Difficult venepuncture--it was all in the head!

AIM

To emphasise the importance of careful observations and demonstrate that significant conditions may, on occasion, be detected during blood donation.

BACKGROUND

Venepunctures, the bread and butter of blood donor services, can be difficult procedures. We describe an unusual presentation of a relatively rare disease detected during routine blood donations because of difficult venepunctures.

METHODS

Case report.

RESULTS

A growth hormone-secreting pituitary adenoma was diagnosed, and successfully treated, following the initial observation of hard-to-puncture skin during blood donations.

CONCLUSIONS

Seemingly trivial abnormalities may prove clinically important. One presentation of acromegaly is hard-to-puncture skin.

Recommended evaluation of adrenal incidentalomas is costly, has high false-positive rates and confers a risk of fatal cancer that is similar to the risk of the adrenal lesion becoming malignant; time for a rethink?

OBJECTIVE

To assess the performance of current clinical recommendations for the evaluation of an adrenal incidentaloma. DESIGN AND METHODS LITERATURE REVIEW: Electronic databases (Pubmed, Ovid and citation searches from key articles) from 1980 to 2008 were searched. Eligible studies were those deemed most applicable to the clinical scenario of a patient referred to an endocrinologist for assessment of an incidentally detected adrenal mass. Surgical series, histopathological series and oncological series were reviewed and most were excluded.

RESULTS

The prevalence of functional and malignant lesions presenting as adrenal incidentaloma was similar to that quoted in most reviews, other than a lower incidence of adrenal carcinoma (1.9 vs 4.7%) and metastases (0.7 vs 2.3%). The development of functionality or malignancy during follow-up was rare (<1% becoming functional and 0.2% becoming malignant). During follow-up, false-positive rates of the recommended investigations are typically 50 times greater than true positive rates. The average recommended computed tomography (CT) scan follow-up exposes each patient to 23 mSv of ionising radiation, equating to a 1 in 430 to 2170 chance of causing fatal cancer. This is similar to the chance of developing adrenal malignancy during 3-year follow-up of adrenal incidentaloma.

CONCLUSION

Current recommendations for evaluation of adrenal incidentaloma are likely to result in significant costs, both financial and emotional, due to high false-positive rates. The dose of radiation involved in currently recommended CT scan follow-up confers a risk of fatal cancer that is similar to the risk of the adrenal becoming malignant. This argues for a review of current guidelines.

HER-2/neu expression in germ cell tumours

AIMS

To determine the rate of HER-2/neu positivity of germ cell tumours by immunohistochemistry (IHC) and by fluorescence in situ hybridisation (FISH).

PATIENTS/METHODS

Ninety six archival, paraffin wax embedded pathology specimens were chosen from four groups of germ cell tumours. IHC for HER-2/neu was performed with the HercepTest kit; FISH analysis was performed with the INFORM assay and confirmed with a centromere 17 probe.

RESULTS

Twenty two of 96 specimens overexpressed the HER-2/neu protein when measured by IHC. Only three specimens showed HER-2/neu gene amplification by FISH. There was no correlation between the results obtained by IHC and FISH.

CONCLUSIONS

The lack of concordance between IHC and FISH makes it unlikely that overexpression of the HER-2/neu protein in germ cell tumours is of prognostic or therapeutic relevance. Because of the low rate of HER-2/neu gene amplification in germ cell tumours, a clinical trial of trastuzumab treatment in patients with germ cell tumours is not warranted.

An aphid repellent glycoside from Solanum laxum

A spirostanic saponin was isolated from the ethanolic extract of the aerial parts of Solanum laxum Steud. The compound, named luciamin, was characterised by NMR spectroscopy, mass spectrometry and chemical methods, as (22R, 25S)-spirost-5-en-3 beta, 15 alpha-diol 3-O-|beta-D-glucopyranosyl (1 --> 2)-beta-D-glucopyranosyl-( 1 --> 4)-[alpha-L-rhamnopyranosyl-( 1 --> 2)]-beta-D-galactopyranoside|. The compound was tested against the aphid Schizaphis graminum by incorporation in artificial diets. It showed a deterrent (toxic) activity against the insect and is the first spirostane glycoside reported to have this activity.

