnRH) in eleven male patients aged 18-30 in whom a diagnosis of acute schizophrenia was made according to Crow's criteria. GnRH administration was followed by a significant increase in plasma GH in five patients; plasma PRL increased in two patients. The two prolactin responders were also GH responders. Non-specific GH response was confirmed on repeated testing in two patients in whom GnRH stimulation was performed twice. During saline control, non-specific hormone responses were not observed. The abnormal hormone responses observed in acute schizophrenia are probably due to the disordered monoamine regulation characteristic of this condition.

Circulating thyroglobulin and antithyroglobulin antibodies after fine needle aspiration of thyroid nodules

Circulating thyroglobulin and antithyroglobulin antibodies were assayed in fifteen patients affected by solitary "cold" nodules of the thyroid who had undergone fine needle aspiration for cytologic diagnosis. The aim of the study was to investigate whether a minor insult to thyroid tissue such as fine needle aspiration is able to release thyroglobulin into the circulation and to induce the formation of antithyroglobulin antibodies. The results obtained are as follows: 1. Circulating thyroglobulin increased substantially after fine needle aspiration in 11 out of 15 patients. 2. Antithyroglobulin antibodies did not appear in any patient during a follow-up period of two months. 3. The magnitude of basal thyroglobulin and thyroglobulin increase after needle aspiration were unrelated to cytologic diagnosis.

Plasma ACTH-response to the corticotropin releasing factor in patients with Cushing's disease. Comparison with the lysine-vasopressin test

In three female patients with Cushing's disease, 100 micrograms of synthetic ovine corticotropin releasing factor (CRF) were administered before surgery and 1 week after transsphenoidal microadenomectomy. In these patients a test with lysine-vasopressin (LVP), 10 U intramuscularly, was also performed before and after pituitary surgery. Before surgery, both stimuli induced a clear increase in plasma ACTH and cortisol in all patients; the response of ACTH to CRF was of greater magnitude. Postoperatively, the responses were virtually absent in two patients, but were still present in the third one in whom the removal of adenoma had been partially unsuccessful. The CRF test was also performed in a female patient with Cushing's syndrome due to adrenal adenoma; in this patient no responses of plasma ACTH and cortisol to CRF were recorded. This paper demonstrates that pituitary microadenomas causing Cushing's disease may retain the ability to respond to CRF; this stimulus may be useful in the differential diagnosis between ACTH-dependent and independent Cushing's syndrome; the lack of response after microadenomectomy indicates successful removal of the tumor. CRF is more potent than LVP in releasing ACTH at the doses employed.

Corticotropin releasing factor stimulates cAMP formation in pituitary corticotropic tumor cells

Addition of corticotropin-releasing factor (CRF) to membranes from two ACTH-secreting pituitary tumors strikingly increased in a dose-dependent fashion adenylate cyclase (AC) activity. Significant stimulation was already apparent at 10(-9)M CRF. Stimulation of AC activity by CRF in membranes from non-tumoral tissue adjacent to tumoral corticotrophs was considerably lower, and was lacking in membranes from a growth hormone secreting tumor. These data correlated well with in vivo pre-surgery and post-surgery ACTH responsiveness to CRF of the tumor bearing patients. Basal AC activity was higher in pituitary adenomas than in non-tumoral adjacent tissue. It is concluded that 1) a CRF-sensitive AC exists in ACTH-secreting tumor cells and, 2) increased sensitivity to CRF, as evidenced by greater stimulation of AC activity, may be responsible for the increased ACTH output of tumoral corticotrophs.

Gonadotropin response to gonadotropin releasing hormone in acute schizophrenia

To evaluate hypothalamic-pituitary-gonadal axis in acute schizophrenia, plasma FSH and LH concentrations were estimated both in basal conditions and after stimulation with gonadotropin releasing hormone (GnRH, 200 micrograms i.v.) in 14 young male patients with acute schizophrenia and in a age-matched group of 14 healthy male controls. Basal plasma PRL and testosterone levels were also measured. The mean basal levels of LH and FSH were slightly lower in schizophrenics, while the mean testosterone and prolactin levels were similar in the two groups. The FSH response to GnRH was significantly reduced in patients with acute schizophrenia, while the response of LH was similar in schizophrenics and in the controls. The possible significance of these findings is discussed in the contest of the complex neuroendocrine regulation of gonadotropin secretion and the overactivity of dopaminergic systems in acute schizophrenia.

[Acute intermittent porphyria]

Acute intermittent porphyria (AIP) is a congenital disease which as its name suggests, runs intermittently. Biochemically it is characterised by over-production of hepatic ALA synthetase (ALA-s), inducible mitochondrial enzyme and an increase in prophyrinic precursors (PBG, ac S-ALA). Clinically it is characterised by an abdominal nervous symptomatology. The primary metabolic error has been identified as a deficiency in enzyme activity which partially blocks haem biosynthesis. During the appearance of clinical manifestations, certain factors are present which have the capacity of inducing hepatic ALA-s production in vitro. Apart from some preventive measures treatment is mainly of symptomatology and complications. More recently the use of ALA-s inhibitors has been introduced.

