Clinical pathology interpretation in geriatric veterinary patients

Routine monitoring of clinicopathologic data is a critical component in the management of older patients because blood and urine testing allows the veterinarian to monitor trends in laboratory parameters, which may be the early indicators of disease. Laboratory profiling often provides an objective and sensitive indicator of developing disease before obvious clinical signs or physical examination abnormalities are observed. The primary key to the power of this evaluation is that the data are collected year after year during wellness checks and are examined serially. Chronic renal failure, chronic active hepatitis, canine hyperadrenocorticism, diabetes mellitus, and feline hyperthyroidism were reviewed and expected laboratory findings are summarized.

[Neurobiological consequences of child sexual abuse: a systematic review]

OBJECTIVE

The results of several studies suggest that there is a critical timeframe during development in which experiences of maltreatment and sexual abuse may lead to permanent or long-lasting neurobiological changes that particularly affect the hypothalamus-pituitary-adrenal axis response. The aim of the present study was to provide an updated review on the main neurobiological consequences of child sexual abuse.

METHODS

We selected articles published between January 1999 and January 2010 in English or Spanish that focused on the neurobiological consequences of child sexual abuse available through Medline, Scopus and Web of Science. We also examined the references in published articles on the consequences of sexual victimization in childhood.

RESULTS

In this review we included 34 studies on neurobiological consequences, indicating different kinds of effects, namely: neuroendocrine, structural, functional and neuropsychological consequences, which affect a large number of victims.

CONCLUSIONS

The existing body of work on the neurobiological consequences of maltreatment shows the need to consider maltreatment and child sexual abuse as health problems that affect different areas of victims' lives, which would in turn favor the development of intervention and treatment programs that take these multiple effects into account.

Hormonanalysen im Urin

Hormonanalysen im Urin werden vorwiegend angewendet, um Störungen des Steroidhormonmetabolismus, um eine erhöhte Produktion biogener Amine und um nicht invasiv humanes β-Choriogonadotropin als Proteinhormon als Indikator einer Schwangerschaft nachweisen zu können. Diese Untersuchungen müssen gegebenenfalls von Plasma-/ Serumbestimmungen komplementiert werden. Klinische Daten einschließlich der aktuellen Medikation sowie das Urinkreatinin als Bezugsgröße sind unabdingbar zur seriösen Beurteilung einer Urinuntersuchung. Die wichtigsten Krankheitsbilder, die mittels Steroidhormonanalyse untersucht werden können, sind der Exzess eines typischen oder atypischen mineralokortikoid wirksamen Steroidhormons, die Hormonaktivität eines Nebennieren- oder ovariellen Tumors, Akne unklarer Ätiologie, Hirsutismus, ein PCO-, ein adrenogenitales oder ein vermutetes Cushingsyndrom. Die Untersuchung biogener Amine wird durchgeführt bei Verdacht auf eine sekundäre bzw. therapierefraktäre Hypertonie, bei Auftreten phäochromozytom- oder paragangliom-assoziierter Symptome oder Verdacht auf einen serotininproduzierenden Tumor. Bei Kindern steht die Suche nach genetisch determinierten Erkrankungen im Vordergrund.

Urinary steroid measurements in some endocrine and psychiatric diseases

In 1990, the worldwide accepted Shackleton method, which provides a possibility of determining the steroid metabolites from urine, was adopted in our laboratory. The procedure is very useful in the diagnosis of different endocrine diseases and in the recognition of dysfunction or absence of enzymes with an important role in steroid metabolism, and it gives possibility to control the treatment in patients with these diseases. Besides the proximate clinical application, the method gives a convenient tool to study the steroid background of these disorders, helping us understand the mechanism of their development. In the last few years, we have examined the steroid profile of patients with hair (androgen alopecia /AA/, effluvium /E/), psychiatric problems (major depression /MD/, eating disorders /EDS/, especially anorexia nervosa and bulimia) and osteoporosis (OP). In all of the examined hair loss diseases, the levels of main androgen metabolites were increased, and elevated 5alpha-reductase activity were found. We could observe the alteration of the activity of 11beta-hydroxysteroid dehydrogenase (11beta-HSD) enzyme and marked gender differences in the changes of the steroid metabolism in patients with major depression (MD). In women with OP, the significantly decreased level of certain metabolites points to the role of testosterone, androstenedione and DHEA in postmenopausal bone loss in women. Our experiences contribute to the knowledge of the nature and steroid background of some endocrine and psychiatric diseases.

Endocrine abnormalities in patients with central serous chorioretinopathy

PURPOSE

To investigate and to identify endocrine and metabolic abnormalities in patients with central serous chorioretinopathy (CSCR).

