Metabolic vs. hedonic obesity: a conceptual distinction and its clinical implications

Body weight is determined via both metabolic and hedonic mechanisms. Metabolic regulation of body weight centres around the 'body weight set point', which is programmed by energy balance circuitry in the hypothalamus and other specific brain regions. The metabolic body weight set point has a genetic basis, but exposure to an obesogenic environment may elicit allostatic responses and upward drift of the set point, leading to a higher maintained body weight. However, an elevated steady-state body weight may also be achieved without an alteration of the metabolic set point, via sustained hedonic over-eating, which is governed by the reward system of the brain and can override homeostatic metabolic signals. While hedonic signals are potent influences in determining food intake, metabolic regulation involves the active control of both food intake and energy expenditure. When overweight is due to elevation of the metabolic set point ('metabolic obesity'), energy expenditure theoretically falls onto the standard energy-mass regression line. In contrast, when a steady-state weight is above the metabolic set point due to hedonic over-eating ('hedonic obesity'), a persistent compensatory increase in energy expenditure per unit metabolic mass may be demonstrable. Recognition of the two types of obesity may lead to more effective treatment and prevention of obesity.

Emerging paradigms on glucose management in the intensive care unit

Hyperglycemia is common in critical illness and leads to increased morbidity and mortality. Controversy exists whether tight glycemic control via intensive insulin therapy can safely and effectively improve outcomes. In this review article, we will sort through the pertinent evidence base to identify salient, yet emergent, paradigms to guide management. To this end, we will discuss underlying biologic mechanisms relevant to hyperglycemia and insulinization in critical illness, summarize results of major randomized controlled clinical trials for glycemic control in the intensive care unit (ICU), and fill in the gaps with necessary information. We will conclude with specific messages, not only reflecting our own clinical experiences, but amenable to implementation in different ICU settings.

Reprogramming cancer cells in endocrine-related tumors: open issues

Reprogramming technologies have been developed to revert somatic differentiated cells into pluripotent stem cells that can be differentiated into different lineages potentially useful in stem cell therapy. Reprogramming methods have been progressively refined to increase their efficiency, to obtain a cell population suitable for differentiation, and to eliminate viral plasmid which could be responsible for many unwanted side-effects when used in personalized medicine. All these methods are aimed to introduce into the cell genes or mRNAs encoding a set of four transcription factors (OCT- 4, SOX-2, KLF-4 and c-MYC) or a set of three lincRNAs (large intragenic non-coding RNAs) acting downstream of the reprogramming transcription factors OCT-4, SOX-2 and NANOG. Translational clinical applications in human pathologies and in developmental, repair and cancer biology have been numerous. Cancer cells can be, at least in principle, reprogrammed into a normal phenotype. This is a recently raised issue, rapidly advancing in many human tumors, especially endocrine-related cancers, such as breast, prostate and ovarian ca. The present review aims to describe basic phenomena observed in reprogramming tumor cells and solid tumors and to discuss their meaning in human hormone-related cancers. We will also discuss the fact that some of the targeted transcription factors are "normally" activated in a number of physiological processes, such as morphogenesis, hypoxia and wound healing, suggesting an in vivo role of reprogramming for development and homeostasis. Finally, we will review concerns and warnings raised for in vivo reprogramming of human tumors and for the use of induced pluripotent stem cells (iPSCs) in human therapy.

Withdrawal of corticosteroids in inflammatory bowel disease patients after dependency periods ranging from 2 to 45 years: a proposed method

BACKGROUND

Even in the biologic era, corticosteroid dependency in IBD patients is common and causes a lot of morbidity, but methods of withdrawal are not well described.

AIM

To assess the effectiveness of a corticosteroid withdrawal method.

METHODS

Twelve patients (10 men, 2 women; 6 ulcerative colitis, 6 Crohn's disease), median age 53.5 years (range 29-75) were included. IBD patients with quiescent disease refractory to conventional weaning were transitioned to oral dexamethasone, educated about symptoms of the corticosteroid withdrawal syndrome (CWS) and weaned under the supervision of an endocrinologist. When patients failed to wean despite a slow weaning pace and their IBD remaining quiescent, low dose synthetic ACTH stimulation testing was performed to assess for adrenal insufficiency. Multivariate analysis was performed to assess predictors of a slow wean.

RESULTS

Median durations for disease and corticosteroid dependency were 21 (range 3-45) and 14 (range 2-45) years respectively. Ten patients (83%) were successfully weaned after a median follow-up from final wean of 38 months (range 5-73). Disease flares occurred in two patients, CWS in five and ACTH testing was performed in 10. Multivariate analysis showed that longer duration of corticosteroid use appeared to be associated with a slower wean (P = 0.056).

CONCLUSIONS

Corticosteroid withdrawal using this protocol had a high success rate and durable effect and was effective in patients with long-standing (up to 45 years) dependency. As symptoms of CWS mimic symptoms of IBD disease flares, gastroenterologists may have difficulty distinguishing them, which may be a contributory factor to the frequency of corticosteroid dependency in IBD patients.

