Prolactin, LH, FSH, GH and cortisol response to surgery and the effect of epidural analgesia

Preoperative Fasting and General Anaesthesia Alter the Plasma Proteome

Background: Blood plasma collected at time of surgery is an excellent source of patient material for investigations into disease aetiology and for the discovery of novel biomarkers. Previous studies on limited sets of proteins and patients have indicated that pre-operative fasting and anaesthesia can affect protein levels, but this has not been investigated on a larger scale. These effects could produce erroneous results in case-control studies if samples are not carefully matched. Methods: The proximity extension assay (PEA) was used to characterize 983 unique proteins in a total of 327 patients diagnosed with ovarian cancer and 50 age-matched healthy women. The samples were collected either at time of initial diagnosis or before surgery under general anaesthesia. Results: 421 of the investigated proteins (42.8%) showed statistically significant differences in plasma abundance levels comparing samples collected at time of diagnosis or just before surgery under anaesthesia. Conclusions: The abundance levels of the plasma proteome in samples collected before incision, i.e., after short-time fasting and under general anaesthesia differs greatly from levels in samples from awake patients. This emphasizes the need for careful matching of the pre-analytical conditions of samples collected from controls to cases at time of surgery in the discovery as well as clinical use of protein biomarkers.

Role of thioridazine in unexplained infertility

A total of 452 women with unexplained infertility were selected for the present study. From them 310 women were put on thioridazine tablet (5 mg), 1 h after dinner from the 8th day of the menstrual cycle to the 18th day in each cycle. Coitus was advised about 1-2 h after the drug intake and proper posture was advised to the patients. The other 142 patients were given placebo therapy. Patients were followed up for pregnancy for 1 year which was confirmed by ultrasonographic examination. Ninety-four patients (30.2%) in the study group conceived in contrast to 22 (15.42%) in the control group (P less than 0.001). Incidence of abortions, congenital malformations and perinatal mortality and mode of delivery were not significantly different in the two groups. Thioridazine due to anxiolytic effect in low dosage appears to be promising in the treatment of unexplained infertility.

Pain Management Strategies for Thoracotomy and Thoracic Pain Syndromes

Pain after thoracic surgery can be severe and, in the acute phase, contribute to perioperative morbidity and mortality. Unfortunately, patients also incur a significant risk of chronic pain. Although there are guidelines for postoperative pain management in these patients, there is no widespread surgical or anesthetic “best practice.” Here, we review the recent literature on techniques specific to perioperative pain control for thoracic patients, including medical management, neuraxial blockade, and other regional techniques, and suggest an algorithm for developing a multimodal pain management strategy.

Effects of blood collection conditions on ovarian cancer serum markers

BACKGROUND

Evaluating diagnostic and early detection biomarkers requires comparing serum protein concentrations among biosamples ascertained from subjects with and without cancer. Efforts are generally made to standardize blood processing and storage conditions for cases and controls, but blood sample collection conditions cannot be completely controlled. For example, blood samples from cases are often obtained from persons aware of their diagnoses, and collected after fasting or in surgery, whereas blood samples from some controls may be obtained in different conditions, such as a clinic visit. By measuring the effects of differences in collection conditions on three different markers, we investigated the potential of these effects to bias validation studies.

METHODOLOGY AND PRINCIPLE FINDINGS

We analyzed serum concentrations of three previously studied putative ovarian cancer serum biomarkers-CA 125, Prolactin and MIF-in healthy women, women with ovarian cancer undergoing gynecologic surgery, women undergoing surgery for benign ovary pathology, and women undergoing surgery with pathologically normal ovaries. For women undergoing surgery, a blood sample was collected either in the clinic 1 to 39 days prior to surgery, or on the day of surgery after anesthesia was administered but prior to the surgical procedure, or both. We found that one marker, prolactin, was dramatically affected by collection conditions, while CA 125 and MIF were unaffected. Prolactin levels were not different between case and control groups after accounting for the conditions of sample collection, suggesting that sample ascertainment could explain some or all of the previously reported results about its potential as a biomarker for ovarian cancer.

CONCLUSIONS

Biomarker validation studies should use standardized collection conditions, use multiple control groups, and/or collect samples from cases prior to influence of diagnosis whenever feasible to detect and correct for potential biases associated with sample collection.