DESIGN

Observational case series.

PARTICIPANTS

Twenty-four patients with CSCR.

METHODS

Serum and urinary catecholamines, glucocorticoids, mineralocorticoids, serum testosterone, and thyroid-stimulating hormone (TSH) function were evaluated prospectively.

RESULTS

Fifty percent (12 of 24) of patients with active acute CSCR showed elevated 24-hour urine cortisol or tetrahydroaldosterone levels. Serum aldosterone levels were low in 7 of 24 (29.1%) patients. Single morning plasma catecholamine levels were elevated in 7 of 24 patients, although 24-hour urine metanephrines (catecholamine breakdown products) were normal. Serum testosterone and TSH levels were normal in nearly all (23 of 24) patients.

CONCLUSION

Many patients with acute CSCR have elevated 24-hour urine corticosteroids, which may contribute to the pathogenesis of the disorder. Endogenous mineralocorticoid dysfunction is a newly described feature of CSCR.

Endocrinological disorders. Focusing on melatonin's interactions

BACKGROUND

The interaction of melatonin to sterility and anovulation as well as related hormonal disorders has not been sufficiently examined yet. We set out to investigate the interaction between melatonin and hyperprolactinemia, hyperandrogenemia, hypothyreosis and obesity in premenopausal females.

METHODS

We evaluated the overnight urinary excretion of 6-sulfatoxymelatonin (6-SMT) in a group of 155 women using a radioimmunoassay.

RESULTS

Melatonin levels in patients with hyperprolactinemia and hyperandrogenemia with normal body mass index are significantly higher compared to matched controls. Obese females without hormonal disorders showed statistically lower 6-sulfatoxymelatonin levels and in hypothyreotic females we found no difference in 6-sulfatoxymelatonin levels compared to controls.

CONCLUSION

Melatonin plays an important role in patients with hormonal disorders such as hyperprolactinemia and hyperandrogenemia. Melatonin should be prescribed restrictively in all sterile patients. In patients with untreated hypothyreosis or obesity, melatonin seems to play a minor part; in those with hyperprolactinemia and hyperandrogenemia additionally to standard sterility treatment light therapy may improve the outcome.

Maximizing efficacy of endocrine tests: importance of decision-focused testing strategies and appropriate patient preparation

The efficacy of endocrine tests depends on the choice of tests, the preparation of the patients, the integrity of the specimens, the quality of the measurements, and the validity of the reference data. Close dialogue among the clinicians, the laboratory, and the patients is a key factor for optimal patient care. The characteristics of urine and plasma samples and the advantages and limitations of paired test measurements are presented. The importance of test sequence strategies, provocative or inhibitory procedures, and elimination of drug interferences is illustrated with four cases involving Cushing syndrome, pheochromocytoma, primary aldosteronism, and hypercalcemia. For each of these scenarios, key clinical issues are highlighted, along with discussions of the best test strategies, including which medications are likely to interfere. The importance of targeting laboratory tests to answer well-focused clinical decisions is emphasized. The roles of some time-honored provocative procedures are questioned in light of more sensitive and specific analytic methods. The importance of decision-focused analytical tolerance limits is emphasized by demonstrating the impact of analytic bias on downstream medical resource utilization. User-friendly support systems to facilitate the implementation of test strategies and postanalytic tracking of patient outcomes are presented as essential requirements for quality medical practice.

Heavy metals and fertility

Heavy metals have been identified as factors affecting human fertility. This study was designed to investigate whether the urinary heavy metal excretion is associated with different factors of infertility. The urinary heavy metal excretion was determined in 501 infertile women after oral administration of the chelating agent 2,3-dimercaptopropane-1-sulfonic acid (DMPS). Furthermore, the influence of trace element and vitamin administration on metal excretion was investigated. Significant correlations were found between different heavy metals and clinical parameters (age, body mass index, nationality) as well as gynecological conditions (uterine fibroids, miscarriages, hormonal disorders). Diagnosis and reduction of an increased heavy metal body load improved the spontaneous conception chances of infertile women. The DMPS test was a useful and complementary diagnostic method. Adequate treatment provides successful alternatives to conventional hormonal therapy.

