Surgery for radiation-induced symptomatic carotid atherosclerosis.

Carotid atherosclerosis occurring secondary to cervical irradiation is known to produce stroke. Transient neurologic symptoms have necessitated surgical intervention to prevent stroke despite concern over technical problems, wound healing, operative risks, and uncertain therapeutic outcome. With this report, 26 surgical procedures in 20 patients are now documented in the literature (12 men--60%; eight women--40%). Mean age of these patients (56 years) was 10 years younger than carotid surgery patients with no prior radiation history. No relationship was noted between elevated serum cholesterol and the subsequent development of radiation-induced carotid atherosclerosis. Surgical procedures performed included carotid endarterectomy in 17 cases (65%) and arterial bypass in nine (35%). The combination of radiation therapy and previous neck surgery, including prior radical neck dissection, did not adversely influence operability. Surgical outcome was uniformly good with only one stroke (4%) documented in the perioperative period. Longer follow-up on our six cases (mean two years) disclosed neither new clinical symptoms nor the development of hemodynamically significant restenosis.

Measuring subacute mood changes using the profile of mood states and visual analogue scales.

Mood lability and mixtures of moods are important clinical features that may contribute to diagnostic formulation and treatment response. Attempts at quantifying such lability and mixtures have been limited. In this preliminary study both the Profile of Mood States (POMS) and comparable Visual Analogue Scales were assessed for their feasibility and relative performance over a 3- to 5-day period in two groups of inpatients. Both demonstrated concurrent validity and feasibility. The performance of the POMS appeared somewhat superior. A major concern remains regression to the mean after multiple sampling. The authors suggest continued exploration of the relationships between POMS change scores and diagnosis, biological markers, and treatment outcome.

Somatostatin inhibits prolactin secretion by multiple mechanisms involving a site of action distal to increased cyclic adenosine 3',5'-monophosphate and elevated cytosolic Ca2+ in rat lactotrophs.

The release of prolactin (PRL) from a clonal cell-line of anterior pituitary cells (GH4C1) was inhibited by somatostatin (SRIH) in a dose-dependent manner (ED50 nM). The inhibition (20% of control levels) was detectable within 50 s and maximal within 90 s. Thyroliberin (TRH) enhancement of PRL secretion was biphasic. SRIH inhibited both phases equally. Ionomycin in combination with the phorbol ester, TPA, mimics the TRH-elicited PRL release, and SRIH partly inhibited this effect. SRIH had no effect on TRH-stimulated formation of inositol trisphosphate, and only small effects on TRH-activated adenylate cyclase. Vasoactive intestinal peptide (VIP) and forskolin stimulated cAMP formation and PRL release potently. SRIH inhibited both effects of VIP and forskolin, and there was a close correlation between the inhibition of PRL secretion and cAMP accumulation. 8-Bromo-cAMP enhanced PRL release, an effect that was also partly reduced by SRIH. The Ca2+ channel activator, BAY-K-8644 and high extracellular K+ increased PRL release, and SRIH caused a partial reduction in the release response to both secretagogues. SRIH lowered [Ca2+]i, and markedly reduced the rise in [Ca2+]i elicited by TRH, VIP and K+. SRIH did not influence the Ca2+ spikes recorded in Na+-free solution, and had no effect on the TRH-induced membrane potential changes. Our results demonstrate that SRIH may inhibit PRL release from GH4C1 cells by (1) inhibiting hormone-sensitive adenylate cyclase, (2) blocking the effect of cAMP and (3) lowering [Ca2+]i. None of these effects is, however, sufficient to explain all the effects of SRIH, suggesting that SRIH also exerts a major action at a step subsequent to cAMP accumulation and [Ca2+]i elevation. Since the GH4C1 cells possess one single class of binding sites, this implies that the same SRIH receptor is coupled to several cellular signalling systems.

Circulating immunoreactive somatostatin in man. Effect of age, pregnancy, growth hormone deficiency and achlorhydria.

