The importance of postprandial glucose to treatments and outcomes in patients with type 2 diabetes.

A primary goal in the management of diabetes is to prevent its long-term complications through the attainment of tight glycemic control, a complex and incompletely understood metabolic process that involves the interaction of the pancreas, insulin-responsive peripheral tissues, and the liver in regulating fasting blood glucose (FBG) and postprandial glucose (PPG) levels. Whereas much of the clinical management of type 2 diabetes has focused on FBG by measurement of blood glucose levels and glycated hemoglobin levels, mounting evidence has formed strong associations between PPG, the temporally immediate physiological management of a glucose load, and diabetes progression, management, and complications. Application of the research may enable health care systems and providers to more closely mimic a normal glycemic response in individuals with type 2 diabetes, leading to improved clinical outcomes and cost control.

Same-day discharge after endoscopic biliary sphincterotomy: observations from a prospective multicenter complication study. The Multicenter Endoscopic Sphincterotomy (MESH) Study Group.

BACKGROUND: Same-day discharge after endoscopic biliary sphincterotomy (ES) is a common clinical practice, but there have been few data to guide appropriate selection of patients. Using a prospective, multicenter database of complications, we examined outcomes after same-day discharge as it was practiced by a variety of endoscopists and evaluated the ability of a multivariate risk factor analysis to predict which patients would require readmission for complications. METHODS: A 150-variable database was prospectively collected at time of ES, before discharge and again at 30 days in consecutive patients undergoing ES at 17 centers. Complications were defined by consensus criteria and included all specific adverse events directly or indirectly related to ES requiring more than 1 night of hospitalization. RESULTS: Six hundred fourteen (26%) of 2347 patients undergoing ES were discharged on the same day as the procedure, ranging from none at 6 centers to about 50% at 2 centers. After initial observation and release, readmission to the hospital for complications occurred in 35 (5.7%) of 614 same-day discharge patients (20 pancreatitis and 15 other complications, 3 severe). Of the same-day discharge patients, readmission was required for 14 (12.2%) of 115 who had at least one independently significant multivariate risk factor for overall complications (suspected sphincter of Oddi dysfunction, cirrhosis, difficult bile duct cannulation, precut sphincterotomy, or combined percutaneous-endoscopic procedure) versus 21 (4.2%) of 499 without a risk factor (odds ratio 3.1: 95% confidence interval [1.6, 6.3], p < 0.001). Of complications presenting within 24 hours after ES, only 44% presented within the first 2 hours, but 79% presented within 6 hours. CONCLUSIONS: Same-day discharge is widely utilized and relatively safe but results in a significant number of readmissions for complications. For patients at higher risk of complications, as indicated by the presence of at least one of five independent predictors, observation for 6 hours or overnight may reduce the need for readmission.

William L. McGuire Memorial Lecture. Antiestrogens: mechanisms of action and resistance in breast cancer.

Antiestrogens have proven to be highly effective in the treatment of hormone-responsive breast cancer. However, resistance to antiestrogen therapy often develops. In addition, although tamoxifen-like antiestrogens are largely inhibitory and function as estrogen antagonists in breast cancer cells, they also have some estrogen-like activity in other cells of the body. Thus, recent efforts are being directed toward the development of even more tissue-selective antiestrogens, i.e. compounds that are antiestrogenic on breast and uterus while maintaining the beneficial estrogen-like actions on bone and the cardiovascular system. Efforts are also being directed toward understanding ligand structure-estrogen receptor (ER) activity relationships and characterizing the molecular changes that underlie alterations in parallel signal transduction pathways that impact on the ER. Recent findings show that antiestrogens, which are known to exert most of their effects through the ER of breast cancer cells, contact a different set of amino acids in the hormone binding domain of the ER than those contacted by estrogen, and evoke a different receptor conformation that results in reduced or no transcriptional activity on most genes. Resistance to antiestrogen therapy may develop due to changes at the level of the ER itself, and at pre- and post-receptor points in the estrogen receptor-response pathway. Resistance could arise in at least four ways: (1) ER loss or mutation; (2) Post-receptor alterations including changes in cAMP and phosphorylation pathways, or changes in coregulator and transcription factor interactions that affect the transcriptional activity of the ER; (3) Changes in growth factor production/sensitivity or paracrine cell-cell interactions; or (4) Pharmacological changes in the antiestrogen itself, including altered uptake and retention or metabolism of the antiestrogen. Model cell systems have been developed to study changes that accompany and define the antiestrogen resistant versus sensitive breast cancer phenotype. This information should lead to the development of antiestrogens with optimized tissue selectivity and agents to which resistance may develop more slowly. In addition, antiestrogens which work through somewhat different mechanisms of interaction with the ER should prove useful in treatment of some breast cancers that become resistant to a different category of antiestrogens.

Response-specific antiestrogen resistance in a newly characterized MCF-7 human breast cancer cell line resulting from long-term exposure to trans-hydroxytamoxifen.