[Average daily values of the isotopic carbon composition in expired air and urea in human urine in normal states and in some endocrine disorders]

Daily average carbon isotope composition of CO2 of expired air and urine urea in patients being in different hormonal-metabolic states was determined. The observations were carried out under conditions of clinic to provide standard diet, and the same daily and food taking regimes. In all persons, a substantial increase enrichment in 12C of CO2 of expired air (by 3-6%) and 13C of urine urea (by 3-5%) relative to carbon of food was revealed. Marked variations in these characteristics in norm, on starvation and in endocrine pathologies were found. A relationship between the carbon isotope composition and the metabolic shifts characterizing the deviations of the studied functional states from norm was established. The changes in the isotope characteristics and their relation to the hormonal-metabolic status of the organism are interpreted in terms of the model for cell fractionation of carbon isotopes proposed earlier.

Effects of disease on the results of diagnostic tests for use in detecting hyperadrenocorticism in dogs

The purpose of the study reported here was to assess 3 commonly used screening tests for hyperadrenocorticism (low-dose dexamethasone suppression test, ACTH stimulation test, and urinary cortisol:creatinine ratio) in dogs with various diseases other than those of the adrenal glands (nonadrenal diseases). A group of 100 dogs was studied: 59 dogs with nonadrenal disease, 21 clinically normal dogs, and 20 dogs with pituitary-dependent hyperadrenocorticism. Of 59 dogs with nonadrenal disease, 20 (34%) had high baseline cortisol concentration (greater than reference range limits), and 22 (38%) and 33 (56%) had inadequate serum cortisol suppression at 4 and 8 hours, respectively, after administration of a low dose of dexamethasone. Compared with clinically normal dogs, dogs with nonadrenal disease had significantly (P < 0.05) higher mean serum cortisol concentration at 4 and 8 hours after administration of a low dose of dexamethasone; however, significant differences were not detected between the mean cortisol concentration at 8 hours after administration for dogs with nonadrenal disease and for dogs with hyperadrenocorticism. After ACTH stimulation, only 8 of 59 (14%) dogs with nonadrenal disease had high serum cortisol concentrations. Significant differences did not exist after ACTH stimulation between mean cortisol concentration of clinically normal dogs and that of dogs with nonadrenal disease. Of 59 dogs with nonadrenal disease, 45 (76%) had a high urinary cortisol:creatinine ratio. When compared with clinically normal dogs, dogs with nonadrenal disease had a significantly higher mean urinary cortisol:creatinine ratio, but significant differences did not exist between the mean urinary cortisol:creatinine ratio of dogs with nonadrenal disease and that of dogs with hyperadrenocorticism.(ABSTRACT TRUNCATED AT 250 WORDS)

Endogenous inhibitors of 11 beta-hydroxysteroid dehydrogenase in hypertension

Exogenous inhibitors of 11 beta-hydroxysteroid dehydrogenase (e.g. glycyrrhetinic acid, a constituent of licorice) raise blood pressure by allowing cortisol to activate mineralocorticoid receptors. Endogenous 11 beta-dehydrogenase inhibitors called glycyrrhetinic acid-like factors (GALFs), have been extracted from urine. Increased GALFs could explain the impairment of 11 beta-dehydrogenase in essential hypertension and ectopic ACTH syndrome. We extracted urine on Sep-Paks and quantified GALFs by their inhibition of 11 beta-dehydrogenase bioactivity in microsomes from rat liver. GALFs have no diurnal rhythm and were no different after dexamethasone treatment, in patients with low ACTH, on in 4 patients with ectopic ACTH secretion. In 79 subjects, GALF excretion did not correlate with blood pressure. In 17 subjects, GALF excretion did not correlate with indices of mineralocorticoid receptor activation on 11 beta-dehydrogenase activity. We conclude that GALFs are not ACTH dependent and have no measurable effect on 11 beta-dehydrogenase in vivo. In hypertension associated with impaired 11 beta-dehydrogenase activity GALFs are unlikely to play a pathophysiological role.