The low dose ACTH stimulation test is less sensitive than the overnight metyrapone test for the diagnosis of secondary hypoadrenalism

OBJECTIVE

The 1 microgram ACTH stimulation test has been advocated as a sensitive indicator of the integrity of the hypothalamic-pituitary-adrenal axis in patients with suspected hypopituitarism. The aim of our study was to define the normal response to 1 microgram ACTH stimulation in a control population and to study the sensitivity and specificity of the test in a group of patients with suspected pituitary disease.

DESIGN

A prospective analysis of the performance of the 1 microgram ACTH stimulation test in a group of patients with pituitary disease.

PATIENTS

The cortisol response to 1 microgram ACTH was evaluated in 21 normal subjects and 65 patients with pituitary disease. The patients with pituitary disease were divided into two groups according to the 11-deoxycortisol response to overnight metyrapone: normal (11-deoxycortisol > 200 nmol/l) and subnormal ACTH secretory status (11-deoxycortisol < 200 nmol/l).

MEASUREMENTS

In both controls and patients, blood was sampled for cortisol at - 15, 0, + 20, + 30, + 40 and + 60 minutes after intravenous administration of 1 microgram synthetic ACTH (Synacthen(R)). The overnight metyrapone test was performed only in the subjects with pituitary disease. Metyrapone (30 mg/kg) was administered orally at 2300 h and blood was sampled at 0830 h the following morning for 11-deoxycortisol.

RESULTS

The 65 patients with pituitary disease were categorized according to the 11-deoxycortisol response to metyrapone as follows: 53 normal (11-deoxycortisol > 200 nmol/l) and 12 subnormal (< 200 nmol/l). The 12 patients who failed the metyrapone test had a significantly impaired cortisol response to low dose ACTH stimulation at all time points when compared with both the control group and the pituitary patients with a normal response to metyrapone (P < 0.001). Comparing the pituitary patients who had a normal response to metyrapone and the control subjects, there was no significant difference in the cortisol response to ACTH (P > 0.05). The minimum cortisol response at 30 minutes in the 21 control subjects was 414 nmol/l and this was defined as the minimum normal cortisol response to 1 microg ACTH. Using this criterion, six of the 12 patients with a subnormal response to metyrapone had a normal cortisol response to low dose ACTH stimulation. Empirically increasing the cortisol cut-off to 600 nmol/l increased the sensitivity of the low dose ACTH test to 83%, although the specificity was reduced from 100% to only 58%.

CONCLUSIONS

The normal cortisol response to low dose ACTH stimulation in 50% of the patients with ACTH deficiency proven on metyrapone testing suggests that the 1 microgram ACTH stimulation test, like the 250 microgram-test, lacks sensitivity for the diagnosis of ACTH deficiency.

Addison's disease in Africa--a teaching hospital experience

OBJECTIVE

Addison's disease may present with diverse and non-specific clinical and biochemical features. Contentious issues include the appropriate criteria for the interpretation of the ACTH stimulation test and the necessary extent of investigation to identify a specific aetiology for the hypoadrenalism. The experience of Addison's disease at a South African teaching hospital was reviewed to (1) record the aetiology and spectrum of presentation, (2) examine the performance of the ACTH stimulation test and (3) determine the utility of adrenal CT scan and biopsy.

METHODS

Retrospective study of patients admitted to a South African teaching hospital from 1980 to 1997 with a diagnosis of acute Addison's disease.

PATIENTS AND MEASUREMENTS

Fifty patients presenting with acute Addison's disease were identified by a search of hospital records. Pretreatment biochemical and haematological parameters were recorded. The cortisol response at 20 and 60 min to an intravenous injection of 250 micrograms synacthen (Cortrosyn) was analysed. In a subgroup of affected subjects, the bone mineral density (BMD) in the lumbar spine and femoral neck was measured during long-term follow-up.

