Prediction of the course of Graves' disease after medical antithyroid treatment

The course of thyrotoxicosis in 33 patients with Graves' disease was evaluated clinically and biochemically (free thyroxine index, serum triiodothyronine, thyroid stimulating antibodies, (TSAb), thyroid stimulating hormone binding inhibiting immunoglobulins (TBII)). Relapse of the disease was found to be correlated to anamnestic information of thyrotoxicosis among first degree relatives (predictive value 90%) and to concomitantly raised levels of TSAb and TBII at the start of treatment (predictive value 71%). Mean duration of treatment of patients with long-lasting remission was 16.8 months. When comparing various information used to predict relapse of Graves' disease, anamnestic information of familial predisposition to thyrotoxicosis carries the highest predictive value.

Serum prolactin and thyrotropin responses to thyrotropin-releasing hormone in men with alcoholic cirrhosis

The serum concentrations of prolactin (PRL) and thyrotropin (TSH) in 12 males with alcoholic cirrhosis during basal condition and after stimulation with thyrotropin-releasing hormone (TRH) were compared with the concentrations in ten thiazide-treated hypertensive and nine normal men. The basal as well as the TRH-stimulated increase in serum PRL was significantly elevated in the cirrhotic males, while the increase in serum TSH was unchanged, compared with hypertensive and normal men. No correlation between clinical or laboratory parameters and serum PRL was found. Serum estradiol was equal in cirrhotic and control subjects and no correlation was found between serum PRL and serum estradiol. These findings favour the concept that raised serum PRL in cirrhotic patients might be caused by a diminished dopaminergic neurotransmission.

TSH and thyroid stimulating antibodies (TSAb) activate thyroid adenylate cyclase through different pathways

Adenylate cyclase activity in human thyroid homogenates was studied after stimulation with thyrotropin (TSH) and thyroid stimulating antibodies (TSAb). The results show: 1) TSAb prepared from different patients with Graves' disease show different adenylate cyclase activation patterns and a lag phase is frequently observed. 2) TSH and TSAb appear to cause mutually inhibitory activation of thyroid adenylate cyclase. 3] The maximal adenylate cyclase activation is higher with TSH than with TSAb, but this could possibly be due to contamination of TSAb preparations with an adenylate cyclase inhibitor. 4) There is no absolute copurification of TSH sensitive and TSAb sensitive adenylate cyclase in various subcellular fractions of thyroid homogenate. 5) Incubation of thyroid homogenate with cortisol cause a dose dependent decrease in the adenylate cyclase response to TSAb whereas the response to TSH is either increased or unchanged. The results indicate that TSH and TSAb activate thyroid adenylate cyclase through different pathways in the plasma membrane.

One-thousand consecutive inguinal hernia repairs under unmonitored local anesthesia

To evaluate the feasibility and safety of unmonitored local anesthesia (ULA) for elective open inguinal hernia repair, we made a prospective, consecutive data collection from 1000 operations on primary and recurrent hernias. Follow-up consisted of a questionnaire 1 mo after surgery and retrieval from the electronic patient data management system. In 921 ASA Group I and II and 79 ASA Group III and IV patients, the median age was 60 yr (range, 18-95 yr). ULA was converted to general anesthesia in 5 of 1000 cases, and 961 patients were discharged on the day of surgery after 95 min (median; interquartile range, 75-150); 29 patients had complications requiring surgical intervention. Within the first month, three patients died of causes unrelated to hernia surgery, and six had cardiovascular or respiratory events. The questionnaire was returned by 940 patients; 124 were dissatisfied with local anesthesia, day-case setup, or both, primarily because of intraoperative pain (n = 74; 7.8%). We conclude that open inguinal hernia repair can be conducted under ULA, regardless of comorbidity, with a small rate of deviation from day-case setup and minimal morbidity. It provides a safe alternative to other anesthetic techniques with an acceptable rate of satisfaction, but intraoperative pain relief needs improvement.

IMPLICATIONS

Inguinal hernia repair can be safely performed under unmonitored local anesthesia with infrequent postoperative morbidity and acceptable satisfaction, but intraoperative pain may be a problem.

Feasibility of local infiltration anaesthesia for recurrent groin hernia repair

OBJECTIVE

To describe the the feasibility of and patients' satisfaction with day case repair of recurrent inguinal hernias under unmonitored local anaesthesia.

DESIGN

Prospective study.

SETTING

Public service university hospital, Denmark.

SUBJECTS

All patients with a reducible recurrent inguinal or femoral hernia unselectedly referred for elective repair during the 4-year period 1 September 1994 to 31 August 1998.

INTERVENTIONS

Data were collected prospectively and consecutively from standardised, detailed files, a questionnaire 4 weeks postoperatively, and the Copenhagen Hospitals electronic patient data management system.

MAIN OUTCOME MEASURES

Feasibility of local anaesthesia in the day case setting, patient satisfaction and morbidity.

RESULTS

215 consecutive operations for recurrent hernias were performed under unmonitored local anaesthesia. No conversion to general anaesthesia took place and no patients developed urinary retention. After 207 operations, the patients were discharged on the day of operation (96%), and the median time from the end of operation to discharge was 90 minutes (IQR 75-140). After 6 operations (3%), patients had complications that required surgical intervention. The 4-week questionnaire was returned after 208 operations (97%). 30 patients were dissatisfied, mainly because of intraoperative pain (17 patients, 8%). No mortality or cardiopulmonary morbidity was recorded during the first 30 days postoperatively.

CONCLUSIONS

Open day-case repair of recurrent inguinal hernias can safely be conducted under unmonitored local anaesthesia with minimal morbidity. Intraoperative pain is the main topic that requires improvement.