Plasma immunoreactive somatostatin (IRS) levels were measured fasting at 09.00 h in groups of adult individuals and children of different ages, as well as in pregnant women, in patients with pernicious anaemia documented to be achlorhydric, and in children with growth hormone deficiency. There was a gradual rise in the mean level of IRS from the third decade (mean 35.8 +/- 3.8 pg/ml), which reached significance at the seventh (61.1 +/- 8.4 pg/ml), eighth (66.7 +/- 5 pg/ml) and ninth decade (82.6 +/- 13.8 pg/ml). No change was observed in the second 28.3 +/- 3.8 pg/ml) and third (31.1 +/- 3.2 pg/ml) trimester of pregnancy when compared with matched, non-pregnant controls (29.7 +/- 2.2 pg/ml); however, the children aged under 2 years (69.6 +/- 11.2 pg/ml) had significantly higher values than the eldest group (12 to 16 years old) (46.3 +/- 7.2 pg/ml) (P less than 0.05). In achlorhydric patients, basal (27.2 +/- 3.7 pg/ml; P less than 0.01) and postprandial IRS (42.8 +/- 7.7 pg/ml; P less than 0.001) was significantly lower than in a matched, normal control group (basal 59.4 +/- 7.2; postprandial 132.1 +/- 26.3 pg/ml). Growth hormone deficiency was not associated with any differences in circulating IRS, basally or after insulin hypoglycaemia, when compared with values in normal children.(ABSTRACT TRUNCATED AT 250 WORDS)

Studies on the mechanisms of somatostatin release after insulin induced hypoglycaemia in man.

Insulin-induced hypoglycaemia, which stimulates gastric acid secretion, is associated with an increase in circulating somatostatin levels in man. In order to assess the mechanisms involved in this rise, six normal volunteers connected to a Biostator for continuous glucose monitoring were studied, on three separate occasions. On each occasion after basal blood sampling, 0.15 i.u./kg body weight of insulin was administered i.v. and further samples were obtained intermittently over 150 min. On one occasion, dextrose was infused by the Biostator to prevent hypoglycaemia, while on the other two, a constant infusion of either normal saline or the specific H2 antagonist cimetidine was administered. Insulin plus dextrose caused no significant changes in circulating somatostatin levels, whereas insulin plus saline was associated with a marked, sustained and significant rise in all subjects; insulin plus cimetidine also produced a rise but it was delayed; the area under the curve was significantly (P less than 0.05) greater with insulin plus saline than with insulin plus cimetidine. These results show that in man insulin itself does not stimulate somatostatin secretion directly, but indirectly via hypoglycaemia. Further, the inhibition of gastric acid secretion with cimetidine reduces somatostatin release during insulin-induced hypoglycaemia. This suggests that gastric acid may mediate somatostatin secretion associated with insulin-induced hypoglycaemia.

Does gastric acid release plasma somatostatin in man?

Food and insulin hypoglycaemia raise plasma concentrations of somatostatin. Both also stimulate gastric acid secretion but it is not clear whether gastric acid itself has any effect on somatostatin secretion. We, therefore, studied the effect on plasma concentrations of somatostatin of infusion of 0.1 N HC1 into the stomach and duodenum of healthy subjects. Plasma somatostatin did not rise with a small dose of HC1 given intragastrically (15 mmol) or intraduodenally (4 mmol). After an intraduodenal infusion of 60 mmol HC1 over 30 minutes, sufficient to reduce intraluminal pH to 2, plasma somatostatin rose moderately in five subjects from a mean value (+/- SEM) of 32 +/- 3 pg/ml to a peak at 10 minutes of 54 +/- 11 pg/ml. It is concluded that: (a) intragastric acid infusions do not release circulating somatostatin in man; and (b) that intraduodenal acidification albeit at grossly supraphysiological doses is a moderate stimulus of plasma somatostatin release. Therefore, gastric acid is unlikely to be a major factor mediating postprandial plasma somatostatin release in man.

