Sleep apnoea in treated acromegaly: relative frequency and predisposing factors.

OBJECTIVES: Sleep apnoea is common in active acromegaly. It is associated with increased morbidity and mortality but can be treated effectively. The objective of this study was to determine the largely unknown relative frequency of, and the predictive factors for, sleep apnoea in treated acromegalic patients. DESIGN: Retrospective cohort study. SETTING: Tertiary referral hospital. PATIENTS: Fifty-four of 100 patients with treated acromegaly. If sleep apnoea had been diagnosed before acromegaly, the patient was excluded. MEASUREMENTS: Sleep studies (using the MESAM-4 device measuring oxyhaemoglobin saturation, heart rate, snoring sounds and body position to determine presence and severity of sleep apnoea); GH and IGF-I levels; body mass index, neck and index-finger circumference; daytime symptoms of sleep apnoea, duration of acromegaly before treatment, shoe and neck-size difference since beginning of acromegaly; age, sex and treatment modes of acromegaly. RESULTS: The relative frequency of sleep apnoea was 39% in the 54 patients with sleep studies and at least 21% in the entire study population of 100 patients. In patients with sleep apnoea, statistically significant higher values were observed for GH (P = 0.002), IGF-I (P = 0.029), age (P = 0.014) and neck circumference (P = 0.016). An index-finger circumference of > or = 8.5 cm was associated with a significantly higher desaturation index (P = 0.012, Mann-Whitney U-test). Adenomectomy had been performed significantly less frequently in patients with sleep apnoea (P < 0.001, X2 test). The body mass index was non-significantly higher in the patients with sleep apnoea. CONCLUSIONS: The relative frequency of sleep apnoea in patients with treated acromegaly is at least 21%. Parameters of predictive value for the presence of sleep apnoea in this population are neck and index-finger circumference as measures of soft tissue hypertrophy, age, GH and IGF-I levels, and whether or not operative therapy was applied.

LINAC-radiosurgery (LINAC-RS) in pituitary adenomas: preliminary results.

From 8/90 through 4/94, 32 consecutive patients with recurrent pituitary macroadenoma (PA) were treated with LINAC-RS after tumour resection and/or radiotherapy. Single doses ranging from 8-20 Gy (median: 14.5 Gy) were applied in 14 patients with acromegaly, 5 with Cushing's disease, 4 with Nelson tumours, 5 with prolactinomas and in 4 with nonfunctioning PA's. Retrospective analysis of 26 patients with a follow-up of > or = 6 months revealed no significant endocrinologic response in patients with Cushing's disease, Nelson tumour or prolactinoma. In contrast in 12 evaluated patients with acromegaly within 6-36 months after LINAC-RS the median GH-value decreased significantly. In 3 nonfunctioning PA's a tumour volume reduction has been observed. We conclude, that LINAC-RS with moderate single doses might be a safe and beneficial treatment in patients with acromegaly or nonfunctioning PA's resistant to conventional therapy. In Cushing's disease, Nelson tumours or prolactinomas higher doses seem to be required.

Sleep apnoea in acromegaly--prevalence, pathogenesis and therapy. Report on two cases.

It has long been known, that irregular, heavy snoring and daytime sleepiness are common features of acromegaly. Only recently has the high incidence (30-60%) and clinical relevance of the sleep apnoea underlying these symptoms been recognized. Both diseases have a group of common symptoms and prognostic features: Increased cardiovascular and respiratory mortality, elevated incidence of hypertension, daytime sleepiness, decreased vitality, headaches and depression. These are very prominent in sleep apnoea and often reversible under treatment. In acromegaly their etiology has been widely unexplained and they commonly persist even when human growth hormone (hGH) levels remain normal after operative treatment. We report on 2 patients presenting with excessive daytime sleepiness and severe obstructive sleep apnoea caused by acromegaly. Both had macroglossia and hypertrophy of hypopharyngeal tissues regressive after surgical therapy. The average hGH-levels were 20 and 31 ng/ml before and 3 and 1.7 ng/ml several months after operation respectively. Apnoea indices and minimal oxygen saturations (SO2) were 59/h and 55/h, and 60% and 58% initially and improved postoperatively to 40/h and 50/h, and 72% and 70%. Polysomnographic parameters were normalized by NCPAP-therapy pre- and postoperatively and daytime sleepiness improved dramatically. In one patient the NCPAP-pressure could be decreased postoperatively. Since patients with sleep apnoea have an increased perioperative risk of hypoxia and because transsphenoidal operation and postoperative nasal tamponade were performed, both patients were tracheostomized perioperatively.(ABSTRACT TRUNCATED AT 250 WORDS)

The stress response to laparoscopic cholecystectomy: investigation of endocrine parameters.