Progress in the preoperative diagnosis of thyroid nodules: managing uncertainties and the ultimate role for molecular investigation

The preoperative evaluation of thyroid nodules currently relies on a clinical assessment of risk factors and an algorithm based on imprecise tests. With serum TSH, thyroid ultrasound and fine-needle aspiration (FNA) with or without ultrasound guide, accounting for the routine initial evaluation, indeterminate aspirates remain the major obstacle for confidently advising patients whether to have surgery or not. Recent clinical guidelines have attempted to settle various controversies but many inherent errors of clinical testing result in delayed diagnosis and unnecessary surgery. A better solution may ultimately involve the use of molecular markers of thyroid carcinogenesis but further research is still needed regarding the basic biology of thyroid cancer.

Thyroid nodule evaluation: what have we really learned from recent clinical guidelines?

Recent guidelines for the evaluation of thyroid nodules clarify the diagnostic algorithm while also reporting important differences. The performance of fine needle aspiration (FNA) for cytological examination follows serum TSH determination and thyroid ultrasonography. Thyroid scintigraphy is recommended following a low TSH value and/or FNA yielding an indeterminate follicular cytology. The use of thyroid ultrasonography is the source of some controversy: though it is recommended as a principal first test, its real-time use to guide FNA ranges from routine to only following an FNA yielding an inadequate or nondiagnostic cytological result. In clinical practice, the proportion of physicians utilizing ultrasonography, scintigraphy and FNA varies and frequently deviates from recommended guidelines. The development of guidelines is necessary to bring about consistency and optimization to the diagnostic work-up of thyroid nodules. It is likely that novel diagnostic procedures, such as molecular markers, large needle aspiration biopsy and thyroid imaging with tracers beyond conventional radioactive iodine or (99m)Tc pertechnetate, will lead to improved performance and implementation of guidelines.

Combined calcitriol-pamidronate therapy for bone hyperresorption in spinal cord injury

OBJECTIVE

To determine the biochemical effects of combined calcitriol-pamidronate therapy on bone hyperresorption in patients with spinal cord injury (SCI).

METHODS

This was a retrospective study of 21 SCI inpatients (4 women and 17 men, mean age 34 years) treated for bone hyperresorption. Initial treatment was 0.5 microg oral calcitriol once daily and 1,250 mg CaCO3 twice a day (1000 mg elemental calcium/day). On days 4 through 6 following the initial treatment, patients received 30 mg pamidronate intravenously once daily (total of 3 doses). Urinary N-telopeptide (NTx) and calcium excretion rates, and serum parathyroid hormone (PTH), 25-hydroxyvitamin D (25-D), 1,25-dihydroxyvitamin D (1,25-D), calcium, and phosphorus levels were measured within 2 weeks prior to and 2 weeks following pamidronate therapy.

RESULTS

Patients demonstrated increased urinary NTx and calcium excretion, indicative of bone hyperresorption, and suppressed PTH and 1,25-D levels as early as 9 days post-SCI. Combined calcitriol-pamidronate therapy decreased urinary NTx and calcium excretion by 71% (P < .001) and 73% (P < .001), respectively. This therapy also increased serum levels of PTH (P <.05) and 1,25-D (P < .005). Post-pamidronate hypocalcemia or hypophosphatemia was observed in 44% (P < .01) or 53% (P < .01), respectively.

CONCLUSION

Combined calcitriol-pamidronate therapy significantly inhibited bone hyperresorption in SCI patients.

The influence of intraoperative parathyroid hormone monitoring on the surgical management of hyperparathyroidism

OBJECTIVE

To examine the role of intraoperative rapid parathyroid hormone (PTH) monitoring in the surgical management of hyperparathyroidism.

DESIGN

Thirty-eight-month retrospective review.

SETTING

Tertiary care academic medical center.

PATIENTS

One hundred consecutive patients undergoing surgery for primary hyperparathyroidism.

INTERVENTION

All patients underwent preoperative technetium Tc 99m sestamibi scan localization and intraoperative blood PTH monitoring by means of a rapid (12-minute) immunochemiluminometric assay.

MAIN OUTCOME MEASURES

The influence of intraoperative PTH levels on extent of surgical dissection and achievement of postoperative normocalcemia.

RESULTS

Intraoperative PTH levels dropped an average of 64%, 75%, and 83% at 5, 10, and 20 minutes, respectively, after excision of all hyperfunctioning parathyroid tissue. A PTH decrease of 46% or more at 10 minutes and 59% or more at 20 minutes after excision of hyperfunctioning tissue was predictive of postoperative normocalcemia. In 79 patients (79%), the sestamibi scan provided accurate preoperative localization; all but 1 of these patients were treated successfully, most often with a limited, gland-specific dissection. In 24 patients with inaccurate, negative, or misleading preoperative sestamibi scans, 23 (96%) were treated successfully with the use of the intraoperative PTH assay.

CONCLUSIONS

The rapid intraoperative PTH assay accurately predicts postoperative success in patients with primary hyperparathyroidism. The rapid PTH assay allows for greater confidence in performing limited dissections in well-localized uniglandular disease. In cases of inaccurate preoperative localization, the rapid PTH assay directly affects surgical decision making and provides greater confidence in determining when surgical success has been achieved.

A normal variant on Tl-201 and Tc-99m MIBI whole-body imaging: the superior right atrial wall (auricle) and superoanterior right ventricular wall are often seen as mediastinal lesions

PURPOSE

The authors have often observed on Tl-201 and Tc-99m sestamibi (MIBI) scans in patients with thyroid cancer a small focus of increased uptake in the right midparasternal region (focus A) or sometimes in the lower mid chest at the level of the lower sternum (focus B) just inferomedial to focus A. The objective of this study was to assess the frequency of this finding on Tl-201 MIBI studies, to assess the incidence of true pathologic lesions corresponding to these foci, and to identify their nature.