RESULTS

Presenting features included hyperpigmentation (86%), weight loss (67%), abdominal pain (20%) and diarrhoea (16%). Thirty-nine patients (78%) were hyponatraemic, while 26 (53%) were hyperkalaemic. Nine patients (18%) were hypoglycaemic and 21% had hypercalcaemia. The mean basal cortisol was 148 nmol/l (range 10-487) and 16 patients (40%) had a normal basal cortisol. The mean cortisol 20 min after ACTH stimulation was 172 nmol/l (range 19-588). There was no significant increase in serum cortisol following ACTH stimulation (P > 0.05). Adrenal CT scans were performed in only 24 patients (48%) and were normal in 10, while abnormalities were detected in 14 patients (bilateral enlargement in 11, calcification in two and atrophic adrenals in one). Eight patients had a DEXA scan performed during follow-up--four were osteopaenic in the lumbar spine and five at the femoral neck. The probable aetiology of Addison's was idiopathic in 42%, related to active TB in 18%, old TB in 16%, autoimmune in 12% and malignancy with metastases in 6%--single cases were due to sarcoid, iron overload and adrenoleukodystrophy. Adrenal biopsy was performed in two patients and was diagnostic of malignancy in both cases. The mortality within the first month after hospitalization was 12%.

CONCLUSIONS

In our experience, Addison's disease is frequently idiopathic, presents with protean manifestations and should be considered in patients with unexplained hyperpigmentation or gastrointestinal complaints, particularly when associated with hyponatraemia and hyperkalaemia. A normal basal cortisol does not exclude the diagnosis which requires ACTH stimulation testing.

Effect of laparoscopic ovarian electrocautery on ovarian response and outcome of treatment with gonadotropins in clomiphene citrate-resistant patients with polycystic ovary syndrome

OBJECTIVE

To evaluate the effect of ovarian electrocautery on the ovarian response to gonadotropic stimulation and pregnancy rate (PR) in clomiphene citrate (CC)-resistant women with polycystic ovary syndrome (PCOS) and high basal serum LH levels.

DESIGN

Retrospective study.

SETTING

Outpatient infertility clinic in a tertiary referral center.

SUBJECTS

Twenty-two women with PCOS, high basal serum LH concentrations, and CC resistance who underwent laparoscopic ovarian electrocautery. Treatment with gonadotropin was scheduled after failure to ovulate spontaneously or conceive after electrocautery. Data from gonadotropin-stimulated cycles were compared with data from treatment cycles in the same patients before ovarian electrocautery.

MAIN OUTCOME MEASURES

Number of ampules, duration of induction phase, daily effective dose, PR, and pregnancy outcome.

RESULTS

Markedly reduced basal serum LH concentrations and normal menstrual cyclicity in 41% of patients were recorded after laparoscopic ovarian electrocautery. Comparison of gonadotropin-stimulated cycles before and after electrocautery revealed significantly higher rates of ovulation and pregnancy after electrocautery as well as significant reduction in the number of ampules, daily effective dose, and duration of the induction phase with hMG and in daily effective dose with FSH.

CONCLUSIONS

Our results indicate an increased ovarian sensitivity to gonadotropins after laparoscopic ovarian electrocautery. A preference for laparoscopic ovarian electrocautery over medical treatment in all or selected groups of CC-resistant PCOS patients is suggested.

Incorporation of D-Ala2 in growth hormone-releasing hormone-(1-29)-NH2 increases the half-life and decreases metabolic clearance in normal men

D-Ala2-GHRH-(1-29) has increased binding affinity and exhibits enhanced biological activity in man. It is not known whether changes in the metabolic clearance of this and other GHRH analogs contribute to their increased biological activity. GHRH-(1-29)-NH2 and D-Ala2-GHRH-(1-29)-NH2 were administered by constant iv infusion at a rate of 25 ng/kg.min to 10 normal men. Blood was sampled during the 90-min infusion and for 20 min afterward and assayed for the infused analog. The MCR of the D-Ala2 analog (mean +/- SE) was significantly less (21 +/- 1.2 mL/kg.min) than that of GHRH-(1-29)-NH2 (39.7 +/- 3.9 mL/kg.min; P < 0.001). The disappearance half-time of the D-Ala2 analog was 6.7 +/- 0.5, whereas that of GHRH-(1-29)-NH2 was 4.3 +/- 1.4 min (P < 0.05). These findings demonstrate that the D-Ala2 substitution contributes to the enhancement of biological activity by reducing metabolic clearance.