Why does ovarian surgery in PCOS help? Insight into the endocrine implications of ovarian surgery for ovulation induction in polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a complex disorder with heterogeneity of clinical and endocrine features. Ovarian surgery for ovulation induction has been used in the management of clomiphene citrate-resistant anovulatory women with PCOS. Various types of ovarian surgery have been employed (wedge resection, electrocautery, laser vaporization, multiple ovarian biopsies and others) and all procedures result in an altered endocrine profile after surgery. The mechanism behind the reversal of endocrinological dysfunction in PCOS after ovarian surgery remains incompletely understood. This review scans the literature systematically to identify the endocrine changes after ovarian surgery in PCOS, in order to glean some knowledge of the mechanism involved. After ovarian surgery in PCOS, a rapid reduction in serum levels of all ovarian hormones is seen, in combination with increased serum levels of pituitary hormones. Folliculogenesis is then initiated and ovarian hormone production increases, synchronically with a reduction of pituitary hormones. Continuation of follicle growth in subsequent cycles after ovarian surgery occurs in an environment with less androgens and lower LH and FSH levels compared with pretreatment levels. The endocrine changes found after ovarian surgery in PCOS women seem to be governed by the ovaries themselves. Rapid reduced secretion of all ovarian hormones restores feedback to the hypothalamus and pituitary, resulting in appropriate gonadotrophin secretion. Initiation of follicular development seems to be induced by increasing FSH levels following a reduction of the follicle excess and (intra-ovarian) androgen levels. Additionally, anti-Müllerian hormone and gonadotrophin surge attenuating factor probably have a role in the endocrine changes.

Anesthetic Requirements and Stress Hormone Responses in Spinal Cord-Injured Patients Undergoing Surgery Below the Level of Injury

Neuraxial anesthesia decreases the minimum alveolar concentration. We determined the effects of spinal cord injury (SCI) on sevoflurane requirements and stress hormone response. Twenty-two chronic SCI patients undergoing surgery below the level of the injury were enrolled in the study, and 15 patients without cord injury served as control patients. Bispectral index score was maintained at 40-50. Measurements included end-tidal sevoflurane concentrations, systolic arterial blood pressure, heart rate, and plasma catecholamine and cortisol concentrations. During surgery, systolic arterial blood pressure, heart rate, and Bispectral index were comparable between SCI and control groups. However, end-tidal sevoflurane concentration was significantly smaller in the SCI (0.81%-1.06%) versus control (1.28%-1.31%) patients. In the control group, plasma norepinephrine and cortisol concentrations were significantly increased during and 1 h after surgery compared with awake baseline values. In the SCI group, the sympathoadrenal and cortisol responses were virtually abolished. We conclude that SCI reduces the anesthetic requirement by 20%-39% during surgery below the level of injury, in association with blunted sympathoadrenal and cortisol responses.

Application of nasal bi-level positive airway pressure to respiratory support during combined epidural-propofol anesthesia

STUDY OBJECTIVE

To examine whether nasal bi-level positive airway pressure (BiPAP) can be used as an airway during combined epidural-propofol anesthesia.

DESIGN

Prospective, consecutive case series study.

SETTING

Operating room at a general hospital.

PATIENTS

213 ASA physical status I and II adult patients undergoing lower extremity or lower abdominal gynecology surgery.

INTERVENTIONS

After epidural anesthesia, propofol was infused at 20 mg/kg/hr (P20) for 4 to 5 minutes followed by 5 mg/kg/hr (P5), and nasal continuous positive airway pressure (CPAP) 8 cm H(2)O and BiPAP 14/8 cm H(2)O was applied. In clinical situations, BiPAP with respiratory rate (RR) 10 breaths/min was applied. Furthermore, tidal volume (V(T)) during anesthesia, the effect of changing pressure support levels, and evaluation of pressure-controlled ventilation without spontaneous breathing were examined.

MEASUREMENTS AND MAIN RESULTS

CPAP resulted in a high RR, marked increased PaCO(2), and slightly decreased PaO(2), whereas BiPAP showed no change or a slightly decreased RR, slightly increased PaCO(2), and no change in PaO(2) or a great increase in PaO(2) with oxygen delivery. In clinical applications, similar results were found and anesthetic conditions were sufficient. Tidal volume increased after induction and maintained increased values under BiPAP 14/8 cm H(2)O. Of V(T) at 2, 6, or 10 cm H(2)O of pressure support levels, the 6 cm H(2)O was appropriate. Vecuronium injection showed a slight decrease and then increase in V(T) and PaCO(2), but the values were within normal (safe) limits. Respiration after rapid and high-dose infusion of propofol showed a markedly decreased RR, but the V(T) was maintained, and PaCO(2) and PaO(2) were at safe values. Rapid induction with 2.0 mg/kg propofol followed by P5 showed satisfactory results, in all but the obese patients.