Relative density of urine: methods and clinical significance

The physical properties and chemical composition of urine are highly variable and are determined in large measure by the quantity and the type of food consumed. The specific gravity is the ratio of the density to that of water, and it is dependent on the number and weight of solute particles and on the temperature of the sample. The weight of solute particles is constituted mainly of urea (73%), chloride (5.4%), sodium (5.1%), potassium (2.4%), phosphate (2.0%), uric acid (1.7%), and sulfate (1.3%). Nevertheless, urine osmolality depends only on the number of solute particles. The renal production of maximally concentrated urine and formation of dilute urine may be reduced to two basic elements: (1) generation and maintenance of a renal medullary solute concentration hypertonic to plasma and (2) a mechanism for osmotic equilibration between the inner medulla and the collecting duct fluid. The interaction of the renal medullary countercurrent system, circulating levels of antidiuretic hormone, and thirst regulates water metabolism. Renin, aldosterone, prostaglandins, and kinins also play a role. Clinical estimation of the concentrating and diluting capacity can be performed by relatively simple provocative tests. However, urinary specific gravity after taking no fluids for 12 h overnight should be 1.025 or more, so that the second urine in the morning is a useful sample for screening purposes. Many preservation procedures affect specific gravity measurements. The concentration of solids (or water) in urine can be measured by weighing, hydrometer, refractometry, surface tension, osmolality, a reagent strip, or oscillations of a capillary tube. These measurements are interrelated, not identical. Urinary density measurement is useful to assess the disorders of water balance and to discriminate between prerenal azotemia and acute tubular necrosis. The water balance regulates the serum sodium concentration, therefore disorders are revealed by hypo- and hypernatremia. The disturbances are due to renal and nonrenal diseases, mainly liver, cardiovascular, intestinal, endocrine, and iatrogenic. Fluid management is an important topic of intensive care medicine. Moreover, the usefulness of specific gravity measurement of urine lies in interpreting other findings of urinalysis, both chemical and microscopical.

Immunoreactive somatomedin B (RIA-B) in the circulation of healthy adults and patients with endocrine disorders

The serum and cerebrospinal fluid (CSF) levels of immunoreactive somatomedin B (RIA-B) were examined throughout life in healthy adult humans. A significant decline in serum RIA-B was observed in subjects over 60 years of age. No significant diurnal, daily, or monthly serum variation was observed in healthy subjects aged 20-60 years. However, women taking oral contraceptives had elevated RIA-B values. No significant decline in CSF RIA-B was observed in subjects over 60 years of age. A significantly lower level of RIA-B in CSF was observed in subjects sampled at 20.00 h compared to subjects sampled in the morning. A significant decline in serum RIA-B was observed in patients with hypopituitarism and diabetes mellitus and a significant elevation of serum RIA-B levels was observed in patients with hyperthyroidism. CSF RIA-B was significantly elevated in patients with Cushing's syndrome.

[Value of the assay of urinary gonadotropins in pediatric endocrinology]

An assay for urinary gonadotropins (UG) performed after acetone extraction is presented. This dosage was performed either on a sample of the 24 assay urine, or on the fractionated 12 hr/12 hr urines (night/day) in normal children whose ages ranged from 2 to 20 years and in children presenting with various endocrine diseases (on about 2,000 urine samples). Normal values were established according to sex and stage of puberty. In boys, the lack of overlap between values of LH (UI/24 hr) observed in stage I (prepubescent, 9-13 yrs) and those observed in stage II represents an obvious biological marker of the onset of puberty. The night/day ratio of LH also increases close to puberty, reflecting the onset of the well-known night secretion of LH, at the time of the first stages of puberty. In girls, the preferential increase in FSH is the best criterion for the onset of puberty. In children with endocrine diseases, assay for UG/24 hr is a valuable parameter of the gonadotropic function allowing 1. to separate delayed puberty from hypogonadotropic hypogonadism; 2. to confirm a diagnosis of precocious puberty and 3. to control a treatment with LHRH analogous.

Lack of specificity of cortisol determinations in human urine

The specificity of 7 different binding proteins (4 antibodies and 3 transins) was investigated in human urine. Pregnant and nonpregnant urine samples were extracted and chromatographed, and values were compared before and after chromatography. Without chromatography, all methods grossly overestimated the amount of cortisol present. Four methods gave higher values than the other 3 even after chromatography, possibly due to cross-reactivity with 20-dihydrocortisone which coelutes in part with cortisol. Interference also occurred in both the less polar and the more polar regions of the chromatograms with all assay systems. Values for a series of 20 urines were closely similar for the RTAs but widely divergent for the RIAs. Close correlations were found for all of the RTAs with each other and with the RIAs if simple methylene chloride extraction was used. A high degree of correlation was also found between extracted and unextracted urine values in the 4 systems studied. Cortisol values by RTA (dog transcortin) after chromatography on Sephadex LH-20 gave mean values of 20.5 +/- 9.7 microgram/day in men, 14.0 +/- 5.7 micrograms/day in cycling women, and 38.0 +/- 24.5 micrograms/day in women in late pregnancy (n = 6 in each group). It is concluded that there is no simple practical method currently available for true cortisol in urine, but that the measurement of adrenal corticoids in urine can afford an accurate reflection of adrenocortical function provided there is no gross metabolic abnormality present and that the normal range is carefully established for each particular method used.

