Spontaneous resolution of diabetes insipidus after pituitary stalk sectioning during surgery for large craniopharyngioma. Endocrinological evaluation and clinical implications for surgical strategy

The mechanism of spontaneous resolution of diabetes insipidus (DI) was investigated after surgery for large craniopharyngioma. Twenty-two adult patients (mean age 48.9 years old), who underwent surgery via the anterior interhemispheric trans-lamina terminalis approach, were divided into three groups: Group I, the entire pituitary stalk was preserved (n = 2); Group II, the stalk was dissected distally from the tumor but ultimately sacrificed (n = 9); Group III, the stalk was not identified and was sacrificed (n = 11). All patients were discharged without neurological deficits 1 month after surgery. Four patients underwent gamma-knife treatment for residual tumor or recurrence. Postoperative endocrinological functions were normal in Group I, and no replacement therapy was required. Hormonal replacement for pan-hypopituitarism and DI was necessary in Groups II and III (mean follow-up period 5.9 years). DI resolved at 2.7 +/- 1.3 years after surgery in four patients in Group II, and a hypertonic saline infusion test revealed production of small amounts of intrinsic antidiuretic hormone (ADH). Urine osmolarity was high in the morning, and a significant increase in urinary osmolarity was noted after Pitressin injection. These results indicate induction of hypersensitivity of the distal renal tubules to small amounts of intrinsic ADH, resulting in decreased urinary output. Recovery from DI can be expected, despite permanent impairment of anterior pituitary function, if the pituitary stalk is dissected as distally as possible.     

Open surgery induces a dramatic decrease in circulating intact IGFBP-3 in patients with colorectal cancer not seen with laparoscopic surgery

Background As shown earlier by the authors via Western blot analysis, open (OS) but not laparoscopic surgery (LS) induces a qualitative decrease in plasma insulin-like growth factor–binding protein 3 (IGFBP-3) levels on postoperative day 1 (POD 1). Intact IGFBP-3 has tumor suppressive effects, but its degradation products do not. Enzyme linked immunoassay (ELISA) inevitably measures both. In this study, using a novel combined Western blot and ELISA analysis method, precise plasma levels of intact IGFBP-3 on POD2 after open and closed colorectal cancer resection (stage I–III) were determined.Methods This study included 15 OS patients with a mean incision length of 26.7 ± 15.5 cm and 16 LS patients with a mean incision length of 5.3 ± 3.1 cm. Intact IGFBP-3 levels were determined via ELISA and Western blot analysis in plasma collected preoperatively and postoperatively.Results In the OS patients, the mean preoperative concentration of intact 43–45 kDa IGFBP-3 protein was 1920 ± 1430 ng/ml. It decreased dramatically on POD2 to 355 ± 545 ng/ml (p < 0.005). In the LS group, no significant difference was noted between the preoperative level (1305 ± 807 ng/ml) and the POD2 level (922 + 714 ng/ml).Conclusions Open cancer resection, unlike its minimally invasive alternative, induces a dramatic decrease in concentration of intact IGFBP-3, which may have important implications with regard to colon cancer recurrence.     

An ultrarapid prognostic index in microprolactinoma surgery.

OBJECT: Prolactinomas account for approximately 40% of pituitary tumors. If the tumor does not exceed 10 mm at its largest diameter (microprolactinoma), the chances of definitive cure as a result of surgery alone vary from 62 to 89% depending on the series. Until now, however, there was no mechanism to predict whether total excision of a tumor had been accomplished. To improve the chances of total excision, we compared the peri- and postoperative kinetics of circulating prolactin (PRL) in patients judged to be cured and those not cured. METHODS: The pre-, peri-, and postoperative variations in blood PRL concentrations were determined using assays conducted at 10-minute intervals. Of the 36 patients included in the study, 27 were considered cured (resumption of a normal menstrual cycle within 6 months, PRL concentration at 9 days [mean +/- standard deviation 2.5+/-2.1 ng/ml] and 12 months [4.5+/-2.2 ng/ml] after the operation < 10 ng/ml and normally stimulated by metoclopramide and thyrotropin-releasing hormone [TRH]). Nine patients were not cured (PRL 20+/-15.7 ng/ml at 9 days after surgery, with no response to metoclopramide and TRH). The kinetics of PRL decrease in definitively cured patients were characterized by the following: 1) the initial slope of the curve decreased by at least 11% within the first 10 minutes after resection, and 2) immediate postoperative PRL concentrations were 20 ng/ml or less. CONCLUSIONS: The measurement of the kinetics of PRL decrease during surgery allows the chance of gross-total resection to be successfully predicted less than 25 minutes after excision of the adenoma. Provided an ultrarapid assay is available (the test used in the present study took < 15 minutes), this prognostic index would be useful to make a decision to continue the surgical procedure when the initial PRL slope is judged to be insufficient. Its use may also be extended to other pituitary tumors such as somatotropic adenoma and basophilic adenoma (Cushing's disease).     