CONCLUSIONS

BiPAP 14/8 cm H(2)0 with RR at 10 breaths/min during combined epidural-propofol anesthesia can be used to provide ventilatory support in lower extremity or lower abdominal gynecology surgery.

Insulin subcutaneous application vs. continuous infusion for postoperative blood glucose control in patients with non-insulin-dependent diabetes mellitus

BACKGROUND

Frequently, the use of insulin is considered for metabolic control in postoperative patients with non-insulin-dependent diabetes mellitus (NIDDM). We sought to determine the best method for control of glucose in NIDDM non-insulin patients during postoperative care.

METHODS

Two algorithms were developed: subcutaneous administration of insulin (SC), and continuous intravenous infusion (IV). A randomized, controlled clinical trial was designed. In addition, both experimental groups were compared with a non-concurrent routinely managed group (RM) with insulin administration under no predetermined algorithm. Eligible patients were those subjected to major surgery under general anesthesia or spinal blockade. They were followed for 48 h after surgery. Target variables were capillary and central blood glucose, insulin dose administered, urine glucose and ketone strip determination, and development of hyper- or hypoglycemia.

RESULTS

A total of 62 patients were studied (RM = 25, SC = 19, IV = 18). Results for both experimental algorithms were similar except for the IV group that required less insulin per hour compared to SC (0.64 vs. 0.34 U/h; p = 0.0003). The RM control group showed poor control in all capillary glucose measurements (194.9 +/- 26.8 mg/dL) compared with the two experimental algorithms (SC = 129.9 +/- 21; IV = 131.6 +/- 20.4) (p <0.05). More hyperglycemia events appeared in the RM group (p = 0.016). Only one hypoglycemia event occurred in the IV group.

CONCLUSIONS

Postoperative control of NIDDM is similar with both tested methods. The use of any of the algorithms studied improves metabolic control substantially because it standardizes postoperative management of the diabetic patient with timely determination of capillary blood glucose and insulin administration. However, IV administration has the advantage of accomplishing adequate control with a smaller insulin dose.

Propofol dosage achieving spontaneous breathing during balanced regional anesthesia with the laryngeal mask airway

STUDY OBJECTIVE

To assess an anesthetic technique achieving spontaneous breathing through the laryngeal mask airway (LMA) during combined epidural block and propofol anesthesia.

DESIGN

Prospective, consecutive case series study.

SETTING

Operating room at a general hospital.

PATIENTS

112 ASA physical status I and II adult surgery patients; 32 patients for lower extremity surgery are enrolled into study 1, and 30 patients for lower extremity surgery and 50 patients for lower abdominal gynecology surgery are enrolled into study 2.

INTERVENTIONS

In study 1, patients were given 1.5 to 2.0 mg/kg followed by a 3 mg/kg/h of infusion of propofol, after epidural block, and they were fitted with the LMA. Thirty minutes after induction, the dose of propofol was increased to 4, 5, 6, and 7 mg/kg/h every 15 minutes. In study 2, the patients were given 1.5 to 2.0 mg/kg and 5 mg/kg/h of propofol and the LMA insertion, after epidural block.

MEASUREMENTS AND MAIN RESULTS

PaO(2)/FIO(2), PaCO(2), tidal volume or respiratory rate, blood pressure, heart rate, and eye opening and motor response scales in conformity with Glasgow coma scale were recorded. Study 1 suggested an induction dose of 1.5 to 2.0 mg/kg and an infusion of 5 mg/kg/h as an appropriate dose to preserve spontaneous breathing with the LMA and to maintain reasonable depth of anesthesia. Study 2 showed that respiratory and circulatory conditions, depth of anesthesia, and other data related to anesthesia were clinically acceptable.

CONCLUSIONS

The best infusion dose of propofol to achieve spontaneous breathing with the LMA seems to be 5 mg/kg/h, and the present balanced regional anesthesia with the LMA, using propofol infusion at 1.5 to 2.0 mg/kg and 5 mg/kg/h combined with epidural block, may be useful in clinical practice for lower extremity and lower abdominal gynecologic operations.