Essential hypertension. The behaviour of the haemorheological determinants and their trends during beta-blocker treatment

We examined the haemorheological determinants in a group of 52 hypertensives (diastolic basal pressure greater than 100 mmHg) subdivided in relation to the clinical stage (I and II or III according to the WHO classification) and in a group of 50 normal controls, matched for age and sex. From this study, it is evident that only plasma viscosity, fibrinogen and the fibrinogen/albumin ratio are able to distinguish normals from hypertensives. It is also clear that the clinical stage does not influence the haemorheological findings. These haemorheological factors were also measured in 3 groups of hypertensives treated with either timolol (20 mg/day), metoprolol (200 mg/day) or oxprenolol (160 mg/day). After a basal evaluation, measurements were performed, at regular intervals of 10 days, for a period of 30 days. The only significant changes were obtained using timolol; metoprolol and oxprenolol, did not affect these haemorheological parameters.

[Erythrocyte filterability in diabetes mellitus (a survey carried out by two methods)]

In 45 diabetic patients (22 men and 23 women) subdivided in relation to type and vascular complications we have evaluated the erythrocyte filterability either by filtering whole blood (VRBC) or red blood cells suspended (5%) in autologous prefiltered plasma (deformability index). From the obtained results it is evident that VRBC is able to distinguish diabetic patients from normal subjects, whereas this does not happen with the deformability index. The explanation of these data is that the whole blood filterability, especially in diabetic patients, depends on the behavior of both cellular and plasmatic extraerythrocyte parameters.

Plasma cortisol response to ACTH does not accurately indicate the state of hypothalamic-pituitary-adrenal axis

The hypothalamic-pituitary-adrenal function was studied in 55 patients with various pituitary disorders. In particular, the consistency between the responses of plasma cortisol to exogenous ACTH and to insulin hypoglycemia was investigated in 5 patients in whom cortisol response to insulin was absent; four of these patients showed a cortisol response to ACTH of variable degree. These 4 patients had surgical or functional hypothalamus-pituitary disconnection and showed a preserved cortisol response to lysine vasopressin. These data demonstrate the unreliability of ACTH test in assessing hypothalamic-pituitary-adrenal function in hypopituitary patients.

[Hemorheological factors and metabolic parameters in a group of diabetic subjects]

Blood viscosity factors and some metabolic parameters were estimated in thirty-eight insulin-treated diabetics. The evaluation was carried out on admission and after eight weeks of controlled therapy. From this study it follows that blood viscosity factors do not permit us to distinguish, at these two stages, diabetics with complications from diabetics without while there is this possibility at the initial observation in diabetics subdivided for sex. Furthermore there are no significant variations, except for the haematocrit, of the average of blood viscosity factors and metabolic parameters at the initial and final observation. Very interesting is the negative relation between the Vrbc, parameter which studies the erythrocyte deformability, and the red cell 2,3-diphosphoglycerate (2,3-DPG) that seems more evident in diabetics with complications. Contrary to what has been reported in literature no relation between Vrbc and glycosylated haemoglobin (GHb) is present.

[Glycosylated hemoglobins and erythrocyte 2,3-diphosphoglycerate in diabetes mellitus]

Investigations carried out on 43 diabetic not ketoacidotic patients (32 women and 11 men) showed that the percentage of glycosylated hemoglobins (GHb) is significantly (p less than 0.01) inversely related to the intra-erythrocytic concentration of 2,3-DPG and to the calculated P50. Preliminary data from a prospective study suggest that the inverse relationship could be referred to the degree of control of the disease. In poorly controlled diabetes, where at the highest percentages of GHb the lowest levels of 2,3-DPG are found, less oxigen can be delivered to peripheral tissues.

Inhibitory effect of calcitonin on growth hormone and insulin secretion in man

The effect of calcitonin administration on basal and arginine-stimulated growth hormone and insulin plasma levels was investigated. The intramuscular injection of synthetic salmon calcitonin (100 U MRC) in five normal subjects produced a significant decrease (p less than 0.05) in insulin concentration. The same amount of calcitonin given 15 min before an arginine infusion test in seven normal subjects significantly reduced the response of growth hormone (p less than 0.025) and insulin (p less than 0.005) to the stimulus.

Pituitary hormone responses to hypothalamic releasing hormones in acromegaly

The pituitary reserve of GH, prolactin, TSH, LH, and FSH has been studied in a group of 13 acromegalic patients with the aim of evaluating the pituitary function and the activity of the disease. Plasma GH, TSH and polactin were determined after thyrotrophin releasing hormone (TRH) administration, plasma gonadotrophins and GH after luteinizing hormone releasing hormone (LH-RH) administration. The plasma TSH response to TRH was generally blunted in the patients treated with pituitary irradiation; however, none of the patients with diminished TSH reserve had signs of hypothyroidism. Six acromegalics showed prolactin basal levels higher than controls; none had galactorrhoea; 4 of them complained of impairment of the gonadal function. The prolactin response to TRH was variable and not related to prolactin basal levels. A subnormal LH reserve after LH-RH stimulation was observed in 5 out of 10 patients; 4 of them had also clinical signs of hypogonadism. A normal FSH response to LH-RH was present in all patients. A non-specific GH response to TRH and/or LH--RH was obtained in about half of the acromegalics studied. The GH responsiveness to TRH and/or LH-RH was not related to the activity of the disease or to a specific derangement of the hypothalamo-pituitary function. A concordant response was observed only between GH and prolactin response to TRH; the highest prolactin responses to TRH were obtained in the GH responsive patients. Each patient showed a constant GH pattern of response on repeated testing. Even after pituitary irradiation the pattern of GH response was unchanged in spite of lowered GH plasma levels.