To understand better the antiestrogen-resistant phenotype that frequently develops in breast cancer patients receiving tamoxifen, we cultured MCF-7 breast cancer cells long-term (>1 yr) in the presence of the antiestrogen trans-hydroxytamoxifen (TOT) to generate a subline refractory to the growth-suppressive effects of TOT. This subline (designated MCF/TOT) showed growth stimulation, rather than inhibition, with TOT and diminished growth stimulation with estradiol (E2), yet remained as sensitive as the parental cells to growth suppression by another antiestrogen, ICI 164,384. Estrogen receptor (ER) levels were maintained at 40% of that in parent MCF-7 cells, but MCF/TOT cells failed to show an increase in progesterone receptor content in response to E2 or TOT treatment. In contrast, the MCF/TOT subline behaved like parental cells in terms of E2 and TOT regulation of ER and pS2 expression and transactivation of a transiently transfected estrogen-responsive gene construct. DNA sequencing of the hormone binding domain of the ER from both MCF-7 and MCF/TOT cells confirmed the presence of wild-type ER and exon 5 and exon 7 deletion splice variants, but showed no point mutations. Compared to the parental cells, the MCF/TOT subline showed reduced sensitivity to the growth-suppressive effects of retinoic acid and complete resistance to exogenous TGF-beta1. The altered growth responsiveness of MCF/TOT cells to TOT and TGF-beta1 was partly to fully reversible following TOT withdrawal for 16 weeks. Our findings underscore the fact that antiestrogen resistance is response-specific; that loss of growth suppression by TOT appears to be due to the acquisition of weak growth stimulation; and that resistance to TOT does not mean global resistance to other more pure antiestrogens such as ICI 164,384, implying that these antiestrogens must act by somewhat different mechanisms. The association of reduced retinoic acid responsiveness and insensitivity to exogenous TGF-beta with antiestrogen growth resistance in these cells supports the increasing evidence for interrelationships among cell regulatory pathways utilized by these three growth-suppressive agents in breast cancer cells. In addition, our findings indicate that one mechanism of antiestrogen resistance, as seen in MCF/TOT cells, may involve alterations in growth factor and other hormonal pathways that affect the ER response pathway.

Complications of endoscopic biliary sphincterotomy.

BACKGROUND: Endoscopic sphincterotomy is commonly used to remove bile-duct stones and to treat other problems. We prospectively investigated risk factors for complications of this procedure and their outcomes. METHODS: We studied complications that occurred within 30 days of endoscopic biliary sphincterotomy in consecutive patients treated at 17 institutions in the United States and Canada from 1992 through 1994. RESULTS: Of 2347 patients, 229 (9.8 percent) had a complication, including pancreatitis in 127 (5.4 percent) and hemorrhage in 48 (2.0 Percent). There were 55 deaths from all causes within 30 days; death was directly or indirectly related to the procedure in 10 cases. Of five significant risk factors for complications identified in a multivariate analysis, two were characteristics of the patients (suspected dysfunction of the sphincter of Oddi as an indication for the procedure and the presence of cirrhosis) and three were related to the endoscopic technique (difficulty in cannulating the bile duct achievement of access to the bile duct by "precut" sphincterotomy, and use of a combined percutaneous-endoscopic procedure). The overall risk of complications was not related to the patient's age, the number of coexisting illnesses, or the diameter of the bile duct. The rate of complications was highest when the indication for the procedure was suspected dysfunction of the sphincter of Oddi (21.7 percent) and lowest when the indication was removal of bile-duct stones within 30 days of laparoscopic cholecystectomy (4.9 percent). As compared with those who performed fewer procedures, endoscopists who performed more than one sphincterotomy per week had lower rates of all complications (8.4 percent vs. 11.1 percent, P=0.03) and severe complications (0.9 percent vs. 2.3 percent, P=0.01). CONCLUSIONS: The rate of complications after endoscopic biliary sphincterotomy can vary widely in different circumstances and is primarily related to the indication for the procedure and to endoscopic technique, rather than to the age or general medical condition of the patients.

Dopaminergic neurons of periventricular and arcuate nuclei of pseudopregnant rats: semicircadian rhythm in Fos-related antigens immunoreactivities and in dopamine concentration.

The activity of the A14 and A12 hypothalamic dopaminergic (DAergic) neurons were characterized throughout a day of pseudopregnancy to establish their relationship to the generation of PRL surges during that time. Double-label immunocytochemistry was performed using fos-related antigens as markers of neuronal activity, and tyrosine hydroxylase antibody to identify DAergic neurons of the periventricular nucleus and the arcuate nucleus (ARN). Dopamine concentrations were measured with HPLC with electrochemical detection from micropunched samples to approximate synthetic activities of A14 and A12 neurons. Serum PRL levels were determined by RIA. On the fifth and sixth day of pseudopregnancy, five rats/time point were killed at 1100 h, 1300 h, 1500 h, 1800 h, 2100 h, 2400 h, 0300 h, and 0600 h. When the serum PRL was low, the incidence of fos-related antigens/tyrosine hydroxylase double-labeled neurons was high, and it decreased twice a day by 1500 and 0300 h in the periventricular nucleus, rostral ARN, dorsomedial subpopulation of the middle ARN, and in the caudal ARN, corresponding to the initiation of PRL surges. Concentrations of DA were high in these areas, and decreased before PRL surges in agreement with the immunocytochemical data. These findings suggest a semicircadian rhythm in the activities of A14 and A12 neurons which, in concert with PRL releasing factors, contribute to the generation of PRL surges in pseudopregnant animals.