Preoperative and postoperative levels of interleukin-6 in patients with acute appendicitis: comparison between open and laparoscopic appendectomy

Background Cytokine interleukin-6 (IL-6) is an early marker of systemic inflammatory response and tissue damage. This study aimed to evaluate the levels of IL-6 after open and laparoscopic appendectomy to compare the degree of surgical stress associated with these procedures.Methods The levels of IL-6 were measured pre- and postoperatively in the plasma of 37 consecutive patients with a diagnosis of acute appendicitis. After preoperative randomization, 22 patients underwent open appendectomy, and 15 patients underwent laparoscopic appendectomy.Results The preoperative concentrations of IL-6 were 7.2 ± 5.6 pg/ml in the open appendectomy group, as compared with 12.1 ± 9.7 pg/ml in the laparoscopic appendectomy group (p < 0.05). The postoperative levels were 16.9 ± 15.7 and 23.2 ± 19.4 pg/ml, respectively. The mean postoperative to preoperative ratio of IL-6 was slightly higher for open (2.7 ± 2.4) than for laparoscopic (2.3 ± 1.6) appendectomy, but the difference did not reach statistical significance.Conclusion The operative stress in open as compared with laparoscopic appendectomy is not reflected by circulating levels of IL-6.     

结直肠癌患者手术前后循环DNA 水平的变化及其意义

目的：探讨结直肠癌患者手术前后循环DNA水平的变化及其临床意义。方法：检测42例结直肠癌患者术前、术后3,14,30 d循环DNA水平,并检测同期14例健康体检者循环DNA水平作为对照。结果：结直肠癌患者术前循环DNA水平明显高于健康人[（92.25±46.88）ng/mL vs.（22.14± 16.16）ng/mL]（P<0.01）;结直肠癌术前循环DNA水平在不同年龄、性别、肿瘤部位分组间差异无统计学意义（P=0.293,P=0.244,P=0.135）。结直肠癌患者术后3 d循环DNA水平达（114.95±62.41）ng/mL,较术前明显升高（P<0.01）,但在术后14,30 d分别为（38.50± 37.71）ng/mL与（31.69±41.48）ng/mL,明显低于术前（均P<0.01）。结论：循环DNA水平在结直肠癌患者中升高,且术后早期一过性进一步升高,随后明显下降。循环DNA水平有望成为结直肠癌术后监测肿瘤状态和评价疗效的标志物。

     

Stimulated Type I Collagen Turnover in Patients With Giant Cell Tumor of Bone

The aim of this study was to determine type I collagen turnover in giant cell tumor of bone (GCT) by biochemical markers of type I procollagen aminoterminal propeptide (PINP) and type I collagen carboxyterminal telopeptide (ICTP) as synthesis and degradation markers, respectively. The serum concentrations of PINP and ICTP were measured in 11 patients with GCT using radioimmunoassay, and analyzed by the correlation to the grades of GCT progression described by Campanacci. Serum of the 11 healthy subjects was available for comparison. The serum concentration of PINP was significantly higher in patients with GCT (82.4 ± 46.2 ng/ml) than in controls (40.8 ± 12.1 ng/ml) (P < 0.01), and that of ICTP was also significantly higher in GCT (5.3 ± 2.0 ng/ml) than in controls (3.2 ± 0.8 ng/ml) (P < 0.01). In GCT, the PINP concentration of grade 3 (127.6 ± 38.8 ng/ml) was higher than that in grade 1 patients (46.9 ± 4.8 ng/ml) (P < 0.01). ICTP concentration of both grades 2 (7.1 ± 1.4 ng/ml) and 3 (5.8 ± 1.8 ng/ml) patients was significantly higher than that of grade 1 (3.5 ± 0.6 ng/ml) patients (P < 0.01, P < 0.05, respectively). Two cases of serum concentration of PINP and ICTP after resection of GCT demonstrated that these biomarkers decreased to the control levels in the absence of GCT. Our results indicated that type I collagen turnover evaluated by ICTP and PINP was stimulated in the presence of GCT. Moreover, this enhanced metabolic turnover reflects the grade of GCT.     