Laparoscopic cholecystectomy, as a typical example of minimal invasive surgery, is associated with low complication rates and minimal patient discomfort, and provides the same safety as conventional cholecystectomy. In the present prospective observational study, endocrine parameters as indicators for stress response were measured. We investigated 53 patient with laparoscopy cholecystectomy and 12 patients with conventional cholecystectomy. Blood samples were taken pre-, peri-, and postoperatively for measurement of ACTH, cortisol, prolactin, and growth hormone. General anesthesia followed a standardized protocol. The increase in all stress hormones did not differ between patients in the two groups, and was comparable with that reported in the literature and the findings of our own previous studies in patients undergoing conventional cholecystectomy and elective colon resection. We conclude that laparoscopic cholecystectomy is associated with a pronounced endocrine stress response that does not account for the observed differences in the peri- and postoperative complication rate or patient comfort.

[Pulmonary valve endocarditis and atrial fibrillation]. / Pulmonalklappenendokarditis und Vorhofflimmern.

A 61-year-old man became ill with a fever of 39.4 degrees C, decreased exercise tolerance and headache as well as chest pain. Physical examination 3 weeks after the onset of symptoms merely revealed irregular heart rate at 100 beats/min. Erythrocyte sedimentation rate was increased (30/61 mm), as were serum bilirubin, lactate dehydrogenase, alkaline phosphatase, gamma-GT and C-reactive protein. The ECG showed atrial fibrillation with a rapid and irregular ventricular rate, as well as ventricular extrasystoles (Lown type IIIA), there were no abnormal findings on either the chest radiography or transthoracic echocardiography. Antiarrhythmic treatment brought about atrial flutter with 4:1 a-v conduction. Transoesophageal echocardiography now revealed vegetation on the pulmonary valve and microthrombi in the left atrial appendage. Ten days after starting intravenous penicillin G (10 mega units four times daily), gentamycin (60 mg three times daily) and heparin (30,000 units over 24 h) sinus rhythm was restored, the vegetation had got smaller and no thrombi were demonstrated. After 27 days antibiotic treatment was changed to oral penicillin V. After 4 weeks the patient was discharged symptom-free.

In vitro effects of tumor necrosis factor-alpha on human thyroid follicular cells.

Tumor necrosis factor-alpha is assumed to be an important mediator in thyroid autoimmunity. In the present study we have shown that human thyrocytes possess a single specific binding site for recombinant tumor necrosis factor-alpha with an average of 9,300 receptors/cell (Kd = 1.9 x 10(-10) mol). The effects of the cytokine on thyroid cell proliferation were assessed by 3H-thymidine uptake as well as by the protein and DNA content of cell monolayers. Low dose tumor necrosis factor-alpha resulted in a moderate stimulation of cell proliferation with an increase of 3H-thymidine incorporation from 44,613 +/- 7,989 cpm under basal conditions to 63,326 +/- 6,822 cpm after 100 U/l tumor necrosis factor-alpha (p < 0.01). Higher doses of the cytokine were less effective. On average, bTSH stimulated cAMP production of human thyrocytes was significantly augmented after preincubation with recombinant tumor necrosis factor-alpha. The maximum effect was observed after 1,000 U/l tumor necrosis factor-alpha (281.5 +/- 107.0 vs 114.5 +/- 33.6 fmol cAMP/micrograms protein under basal conditions: p < 0.05), whereas higher doses of the cytokine were again less effective. This phenomenon could at least partly be explained by a cytokine-mediated downregulation of tumor necrosis factor-alpha binding. We conclude that in vitro tumor necrosis factor-alpha modulates in addition to its well known synergistic effect on interferon-gamma induced HLA class II expression the function and proliferation of human thyroid follicular cells as well. These effects are mediated via specific cell surface receptors.

Gel chromatographic characterization of immunoreactive adrenocorticotropin in patients with ACTH hypersecretion.