Bombesin-like immunoreactivity in human gastrointestinal tract.

In the present study the distribution and molecular characteristics of bombesin-like immunoreactivity (BLI) were studied in acid extracts of human gastrointestinal tract. The highest levels were found in the fundus, antrum, pylorus and pancreas with lower levels in the duodenum, jejunum, terminal ileum and colon. BLI was also detected in both the muscle and mucosal layers of the antrum and colon. Sephadex G-50 gel chromatography under acid dissociating conditions revealed two peaks of immunoreactivity, one in the position of synthetic porcine gastrin releasing peptide (GRP) and the second eluting with synthetic amphibian bombesin. Variations in the proportions of the two molecular forms were seen in different regions of the gut. In the stomach and pancreas greater than 70% of the BLI eluted with the GRP marker while in pylorus, jejunum and terminal ileum only 20% was present in this form. Reverse-phase ODS silica HPLC of the major antral BLI peak, utilising a methanol/trifluoroacetic acid gradient indicated that this peptide was similar to porcine GRP. We have therefore (1) demonstrated the presence and heterogeneity of bombesin-like immunoreactivity throughout the human gastrointestinal tract and (2) shown for the first time that a proportion of this BLI closely resembles porcine GRP.

Circulating growth hormone releasing factor concentrations in normal subjects and patients with acromegaly.

A highly specific and sensitive radioimmunoassay was developed for measuring circulating growth hormone releasing factor (GRF) in human plasma. Before measuring immunoreactive GRF plasma samples were extracted on to Vycor glass. Immunoreactive GRF concentrations in plasma samples from 37 fasting normal subjects ranged from less than 10 to 60 ng/l (mean 21 ng/l). Fasting concentrations in 76 out of 80 acromegalic subjects were within the normal range, but the remaining four patients had values of 92 to 25 000 ng/l. Of these, only the patient with the highest concentration had evidence of ectopic GRF secretion from a disseminated carcinoid tumour. Two of the others had longstanding pituitary tumours, and the fourth patient had a pituitary growth hormone (GH) secreting tumour proved by its removal and subsequent remission of acromegaly. There was no correlation between serum GH and plasma immunoreactive GRF concentrations, irrespective of whether the patients were untreated or had been given radiotherapy or dopamine agonists. The assay should help elucidate the physiological role(s) of GRF and may also prove useful in differentiating between pituitary and hypothalamic defects in patients with acromegaly.

Characterisation of bombesin-like immunoreactivity in human fetal lung.

A sensitive radioimmunoassay for bombesin-like immunoreactivity (BLI) was developed and utilised in conjunction with G50 gel chromatography and reverse-phase HPLC, to study the content and molecular characteristics of bombesin-like peptides in acid extracts of human fetal lung. The antiserum, (B5), is directed towards the C-terminal region of the bombesin molecule and cross-reacts 70% with synthetic porcine GRP and the synthetic GRP fragment, GRP (14-27). Specimens of lung were collected from fetuses of gestational ages 15-22 weeks, following prostaglandin termination of pregnancy. The tissue was extracted into 0.1 N HCl at 90 degrees C. The mean BLI content was 50.2 pg/mg wet weight of tissue (range 15.5-136 pg/mg; n = 13). No correlation between gestational age and BLI content could be established. G50 gel chromatography of acid extracts, under dissociating conditions, revealed two peaks of BLI, one in the position of synthetic porcine GRP and the second, constituting greater than 90% of the immunoreactivity, eluting with synthetic amphibian bombesin. Reverse-phase ODS silica HPLC of this major G50 peak, utilising a methanol/trifluoroacetic acid gradient, indicated that this peptide was similar to the GRP C-terminal fragment, GRP (14-27). We have therefore (1) confirmed the presence and heterogeneity of BLI in human fetal lung, and (2) shown, for the first time, that the majority of this BLI more closely resembles a fragment of GRP than amphibian bombesin itself.

Distribution and characterisation of immunoreactive somatostatin in human gastrointestinal tract.