Methods for assessment of future demand of medical doctors in Denmark

BACKGROUND

Whereas supply prognoses is mainly a matter of establishing mathematical scenarios with ongoing adjustments of variables, reliable demand prognoses are more difficult and complex to establish. However, optimum use of human and educational resources and--on the other hand--sufficient supply of medical doctors calls for reliable supply as well as demand prognoses.

METHODS

Based on a number of technical and political considerations the first demand prognosis was based on three different methods; 1. Changes in demand due to demographic changes. 2. An evaluation made by the owners of the hospitals. 3. An evaluation made by the scientific medical societies.

RESULTS

The demand prognosis was found to be hampered by a number of limitations. Demographic changes beyond the next 10 years was found to be unreliable. Moreover, the demand observed during the last 20 years was only to a very limited extent explained by demographic changes. The owners of the hospitals could only prognosticate for an election period, i.e. for about 5 years,--and only in very general terms that were difficult to interpretate. From some counties the answers did only seem to be based on rather superficial analysis and gave very little information. Each of the Scientific Medical Societies claimed increasing demands for the next 25 years, despite marked expectations for diagnostic and therapeutic advantageous technological developments. The overall conclusion from the combined weighed analysis was an expected increase in the demand of medical doctors of about 1% per year in the short as well as in the long term (25 years). This should be compared to the observed development during the last 10 years, i.e. an annual increase of 1.7-1.8%.

Dimensioning of the postgraduate educational training in Denmark

BACKGROUND

Postgraduate medical training in Denmark consists of basic training, offered to all medical doctors, followed by specialist training. The National Board of Health is responsible for the overall frame of medical training in Denmark and determines the number of trainee positions for each of the 42 specialities available. The total number of positions and their distribution between specialities are based on demand, supply and demographic considerations. Approximately 85% of medical doctors finalise specialist training.

METHODS

Denmark is divided into three educational regions: North, South and East. Each region consists of counties, with their own administration. The National Board of Health approves each position for postgraduate training. All new positions and changes of existing positions are evaluated before approval by The National Board of Health. An updated version of the list of educational positions is available on the internet.

CONCLUSION

The Danish governmental authorities have an efficient tool to control the dimensioning of the postgraduate medical education and thereby the production of specialists. Medical doctors can easily get information about where to obtain trainee positions. The majority of hospital departments improve their recruitment potential by participating in medical training. A number of structural changes, for instance establishing of medical centres and corporations within larger entities across an extended geographic area, specialisation between hospitals and reduced number of hospitals, calls for decentralisation of the administration in order to improve flexibility in the organisation of postgraduate medical training. However, the National Board of Health will still co-ordinate at the national level.

[Peroperative "lavage" and primary anastomosis in acute left-sided colon ileus]

AIM

A description of technique, course and results of operation for left-sided obstruction of the colon with primary resection, perioperative lavage of the colon and primary anastomosis.

DESIGN

Retrospective examination of case records.

MATERIAL

From January 1st 1994-December 31st 1997 eight operations were performed including primary resection, perioperative lavage and primary anastomosis.

RESULTS

No anastomotic leaks were found. One patient died five days postoperatively due to cardiac complications. Three patients had postoperative cardiopulmonary complications treated medically. One patient had rupture of the fascia, was reoperated, experienced wound infection, transient serum elevation of liver enzymes and underwent ERCP with papillotomy and extraction of stones from the common bile duct two months postoperatively.

CONCLUSION

In this small series the technique has appeared safe, thus confirming previous reports.

[Surgical treatment of stomach cancer at a university hospital. A retrospective survey of the period 1990-1995]

AIM

A retrospective study of 69 cases of gastric cancer seen during the period from 1/1-1990 to 31/12-1994 treated in a University Hospital. The aim of the study was to describe morbidity, mortality and identify independent prognostic variables for mortality.

METHOD

Patient data were recovered from the hospital's central database. Mortality was chosen as end-parameter. Univariate log-rank-test identified statistically significant variables which were then analysed by Cox backward stepwise regressional analysis.

MATERIAL

Sixty-nine patients were available for analysis, median age 73 years. Fifty-one patients underwent operation. Eighteen patients did not have a surgical procedure due to disseminated disease. The overall postoperative morbidity was 25% and postoperative mortality 10%. The overall five-year survival rate was 8%, 12% for operated patients, 35% after radical and 0% after non-radical or omitted surgery. Age, radicality of operation, type of operation, Borrmann's tumour classification, and degree of depth of local infiltration were identified as significant factors for survival. Cox's analysis identified type of operation (p = 0.0002) and Borrmann's tumour classification (p = 0.001) as independent variables.

DISCUSSION

The overall five-year survival is low and has not changed over two decades in Denmark, whereas mortality and morbidity rates have improved. It should be recommended that: The treatment of gastric cancer must be centralised in order to develop preoperative examinations, operative technique and the necessary routine for the surgeons. All gastric ulcers must be considered malignant and biopsies taken accordingly.

Prospective study of chronic pain after groin hernia repair

BACKGROUND

The aim was to provide a detailed description of any residual pain 1 year after elective day-case open groin hernia repair under local anaesthesia.

METHODS

This was a prospective consecutive case series study by questionnaire of 500 consecutive operations in 466 unselected adult patients 1 year after surgery. Pain was scored (none, mild, moderate or severe) at rest, while coughing and during mobilization, and compared with similar data collected 1 and 4 weeks after operation.