Complement activation by propofol and its effect during propofol anaesthesia

We have examined whether propofol activates complement. In the first study, blood was mixed with saline, propofol or the lipid solvent for propofol, and the activated complement 3 (C3a) and 4 (C4a) concentrations in the supernatant were assayed. In the second study, blood and propofol were mixed with various levels of nafamostat mesilate (anti-complement agent) up to 0.3 mmol/l and the C3a was assayed. In the third study, the time course of plasma C3a concentration in patients during propofol anaesthesia was examined. The results showed that the lipid solvent activated complement and produced similar levels of C3a to propofol, probably via both the classical and alternative pathways. This activation was not inhibited by any of the nafamostat concentrations used. There was no significant change in plasma C3a concentration during propofol anaesthesia. These results suggest that C3a is generated by the lipid solvent, but its accumulation during propofol anaesthesia is minimal.

Epidural anesthesia during hysterectomy diminishes postoperative pain and urinary cortisol release

PURPOSE

To examine the hypothesis that epidural anesthesia throughout lower abdominal surgery would depress both postoperative pain and cortisol release.

METHODS

Forty adult patients undergoing abdominal total hysterectomy were studied. The patients were randomly assigned to two groups. Group G received general anesthesia alone (sevoflurane 1.5%-2.5%); group E received a combination of epidural anesthesia (1.5% mepivacaine) with a light plane of general anesthesia (sevoflurane<0.5%). Postoperative analgesia was obtained epidurally by patient-controlled analgesia. Postoperative pain at rest and during movement was assessed by a visual analogue scale (VAS) at 2, 24, and 48 h following surgery. The plasma concentration and urinary excretion of cortisol were measured during the perioperative period.

RESULTS

VAS values were lower in group E than in group G during movement at 24h (4.6±0.5vs 6.1±0.4 cm). Urinary cortisol excretion on the first postoperative day was less in group E than in group G (192±34vs 480±120μg).

CONCLUSIONS

Epidural blockade prior to surgical stimuli and throughout lower abdominal surgery reduces the postoperative dynamic pain and stress response.

The role of the phrenic nerves in stress response in upper abdominal surgery

Previous studies have failed to demonstrate a block of the endocrine response to upper abdominal surgery by thoracic epidural analgesia. To clarify the bases for this failure, we compared the effects of epidural analgesia of different dermatome levels up to C8-T2 or C3-4. The patients who received general anesthesia alone showed significant increases of adrenocorticotropic hormone (ACTH) and arginine vasopressin (AVP) immediately after skin incision. The patients with C8-T2 blocked developed significant increases in these hormones, not after the skin incision, but after the intraabdominal procedure. Of the eight patients with C3-4 block, six developed no such responses throughout the study period. The responses of oxytocin (OXT) and prolactin (PRL) were more susceptible to epidural analgesia and were blocked at the C8-T2 level. Growth hormone (GH) showed no correlation with surgical procedures and epidural block. These findings indicate that the nociceptive neural information during upper abdominal surgery is conveyed by the sensory fibers included in both the thoracic and lumbar spinal nerves that innervate the abdominal wall and the intraabdominal viscera, and by the phrenic nerves that innervate the diaphragm. The rationale for postulating the involvement of the phrenic nerves can be referred to the embryonal descent of the diaphragm from the C3-5 myotomes that serves as the upper wall of the abdominal cavity.

Evaluation of transvaginal ultrasound-guided follicle puncture to collect oocytes and follicular fluids at consecutive times relative to the preovulatory LH surge in eCG/PG-treated cows

Holstein-Friesian cows (n=56) were synchronized with Syncro-Mate B, and those cows (n=47) developing a normal progesterone pattern were further treated im with 3,000 I.U. eCG at Day 10 and 22.5 mg PGF2alpha 48 h later. Blood samples were collected every hour from 30 until 49 h after PG administration. Cows (n=17, 36.2%) with fewer than 8 follicles larger than 8 mm in diameter at 28 to 30 h after PG treatment and animals without an LH peak (n=7, 23%) were excluded from the study. Transvaginal ultrasound-guided puncture of the follicles was carried out two times per cow, at 30 h after PG injection (4 to 5 follicles) and again at 1 to 5 (n=6), 12 (n=8) or 22 h (n=9) after the LH peak. No differences in the concentrations of progesterone and LH were observed among the 3 groups. An average of 18 follicles per cow was punctured (total of 415 punctures, n=23); 116 cumulus-oocyte-complexes and 370 follicular fluid samples were obtained producing average recovery rates of 28.0% and 89.2%. The number of cumulus-oocyte-complexes varied between puncture times; shortly before ovulation, at 22 h after the LH peak, the recovery rate was significantly 5 times higher than immediately after the LH peak. Overall, in 75 punctures the cumulus-oocyte-complex was accompanied by a pure follicular fluid sample (3.3 per cow). In conclusion, the transvaginal ultrasound-guided puncture of preovulatory-size follicles can be used to collect follicular fluids to study changes in the microenvironment of maturing oocytes upon superovulation. However, further research is required in order to obtain an equivalent number of accompanying cumulus-oocyte-complexes.