Oligomenorrhea in adolescent girls

Forty-two patients ages 15 to 20 years (average 17.3 years) were evaluated for oligomenorrhea. Group I consisted of 19 patients with evidence of androgen excess (hirsutism, clitoromegaly, acne); and Group II included 23 patients without evidence of androgen excess. Sixteen of the 19 patients in Group I had elevated serum LH and normal FSH values. Serum total testosterone concentration was elevated in 12 patients and free T was elevated in one additional patient. In nine patients urinary 17KS excretion was elevated and dexamethasone suppressible. For the purpose of treatment, patients in Group I were divided into three subgroups: IA, polycystic ovary syndrome--12 patients; IB, adrenal block--two patients; IC, combined adrenal and ovarian hyperandrogenism--five patients. Among the 23 Group II patients, four had persistently elevated serum LH and normal FSH values, suggesting PCO; three had menopausal levels of LA and FSH; one had hyperprolactinemia and a depressed floor of the pituitary sella; and the remaining 15 patients had low to normal serum levels of LH and FSH, consistent with hypothalamic suppression. Guidelines for the diagnosis and treatment of adolescents with oligomenorrhea are discussed on the basis of these findings.

Comparison of estimates of gonadotropin levels by isolated blood samples, integrated blood concentrations, and timed urinary fractions

Gonadotropin levels in isolated blood samples, integrated plasma concentrations (IC), and timed urinary collections have been compared in 5 males with delayed puberty and 7 normal adult males. There was a significant correlation between urinary levels in 24-h collection and those in each of four shorter timed collections for both LH and FSH. Similarly, 24-h integrated plasma concentration and 4-h (0800--1200 h) integrated plasma concentration obtained on 10 additional subjects showed significant correlation. The 4-h integrated plasma concentrations correlated with single blood samples or the mean of three samples obtained at 0800, 1200, and 1600 h. These 4-h plasma samples also correlated significantly with all urine collections for FSH but only with the 2200--0800 h urine collection for LH. The study suggests that LH and FSH levels in urine samples collected over several hours correlate with 24-h urinary excretion and that levels in single blood samples estimate the 24-h plasma integrated concentration.

Method for screening urinary steroids by gas chromatography

Numerous methods are available for measuring urinary steroids in evaluating endocrine dysfunctions. Measurements of these particular steroids, or groups of them, usually involve tedious isolation methods, corrections for interferences and losses of the steroid, and (or) expensive reagents. We show how gas-liquid chromatography provides a rapid, sensitive, and direct method for several steroid metabolites in urine. Androstanol, androsterone, etiocholanolone, dehydroisoandrosterone, pregnanediol, pregnanetriol, 11-keto-17-ketosteroids, and the 11beta-hydroxy-17-ketosteroids can be identified and quantified.

Demonstration of antibodies to testicular basement membrane by immunofluorescence in a patient with multiple primary endocrine deficiencies

Circulating antibodies directed against testicular basement membrane and germinal cells are demonstrated in a patient with multiple primary endocrine gland deficiencies involving the thyroid, adrenals, testes, and pernicious anemia. Testicular biopsy revealed focal destruction of seminiferous tubules and interstitial fibrosis. The tubular basement membranes showed sharply positive immunofluorescence when stained with the patient's FITC conjugated gamma globulins.

Plasma and urinary luteinizing hormone levels in the diagnosis of endocrine disease

The diagnostic value of measurements of plasma and urinary luteinizing hormone (LH) has been studied in 209 patients with endocrine disease. In 44 patients puberty was either delayed or had failed to occur. In those with chromosomal abnormalities the LH levels were often within the normal range, whereas those with a pituitary cause usually had low levels. In boys with delayed puberty plasma LH levels rose before physical changes occurred and had prognostic value. In patients with later gonadal failure, men with impotence or infertility, and women with secondary amenorrhoea LH assays proved of little value, although in one case a premature menopause was suspected and six patients with anorexia nervosa had low LH levels.Sixty patients with disorders of the hypothalamicpituitary area were studied. Levels of LH were measured and considered in relation to the other anterior pituitary hormones. Impairment of LH secretion was one of the first effects on hormone production of disease affecting this area, and this was, of course, most readily detected in postmenopausal women.The normal ranges of both plasma and urine LH are wide and there seems to be considerable day-to-day variation, especially of urinary output. Several samples should, therefore, be measured if therapeutic decisions are involved.

Polyostotic fibrous dysplasia with raised steroid excretion

Four female patients with polyostotic fibrous dysplasia and sexual precocity are presented in detail. Two of the patients suffered spontaneous fracture of the femur. Steroid excretion was raised in 3 out of the 4 girls, but excretion of total urinary gonadotrophins was normal in 2 of them.