RESULTS

Some 419 questionnaires were returned (response rate 93 per cent); 20 patients had died within the year and 30 data sets from patients who had a subsequent operation during the study were excluded. Eighty patients (19 per cent) reported some degree of pain, and 25 (6 per cent) had moderate or severe pain. Pain restricted daily function in 24 patients (6 per cent). The incidence of moderate or severe pain was higher after repair of recurrent than primary hernias (14 versus 3 per cent; P < 0.001). The risk of developing moderate or severe pain was increased in patients who had a high pain score 1 week after operation (9 versus 3 per cent; P < 0.05) and also in patients who had moderate or severe pain 4 weeks after operation (24 versus 3 per cent; P < 0.001).

CONCLUSION

Chronic pain is a significant problem after open groin hernia repair. It may be worse after surgery for a recurrent hernia and may be predicted by the intensity of early postoperative pain.

Pain after primary inguinal herniorrhaphy: influence of surgical technique

BACKGROUND

Pain is an important problem after ambulatory hernia repair. To assess the influence of the surgical technique on postoperative pain, two separate randomized, patient-blinded, controlled trials were performed in men with an indirect inguinal hernia.

STUDY DESIGN

In study A, 48 patients with an internal inguinal ring smaller than 1.5 cm were randomly allocated to either simple extirpation of the hernial sac or extirpation plus annulorrhaphy. In study B, 84 patients with an internal inguinal ring wider than 1.5 cm were randomly allocated to extirpation plus annulorrhaphy or extirpation plus Lichtenstein mesh repair (modified). All operations were performed under unmonitored local anesthesia with standardized perioperative analgesia using methadone and tenoxicam. Pain was scored daily for the first postoperative week and after 4 weeks on a four-point verbal-rank scale (no, light, moderate, or severe pain) during rest, while coughing, and during mobilization (rising to the sitting position). Use of supplementary analgesics (paracetamol) was recorded. Cumulative daily pain scores for the first postoperative week and the number of patients who used supplementary analgesics were the main outcome measures.

RESULTS

There were no significant differences in cumulative pain scores or use of supplementary analgesics between the treatment groups in either study. Cumulative pain scores were significantly higher during coughing and mobilization than during rest in both studies.

CONCLUSIONS

Choice of surgical technique for open repair of a primary indirect inguinal hernia has no influence on postoperative pain.

Short convalescence after inguinal herniorrhaphy with standardised recommendations: duration and reasons for delayed return to work

OBJECTIVE

To provide a detailed description of post-herniorrhaphy convalescence.

DESIGN

Prospective, descriptive, consecutive questionnaire case series.

SETTING

Public university hospital, Denmark.

PATIENTS

100 consecutive patients treated for inguinal hernia.

INTERVENTION

Elective open inguinal herniorrhaphy under local anaesthesia. One day convalescence for light/moderate and three weeks for strenuous physical activity was recommended.

MAIN OUTCOME MEASURE

Duration of absence from work or main recreational activity.

RESULTS

Overall median absence (including the day of operation) was 6 days (interquartile range 1-16). For unemployed patients it was 1 day (0-7), for patients with a light or moderate workload 6 days (3-12), and for those with a heavy workload 25 days (21-37). Among the 64 patients, who did not follow the recommendations, pain was contributory in 33 and advice from the general practitioner in 12. Pain was the main cause of impairment of activities of daily living.

CONCLUSION

Well-defined recommendations for convalescence may, together with improved management of postoperative pain, shorten convalescence; they are essential in the evaluation of effects of different surgical techniques of herniorrhaphy on convalescence.

Levobupivacaine vs bupivacaine as infiltration anaesthesia in inguinal herniorrhaphy

We have compared the anaesthetic and analgesic efficacy of levobupivacaine with that of racemic bupivacaine in 66 male patients undergoing ambulatory primary inguinal herniorrhaphy. Patients were allocated randomly in a double-blind manner to local infiltration anaesthesia (0.25% w/v 50 ml) with either racemic bupivacaine (n = 33) or levobupivacaine (n = 33). Scores for intraoperative pain and satisfaction with anaesthesia were recorded, together with perception of postoperative pain and need for supplementary postoperative analgesic medications in the first 48 h after operation. Intraoperative satisfaction with the infiltration anaesthesia was similar, with median scores of 77 (levobupivacaine) and 80 (bupivacaine) (VAS; 100 mm = extremely satisfied). Time averaged postoperative pain scores (48 h) were 8 (levobupivacaine) and 10 (bupivacaine) in the supine position, 13 (levobupivacaine) and 12 (bupivacaine) while rising from the supine position to sitting, and 9 (levobupivacaine) and 13 (bupivacaine) while walking (VAS; 100 mm = worst pain imaginable) (ns). There was no difference in the use of peroral postoperative analgesics between the two groups. We conclude that racemic bupivacaine and its S-enantiomer levobupivacaine had similar efficacy when used as local infiltration anaesthesia in inguinal herniorrhaphy.

Cryoanalgesia: effect on postherniorrhaphy pain

Cryoanalgesia versus sham treatment was applied to the ilioinguinal and iliohypogastric nerves after mesh repair of an inguinal hernia under local anesthesia in 48 male patients in a prospective, randomized, and observer- and patient-blinded trial. Pain was scored daily during rest, while coughing, and during mobilization to the sitting position for 1 wk and weekly for 8 wk on a four-point verbal rank scale. Use of supplementary analgesics and sensory disturbances were recorded. Assessments were made for allodynia, hyperalgesia, and mechanical pain detection thresholds 8 wk postoperatively. Cumulative pain scores for the first postoperative week were equal in the two groups, as was the use of analgesics. Eight weeks postoperatively, three cases of hyperalgesia to pinprick were detected in the cryoanalgesia group, and 10 patients in the cryoanalgesia group versus 5 in the sham-treatment group reported disturbed sensibility. We conclude that cryoanalgesia of the iliohypogastrical and ilioinguinal nerve does not decrease postherniorrhaphy pain.