We investigated the molecular size of circulating immunoreactive ACTH by gel chromatography in patients with ACTH hypersecretion due to various disorders of the hypothalamic-pituitary-adrenal axis. 4 patients with Addison's disease, 2 with Nelson's syndrome, 4 with Cushing's disease, 6 with the ectopic ACTH syndrome (2 bronchial carcinoma, 1 medullary carcinoma, 1 metastatic islett cell carcinoma, 1 benign bronchial carcinoid and 1 patient with occult ectopic Cushing's syndrome) and 1 patient with hypersecretion of ACTH from a clinically nonfunctioning pituitary adenoma were studied. Analysis of the molecular size of immunoreactive ACTH was performed by gel chromatography on a Sephadex G-75 column (superfine, 100 x 1.5 cm) equilibrated with 1% formic acid. 2 ml fractions were collected and evaporated to dryness. The ACTH content of the recovered samples was determined by RIA. In Addison's disease, Nelson's syndrome and Cushing's disease the plasma showed a single peak of ACTH immunoreactivity at the expected position of 1-39 ACTH. In the ectopic ACTH syndrome the plasma of 4 patients revealed at chromatography at least one other peak eluting between the void volume and 1-39 ACTH suggestive of a high molecular weight form of ACTH whereas plasma of 2 patients showed only a single ACTH peak at the position of labeled 1-39 ACTH. The patient with a clinically non-functioning pituitary adenoma revealed a gel filtration pattern similar to the patients with ectopic ACTH syndrome and secretion of high molecular weight ACTH. We conclude that secretion of high molecular weight forms of ACTH is not a unique feature of the ectopic ACTH syndrome.(ABSTRACT TRUNCATED AT 250 WORDS)

[Recent aspects of the pathogenesis of endocrine autoimmune diseases in the human: what role does expression of class II HLA molecules in the endocrine target cell play?]. / Neuere Aspekte zur Pathogenese endokriner Autoimmunerkrankungen des Menschen: Welche Rolle spielt die Expression von HLA Klasse-II-Molekülen durch die endokrine Zielzelle?

The inappropriate expression of HLA Class II molecules by the target cells of endocrine autoimmune diseases is a recent observation that has been intensively studied in thyroid autoimmunity and type I diabetes mellitus. In vitro studies have shown that interferon-gamma can induce Class II expression, either alone, as in thyrocytes, or in combination with other mediators like tumour necrosis factor or lymphotoxin, as in islet cells, pointing to possible mechanisms operating in vivo. Endocrine cells expressing Class II molecules are able to present their autoantigens to helper T cells, thus possibly inducing the autoimmune process. However, until now it is still unclear if the expression of Class II molecules by the target cells is the primary immune phenomenon, which might possibly be triggered by a latent viral infection of the endocrine cell. Alternatively, it might be a secondary response in an ongoing autoimmune process. Particularly data obtained in the diabetic pancreas favour the first possibility, but only progress in our understanding of the role of HLA antigens in immunoregulation will make it possible to interpret the phenomenon properly.

Influence of tumor necrosis factor-alpha on the modulation by interferon-gamma of HLA class II molecules in human thyroid cells and its effect on interferon-gamma binding.

Cytokines are important modulators of immunological reactions, but it has been postulated that they might act on other unrelated epithelial cells. We studied the effects of recombinant interferon-gamma (rIFN gamma) and recombinant tumor necrosis factor-alpha (rTNF alpha) on normal human thyroid cells. We found that the combination of these two cytokines enhanced HLA class II molecule expression on these cells compared with the effect of rIFN gamma alone. This was proven by both immunofluorescence as well as a more sensitive and quantitative RIA. rTNF alpha alone had no effect on HLA class II molecule induction on the same thyrocytes, suggesting a synergistic rather than an additive action in combination with rIFN gamma. The addition of 600 U/ml rTNF alpha to low dose rIFN gamma (10 U/mL) enhanced class II expression by 50%, as quantified by RIA. We also demonstrated that normal thyrocytes possess distinct receptors for the two cytokines and that rTNF alpha probably augments IFN gamma binding, since it increased when the cells were first incubated with rTNF alpha. This increased binding provides an explanation for the synergistic action of rTNF alpha in enhancing class II molecule expression by rIFN gamma. We conclude that the presence of receptors for these cytokines on human thyroid cells gives a direct demonstration of their potential biological action on cells normally not involved in the immunological circuit. The phenomenon might also explain their direct or indirect involvement in vivo, such as in influencing inappropriate HLA class II molecule expression in epithelial cells affected by autoimmunity.

Nomifensine-induced immune hemolytic anemia and posttransfusion purpura in the same patient.

A 53-year-old white woman had severe hemolytic anemia while taking nomifensine. A drop of hemoglobin to 61 g per I prompted the transfusion of two units of packed red cells. Nine days later, severe thrombocytopenia with multiple petechiae ensued. Both hemolysis and thrombocytopenia resolved promptly upon withdrawal of the drug and short-term prednisolone treatment. Serologic studies showed nomifensine-dependent, metabolite-specific red cell antibodies as the cause of immune-mediated hemolysis and, in serum samples obtained after purpura, strong platelet-specific PlA1 and weak HLA antibodies suggested a diagnosis of posttransfusion purpura.