MATERIALS AND METHODS

One hundred ten whole body Tl-201 studies using 4 mCi (148 MBq) and 84 MIBI studies using 20 mCi (740 MBq: first-pass, planar, and SPECT images) were reviewed. The appearance of either focus A or focus B on three orthogonal SPECT images was correlated with an atlas of cross-sectional anatomy and computed tomography. If focus A was seen on the immediate static image (obtained at the end of the first-pass acquisition without moving the patient), this image was coregistered with a selected image from the first-pass study showing the superior vena cava and also with another selected image showing the ascending aorta.

RESULTS

Focus A was seen in 40% of Tl-201 scans and in 49% of MIBI scans, whereas focus B was seen in 20% of Tl-201 scans and 39% of MIBI scans. On correlation of the SPECT images with a cross-sectional anatomy atlas, focus A and focus B invariably corresponded to the superior portion of the right auricle and basal superoanterior right ventricular wall, respectively. These myocardial regions are prominent and sometimes appear as discrete foci because they are considerably thicker than other parts of the right atrial and right ventricular muscle, respectively, and because they are seen partly end-on in the anterior projection.

CONCLUSIONS

The superior portion of the right auricle and basal superoanterior right ventricular myocardium often appear as isolated foci on whole-body Tl-201 and MIBl scans. Neither focus should be interpreted as a metastatic lesion in patients with possible cancer or as an ectopic parathyroid adenoma in patients with hyperparathyroid disease.

Diagnostic accuracy of fine-needle aspiration and frozen section in nodular thyroid disease

OBJECTIVE

To assess the diagnostic accuracy of fine-needle aspiration (FNA) and frozen section (FS) in nodular thyroid disease.

SETTING

Tertiary care academic medical center.

STUDY DESIGN

Retrospective review of 139 consecutive patients undergoing surgery for nodular thyroid disease. FNA and FS sensitivity, specificity, and accuracy were calculated with respect to permanent section histology.

RESULTS

Among 63 patients with an FNA interpreted as either benign (n = 38) or malignant (n = 25), FNA was accurate (sensitivity 89%, specificity 97%, accuracy 94%). FS identified only one case of carcinoma missed by FNA. Among 76 patients with a "suspicious" FNA, FS was reasonably accurate (sensitivity 67%, specificity 100%, accuracy 89%), but was deferred in 50% of cases.

CONCLUSION

Given high FNA accuracy, more selective use of FS is suggested.

SIGNIFICANCE

The study results will assist with intra-institutional patient counseling and intraoperative decision-making with respect to FNA and FS results in patients with nodular thyroid disease.

Biochemical response to treatment of bone hyperresorption in chronically critically ill patients

STUDY OBJECTIVE

The chronically critically ill (CCI) are a subgroup of critically ill patients who have survived an acute critical illness but remain profoundly debilitated and ventilator dependent. We have previously shown that CCI patients have a very high prevalence of bone hyperresorption. The objective of this present study was to determine the biochemical response of bone hyperresorption in CCI patients to treatment with either calcitriol alone or calcitriol and pamidronate.

DESIGN

Retrospective survey.

SETTING

Respiratory care step-down unit (RCU) at a tertiary-care teaching hospital.

PATIENTS

Fifty-five ventilator-dependent CCI patients transferred from ICUs within the same institution who had elevated urine N-telopeptide (NTx) levels at RCU admission, who were treated with either calcitriol alone (n = 44) or calcitriol and pamidronate (n = 11), and who had urine NTx levels remeasured following treatment.

INTERVENTION

None.

MEASUREMENTS AND RESULTS

Patients treated with calcitriol alone had a significant reduction in serum parathyroid hormone (PTH; 93+/-145 pg/mL vs 40+/-28 pg/mL; p = 0.02) but not in urinary NTx (187+/-146 nmol bone collagen equivalents [BCE]/mmol creatinine [Cr] vs. 178+/-123 nmol BCE/mmol Cr, p = 0.59). In contrast, patients treated with both calcitriol and pamidronate had a significant decrease in urine NTx at follow-up (329+/-238 to 100+/-85 nmol BCE/mmol Cr; p<0.01) but not in serum PTH (36+/-29 to 53+/-51 pg/mL; p = 0.44).

CONCLUSION

The bone hyperresorption of CCI patients is PTH independent and biochemically responds to treatment with calcitriol and pamidronate but not calcitriol alone.

Hypotestosteronemia in chronically critically ill men

OBJECTIVE

To determine the prevalence of hypotestosteronemia in chronically critically ill (CCI) men.

DESIGN

Prevalence survey.

SETTING

Step-down respiratory care unit (RCU) at a tertiary care teaching hospital.