Morphometrical variations of prolactin cells in response to prolonged and systemic administration of Met-enkephalin in female rats

A stimulatory effect on prolactin secretion had been describe after acute and systemic administration of met-enkephalin, but the effects of this opioid after chronic administration has not been reported, and the response of mammotroph cells is not clear. As a complement to previous studies, a morphometric analysis (light and electron microscopy) was carried out on prolactin cells from female rats treated chronically with met-enkephalin. Clear features of cellular hyperactivity appeared after chronic and systemic administration of the opioid, and these persisted for two weeks. The changes consisted in increases of cellular, cytoplasmic and nuclear areas, volume and surface densities of the Golgi complex and rough endoplasmic reticulum, as well as the numbers of exocytotic figures. These morphological alterations were paralleled by an increase in serum prolactin levels as detected by RIA. It is concluded that the increase in the synthesis and secretory activity of prolactin cells following chronic and systemic administration of met-enkephalin is very similar to those observed after acute and intraventricular administration.

Abnormalities of the hypothalamo-pituitary-gonadal axis after head injury

OBJECTIVE

We aimed to investigate the mechanisms of hypogonadism which develops after head injury.

DESIGN

Pulsatile secretion of LH was studied in subjects 6-10 days after major head injury.

PATIENTS

We studied five male subjects admitted with major head injuries and six healthy age-matched control subjects.

MEASUREMENTS

During the pulsatility study, LH was measured at 5-minute intervals for 4 hours and 15-minute intervals for a further 2 hours. In addition, testosterone and LH were measured on Days 1-5, 14 and after 3-6 months.

RESULTS

The analysis of pulsatile secretion of LH demonstrated an LH pulse frequency similar to control subjects, but a significantly reduced LH pulse amplitude (P less than 0.001, fixed threshold method; P less than 0.02, Detect method). Both testosterone and LH levels were reduced after injury with the nadir occurring on Day 4.

CONCLUSIONS

Hypogonadism after head injury is due to defective LH secretion, with normal pulse frequency but a reduced pulse amplitude.

Effect of acipimox, a lipid lowering drug, on growth hormone (GH) response to GH-releasing hormone in normal subjects

Growth hormone (GH) induces lipolysis and an increase of free fatty acids (FFA), and FFA inhibit the GH response to arginine and to GH-releasing hormone (GHRH). The aim of this study was to evaluate the effect of the pharmacologic blockade of lipolysis on the GH response to GHRH. Eleven normal men underwent a saline infusion starting at 09:00 h, after administration of placebo or 500 mg acipimox, an antilipolytic agent; at 13:00 h (0 min) they received GHRH, 50 micrograms iv The GH response to GHRH (0 to 120 min) was significantly higher in subjects pretreated with acipimox than in subjects pretreated with placebo. In subjects receiving placebo, but not in those receiving acipimox, a progressive increase of plasma FFA levels took place, and the GH response to GHRH was inversely related to the plasma FFA levels at 0 min. These data indicate that FFA play an important role in the control of GH release, and that acipimox prevents the FFA rise induced by GH.

Effects of epidural analgesia on plasma calcitonin gene-related peptide

The effects of epidural analgesia on plasma calcitonin gene-related peptide (CGRP) values during and after hysterectomy were investigated in 14 healthy patients. In seven patients who received general anaesthesia alone for pelvic surgery, there were no significant changes in plasma CGRP concentrations. In the remaining patients, who received extensive epidural blockade in addition to general anaesthesia, there were again no significant changes in plasma CGRP values. This was in spite of profound sympathetic blockade, as shown by marked hypotension and a significant decline in plasma catecholamines. The epidural group of patients showed the expected attenuation of the glucose, cortisol and growth hormone responses to surgery. The results show that circulating CGRP is unlikely to be involved in the modulation of peripheral vascular tone during pelvic surgery under either general or epidural anaesthesia.