IMPLICATIONS

Does freezing of sensory nerves in the groin reduce pain after hernia repair? Extreme cold (-60 degrees C) was applied in a double-blind, randomized study. No difference in pain scores was found. Sensory disturbances were seen in treatment and control patients. Freezing cannot be recommended for pain relief after hernia repair.

Pain after groin hernia repair

BACKGROUND

The purpose of the study was to provide a detailed description of postoperative pain after elective day-case open inguinal hernia repair under local anaesthesia.

METHODS

This was a prospective consecutive case series study. After 500 hernia operations in 466 unselected patients aged 18-90 years, pain was scored (none, light, moderate or severe) at rest, while coughing and during mobilization, daily for the first postoperative week and after 4 weeks. Pain scores were added together over the first postoperative week.

RESULTS

On days 1, 6 and 28, 66, 33 and 11 per cent respectively had moderate or severe pain while coughing or mobilizing. Total pain scores were higher while coughing or mobilizing than at rest (P < 0.001). Younger patients had higher total pain scores than older patients while coughing or mobilizing (P0< 0.01), but not at rest. No significant differences were found between types of surgery or hernia.

CONCLUSION

Pain remained a problem despite the pre-emptive use of opioids, non-steroidal anti-inflammatory drugs and local anaesthesia, irrespective of surgical technique.

[Organization and results of ambulatory surgery for inguinal hernia]

The results of a reorganization of surgery for inguinal hernias within a department of surgical gastroenterology were assessed concerning staff simplifications, feasibility, patient satisfaction, safety, complications and resources. Five hundred consecutive, elective, open operations for unilateral reducible inguinal hernias were performed in 466 patients under local anaesthesia in an ambulatory setup. One hundred and fourteen of the operations were for a recurrent hernia. The median age was 60 years (44-74 years as 25% and 75% quartiles). Two of the operations were converted to general anaesthesia. The patients were discharged 85 min (median) post-operatively, but 12 patients were not discharged on the same day. Bleeding or wound infections in need of treatment were seen postoperatively in 1.6% and 1.6%, respectively. All patients were given a postoperative questionnaires with a response rate of 95%, 89% of the respondents were satisfied with the whole procedure, 11% were dissatisfied. A reorganization of surgery for inguinal hernias to a standardized ambulatory setup induced staff simplifications and saved resources with a preserved high patient satisfaction, safety and a low complication rate.

The feasibility, safety and cost of infiltration anaesthesia for hernia repair. Hvidovre Hospital Hernia Group

Data from 400 consecutive elective ambulatory operations for inguinal hernia under unmonitored local anaesthesia with limited pre-operative testing were prospectively obtained by the use of standardised files and questionnaires to assess the feasibility, patient satisfaction and potential cost reductions for such a technique. The median age of the patients was 59 years, and 29 operations were performed in ASA group III patients. The median postoperative hospital stay was 85 min. Conversion to general anaesthesia was necessary only in two cases, and nine patients needed overnight admission. One week postoperative morbidity was low with one case of transient cerebral ischaemia and one case of pneumonia, but no case of urinary retention. On follow-up, 88% were satisfied with the procedure, including unmonitored local anaesthesia. The cost reduction was at least 160 Pounds per patient compared with general/regional anaesthesia. We conclude that elective inguinal herniorrhaphy may be performed routinely under unmonitored local anaesthesia with a low postoperative morbidity, a high satisfaction rate and significant cost reductions.

[Segmental "portal hypertension". A rare cause of severe tractable variceal bleeding]

We present a 33 year-old man with massive upper gastrointestinal bleeding caused by a rare form of segmental portal hypertension. The patient developed a pancreatic abscess, which caused an isolated thrombosis in the splenic vein and the development of pronounced collaterals and bleeding fundus varices. The patient underwent splenectomy and recovered quickly hereafter. The literature is sparse on severe bleeding complications due to acute pancreatitis. The present case emphasizes the importance of recognition of unusual manifestations of common clinical conditions.

[Recurrence of inguinal hernia: ambulatory surgery under local anesthesia]

In order to assess the feasibility of repair of a recurrent inguinal hernia in unmonitored local anaesthesia in an ambulatory set-up pain scores and data on patient satisfaction were obtained from 76 unselected patients after 79 consecutive operations. Median age was 63 years, and 25%- and 75% quartiles were 49 and 72 years respectively. All operations were conducted in local anesthesia. Three patients stayed in hospital overnight after the operation. Pain: After one, six and 28 days 27, 14 og 7% respectively had severe pain during function (cough and/or rising). Satisfaction: 82% were satisfied with ambulatory surgery in local anaesthesia, 82% were satisfied with the analgesic therapy (tenoxicam and methadone), but one third needed supplementary analgesics during the first week (acetaminophen was recommended). It is concluded, that ambulatory repair of a recurrent inguinal hernia in unmonitored local anaesthesia is a safe and cost effective alternative to operation in general or spinal anaesthesia.