Immunoreactive somatostatin (IRS) was measured in acid extracts of human gastrointestinal tissue. The highest levels were found in the duodenum, pancreas, jejunum and stomach with lower levels in the ileum and colon. In the antrum, pylorus, duodenum and pancreas the main peak of IRS (1.6K IRS) coeluted with synthetic somatostatin-14 on both gel filtration chromatography and HPLC. In the body of stomach, jejunum, ileum and colon, a large peak coeluting with synthetic somatostatin-28 (3.5K IRS) on both chromatographic systems was also identified, while minor peaks of IRS assigned molecular weights of 6000 (6K) and greater than 15 000 (15K) were seen in some extracts. The total IRS content and pattern of molecular forms were similar in tissues obtained from adults at surgery or rapid post mortem, and in tissue taken from human fetuses after prostaglandin termination of pregnancy. When tissues were divided into mucosal and muscle layers, greater than 90% of the IRS was in the mucosa with less than 10% in the muscle layer. In the muscle layer the IRS was almost entirely the 1.6K form in all tissues. Immunohistochemical studies showed the IRS in the mucosa to be localised in endocrine-type cells, while in the muscle layer the IRS is present in nerve fibres and neurones of the myenteric plexus. It is suggested that (1) different mechanisms may control the biosynthesis of somatostatin-14 and somatostatin-28 in mucosal cells in different parts of the gut, (2) different biosynthetic controls may operate in endocrine-like and neuronal cells in the same region of the gut.

Effect of dynorphin on insulin and somatostatin secretion, calcium uptake, and c-AMP levels in isolated rat islets of Langerhans.

Dynorphin-[1-13], at concentrations of 5.8 X 10(-12) to 5.8 X 10(-9) M, stimulated insulin secretion from isolated islets of Langerhans of the rat, in medium containing 6 mM glucose. Higher concentrations of dynorphin had no significant effect on secretion. Dynorphin (5.8 X 10(-9) M) was unable to initiate insulin release from islets in the presence of 2 mM glucose, or to increase insulin secretion further in the presence of 20 mM glucose or 6 and 12 mM glyceraldehyde. Dynorphin-induced insulin secretion from islets was blocked by verapamil (5 microM) or by chlorpropamide (72 microM), but not by a mu opiate receptor antagonist, naloxone (0.11 microM), or by ICI 154129, a specific antagonist for the delta receptor (0.25 microM). Dynorphin had no effect on islet somatostatin secretion, under conditions in which insulin secretion was greatly stimulated. Glucose (20 mM) and glyceraldehyde (6 and 12 mM) significantly increased both insulin and somatostatin secretion. Dynorphin (5.8 X 10(-9) M) increased 45Ca2+ uptake into islets, and also increased intracellular islet c-AMP levels. These changes persisted when higher concentrations of dynorphin were used. These results suggest that (1) dynorphin is a very potent stimulus for insulin secretion; (2) dynorphin does not affect somatostatin secretion in static incubations of islets, in the same way as does glucose and glyceraldehyde; (3) dynorphin's effects may involve increased calcium ion movement and can be blocked by verapamil; (4) dynorphin can also increase islet c-AMP, and could thereby modulate the responsiveness of other secretagogues; (5) the actions of dynorphin on insulin secretion are not mediated by delta or mu opiate receptors in islets.

Evidence for direct production of somatostatin-14 from a larger precursor than somatostatin-28 in a phaeochromocytoma.