Alterations in transforming growth factor-alpha and -beta production and cell responsiveness during the progression of MCF-7 human breast cancer cells to estrogen-autonomous growth.

Hormonal management of breast cancer is confounded by an almost inevitable progression of cell growth from a steroid-regulated to a steroid-autonomous state. We have experimentally induced this progression in the estrogen growth-responsive MCF-7 human breast cancer cell line by long-term culture in the absence of steroids. After an initial period (10-12 weeks) of slowed growth in response to steroid deprivation, rapid, steroid-independent growth rates were consistently established. In these cells, which contained 3-fold elevated, functional estrogen receptor levels (as determined by induction of PgR and transactivation of a transiently transfected estrogen-responsive gene construct), antiestrogens still effectively suppressed cell proliferation, although estrogens only minimally increased the proliferation rate. Depletion of steroids from the growth media also resulted in a marked (70-80%) transient decrease in transforming growth factor (TGF) alpha mRNA and TGF-alpha protein production at 2 weeks that was followed by a progressive, partial return to the initial parental TGF-alpha mRNA and protein levels. In contrast, the mRNAs for TGF-beta 1, -beta 2, and -beta 3 and bioactive TGF-beta proteins transiently increased (3-10-fold) at 2 to 10 weeks of steroid deprivation and then returned by 24 weeks to the lower levels of the parental MCF-7 cells. These results suggest that the cells acquired steroid-independent means to regulate the production of these peptides. The long-term steroid-deprived sublines showed a loss of regulation of proliferation by TGF-alpha or anti-TGF-alpha antibodies and a 10-fold decrease in sensitivity to the growth-suppressive effects of TGF-beta 1, despite little change in receptor levels for these factors. The diminished contributions of TGF-alpha and TGF-beta s to the regulation of cell proliferation in long-term steroid-deprived MCF-7 breast cancer cells suggest that the TGFs do not act as major growth regulators in these estrogen-autonomous sublines. However, the marked, transient alterations in the levels of these growth factors indicate that they may play a role in the events which accompany the progression from estrogen-responsive to estrogen-autonomous growth. In addition, continued exposure to estrogen may be needed for the long-term maintenance of cell responsiveness to these TGFs.

Development of stenoses in transjugular intrahepatic portosystemic shunts.

PURPOSE: To evaluate the frequency and significance of stenoses or occlusions developing within transjugular intrahepatic portosystemic shunts (TIPS) and identify predictive factors. MATERIALS AND METHODS: Medical records of 52 patients who underwent TIPS placement between September 1991 and October 1993 were reviewed. Various shunt parameters were correlated with the development of shunt abnormalities. Findings at follow-up portography and frequency of variceal bleeding and paracentesis were also noted. RESULTS: Twenty-four patients were followed up for at least 6 months. In eight patients, stenoses developed within 6 months; one shunt occluded. No clear correlations were found between shunt parameters and development of shunt abnormalities. Two of four patients with recurrent variceal bleeding had associated shunt abnormalities. The frequency of stenosis of TIPS was high. CONCLUSION: Early detection and prompt revision of stenotic shunts may decrease the frequency of recurrent variceal bleeding and ascites.

Gonadotropin secretion in ovariectomized ewes: effect of passive immunization against gonadotropin-releasing hormone (GnRH) and infusion of a GnRH agonist and estradiol.

Gonadotropin secretion was examined in ovariectomized sheep after passive immunization against gonadotropin-releasing hormone (GnRH). Infusion of ovine anti-GnRH serum, but not control antiserum, rapidly depressed serum concentrations of luteinizing hormone (LH). The anti-GnRH-induced reduction in serum LH was reversed by circhoral (hourly) administration of a GnRH agonist that did not cross-react with the anti-GnRH serum. In contrast, passive immunization against GnRH led to only a modest reduction in serum concentrations of follicle-stimulating hormone (FSH). Pulsatile delivery of the GnRH agonist did not influence serum concentrations of FSH. Continuous infusion of estradiol inhibited and then stimulated gonadotropin secretion in animals passively immunized against GnRH, with gonadotrope function driven by GnRH agonist. However, the magnitude of the positive feedback response was only 10% of the response noted in controls. These data indicate that the estradiol-induced surge of LH secretion in ovariectomized sheep is the product of estrogenic action at both hypothalamic and pituitary loci. Replacement of the endogenous GnRH pulse generator with an exogenous generator of GnRH-like pulses that were invariant in frequency and amplitude could not fully reestablish the preovulatory-like surge of LH induced by estradiol.