PATIENTS

Thirty ventilator-dependent CCI men transferred from intensive care units (ICUs) within the same institution.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Total testosterone and bioavailable testosterone (bioT) concentrations were measured within 48 hrs of RCU admission. Patients were hospitalized a median of 40 days (range, 9-185 days) before RCU admission, with a median ICU length of stay of 25 days (range, 9-177 days). At RCU admission, total testosterone concentrations averaged 104+/-96 ng/dL, with average bioT concentrations of 19+/-20 ng/dL (16+/-9% of total testosterone). Twenty-nine of the 30 patients (96%) had bioT concentrations well below the lower limit of normal for their age range. bioT concentrations, expressed as a percentage of the normal mean for each patient's age range, were positively correlated with the number of days that the patient was in the ICU before transfer to the RCU (n = 30, r2 = .17, p = .025). However, if the single patient who remained in the ICU for 177 days was excluded, this correlation disappeared (n = 29, r2 = .07, p = .09). No other relationship was found between bioT concentrations and any other variable, including type of patient, ICU length of stay, reason for either initial admission to the ICU or prolonged mechanical ventilation, type of nutritional support, or use of dopamine.

CONCLUSIONS

CCI men have a very high prevalence of hypotestosteronemia, which may impede their recuperation and rehabilitation. Further studies are needed to determine whether additional pharmacologic treatment with testosterone can improve the recovery of these patients.

Bone hyperresorption is prevalent in chronically critically ill patients

STUDY OBJECTIVE

Chronically critically ill (CCI) patients are primarily elderly people who have survived a life-threatening episode of sepsis but remain profoundly debilitated and ventilator dependent. The objective of this study was to determine the prevalence of bone hyperresorption and parathyroid hormone (PTH)-vitamin D axis abnormalities in these patients.

DESIGN

Prevalence survey.

SETTING

Respiratory care step-down unit (RCU) at a tertiary care teaching hospital.

PATIENTS

Forty-nine ventilator-dependent CCI patients transferred from ICUs within the same institution.

INTERVENTION

None.

MEASUREMENTS AND RESULTS

N-telopeptide (NTx) levels in 24-h urine collections and serum intact PTH, 25-vitamin D, and 1,25-vitamin D levels were measured within 48 h of RCU admission. Patients were hospitalized a median of 30 days before RCU admission. Four patients (9%) had normal NTx and PTH levels. Forty-five patients (92%) had elevated urine NTx levels consistent with bone hyperresorption. Nineteen patients (42% of total patients) had elevated PTH levels consistent with predominant vitamin D deficiency, 4 patients (9%) had suppressed PTH levels consistent with predominant hyperresorption from immobilization, and 22 patients (49%) had normal PTH levels consistent with an overlap of both vitamin D deficiency and immobilization. There were no differences in vitamin D metabolites among these groups.

CONCLUSIONS

CCI patients have a high prevalence of bone hyperresorption in which PTH levels may clarify the cause. Further studies will determine the efficacy and cost-effectiveness of routine NTx and PTH screening in these patients and the role of vitamin D and antiresorptive therapies.

Hypothalamic-pituitary axis dysfunction in critically ill patients with a low free thyroxine index

The purpose of this study is to investigate the association of hypothalamic-pituitary axis abnormalities with the free thyroxine index (FTI) in critically ill patients. Fourteen critically ill patients and twenty healthy volunteers were studied using combined anterior pituitary gland testing with CRF, GHRH, TRH, and GnRH. The subjects were grouped as follows: I-healthy volunteers; II-sick/normal FTI; and III-sick/low FTI. Serial measurements of hormones were performed over a two-hour interval and the following parameters were measured: baseline level, response amplitude and time to maximal response. Response velocities and area-under-the-curves (integrated responses) were also computed. Group III had a longer mean ICU duration prior to testing than group II. Urinary cortisol, serum cortisol and serum PRL levels were elevated in groups II and III. However, group III had lower baseline ACTH levels, slower ACTH and TSH response velocities and decreased PRL integrated responses. Cortisol response parameters were similar between groups II and III. There were no differences in LH, FSH or GH response velocities or integrated responses among the 3 groups. These data confirm that critically ill patients develop hyperprolactinemia and hypothalamic-pituitary-adrenal axis activation but when a low FTI exists, a plurality of changes occur reflected by attenuated PRL, TSH and ACTH responses despite unaffected adrenal cortisol output.

Parathyroid hormone suppression in spinal cord injury patients is associated with the degree of neurologic impairment and not the level of injury

OBJECTIVE

To demonstrate that after spinal cord injury (SCI) suppression of the parathyroid-vitamin D axis is associated with the degree of neurologic impairment and not the level of injury.

DESIGN

A retrospective analysis of clinical and biochemical data obtained from hospital records of patients with SCI compared to a control group of patients with traumatic brain injury (TBI).

SETTING

The inpatient rehabilitation unit of a tertiary care hospital.

SUBJECTS

The medical records of 82 consecutive admissions to the rehabilitation unit with a diagnosis of SCI or TBI were reviewed. Patients with SCI were classified by the American Spinal Injury Association (ASIA) impairment scale and then grouped based on the completeness and level of injury.

MAIN OUTCOME MEASURE

Comparisons of serum parathyroid hormone (PTH), 25-hydroxyvitamin D, and 1,25-dihydroxyvitamin D (1,25-D) were planned. Multiple comparisons were performed for total and ionized serum calcium levels, serum phosphorus levels, and 24-hour urinary calcium excretion rates to reflect changes in mineral homeostasis. Multiple comparisons were also performed for serum albumin, prolactin, thyroid function tests, and AM cortisol levels, as well as 24-hour urinary urea nitrogen and cortisol excretion rates to reflect metabolic responses to stress.