Effects of surgery and general or epidural anesthesia on plasma levels of cortisol, growth hormone and prolactin in infants under one year of age

Twenty infants under one yr of age undergoing minor surgery were divided in two groups according to the type of anesthesia (epidural, Group 1, n = 10; general, Group 2, n = 10) which was randomly performed. Blood samples for cortisol (F), growth hormone (GH), and prolactin (PRL) determination were taken from each infant in baseline conditions, before surgery, and at the end of surgery. Mean plasma F levels in infants of group 2 rose significantly (p less than 0.01) before surgery to attend a maximum at the end of surgery (p less than 0.005). In infants of Group 1 a significant increase was also observed before surgery (p less than 0.05) but at the end of surgery mean plasma cortisol returned to levels comparable to baseline. Mean GH plasma levels were not significantly affected by both types of anesthesia, however an increase (not statistically significant) was observed at the end of surgery in both groups. Mean plasma PRL levels showed a significant increase before surgery (p less than 0.05 and p less than 0.01 in group 1 and 2, respectively) and a further increase at the end of surgery in both groups of infants (p less than 0.005). These results suggest that in infants under one yr of age both types of anesthetic procedures preceding surgery have no significant effect on plasma GH, but produce a significant increase of cortisol and prolactin mean plasma levels. The cortisol response to surgery and general or epidural anesthesia was similar to that reported in adults and prepubertal boys.(ABSTRACT TRUNCATED AT 250 WORDS)

Morphofunctional study of mammotropic cells following intraventricular administration of met-enkephalin

An ultrastructural and morphometric study was carried out on the adenohypophyseal mammotropic cells of rats treated intraventricularly with an acute dose (150 micrograms) of Met-enkephalin. In the female rats, clear features of cellular hyperactivity appeared after opioid administration. The changes affected the Golgi complex, the rough endoplasmic reticulum, the mature and immature secretory granules and the images of exocytosis. Such changes did not appear when naloxone was administered before the opioid, and naloxone induced an increase in the numerical density of lysosomal dense bodies with lipoid inclusions. In the male animals, administration of an identical dose of Met-enkephalin caused only a few significant changes, similar to those observed in the controls. It is concluded that Met-enkephalin administered intraventricularly causes evident modifications in the mammotropic cells of female rats whereas such changes in the male animals are not significant.

Retinal laser photocoagulation in diabetic patients causes prolactin, growth hormone and cortisol release

Stress of many kinds (psychological, physical, metabolic) is able to induce endocrine modifications in humans, such as growth hormone (GH), prolactin (PRL), luteinizing hormone (LH), glucagon and cortisol release. Argon laser photocoagulation of the retina (RP), the treatment of choice for diabetic retinopathy, is a painful and stressful maneuvre and represents a direct injury onto a nervous tissue. Therefore it was decided to evaluate the possible endocrine modifications induced by RP in diabetic patients affected by retinopathy. In 19 insulin-dependent diabetic patients (12 men and 7 women), RP induced cortisol release in all cases, GH and PRL release in men, but not in women, and no modification of LH and glucagon plasma levels; in 12 similar patients receiving saline infusions without RP, no endocrine modifications were observed. It is concluded that RP elicits GH, PRL and cortisol release in diabetic patients.

Natural killer cell activity during cortisol and adrenaline infusion in healthy volunteers

The effects of cortisol and adrenaline on natural killer (NK) cell activity and the distribution of circulating lymphocyte subpopulations were studied in twenty volunteers, using a continuous intravenous infusion pattern to simulate some of the hormonal changes induced by major surgery. The participants were allocated to receive either cortisol for 5 h, adrenaline for 1 h, cortisol for 5 h with simultaneous adrenaline during the last hour, or placebo for 5 h. Cortisol induced leucocytosis, neutrophilia, and lymphopenia with marked reduction in the number of T-lymphocyte subsets (OKT3+, OKT4+, and OKT8+ cells). No changes were induced in the activity or number of NK (Leu 11+) cells. Adrenaline produced an instantaneous increase in NK-cell activity accompanied by a selective increase in circulating NK cells. Significant leucocytosis, lymphocytosis and neutrophilia occurred. All measurements returned to preinfusion levels within 15 min after completing infusion. The effects of simultaneous infusion of cortisol and adrenaline were equal to the additive response to the hormones administered separately, except for the leucocytosis, which clearly exceeded this. In the placebo group all measurements remained unchanged. The results confirm the role of adrenaline as a potent stimulator/inducer of NK-cell activity. Adrenaline may be responsible for the increase in NK-cell activity during anaesthesia and major surgery.