Size heterogeneity of immunoreactive prolactin in patients with prolactinoma.

We investigated the chromatographic pattern of serum prolactin in 41 patients with prolactinoma and correlated the distribution of immunoreactive prolactin with the clinical variables sex, tumour size, age, and response to bromocriptine therapy. In addition, the effect of long-term storage and repeated freezing and thawing on the different molecular weight forms of prolactin was evaluated. Gel chromatography (column 100 cm X 1.5 cm) was performed in 0.1 mol/l phosphate buffer, pH 7.5, using Ultrogel ACA 54 (LKB). No correlation of age or the response to drug therapy to the elution pattern of prolactin was found. Females showed a higher percentage of big prolactin than males (10.4 +/- 1.2% vs 6.8 +/- 0.7%, mean +/- SEM, P less than 0.05) and patients with microprolactinomas too had a higher percentage of big prolactin than those with macroprolactinomas (11.3 +/- 1.8% vs 7.7 +/- 0.7%, P less than 0.05). Serum samples kept frozen for more than 2 years showed a higher percentage of bigbig prolactin (P less than 0.01) than samples stored for less than 12 months suggesting formation in vitro. However, examination of fresh samples prior to freezing also demonstrated bigbig prolactin, indicating that bigbig prolactin circulates in vivo. Repeated freezing and thawing of bigbig prolactin led to almost complete interconversion to little prolactin without any increase in immunoreactivity. This finding supports the concept that bigbig prolactin represents little prolactin loosely associated to a carrier molecule.

Effect of oral morphine and naloxone on pituitary-adrenal response in man induced by human corticotropin-releasing hormone.

To further investigate the role of opioids in the regulation of the pituitary-adrenal axis we studied the effect of morphine and naloxone on human corticotropin-releasing hormone (hCRH)-induced ACTH, immunoreactive (ir) beta-endorphin, and cortisol release in normal subjects. Protocols: 1. 30 mg of a slow-release preparation of morphine or placebo was given orally 3 h prior to administration of hCRH (0.1 mg iv) (N = 7). 2. Naloxone (4 mg as bolus iv) or placebo was given 5 min prior to hCRH (N = 7). 3. Naloxone (4 mg iv as bolus followed by a continuous infusion of 6 mg over 75 min) or placebo was started 15 min prior to hCRH (N = 6). hCRH was injected at 11.00 h (protocol 1, 2) or at 17.00 h (protocol 3). Oral morphine not only suppressed basal hormone levels (P less than 0.02), but also the peak response to hCRH compared with placebo (cortisol: 270 +/- 50 vs 559 +/- 80 nmol/l; ACTH: 5.1 +/- 1.5 vs 13.1 +/- 2.7 pmol/l; ir beta-endorphin: 48.5 +/- 8.7 vs 88 +/- 14 pmol/l; mean +/- SEM, P less than 0.02). Similarly, the maximum incremental changes and the area under the curve were significantly reduced for all three hormones compared with placebo (P less than 0.05). After 4 mg of naloxone in the morning, no significant hormonal changes in response to hCRH were observed.(ABSTRACT TRUNCATED AT 250 WORDS)

Naloxone in treatment of circulatory shock resistant to conventional therapy.

The effect of naloxone (4.4-5.9 mg i.v.) was evaluated in 10 patients with circulatory shock (sepsis, n = 7; intoxication, n = 1; cardiogenic shock, n = 2) not responding to full conventional therapy. In addition, we measured plasma ACTH and immunoreactive beta-endorphin before and 60 min after administration of naloxone and compared the results with hormone concentrations in 10 intensive care patients without shock. Only in two patient with septic shock a transient increase (duration 15 min and 60 min, respectively) of systolic blood pressure was observed, while naloxone was ineffective in the remaining eight patients. No adverse effects of naloxone were found. Plasma ACTH and immunoreactive beta-endorphin concentrations in patients with shock were not different from those in controls (ACTH, 79 +/- 28 vs 120 +/- 60 pg/ml; immunoreactive beta-endorphin, 952 +/- 262 vs 1,070 +/- 378 pg/ml). Our findings suggest that naloxone in a single dose of 4.4-5.9 mg i.v. does not improve the management of circulatory shock unresponsive to conventional treatment. beta-endorphin seems to play no major role in the hypotension of shock.

Cyproheptadine inhibits the corticotropin releasing hormone (CRH)--induced hormone release in normal subjects.