Gel-filtration chromatography of an acid-extract of a phaeochromocytoma, under dissociating conditions, revealed 4 peaks of immunoreactive somatostatin (IRS) of approx. 8-10 kilodaltons (K), 6K, 3.5K and 1.6K as detected by an antiserum (R9) directed against the central region of tetradecapeptide somatostatin (S14). The 3.5K and 1.6K forms of IRS co-eluted with synthetic cyclic S28 and S14 respectively on reversed phase HPLC. Using another radioimmunoassay for the 1-14 sequence of S28 (N-peptide) a peak of immunoreactive N-peptide (IRN) with a molecular weight of approx. 4500 was observed. The antiserum (N3) used in the N-peptide assay was raised against N-Tyr N-peptide and cross-reacts less than 5% with synthetic S28. Two peaks were further characterised by partial tryptic digestion and gel-filtration chromatography. The 3.5K IRS peak was partially converted to a 1.6K IRS form together with an approximately equimolar amount of IRN with apparent molecular weight of 2500. This 2.5K IRN co-eluted both with N-Tyr N-peptide and with the IRN generated by tryptic digestion of synthetic cyclic S28. No IRN peak of this size was observed in the original extract. Tryptic digestion of the 6K IRS peak generated 3.5K and 1.6K IRS and 2.5K IRN. These results suggested that (1) this human phaeochromocytoma contains IRS very similar to the known structure of ovine and porcine S28 and S14. (2) The 6K IRS is composed of an unknown peptide sequence attached via trypsin-susceptible bond to the N-terminus of S28. (3) In this tumour S14 is being generated directly from 6K IRS and not via S28.

Response of circulating immunoreactive somatostatin to nutritional stimuli in normal subjects.

We have previously reported that in normal subjects plasma immunoreactive somatostatin levels rise after a mixed meal. The contribution of individual nutrients to this rise, and the molecular nature of the somatostatin immunoreactivity measured, have now been studied. Six normal healthy subjects received, on separate occasions, isocaloric (520 calories) and isovolumetric (260 ml) quantities of carbohydrate, protein, and fat. The mean fasting plasma somatostatin level was 29 +/- 5 pg/ml. After carbohydrate a peak of 48 +/- 7 pg/ml was reached at 30 min, and after protein and fat there were more sustained rises with peak levels of 74 +/- 8 pg/ml and 80 +/- 9 pg/ml, respectively. Sephadex G50 chromatography of extracts of fasting peripheral plasma showed two main peaks of somatostatin immunoreactivity, one coeluting with cyclic somatostatin and a larger peak of approximately 3500 molecular weight (mol wt). Levels of both 1600 and 35000 mol wt somatostatin were increased 60 min after a mixed meal. Approximately 80% of the 3500 mol wt form of somatostatin could be converted to the 1600 mol wt form by treatment with dithiothreitol (an agent which reduces disulphide bonds). It is concluded that: (a) in normal subjects fat and protein are potent stimuli for somatostatin release; (b) somatostatin in normal peripheral plasma exists in multiple forms, and that both 1600 and 35000 mol w forms of somatostatin immunoreactivity are stimulated by feeding; (c) the 3500 mol wt form could represent a dimer of somatostatin or a somatostatin molecule linked to a second peptide chain by disulphide bonds.

Somatostatin secretion by lung and thymic tumours.

Ectopic secretion of somatostatin in one patient with a thymic tumour and in two patients with lung tumours is described. All three patients also had ectopic ACTH secretion. Gel filtration chromatography under dissociating conditions showed the two lung tumour extracts to contain predominantly 1600 MW somatostatin monomer while the thymic tumour contained predominantly a 3000-3500 MW form of somatostatin, 77% of which was not converted to 1600 MW somatostatin by dithiothreitol (an agent which reduces disulphide bridges). This form may therefore represent a covalently-bound precursor of somatostatin rather than a dimer of two somatostatin monomers. Plasma from all three tumour patients and from normal subjects contained both 1600 and 3000--3500 MW somatostatin. It is suggested that somatostatin secretion may frequently be associated with multiple hormone producing tumours.

CSF and plasma somatostatin levels in acromegaly.