Metabolic control in newly kidney transplanted insulin-dependent diabetics: improvement by insulin pump treatment (CSII)

Management of glucose homeostasis in newly kidney transplanted insulin-dependent diabetic patients is difficult. To examine whether continuous subcutaneous insulin infusion (CSII) could reverse this problem, six consecutive kidney-transplanted Type I diabetic patients either proceeded with conventional insulin therapy (CIT) or were changed to CSII beginning on the third postoperative day. After a mean of 13 days, the insulin administration mode was changed from CIT to CSII (n = 3) or from CSII to CIT (n = 3), and continued for a further 15 days. Mean blood glucose calculated on the basis of four daily measurements (8.00, 12.00, 17.00, 22.00 h) during the study periods was significantly lower during CSII (8.0 +/- 0.4 mmol/l, mean +/- SEM) than on CIT (11.0 +/- 0.6 mmol/l; p less than 0.005). Moreover, the variability of blood glucose expressed as the M-value was lower during the pump treatment compared to CIT (p less than 0.001), while the number of blood glucose values below 3.0 mmol/l was similar (3.8 vs. 4.4%). Diurnal metabolic and hormonal profiles were twice determined on each regimen with 2 hourly sampling. Glycemic control was again found to be improved during CSII therapy as compared to CIT (p less than 0.01 or 0.05 less than p less than 0.10). Moreover, insulin pump treatment resulted in a significant reduction of two major intermediary metabolites, lactate and glycerol (p less than 0.05 and p less than 0.01, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

The neuroendocrinology of physical injury

Physical injury of any sort--accidental injury, burns or elective surgery--provokes an immediate neuroendocrine response. Neural input arising from the cerebral cortex, damaged tissues and receptors detecting fluid loss leads to increased secretion of ACTH, growth hormone, prolactin and vasopressin from the pituitary, and to a general activation of the sympathetic nervous system, with rises in adrenaline and noradrenaline concentrations. Secondary changes include stimulation of cortisol and aldosterone and inhibition of insulin and somatomedin secretion. The glucagon concentration and plasma renin activity may also be increased, either immediately or after a delay. The duration of these responses generally depends upon the severity of the injury and differs considerably between hormones, for reasons that are not understood. The only endocrine changes consistently seen at later times after trauma are an increase in insulin secretion, which supersedes the initial suppression, and decreases in the concentrations of T3 and gonadal steroids. Some of the changes in steroid, thyroid and pancreatic hormones differ temporally or even qualitatively from those of their usual stimuli and are unexplained. The initial neuroendocrine response to injury can be construed as playing a defensive role, but the function of the later changes is not understood; it seems likely that they are adaptive in nature, but the scope for therapeutic intervention remains unclear.

Arylsulphatase activity in the oviduct of the frog Rana esculenta. I. Oestradiol-induced changes following ovariectomy and hypophysectomy

The effects of oestradiol treatment on arylsulphatase activity in the frog oviduct are reported. Oestradiol-induced changes were also investigated in ovariectomized and hypophysectomized animals. Under all the experimental conditions, hormonal treatment causes an increase in enzyme activity. This can be observed biochemically and also histochemically on frozen sections. Hypotheses are advanced to explain fluctuations in arylsulphatase activity.

Modifying effects of epidural analgesia or general anesthesia on the stress hormone response to laparoscopy for in vitro fertilization

Modifying effects of epidural analgesia and general anesthesia on stress hormone release was studied during laparoscopy for in vitro fertilization (IVF). In 24 women follicle development was stimulated by clomiphene and gonadotropin treatment, and oocytes were collected by laparoscopy under epidural analgesia in 11 women and under fentanyl-supplemented nitrous oxide-oxygen anesthesia in 13. The plasma levels of immunoreactive beta-endorphin (ir beta-E), cortisol, and prolactin (PRL) did not change under epidural analgesia per se, but after the start of laparoscopy, increased release of all these stress hormones was observed. General anesthesia per se increased the release of PRL, whereas the release of cortisol and ir beta-E decreased, probably due to the effects of fentanyl and thiopentone. During the stress attributed to laparoscopy, significantly more ir beta-E and cortisol was released under epidural than under general anesthesia, whereas the release of PRL was more significant under general anesthesia. These results show that neither mode of anesthesia prevented the stress response to laparoscopy. In the subsequent midluteal phase, the mean plasma level of progesterone and the mean progesterone-estradiol ratio were significantly greater in the epidural than in the general anesthesia group, suggesting that the mode of anesthesia may have an effect on the luteal phase. The significance of this difference on the conception rate remained unsolved, however.

Relationship between growth hormone levels and time spent by soldiers in an active war zone

In a study involving soldiers in an active war zone, we found that serum levels of growth hormone correlated significantly with the amount of time spent in the war zone. Serum cortisol and prolactin showed no such correlation. Our observation suggests that growth hormone may be a useful marker of chronic stress.