Proceedings of the Alaskan and Russian Natives' Health and Social Issues Conference Alaska

An Alaska-Russia Native People's Health and Social Issues Conference, sponsored by the Alaska Department of Health and Social Services, the Alaska Native Foundation, the University of Anchorage Institute for Circumpolar Health Studies, The International Scientific Center 'ARTIKA' (Magadan, Russia), the Associations of Native People of Chukotka and Kolyma, and the Magadan Native Association, was held in Wasilla, Alaska in May, 1992. The conference brought together Native people, primarily health and social services workers, to discuss differences and similarities in issues and approaches, and to lay the foundation for future collaboration. The primary participants came mostly from rural villages and small regional cities, and represented Native Health Corporations, Native Associations, and villages. Additional participants came form the University of Alaska, the Alaska Department of Health and Social Services, the Indian Health Service, the Magadan Health Department, the Inuit Circumpolar Conference, and the International Circumpolar Health Union. A total of 39 people participated, including: eight Russian Natives (Chukchi, Even, and Siberian Yup'ik); three non-Native Russians; 18 Alaska Natives (Aleut, Athabaskan, Inupiat, Siberian Yup'ik, Yup'ik); nine non-Native Alaskans; one Canadian. The issues discussed in individual and panel presentations, and in small groups, included history, demography, settlement patterns, the cash and subsistence economies, mental and physical health (epidemiology, etiology, treatment and prevention), education, governance, culture and language.(ABSTRACT TRUNCATED AT 250 WORDS)

Proceedings of the Alaska-Russia Native Peoples Health and Social Issues Conference. May 1992, Alaska

An Alaska-Russia Native People's Health and Social Issues Conference, sponsored by the Alaska Department of Health and Social Services, the Alaska Native Foundation, the University of Anchorage Institute for Circumpolar Health Studies, the International Scientific Center "ARTIKA" (Magadan, Russia), the Associations of Native People of Chukotka and Kolyma, and the Magadan Native Association, was held in Wasilla, Alaska in May, 1992. The conference brought together Native people, primarily health and social services workers, to discuss differences and similarities in issues and approaches, and to lay the foundation for future collaboration. The primary participants came mostly from rural villages and small regional cities, and represented Native Health Corporations, Native Associations, and villages. Additional participants came from the University of Alaska, the Alaska Department of Health and Social Services, the Indian Health Service, the Magadan Health Department, the Inuit Circumpolar Conference, and the International Union for Circumpolar Health. A Total of 39 people participated, including: eight Russian Natives (Chukchi, Even, and Siberian Yup'ik); three non-Native Russians; 18 Alaska Natives (Aleut, Athabaskan, Inupiat, Siberian Yup'ik, Yup'ik); nine non-Native Alaskans; one Canadian. The issues discussed in individual and panel presentations, and in small groups, included history, demography, settlement patterns, the cash and subsistence economies, mental and physical health (epidemiology, etiology, treatment and prevention), education, governance, culture and language. As the conference participants came to know each other better, the discussions became increasingly open, and, particularly around shared feelings of cultural oppression and loss, emotional.(ABSTRACT TRUNCATED AT 250 WORDS)

Two Eskimo villages assess mental health strengths and needs

Due to a growing consensus of the inadequacy of the current mental health system in rural Alaska, an assessment of mental health strengths and needs was conducted in two Eskimo villages. Respondents were 216 Eskimos who completed a structured interview. Results document perceptions of problems and strengths unique to the village cultures and settings. To increase effectiveness, programs must take into account the perspectives expressed by village people.

Systematic error between erythrocyte protoporphyrin in proficiency test samples and patients' samples as measured with two hematofluorometers

Hematofluorometers manufactured by two different companies (Aviv Biomedical and Environmental Science Associates) performed satisfactorily for protoporphyrin determinations with proficiency test samples but showed about a 30% low bias with actual clinical blood specimens.

Systematic error between erythrocyte protoporphyrin in proficiency test samples and patients' samples as measured with two hematofluorometers

Hematofluorometers manufactured by two different companies (Aviv Biomedical and Environmental Science Associates) performed satisfactorily for protoporphyrin determinations with proficiency test samples but showed about a 30% low bias with actual clinical blood specimens.