Cerebrospinal fluid (CSF) and plasma levels of somatostatin have been measured in patients with active acromegaly and the results compared to those obtained in patients with non-endocrine diseases. Plasma levels have also been studied in acromegalics given oral glucose. The mean CSF somatostatin level in twenty patients without endocrine disease was 76 pg/ml (range 46-112) which did not differ significantly from that found in eight acromegalics (mean 87 pg/ml, range 48-160). Plasma somatostatin in twenty-two acromegalic patients on no medical treatment was 43 pg/ml (range 9-113), not significantly different from values in a normal control population. There were no differences in the somatostatin levels of non-diabetic acromegalics. After oral glucose, there was a rise in circulating somatostatin in eleven out of twelve acromegalic patients, and this rise did not differ from that seen in normal subjects. It is probable that altered somatostatin secretion is neither the cause nor the result of acromegaly; however it is possible that local changes in somatostatin concentration which are not reflected in peripheral plasma or CSF levels may occur near the site of its production.

Circulating somatostatin after food and glucose in man.

Using a recently validated radioimmunoassay, changes in circulating somatostatin have been measured in normal subjects after food (a standard breakfast), and oral and intravenous glucose. After the standard breakfast, a clear and sustained rise in plasma somatostatin was seen in all subjects from a mean value (+/-1 SE) of 28 +/- 7 pg/ml to a mean peak value, at 60 min of 57 +/- 11 pg/ml. When glucose was taken by mouth a significant but smaller rise was seen, but intravenous glucose caused no significant change in plasma somatostatin. A rise in circulating somatostatin after feeding has not previously been demonstrated in normal man and it is suggested that somatostatin may have an important endocrine role in the gut.

Pancreatic somatostatinoma presenting with hypoglycaemia.

A 33-year-old woman with a 2 month history of vague ill health was admitted to hospital in hypoglycaemic coma. Preoperative investigation suggested malignant insulinoma as the probable cause of illness, but immunohistological examination of the tumour showed it to consist mainly of somatostatin-containing cells but sparse insulin-secreting cells were also present. Plasma immunoreactive somatostatin levels were from fifty to 200 times the upper limit of normal and rose in response to arginine and fell during diazoxide infusion. The hypoglycaemia was unusually sensitive to the hyperglycaemic effects of diazoxide and chlorothiazide and, with 5-fluorouracil as the only specific anti-tumour agent, there has been clinical, biochemical and radiological evidence of tumour regression.

Molecular forms of somatostatin in normal subjects and in patients with pancreatic somatostatinoma.

Two patients with somatostatin-secreting pancreatic tumours are described, one presenting with hypoglycaemia due to hyperinsulinism, and the other with Cushing's syndrome due to ectopic ACTH production. When plasma from these patients was subjected to gel chromatography under conditions designed to prevent somatostatin binding to larger proteins, a peak of monomeric immunoreactive somatostatin was observed as well as several large molecular weight forms. These larger forms of somatostatin could be dissociated into monomeric somatostatin by dithiothreitol. Similar studies on plasma obtained from normal subjects also showed heterogeneity of circulating somatostatin. Extracts of tumour tissue from both patients contained predominantly monomeric somatostatin, but only small amounts of high molecular weight somatostatin which differed from the profile seen in plasma. The site(s) of origin of the large molecualr weight forms of somatostatin seen in plasma and their relative biological activities remain to be established.

Immunoreactive somatostatin changes during insulin-induced hypoglycaemia and operative stress in man.

Little is currently known about the factors controlling somatostatin secretion. A radioimmunoassay has been developed that is sufficiently specific and sensitive to be used for physiological studies of circulating levels in man. During insulin-induced hypoglycaemia a rise in plasma somatostatin was seen in each of ten subjects studies. Although this paralleled the rise in circulating glucagon and growth hormone, no individual relationships were found either between these variables or to any change in cortisol or insulin C-peptide. In contrast no rise in somatostatin was seen during surgical stress. Thus, contrary to expectation, circulating somatostatin levels can be altered by metabolic stimuli. It seems likely that this peptide may serve an endocrine as well as a paracrine role since its modulating effects may occur not only near to but also at a distance from the site of secretion. It is not yet clear whether the somatostatin measured comes from the hypothalamus, any other part of the central nervous system or the gastrointestinal tract.