Human thyroid epithelial cells cultured in monolayers. I. Decreased thyroglobulin and cAMP response to TSH in 12-week-old secondary and tertiary cultures

An in vitro system of secondary and tertiary cultures of human thyroid epithelial cells (TFECs) in monolayer is described. The function of the cells was evaluated by the second messenger cAMP and the end product thyroglobulin (Tg). The Tg production from the cells was measured in the supernatant by a newly developed enzyme-linked immunosorbent assay. The TFECs in secondary monolayer cultures had preserved the ability to produce Tg and cAMP despite lack of polarization. Furthermore, a preserved ability of TSH-stimulated production of Tg and cAMP in 12-week-old secondary and tertiary cultures was found. However, the Tg and cAMP levels decreased gradually with the age of the cultures. In the secondary culture the TSH-stimulated Tg production decreased from 253 ng/micrograms DNA (205-263) after 3 weeks to 18 ng/micrograms DNA (6-81), P < 0.001, n = 6 after 12 weeks and TSH-stimulated cAMP production from 660 pmol/micrograms DNA (500-840) to 60 (40-200), P < 0.001, n = 6. The decreased responsiveness of long-term cultures results in preference of short-term secondary cultures, which provide a more suitable experimental model for in vitro investigation of human thyroid cell functions.

Human thyroid epithelial cells cultured in monolayers. II. Influence of serum on thyroglobulin and cAMP production

An in vitro system of secondary cultures of human thyroid follicular epithelial cells in monolayer is described. The 72-h influence of serum and six supplements (thyrotropin, insulin, somatostatin, transferrin, hydrocortisone, glycyl-histidyl-lysine acetate) on growth and function in presence of 3-isobutyl-L-methyl-xanthine (IBMX) was investigated. The function of the cells was evaluated by production of the second messenger adenylate cyclase (cAMP) and the end product thyroglobulin (Tg). Growth was measured as the 3H-thymidine uptake of the cells. Three days of TSH-depletion preceeded the experiments. In presence of IBMX TSH stimulated cAMP production, while stimulation of Tg was only present in some cultures. In absence of IBMX TSH always stimulated the Tg production. The stimulation was independent of the presence of the other five investigated nutritional factors in physiological concentrations. TSH in concentrations from 0.1-10 U/1 stimulated the 72ih 3H-thymidine uptake of the cells. The TSH-stimulated production of Tg and cAMP decreased significantly with increasing concentrations of fetal calf serum (0-10%), (tau = 0.49, P < 0.001, n = 6-29 and tau = 0.75, P < 0.001, n = 6-29, respectively). Thus, serum as a complex, variable and not fully characterized mixture of hormones and growth factors was crucial to the attachment of the cells to the substrate, but inhibited differentiated functions of the human thyroid cells.

beta-cell function and glucose and lipid oxidation in Graves' disease

OBJECTIVE

Abnormal glucose metabolism with impaired glucose tolerance has been documented in patients with thyrotoxicosis but the pathogenesis is not fully understood. Therefore, the aim of the present study was to study the beta-cell function and the meal induced oxidative glucose and lipid metabolism in patients with thyrotoxicosis.

DESIGN

After an overnight fast the impact of hyperthyroidism on standard mixed meal induced glucose oxidation, lipid oxidation and beta-cell function was studied.

PATIENTS

Nine untreated patients with Graves' disease were compared to 9 age and weight matched healthy controls.

MEASUREMENTS

Glucose and lipid oxidation were studied by indirect calorimetry before and after the meal. The insulin secretion rate was calculated by the 'combined model' approach, after which the insulin secretion rates and the ambient glucose levels were cross-correlated. The slope of these regression lines was used as a measure of beta-cell sensitivity to glucose and denotes the insulin secretory capacity. beta-Cell function was further evaluated by measurement of proinsulin and its conversion intermediates. Glucoregulatory hormones were also measured. The findings were correlated to the thyroid hormone levels.

RESULTS

Fasting blood glucose and post-prandial glucose response were increased in patients (P < 0.01). The hyperthyroid patients displayed a 'dual' beta-cell defect: (a) inability to increase the insulin response appropriately to hyperglycaemia and (b) increased proinsulin levels both in the fasting state and in response to a meal. Indirect calorimetry showed increased lipid oxidation in the fasting state and at the end of the meal (P < 0.01). No difference in glucose oxidation was demonstrated in the fasting state but the post-prandial glucose oxidation was enhanced in the patients (P < 0.01). The adrenaline response was normal, whereas the noradrenaline response was impaired or absent in the patients. The thyroid hormone levels were significantly correlated to fasting levels of blood glucose, insulin, free fatty acids and lipid oxidation, but not to fasting C-peptide, glucose oxidation or catecholamines.

CONCLUSIONS

Untreated Graves' disease was associated with glucose intolerance due to quantitative as well as qualitative beta-cell defects. The lipid oxidation was increased in the fasting state and at the end of the meal; after the meal the increase in glucose oxidation was more pronounced in the patients. Thyroid hormones thus increased the oxidation but not by an increase in catecholamines. Indeed, the post-prandial sympathetic response was blunted.

[Spontaneous esophageal rupture during the 3rd trimester]

A 30-year-old woman, 35 weeks pregnant, developed spontaneous rupture of the oesophagus following severe vomiting, probably caused by treatment with Ritodrin (Utopar). The symptoms, diagnosis and treatment of spontaneous oesophageal rupture are discussed.

Thyroid stimulating immunoglobulins are not influenced by smoking in healthy subjects

In view of the increasing suggestion of an effect of cigarette smoking on thyroid disease and in particular Graves' ophtalmophathy we investigated thyroid stimulating immunoglobulins in relation to smoking habits in healthy subjects. No difference between smokers and non-smokers could be demonstrated, therefore, our study does not support the previously suggested altered immunologic surveillance of the thyroid in cigarette smokers.