Prolonged follicular phase and depressed gonadotrophins following hysterectomy and corpus lute-ectomy in women with premenstrual tension syndrome

In an attempt to obtain further information on the aetiology of premenstrual syndrome (PMS), the endocrine changes following enucleation of the corpus luteum in the mid-luteal phase of the cycle were studied in seven patients with PMS, and the results compared to details of seven control patients undergoing hysterectomy for menstrual problems. In the luteal phase, before surgery, the concentration of progesterone and FSH was lower, while that of oestradiol was slightly higher, in women with PMS. Following enucleation of the corpus luteum, follicular development and ovulation recommenced more slowly in women with PMS compared to controls (time to ovulation: 21 (range 18-24, vs 19(14-20) d, P less than 0.01). During the follicular phase there was no difference between the two groups in the concentration of oestradiol. The rise in concentration of FSH following enucleation was delayed in patients with PMS, and the serum FSH concentration was significantly lower during the late follicular phase of the cycle, but not during the mid follicular phase. The results suggest that these women with PMS have a more sensitive 'feed-back' than the controls, resulting in a lower preovulatory FSH level even though the oestradiol levels were not different. The results also suggest that the abnormalities described during the preoperative luteal phase are associated with the delay in the initial FSH rise.

Effect of clonidine on stress-induced cortisol release in man during surgery

The effect of clonidine on stress-induced cortisol secretion was studied in 10 patients undergoing general anesthesia for surgery; six other patients served as a control group and none of them was given clonidine. Central and peripheral alpha 2 stimulation by clonidine (average dose:0.45 mg over 60 minutes) was able to completely suppress cortisol release during surgery.

Age-related differences in the serum prolactin response during standardized surgery

The aim with the present study was to assess possible age-related differences in the serum prolactin, cortisol and blood glucose responses to standardized surgical stress in humans. Relatively healthy men suffering from inguinal hernias were selected. The subjects were divided into a group of younger people (M=36.4 years, r=23-45, n=7) and one of older people (M=66.5 years, r=56-75, n=9). Surgery was carried out under general anesthesia. Blood was drawn before, during and following the operation. Blood pressure and pulse rate were also monitored. No differences were noticed in plasma prolactin, cortisol, and blood glucose during basal conditions. Even though plasma prolactin increased significantly in both groups during surgery, it was higher in the younger group (M=56.2 micrograms/1) as compared with 28.7 micrograms/l for the older group, p less than .01. Plasma prolactin during surgery, but not under basal conditions, correlated inversely with age. No differences between groups were found during surgery in blood glucose and serum cortisol. This study indicates a diminished stress response in older subjects, possibly due to age-related neuroendocrine changes.

Maternal serum hormone changes during abortion induced with 9-deoxo-16, 16-dimethyl-9-methylene prostaglandin E2

Serum hormone levels in women undergoing successful first and second trimester abortions induced by 9-deoxo-16, 16-dimethyl-9-methylene prostaglandin E2 vagitories have been measured. Significantly decreased levels of prolactin (p less than 0.01) and TSH (p less than 0.05) were seen in both groups of women but the drop appeared sooner, within two hours, in first trimester abortions. Regardless of gestational length there was a significant decrease in serum human chorionic gonadotropin (hCG) (p less than 0.01) concentrations in maternal serum six hours into treatment. In the second trimester abortions total estriol, alpha-fetoprotein and lactoplacental hormone hPL were analysed in maternal serum but the levels did not change over the eight hour investigation period. It is speculated that the PGE2-derivative most likely affects the maternal pituitary secretion of prolactin and TSH, possibly via direct or indirect interference with TRH mechanism(s).

Mechanisms of control of prolactin release in response to apprehension stress and anesthesia-surgery stress

The response of prolactin to stress may not be controlled by a single mechanism. This study was designed to measure the prolactin response in the human female to two reproducible stresses: the apprehension (A) prior to surgery (laparoscopy and hysteroscopy) and the stress of the anesthesia-surgery (AS). Attempts to modify the release of prolactin was made by pharmacologic means. Thirty-eight normally menstruating women served either as controls or received histamine (H1), serotonin, opioid, or dopamine receptor-blocking agents and the prolactin response was measured. The release of prolactin to AS was blunted by higher-dose of opioid and by dopamine antagonists. The A release of prolactin was enhanced by the dopaminergic antagonist and blunted by the other three agents. It was concluded that the mechanism for the stress-induced release of prolactin may vary depending upon the nature of the stress.