Comparison of effects of combined ACE inhibitor and low-dose thiazide diuretic with ACE inhibitor alone on insulin action in patients with hypertension and Type 2 diabetes: a double-blind crossover study.

AIMS: To establish the safety in terms of insulin sensitivity of a low dose thiazide/ACE inhibitor combination. METHODS: We examined the effects on insulin sensitivity of captopril either alone or in combination with low-dose bendroflumethiazide (1.25 mg) in 15 hypertensive Type 2 diabetic patients. Insulin action was assessed using an isoglycaemic hyperinsulinaemic clamp in a double-blind, randomised, crossover study after a 6-week placebo run-in and following two 12-week treatment periods with captopril (C) (100 mg) alone or in combination with bendroflumethiazide (CB) (1.25 mg). RESULTS: Blood pressure was lower following CB compare to C (138/83 vs. 144/85 mmHg; P < 0.05) and both were lower than baseline (153/92 mmHg; P < 0.01). CB resulted in a significant increase in fasting plasma glucose compared to C (9.6 +/- 2.6 vs. 8.5 +/- 1.6 mmol/l; P < 0.05). Exogenous glucose infusion rates required to maintain isoglycaemia during hyperinsulinaemia were lower after CB compared to C (25.1 +/- 13.3 vs. 34.2 +/- 16.8 micromol/kg/min; P < 0.01) as were isotopically determined glucose utilisation rates (29.0 +/- 12.4 vs. 36.6 +/- 17.3 micromol/kg/min; P < 0.05). There was no significant difference in fasting endogenous glucose production between treatments (CB 9.3 +/- 3.3 vs. C 8.6 +/- 1.6 micromol/kg/min), nor between suppression following insulin (CB 4.0 +/- 2.1 vs. C 4.3 +/- 3.1 micromol/kg/min). CONCLUSIONS: Combination of low-dose bendroflumethiazide with captopril lowered blood pressure but resulted in deleterious effects on insulin action compared to captopril alone.

Plasmacytoma: an unusual cause of a pituitary mass lesion. A case report and a review of the literature.

A sixty six year old female presented with headache and decreased hearing. Clinical examination confirmed the presence of impaired hearing on the left side. Visual fields were full to confrontation and corrected visual acuity was normal. CT scan of brain revealed a pituitary mass. Preoperative anterior pituitary function was normal. Transsphenoidal decompression was performed, and histology was that of a plasmacytoma. Post operative pituitary function was normal. The patient had no symptoms or signs of multiple myeloma and subsequent investigations revealed no evidence of the disease. One year after diagnosis a course of radiotherapy was administered for local tumour recurrence. During seven years of follow-up, no evidence of multiple myeloma has emerged. Only thirteen similar cases have been described. Four of these had evidence of multiple myeloma at presentation and six progressed to it during follow-up. In twelve patients cranial nerve deficits were recorded. In any cases where it was documented, preoperative anterior pituitary function was normal. In a number of cases histology was reported initially as being that of a non-functioning adenoma, the true diagnosis being discovered, either by electron microscopy findings or after the development of multiple myeloma. Plasma cell tumours of the pituitary area are rare and can present with symptoms and signs indistinguishable from non-functioning adenoma. Atypical symptoms such as cranial nerve involvement or unexpected preservation of anterior pituitary function should arouse suspicion.