Recruiting a community sample of adolescent children of alcoholics: a comparison of three subject sources

Although there has been substantial research interest in adolescent children of alcoholics, the generalizability and consistency of previous findings have been limited by the specialized nature of the research samples (e.g., treatment samples, school-based samples). However, attempting to address this problem by recruiting subjects from community sources raises a variety of sampling issues, including the comparability and accessibility of subjects from different sources. This article compares the recruitment rates and characteristics of families enrolled from three sources--DUI records, HMO records and telephone surveys. Implications for research on children of alcoholics are discussed.

Intranasal administration of insulin with phospholipid as absorption enhancer: pharmacokinetics in normal subjects

The pharmacokinetics of intranasal insulin containing a medium-chain phospholipid (didecanoyl-L-alpha-phosphatidylcholine) as absorption enhancer, was studied in normal volunteers by measuring plasma glucose, insulin, C-peptide, and glucagon. Eleven fasting subjects received 4 U insulin intravenously, 6 U subcutaneously, or three doses intranasally (approximately 0.3 U kg-1, 0.6 U kg-1, 0.8 U kg-1) in random order on five separate days. Intranasal insulin was absorbed in a dose-dependent manner with a mean plasma insulin peak 23 +/- 7 (+/- SE) min after administration. Mean plasma glucose nadir was seen after 44 +/- 6 min, 20 min later than following intravenous injection. Furthermore, intranasal administration of insulin resulted in a faster time-course of absorption than subcutaneous injection, with significantly reduced intersubject variation (p less than 0.001). Bioavailability for the nasal formulation was 8.3% relative to an intravenous bolus injection when plasma insulin was corrected for endogenous insulin production estimated by C-peptide. A dose-dependent suppression of C-peptide and stimulation of glucagon secretion occurred after intranasal administration of insulin. Nasal irritation from spraying was absent or slight.

[Requirement of hospital beds in connection with screening for colorectal cancer. The first 5-years of a randomized population survey]

Colorectal cancer puts a major burden on the hospital resources because of its frequency and demands for extensive surgery. Screening with Hemoccult-II detects the disease at an earlier stage in a number of persons. The possible influence upon length of hospital stay is investigated in a randomised trial of 61,938 persons between 45 and 74 years, 30,970 being invited to screening with Hemoccult-II bianually. The first screening was accomplished in 20,672 persons and 17,284 have completed three screenings from 1985 to 1990. The test was positive in 1%, and further examination (colonoscopy) among these revealed cancer in 74 and adenomas in 248 persons. The whole screening group contained 239 persons with cancer and 380 with adenomas, the figures among controls being 216 and 181, respectively. The excess hospital stay in the screening group was 487 days (7%), the major part being one-day admissions for colonoscopy. The average stay was shorter in the screening group and shortest among those with colorectal neoplasia being detected because of positive Hemoccult-II. Measurements of hospital stay included admissions for diagnosis, treatment and complications as well as recurrence within the first year of diagnosis. In conclusion, the excess use of hospital days introduced by screening was limited in the first five years. This will probably later disappear and become negative because of decreasing numbers of cancers in the screening group. Advanced cancers and admissions for possible colorectal cancer will also be less frequent in the screening group.

Prevalence of micro- and macroalbuminuria, arterial hypertension, retinopathy and large vessel disease in European type 2 (non-insulin-dependent) diabetic patients

The prevalence of micro- and macroalbuminuria was determined in Type 2 (non-insulin-dependent) diabetic patients, less than 76 years of age, attending a diabetic clinic during 1987. All eligible patients (n = 557) were asked to collect a 24-h urine sample for quantitative albumin analysis. Urine collections were obtained in 296 males and 253 females (96%). Normoalbuminuria were defined as urinary albumin excretion less than or equal to 30 mg/24 h (n = 323), microalbuminuria as 31-299 mg/24 h (n = 151), and macroalbuminuria as greater than or equal to 300 mg/24 h (n = 75). The prevalence of macroalbuminuria was significantly higher in males (20%) than in females (6%), while the prevalence of microalbuminuria was almost identical in males (26%) and females (29%). The prevalence of arterial hypertension increased with increased albuminuria, being 48%, 68%, and 85% in patients with normoalbuminuria, microalbuminuria, and macroalbuminuria respectively. Prevalence of proliferative retinopathy rose with increasing albuminuria, being 2%, 5% and 12% in patients with normoalbuminuria, microalbuminuria, and macroalbuminuria respectively. Prevalence of coronary heart disease, based on Minnesota coded electrocardiograms, was more frequent in patients with macroalbuminuria (46%) compared to patients with microalbuminuria (26%) and patients with normoalbuminuria (22%). Foot ulcers were more frequent in micro- and macroalbuminuric patients, being 13% and 25%, respectively, compared to 5% in patients with normoalbuminuria. This cross-sectional study has revealed a high prevalence of microalbuminuria (27%) and macroalbuminuria (14%) in Type 2 diabetic patients. Patients with raised urinary albumin excretion are characterized by obesity, elevated haemoglobin Alc, increased frequency of arterial hypertension, proliferative retinopathy, coronary heart disease and foot ulcers.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of maternal thyroid autoantibodies and post-partum thyroiditis on the fetus and neonate

Thirty-five pregnant women with thyroid antibodies were followed during pregnancy and 12 month post partum. Twenty antibody-negative women served as controls and none of these developed postpartum thyroiditis in contrast to 12 of 35 antibody-positive women. Umbilical cord blood was collected at birth for measurements of thyroid antibodies, and blood samples for measurements of thyroid hormones were obtained at 5 and 30 days of age in the infants together with a clinical examination. There were no differences between the infants of antibody-positive and -negative mothers or the infants of those who developed postpartum thyroiditis with regard to gestational age at birth, birth weight, birth length or Apgar score, and no difference in thyroid function of the mothers and infants. However, serum TSH level was significantly higher in mothers who subsequently developed postpartum thyroiditis. Furthermore, a significantly lower growth during the first 30 days of life was observed in their infants. Our observations suggest a relationship between the maternal thyroid status in pregnancy and early growth in infancy.