RESULTS

Patients with SCI had significant suppression in PTH (p < .000009) and 1,25-D (p < .02) levels with elevated phosphorus (p < 0.03) and prolactin (p < .03) levels compared to patients with TBI. Also, more patients with SCI were hypoalbuminemic (p < .003) than patients with TBI. Patients with complete SCI (ASIA A) had more suppressed PTH (p < .03) and higher urinary urea nitrogen (p < .05) levels than SCI patients with incomplete injuries (ASIA B-D). Patients with complete, but not incomplete, SCI had lower albumin levels than patients with TBI (p < .05). These differences were not found between patients with tetraplegic and paraplegic SCI. ASIA motor scores did not correlate with any of the measured parameters but when used as a covariate did abolish differences in PTH and 1,25-D among the study groups by ANOVA.

CONCLUSION

In patients with SCI, the degree of neurologic impairment, and not the level of injury, is associated with PTH suppression and markers of metabolic stress.

Conversion of non-iodine-concentrating differentiated thyroid carcinoma metastases into iodine-concentrating foci after anticancer chemotherapy

We present the unusual case of a 29-year-old man diagnosed in 1975 with papillary carcinoma of the thyroid metastatic to regional lymph nodes. The patient underwent surgical resection, postoperative iodine-131 (131I) radioablation and levothyroxine suppression. He was subsequently lost to follow-up. In 1991, he presented with extensive metastatic disease that was not demonstrable on whole-body 131I imaging, but was seen on computerized tomography and whole-body thallium chloride scanning. The patient was treated with cisplatin (Platinol) and doxorubicin (Adriamycin). Repeat 131I imaging after three cycles of chemotherapy showed significant 131I uptake in previously non-iodine-concentrating lesions. The patient was subsequently treated with 200 mCi 131I. We postulate this patient's non-iodine-concentrating thyroid cancer may have become functional by either a differentiating effect of chemotherapy on the tumor cells, or perhaps a selective cytotoxicity against nonfunctional, less differentiated papillary thyroid cancer cells, or both. This would allow more functional differentiated cells to overgrow and become the predominant cell type in the lesions. Chemotherapy may be beneficial in patients with advanced non-iodine-concentrating differentiated thyroid carcinoma by inducing radioiodine uptake and allowing subsequent radioiodine therapy. The possible mechanisms of induction of iodine uptake by chemotherapy are discussed.

Transthoracic bioimpedance can measure extravascular lung water in acute lung injury

We used a porcine endotoxemic model of acute lung injury to compare extravascular lung water (EVLW) measured by right transthoracic bioimpedance to postmortem gravimetric EVLW measurements. Adult pigs were randomized into control (N = 5) or endotoxin groups [150 microgram/kg Escherichia coli lipopolysaccharide B for 1 hr followed by 3 hr of resuscitation for a thermodilution cardiac output less than 90% of baseline using either isotonic saline (N = 5) or isooncotic albumin (N = 5)]. Right lung resistance was measured using a novel electrode array and a highly sensitive analyzer and was used to calculate right lung resistivity. At the end of the experiment, animals in the endotoxin-albumin group had higher gravimetric EVLWs than those in the endotoxin-saline or control groups (P < 0.05). Right lung resistivity corrected for body weight significantly correlated with gravimetric EVLW (r2 = 0.49; SEE = 0.96; P = 0.0038). Using multiple regression analysis, a predictive equation for EVLW based on right lung resistivity, body weight, and mean pulmonary artery pressure was generated (r2 = 0.81; SEE = 0.60; P < 0.0001). These results demonstrate that right lung resistivity measurements can provide a noninvasive estimate of EVLW. In addition, crystalloid may be preferable to colloid for fluid resuscitation in noncardiogenic pulmonary edema.

Accelerated thyrotoxicosis induced by iodinated contrast media in metastatic differentiated thyroid carcinoma

A 67-yr-old woman who underwent total thyroidectomy 32 yr ago developed accelerated hyperthyroidism after injection of iodinated contrast media to evaluate a left hemipelvis mass. The patient was managed with propylthiouracil, beta-blockers and digoxin. Whole-body 201TI and 131I scans demonstrated a functioning metastasis in the left hemipelvis where biopsy revealed a well differentiated follicular thyroid carcinoma. Palliative external beam radiotherapy was administered. The patient then received radioiodine treatment with granulocyte colony-stimulating factor to minimize bone marrow toxicity. Clinically significant thyrotoxicosis occurring in metastatic thyroid carcinoma is rare and results from abnormal ectopic thyroidal tissue iodine metabolism. Iodide-containing medications and contrast media should be avoided in patients with functioning thyroid metastases to prevent abrupt increases in circulating thyroid hormone levels.

Thallium-201 and iodine-131 scintigraphy in differentiated thyroid carcinoma

The purpose of this study was to determine the concordance and discordance between diagnostic 131I and 201TI whole-body scintigraphy in patients with differentiated carcinoma of the thyroid.

METHODS

Following thyroidectomy for differentiated thyroid carcinoma, 50 patients underwent whole-body 131I and 201TI scanning (60 pairs of scans in total). Fifteen pairs of studies were obtained before ablative therapy, 30 pairs after ablative therapy and 15 pairs after 131I therapy for metastatic disease. Serum thyroglobulin levels were concurrently determined by radioimmunoassay.