To further elucidate the inhibitory action of cyproheptadine on ACTH release, we studied the influence of cyproheptadine (0.1 mg/kg body weight) on the corticotropin releasing hormone (CRH)--induced hormone release in normal subjects. On two occasions six healthy volunteers underwent a CRH-test (0.1 mg hCRH as bolus i.v.) combined with an infusion of either cyproheptadine or saline starting 30 min prior to the CRH injection. Cyproheptadine led to a significant suppression of the plasma ACTH (p less than 0.05) and serum cortisol (p less than 0.005) response to CRH compared to placebo suggesting a direct inhibitory action of cyproheptadine at the pituitary level.

FK 33-824, a met-enkephalin analog, blocks corticotropin-releasing hormone-induced adrenocorticotropin secretion in normal subjects but not in patients with Cushing's disease.

To further elucidate the site of action of opioids on the pituitary-adrenal axis, we studied the effect of D-Ala2,MePhe4,met-(O)enkephalin-ol (Sandoz, FK 33-824) on plasma ACTH and beta-endorphin immunoreactivity and serum cortisol in 7 normal subjects and 11 patients with Cushing's syndrome (Cushing's disease, n = 7; adrenal adenoma, n = 2; ectopic Cushing's syndrome, n = 2) after administration of human corticotropin-releasing hormone (hCRH). hCRH (0.1 mg; Bachem) was injected iv after pretreatment with 0.5 mg FK 33-824, im, or 0.9% saline. In normal subjects, the hCRH-induced ACTH, beta-endorphin, and cortisol increases were almost completely abolished by pretreatment with FK 33-824. Mean peak (+/- SEM) hormone concentrations were significantly reduced (ACTH, 16.7 +/- 3.5 vs. 45.3 +/- 7.8 pg/ml; beta-endorphin, 151 +/- 25 vs. 277 +/- 51 pg/ml; cortisol, 8.1 +/- 1.2 vs. 19.5 +/- 2.6 micrograms/dl; P less than 0.02), as were secretory areas (P less than 0.02). These results indicate a direct pituitary action of the synthetic met-enkephalin. In contrast, in patients with Cushing's disease, FK 33-824 did not inhibit hCRH-induced hormone release. Instead, maximum ACTH and beta-endorphin concentrations were slightly but not significantly higher after the administration of FK 33-824 (ACTH, 292 +/- 143 vs. 131 +/- 32 pg/ml; beta-endorphin, 2409 +/- 763 vs. 1921 +/- 600 pg/ml). These findings indicate a defect in inhibitory opiodergic control of ACTH secretion in patients with Cushing's disease, which may contribute to the pathological ACTH hypersecretion. In patients with Cushing's syndrome due to an adrenal adenoma or ectopic ACTH secretion, neither hCRH nor FK 33-824 altered hormone concentrations.

Posttransfusion purpura. A survey of 13 cases.

Thirteen cases of posttransfusion purpura (PTP) which were diagnosed in Germany and Austria from 1977-1985 are described. All patients were women with a mean age of 58.6 years (range, 36-77 years). All but one had been pregnant and received blood transfusions 2 to 12 days prior to the onset of PTP. The thrombocytopenic purpura was always severe with a nadir of platelet counts below 10 X 10(9)/l and lasted between 3 and 60 days. All patients recovered from PTP. Optimal therapy consisted of administration of high-dose IgG. Twelve of the 13 patients had developed platelet-specific Zwa antibodies (eight of them together with HLA antibodies), in one Zwa positive individual only HLA antibodies were detectable. Five of six HLA-DR typed patients carried DR3 which is considered an immunogenetic risk factor in PTP. Clinical awareness of this rare, but serious iatrogenic transfusion complication is prerequisite for prompt diagnosis and improved therapy.

Effects of high-dose and low-dose naloxone on plasma ACTH in patients with ACTH hypersecretion.

The effect of a high (5.4 mg/h) and a low (0.8 mg/h) dose of naloxone (i.v. over a period of 90 min) on ACTH secretion was compared with placebo in patients with Addison's disease, congenital adrenal hyperplasia, Cushing's disease or Nelson's syndrome. In seven patients with primary adrenal insufficiency the high dose of naloxone provoked a significant increase of plasma ACTH concentrations (P less than 0.02) whereas the low dose of naloxone failed to influence ACTH secretion. In six patients with ACTH dependent Cushing's disease or Nelson's syndrome both doses failed to alter plasma ACTH levels. These results support the concept of inhibitory delta- or kappa-opiate receptors in the regulation of ACTH secretion. In patients with Cushing's disease or Nelson's syndrome ACTH secretion is insensitive to naloxone, presumably because of an autonomous pituitary adenoma or hypothalamic derangement.