Influence of interleukin 6 on the function of secondary cultures of human thyrocytes

Interleukin 6 has been suggested as second mediator of the effects of interleukin 1 in some cell systems. Interleukin 1 has previously been shown to inhibit the function of human thyrocytes in secondary cultures. We have therefore studied the influence of interleukin 6 (10(-1)-5.10(7) U/l) on the function of thyroid cells. Recombinant interleukin 6 slightly inhibited the production of cAMP, but failed to influence the production of thyroglobulin or the DNA content. Endotoxins (lipopolysaccharides from Salmonella abortus equi or Yersinia enterocolitica) had only a slightly inhibitory effect on thyroid cell functions, and the effect of interleukin 6 could not by itself be explained by endotoxin contamination. The effect of interleukin 6 did not mimic effects on thyroid cells afforded by recombinant interleukin 1 alpha and 1 beta. Furthermore, antibodies to interleukin 6 were not able to inhibit the interleukin 1 beta-induced inhibition of thyroid cell functions. In conclusion, it is unlikely that interleukin 6 by itself mediates the biological effects of interleukin 1 on human thyroid cells.

Thyroid function and autoimmune manifestations in insulin-dependent diabetes mellitus during and after pregnancy

Insulin-dependent diabetes is associated with other autoimmune diseases and subclinical hypothyroidism has been reported in pregnant diabetic women. We studied the thyroid function of 85 women with diabetes during pregnancy and after delivery, as well as various autoantibodies. During pregnancy, thyroid microsomal antibodies were present in 17/85, antibodies against thyroid peroxidase in 16/85, thyroglobulin antibodies in 2/85, parietal cell antibodies in 23/85, adrenal antibodies in 4/77, rheumatoid factor in 15/85, and thyroid-stimulating antibodies in 43/85. Presence of antibodies was not combined with thyroid dysfunction, but TSH and HbA1c was increased (p less than 0.005) in women with thyroid antibodies. The gestational age of the infants was lower (p less than 0.01) in women with positive thyroid-stimulating antibody titre, whereas the ponderal index was only lower in those with peroxidase antibodies (p less than 0.05). After delivery, microsomal and peroxidase antibodies were positive in 10 (17.5%) of 57 patients followed. Six women developed postpartum thyroiditis (10.5%), of whom 5 were positive for both microsomal and peroxidase antibodies; two of those showing a hyperthyroid phase also had positive thyroid-stimulating antibody titre. We conclude that autoantibodies occur with increased incidence in pregnant diabetic women. Thyroid antibodies are related to a slightly reduced thyroid capacity and involve a high risk of postpartum thyroiditis. Further, thyroid antibodies seem to influence the nutritional status of the infant.

Interleukin-6 production by thyroid epithelial cells. Enhancement by interleukin-1

Interleukin-1 is a potent inhibitor of thyroglobulin and cAMP production in human thyroid cells and the inhibitory effect is enhanced by tumor necrosis factor-alpha and interferon-gamma. In the present study secondary cultures of human thyroid cells produced interleukin-6 and the production was significantly increased after exposure of the cells to recombinant interleukin-1 alpha and -1 beta. This increase was dose-dependent and concomitant of the IL-1 induced decrease in cAMP and thyroglobulin production. Both tumor necrosis factor-alpha and -beta also augmented interleukin-6 production, but less potently than interleukin-1. Interferon-gamma did not affect the production of interleukin-6. The rat thyroid cell line FRTL-5 produced interleukin-6 spontaneously, and the production was enhanced after addition of recombinant interleukin-1 beta. A pathogenetic role of interleukin-6 in autoimmune thyroid disease is suggested.

Immunoglobulins of patients recovering from Yersinia enterocolitica infections exhibit Graves' disease-like activity in human thyroid membranes

Substantial evidence suggests a link between infections with Yersinia enterocolitica (YE) and Graves' disease. We have now examined the sera of 72 patients recovering from YE infection for immunoglobulins that interacted with the TSH receptor in human thyroid membranes. Compared with controls, in concentrations between 1 and 4 mg/mL, patient IgG produced a significant, concentration-dependent inhibition of TSH binding (p less than 0.001) and stimulation of adenylate cyclase activity (p less than 0.005-0.05). Whereas IgG from normal individuals caused no stimulation of adenylate cyclase, IgG from controls caused some concentration-dependent displacement of TSH, as previously reported. However, IgG from convalescents of YE infections was significantly more potent than normal IgG in reducing the binding of TSH to the membrane. Thus, at each examined concentration, YE patients' IgG displaced more TSH than IgG from normal controls. For each milligram per milliliter increment of IgG in the assay, patients' IgG caused a 10.2% inhibition of TSH binding (r -0.90, p less than 0.001), significantly greater than that seen with normal IgG (p less than 0.02). The present studies provide the first demonstration that IgG of patients recovering from YE infections react with the human TSH receptor. The antibodies presumably are produced against the TSH-binding protein present in YE. However, in view of lack of evidence for thyroid dysfunction in the sera of patients recovering from yersiniosis and the presence of TSH-binding proteins in other bacteria, we postulate that infection with YE is neither necessary nor sufficient to cause thyroid autoimmune disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Adenomas and hyperplastic polyps in screening studies