RESULTS

Thirty-six 131I whole-body scans (in 34 patients) showed residual uptake in the neck, but only six (17%) of the corresponding whole-body thallium studies had detectable uptake in the neck. Fourteen 131I scans (in nine patients) identified multiple metastatic lesions, whereas the thallium scans were interpreted as either negative, nonspecific or showing fewer lesions. In four study pairs, the thallium scans showed solitary lesions that were not detected by the corresponding radioiodine scans. In 16 scans, the thallium studies gave false-positive results.

CONCLUSION

Iodine-131 scintigraphy for differentiated thyroid carcinoma is more sensitive and more specific than 201TI scintigraphy for detection of distant metastases and residual activity in the neck following thyroidectomy.

Parenteral Nutrition Formulation: An Integral Part of the Endocrinologist’s Metabolic Support Consultation Service

Endocrinologists are uniquely suited to provide consultation in the new field of metabolic support. This specialty incorporates management of electrolyte and mineral disorders, diabetes mellitus, and malnutrition. Principles of formulation of parenteral nutrition are discussed, with an emphasis on distinguishing marasmus from kwashiorkor types of cachexia, disease-specific treatment, nutritional pharmacology, and relevant controversies.

Resolving receptor heterogeneity using Fourier-derived affinity spectrum analysis and LIGAND: benzodiazepine receptors in the rat spinal cord

In the present study, we combined a powerful and novel receptor binding data analysis technique. Fourier-derived affinity spectrum analysis (FASA), with the nonlinear regression analysis program LIGAND to resolve benzodiazepine receptor heterogeneity in rat spinal cord. With FASA, we identified three distinct [3H]Ro15-1788 binding populations: two high-affinity sites (0.4 and 5 nM) for the radioligand and a lower-affinity site (150 nM) that is insensitive to the imidazopyridine alpidem. With the affinities for the radioligand determined with FASA, the Ki values of 13 competing ligands were calculated with LIGAND. All of the ligands studied displayed the highest affinity for site 1 (the highest-affinity [3H]Ro15-1788 binding site), with the exception of AHR 11797. Site 2 had high affinity for Ro15-1788, lower affinity for flunitrazepam and beta-CCM and very low, but measurable, affinity for zolpidem. The alpidem-insensitive binding site, studied in isolation by performing competitive binding assays in the presence of 65 microM alpidem, showed relatively low affinity for all of the ligands studied, and its physiological relevance is not yet known.

Unusual scintigraphic findings in a thyroid adenoma

Thallium imaging is increasingly being used to evaluate the thyroid. Uptake patterns of 201Tl in benign and malignant thyroid nodules have been described. Thallium localizes all thyroid tissue with possibly different rates of washout in benign and malignant nodules. This case demonstrates a follicular adenoma presenting 123I as a clinically palpable nodule with nonvisualization of the remainder of the thyroid gland consistent with the diagnosis of an autonomously hyperfunctioning module. Subsequent thallium scanning revealed a complete reversal of tracer distribution with lack of uptake of 201Tl in the nodule while the rest of the gland showed normal thallium accumulation. Surgical excision of the nodule demonstrated follicular adenoma.

Proopiomelanocortin gene expression in a distinct population of rat spleen and lung leukocytes

Existence of proopiomelanocortin (POMC) messenger RNA (mRNA) and related peptides in extrapituitary sites has been demonstrated in immune cells, although the particular type of immune cell has been the source of considerable debate. Specifically, double labeling studies have shown that POMC peptide expressing cells in the spleen represent a subpopulation of red pulp macrophages, while splenic lymphocyte areas are POMC negative. In addition, it has also been reported that peripheral blood leukocytes express the POMC gene. Using a sensitive solution hybridization technique with a POMC exon-1 RNA probe, we detected 70 +/- 20 fg and 65 +/- 5 fg POMC mRNA per microgram total RNA in whole spleen and lung, respectively, approximately 20,000-fold lower concentrations than found in the neurointermediate lobe of the pituitary. The presence of nuclease protected full length exon-1 bands, rather than the 5' truncated POMC RNAs seen in many nonpituitary tissues, indicates transcription initiation at the normal pituitary POMC promoter site in lung and spleen. In order to localize POMC gene expression in these tissues we employed an in situ hybridization method. There was an intense signal in a small population of large mononuclear cells scattered throughout the splenic red pulp and lung parenchyma. In the lung, these cells were concentrated in the periarteriolar zone in a manner suggestive of migration from the intravascular lumen. These cells had a histomorphology suggestive of monocyte-macrophages. POMC mRNA was undetectable in the splenic white pulp and bronchus-associated lymphoid tissue, indicating an absence of POMC gene expression in splenic and lung lymphocytes. Immunocytochemical studies suggested that POMC-positive cells made up a subpopulation of cells expressing the rat monocyte-macrophage markers ED1 and ED2. Similarly, the distribution of Jenner-Giemsa stained monocyte-macrophages appeared to overlap with POMC positive cells. Studies with anti-rat beta-endorphin antisera revealed scattered cells in the splenic red pulp and lung parenchyma, suggesting that the POMC mRNA is translated in these cells. In summary, POMC mRNA is expressed in a small population of monocyte-macrophage-like cells in lung and spleen but not in lymphocytes in these tissues.

A C version of Fourier-derived affinity spectrum analysis (FASA) to resolve binding heterogeneity

The computer program described in this paper facilitates resolution of binding affinity heterogeneity by transforming binding curve data (bound versus free) into affinity spectra (density versus affinity). The original program, written in FORTRAN, is extended and presented here in the language C. New applications include an ability to transform competition curves into affinity spectra and to evaluate the effects of sampling and experimental error on spectrum analysis. We propose that this program be incorporated in the routine evaluation of binding systems.

Hirsutism

The clinical presentation and management of the hirsute woman is illustrated in cases of idiopathic hirsutism, polycystic ovarian disease, and nonclassical congenital adrenal hyperplasia. Therapeutic regimens manage hyperandrogenic signs, induce ovulation, and protect the endometrium.

Altered estrogen receptor system in estrogen-unresponsive human endometrial adenocarcinoma cells

Previous studies from our laboratories demonstrated that cells from a human endometrial adenocarcinoma cell line (Ishikawa) responded to estradiol whereas cells from another endometrial cancer line (HEC-50) did not. In an attempt to identify factors responsible for the observed estrogen insensitivity we compared the characteristics of the estradiol receptor (ER) systems in Ishikawa and HEC-50 cells. Saturation analyses of cytosolic estrogen binders were performed over a 0.1-70 nM range of [3H]estradiol concentrations. Equilibrium dissociation constants and number of binding sites were determined by graphic analysis of Scatchard plots or computed by applying Fourier-derived affinity spectrum analysis (FASA) of the binding data. No significant differences were noted in the dissociation constants (Kd approx. 0.6 nM) or number of binding sites (approx. 6-10 fmol/mg protein) for the single binder that could be evaluated by the graphic method in cytosol from the two cell lines. However, 2 binders in Ishikawa cells (Kd approx. 0.2 and 6 nM) could be detected by the FASA method; the higher affinity binder in HEC-50 cells could not be clearly demonstrated. Structural differences in the specific estrogen binders which might distinguish HEC-50 from Ishikawa cells or normal endometrial tissue were investigated by using the anti-ER monoclonal antibody JS 34/32. Interaction of the antibody with [3H]estradiol binders of estrogen-responsive cells and tissue was evident from the formation of labeled complexes that were shown to sediment faster in glycerol density gradients and could be immunoprecipitated with Protein A attached to Sepharose beads. In contrast, the antibody did not recognize labeled specific binders in the HEC-50 cells. Furthermore, [3H]estradiol receptors in Ishikawa cells could be transformed into a species that exhibited increased hydrophilicity, evident from its binding to DNA-cellulose, whereas binders from HEC-50 could not. These results indicate that the lack of responsiveness of HEC-50 cells to estrogens might be due to structural or functional alterations in the ER protein resulting in a loss of its capability to undergo estrogen-directed conformational changes required for biological activity.

Cyclic therapy of osteoporosis with neutral phosphate and brief, high-dose pulses of etidronate

We have designed a cyclic regimen for the treatment of osteoporosis based on the activate, depress, free, and repeat (ADFR) concept. Osteoclastic bone resorption is activated by 7 days of oral neutral phosphate and inhibited with a brief pulse (5 days) of etidronate disodium at a high dose (20 mg/kg body weight). Patients next take calcium supplements for 48 days before resuming phosphate to enter the next cycle. Osteoporotic women increased the bone mineral density of the lumbar spine at 6 months by 7.2 +/- 5.2% (mean +/- SD, N = 14) and at 12 months by 8.2 +/- 4.0% (N = 8). Control observations in regularly exercising postmenopausal women (N = 30) showed no significant change in spine mineral density after 20 months (0.5 +/- 3.2%), confirming the stability of the measurement technique. The two patients who responded poorly to the cyclic regimen each showed a blunted rise in serum PTH during oral phosphate administration, suggesting that the rise in PTH induced by oral phosphate may be an important component of this cyclic regimen. This preliminary study does not identify which component or components of the regimen are responsible for the increase in bone mass but provides positive encouragement for randomized studies designed to determine the optimum dosage, duration, and timing of each component of the regimen.

Heritable syndrome of pseudoxanthoma elasticum with abnormal phosphorus and vitamin D metabolism

A patient with pseudoxanthoma elasticum was documented to be hyperphosphatemic and mildly hypercalcemic for six years. Complications included metastatic calcification, absorptive hypercalciuria, and renal insufficiency. The 1,25-dihydroxyvitamin D value was elevated, despite normal serum parathyroid hormone values, high serum phosphate levels, and renal insufficiency. Either increased dietary calcium or prednisone seemed to suppress the 1,25-dihydroxyvitamin D value. Nephrolithiasis or abnormalities suggestive of pseudoxanthoma elasticum occurred in the patient's father, daughter, and several siblings, suggesting a distinct familial syndrome in which connective tissue changes are accompanied by abnormalities of phosphorus and vitamin D metabolism that may resemble those in the syndrome of familial tumoral calcinosis. Nine similar cases were described before 1970.