A survey is given of colorectal polyps detected in a prospective randomized screening study with the fecal occult blood test. It is demonstrated that colonoscopy in persons with positive Hemoccult-II tests results in detection of and removal of a higher number of adenomas than among controls. The strategy may, therefore, possibly be followed by a reduction of the incidence of colorectal cancer. Screen-detected adenomas were most often in males and were larger than among controls; they were most often in the sigmoid colon, whereas the rectum was the most frequent location for adenomas in controls. Eight percent of persons with screen-detected adenomas had some symptoms, which could be referred to adenomas, in contrast to 50% among controls. Hyperplastic polyps served as markers for adenomas in persons with positive Hemoccult-II as well as in controls with adenomas detected by colonoscopy; however, most persons with adenomas had no hyperplastic polyps. Endoscopic polypectomy did not result in any severe complications, but surgical removal in 2 of 22 patients proved fatal. The results presented are compared with those of other prospective randomized trials. The optimistic view--that the incidence of cancer may be reduced by polypectomy in persons with positive Hemoccult-II tests--stresses the importance of securing optimal colonoscopy service.

BRL 24924, a 5-hydroxytryptamine type 3 antagonist, and gastric secretion of acid and pepsin in vivo

BRL 24924, a specific 5-hydroxytryptamine type 3 (5-HT3) receptor antagonist, was evaluated for effects on gastric secretion of acid and pepsin and possible influences on the effects of serotonin on gastric secretion. Experiments were carried out in conscious dogs with a gastric fistula during a background stimulation of gastric secretion by continuous infusions of pentagastrin, bethanechol or histamine. During infusion of pentagastrin or histamine, BRL 24924, by itself, influenced gastric secretion with stimulation during a low potent background stimulation and inhibition during a potent background stimulation. A serotonin-counteracting effect of BRL 24924 on gastric secretion was found only during infusion of pentagastrin. The secretory stimulation attained by BRL 24924 could be blocked by atropin suggesting a cholinergic mechanism--5-HT4 receptors? The inhibitory effects on gastric secretion and the serotonin-counteracting effects of BRL 24924 are supposed to be via 5-HT3 receptors.

Intra-arterial versus intravenous administration of gastric secretory inhibitors in conscious dogs. Effects of somatostatin, serotonin and isoprenaline on acid and pepsin secretion

The purpose of the present study was to evaluate the effects of both intra-arterial and intravenous infusions of somatostatin, serotonin (5-hydroxytryptamine) and isoprenaline beta 1- + beta 2-adrenoceptor agonist) on gastric acid and pepsin secretion in conscious dogs with a gastric fistula. The drugs mentioned have been examined earlier for effects on gastric secretion in vivo during intravenous infusions and these effects could be hampered by the possible indirect mechanism of action as well as the different kinetics of metabolism. A catheter (vascular access port) allowed repeatedly gastric intra-arterial infusions. Somatostatin and serotonin possessed inhibitory effects on gastric acid and pepsin secretion and were without significant differences between the analyzed ways of administration. Intra-arterial infusion, isoprenaline possessed less potent inhibitory effects on gastric secretion: the effects were significant for pepsin secretion but were nonsignificant for acid secretion. The results suggest the mechanism of action of isoprenaline, somatostatin and sertonin to diverge, and for somatostatin and serotonin it was independent of the route of administration.

Anti-thyroid peroxidase antibodies in thyroid disorders and non-thyroid autoimmune diseases

A new commercial method for measurement of anti-thyroid peroxidase (anti-TPO DYNOtest, Henning, Berlin) was evaluated in normal subjects and in patients with autoimmune thyroid and non-thyroid diseases, and compared to an immune fluorescence method for measurement of anti-microsomal antibodies (MicAb), and a radioimmunological method for quantifying thyroglobulin antibodies (TgAb). The majority of normal subjects had anti-TPO levels below 52 U/ml and patients with Hashimoto's thyroiditis had levels above 200 U/ml, with a good correlation to MicAb. In other autoimmune thyroid diseases the correlation was less pronounced. In non-thyroid autoimmune diseases MicAb showed falsely positive reactions in the presence of other autoantibodies, e.g. mitochondrial antibodies. The present study indicates that the anti-TPO method should probably replace measurements of MicAb for routine clinical use, thus providing a sensitive, precise, antigen specific method with the ability to reveal quantitative fluctuations. The study also indicates that TgAb could be abolished in routine diagnosis of autoimmune thyroid diseases and be reserved for special clinical situations, research purposes as well as measurement in sera before evaluation of serum thyroglobulin levels.

Differential effects of interleukin 1 alpha and 1 beta on cultured human and rat thyroid epithelial cells

The effects of human recombinant interleukin 1 alpha (20 pg/1-2 micrograms/l) and 1 beta (200 pg/1-20 micrograms/l) on two systems of thyroid cells have been compared. The thyroglobulin and cAMP secretion and the DNA content of human thyroid cells cultured in monolayer and of continuously grown rat thyroid cells, Fischer rat thyroid cell line have been studied. The growth of the rat thyroid cell line was inhibited by interleukin 1 beta (20 ng/1-20 micrograms/l), but not by interleukin 1 alpha. None of the cytokines changed the cAMP production of the rat thyroid cells. In contrast, both cAMP production and thyroglobulin secretion were inhibited dose-dependently by the cytokines in human thyroid cells in secondary cultures. These results caution the interpretation and extrapolation of changes induced by interleukin 1 from one cell system to the other.