Distribution of 3,4-dihydroxyphenylacetic acid (DOPAC) and 3,4-dihydroxyphenylglycol (DOPEG) in microdissected brain structures and the pituitary gland: metabolite changes in the median eminence in response to hyperprolactinemia and suckling

Dopamine (DA), norepinephrine (NE), epinephrine (E), 3,4-dihydroxyphenylglycol (DOPEG) and dihydroxyphenylacetic acid (DOPAC) were determined simultaneously by a radioenzymatic, thin-layer chromatographic assay able to detect 1-10 pg of the parent compounds and 80-120 pg of their metabolites. A localization study of these compounds in 20 micro-dissected hypothalamic and limbic structures and the anterior and posterior pituitary glands of male rats was completed. DOPAC was detectable in 14 of 22 structures with the lowest DOPAC/DA ratio being found in the caudate nucleus (7.1%) and the highest in the medial aspect of the ventromedial nucleus of the hypothalamus (422.0%). There was a higher DOPAC/DA ratio in the lateral (21.5%) than in the medial (11.3%) portion of the median eminence suggesting that a greater portion of released DA in the medial median eminence enters the portal circulation. DOPEG was detectable in 6 of 22 structures with DOPEG/NE ratios ranging from 8% (interstitial nucleus of the stria terminalis, ventral aspect) to 32% (medial median eminence). A poor correlation exists between DOPAC and DA concentrations in the various brain regions while there was a stronger relationship between DOPEG and NE concentrations. Male rats were rendered hyper-prolactinemic for 48 hours with injections of ovine prolactin (oPRL) every 8 hours (4 mg/kg body weight sc). In such rats there was a suppression of endogenous rat PRL (rPRL) secretion, the DOPAC/DA ratio increased 2.2-fold in the medial (MEm) and 1.9-fold in the lateral median eminence (MEl), and the DA concentration in the anterior pituitary also increased 2.6-fold. In 10 day postpartum lactating rats, suckling produced marked increases in serum rPRL but no change in DOPAC/DA ratios in the ME or in the DA concentration in the anterior pituitary. The data reveal a wide range of DOPAC/DA ratios (7-422%) in brain regions containing cell bodies, axons and terminals of the different dopaminergic neuronal tracts in brain and pituitary. Considering the DOPAC/DA ratios in the MEm and MEl, it is suggested that a large perturbation of dopaminergic transmission produces a significant ratio change while a smaller perturbation is not detected by this index of neuronal metabolism.

Myotonic dystrophy presenting as male infertility: a case report

A 28-year-old man presented with azoospermia, low plasma testosterone levels, and an elevated follicle stimulating hormone (FSH) concentration. Bilateral testicular biopsies revealed tubular atrophy with normal-appearing Leydig cells. One year later, symptoms and signs consistent with myotonic dystrophy (MyD) were noted. The rarity of male hypogonadism preceding the neurological manifestations of MyD is stressed.

Hypothalamic dysfunction following whole-brain irradiation

The authors describe 15 cases with evidence of hypothalamic dysfunction 2 to 9 years following megavoltage whole-brain x-irradiation for primary glial neoplasm. The patients received 4000 to 5000 rads in 180- to 200-rad fractions. Dysfunction occurred in the absence of computerized tomography-delineated radiation necrosis or hypothalamic invasion by tumor, and antedated the onset of dementia. Fourteen patients displayed symptoms reflecting disturbances of personality, libido, thirst, appetite, or sleep. Hyperprolactinemia (with prolactin levels up to 70 ng/ml) was present in all of the nine patients so tested. Of seven patients tested with thyrotropin-releasing hormone, one demonstrated an abnormal pituitary gland response consistent with a hypothalamic disorder. Seven patients developed cognitive abnormalities. Computerized tomography scans performed a median of 4 years after tumor diagnosis revealed no hypothalamic tumor or diminished density of the hypothalamus. Cortical atrophy was present in 50% of cases and third ventricular dilatation in 58%. Hypothalamic dysfunction, heralded by endocrine, behavioral, and cognitive impairment, represents a common, subtle form of radiation damage.

Resolution of steroid binding heterogeneity by Fourier-derived affinity spectrum analysis (FASA)

A new mathematical method of analyzing radioreceptor assay data is presented. When there are many binding classes with different affinities, the probability-density function B(p) is described by the equation B(p) = (integral negative infinity to infinity) q(k)f(p-k)dk, where q(k) is the affinity spectrum (density of a particular binding class as a function of affinity) and f(p-k) is a probability function (probability that dissociation constants will fall between k and p-k, where p is the free ligand concentration). This equation is solved for q(k) and evaluated explicitly by Fourier transformation, namely, q(w) = b(w)/f(w), where w is frequency. Since division by f(w) can amplify and high frequency noise present in the experimental data, a Gaussian smoothing function is introduced thus: qs(w) = q(w)e(-w/W0)2, where W0 is a constant. This produces an affinity spectrum defined as a plot of the number of binding sites, qs(k), versus their respective dissociation constants, k. Using a FORTRAN computer program, we verify this algorithm using simulated data. We also apply the procedure to resolve heterogeneous populations of estrogen binders in human endometrium using [3H]estradiol as ligand. Two estrogen binder classes are revealed with dissociation constants approximately 2.5 natural logarithmic units apart. We identify one high-affinity (Kd = 0.18 nM)-low density (70 pM [or 72 fmol/mg protein]) subpopulation and one low affinity (Kd = 2.5 nM)-high density (101 pM [or 102 fmol/mg protein]) subpopulation of estradiol binders. The management of experimental error, sampling limitations, and nonspecific binding are discussed. This method directly transforms experimental data into an easily interpretable representation without mathematical modeling or statistical procedures.