Growth hormone-producing pituitary adenoma in an 8-year-old girl: case report

A rare case of pituitary adenoma in childhood presenting as giantism is reported. A 6-year-old girl came to our attention in 1982 because of excessive growth noted since the age of 3 yr. Her appearance revealed giantism. She also had a 4 year history of genital bleeding, but no development of external genitalia nor mammary gland. Endocrinological studies revealed markedly elevated serum basal levels of both growth hormone (GH) and prolactin (PRL). She had a bromocriptine therapy for 1 year and 8 months, but it was difficult to suppress her excessive growth rate. So she was admitted at the age of 8 years to undergo the operation. Visual fields were intact. X-ray examination of the skull demonstrated a slightly enlarged sella turcica. Computerized tomography revealed an isodense mass at the pituitary fossa without extrasellar extention. Repeated endocrinological studies were carried out. Basal levels of GH and PRL were 43.8 ng/ml and 67 ng/ml. All other pituitary function were normal, except for puberal responses of luteinizing hormone (LH) and follicle stimulating hormone in LH-RH loading test. 50 g oral glucose tolerance test was normal. Transsphenoidal microsurgery was performed in August 1984. The tumor filled up the pituitary fossa with fibrous element. Histological examination disclosed a mixed adenoma, predominantly chromophobe, with a few granulated eosinophils. Immunoperoxidase staining was also performed on the adenoma. Most of the tumor cells stained for GH, and a few of them stained for PRL. Postoperatively hypopituitalism was not complicated. Surgery produced a decrease in serum PRL level under 20 ng/ml, but serum GH level was not enough reduced under 10 ng/ml.(ABSTRACT TRUNCATED AT 250 WORDS)     

Calcitonin kinetics in the early postoperative period of medullary thyroid carcinoma

INTRODUCTION: Calcitonin is a sensitive marker for medullary thyroid carcinoma. Normalisation of calcitonin levels following resection of medullary thyroid carcinoma has been described after a few hours; however, it may be observed more than 4 weeks after surgery. The aim of this study was to correlate the postoperative calcitonin kinetics with preoperative calcitonin levels and tumour stage. Furthermore, we wanted to test the prognostic impact of the calcitonin kinetics. Therefore, only patients with postoperative normalisation of calcitonin levels (biochemical cure) were included in this study. METHODS: Fourteen biochemically cured patients were analysed, including measurement of postoperative basal and pentagastrin-stimulated calcitonin concentration. With respect to the time of postoperative basal calcitonin normalisation, patients were classified into two groups: (A) patients with normalisation of basal calcitonin levels within 24 h and (B) patients with normalisation of basal calcitonin levels later than 24 h postoperatively. RESULTS: Eight patients were found to have normalisation of basal calcitonin levels within 24 h (group A). In the remaining six patients (group B), the period to normalisation of basal calcitonin levels varied from 6 days to 14 days and longer. There were no differences between the two groups with regard to tumour size, number and pattern of lymph node metastases and tumour stage. However, preoperative basal calcitonin levels were significantly different (258 ng/ml vs 955 ng/ml, P<0.01). In the group with slow-decreasing calcitonin levels, no strong correlation between the preoperative level and the postoperative time to normalisation of basal calcitonin levels could be established, which may be due to the small number of patients. After a median follow-up of 21 months, no patient developed tumour recurrence. However, an increased basal calcitonin level was observed in one patient from group B. All other patients had normal basal and peak calcitonin levels. CONCLUSION: Using a highly sensitive calcitonin assay, we demonstrated that normalisation of basal calcitonin levels may be delayed in patients suffering from medullary thyroid carcinoma. The lack of correlation of preoperative levels and the time to normalisation of the basal calcitonin levels, as well as the positive pentagastrin test in some of the patients, argues that this phenomenon is not simply due to prolonged biochemical calcitonin elimination. Nevertheless, a prognostic influence could not be shown in this study due to the short follow up-period. Further investigations and a longer follow-up are necessary to determine the nature and the prognostic impact of delayed normalisation of calcitonin levels.     

Perioperative levels of atrial natriuretic peptide and troponin-T in patients with uncomplicated coronary artery surgery

BACKGROUND: Hypothesis: increased ANP levels after uncomplicated coronary artery surgery (CAS) indicate functional reduction. METHODS: Experimental design: prospective, randomized. Preoperative upto the 12 week postoperative. Setting: Thoracic and Cardiovascular Surgery, University of Düsseldorf. Patients: 15 patients (mean age: 58+/-6.1 years; 13 months, 2 weeks; no myocardial infarction, no congestive heart failure) with 3 vessel disease. Interventions: levels of atrial natriuretic peptide (ANP) (pg/ml; radioimmunoassay), Troponin T (TnT) (ng/ml; ELISA test), haemodynamic parameters, ECG monitoring, m-mode echocardiography (Echo). Measures: increase of ANP, TnT levels during extracorporeal circulation (ECC), decrease after operation. RESULTS: Maximal increase of ANP from preoperative 90+/-10 (M+/-SEM) pg/ml (p<0.05) up to intraoperative 380+/-38 pg/ml. Ten days postoperative ANP (26+/-33 pg/ml) still threefold increased compared to preoperative level. Increasement of TnT from preoperative 0.02+/-0.01 ng/ml upto intraoperative 3.44+/-0.47 ng/ml. Ten days postoperative TnT concentration normal (0.13+/-0.11 ng/ml). Correlation of ANP and TnT five min after bypass up to 6 hrs postoperative (p<0.05, r =3.4). Increase of left atrial diameter preoperative 42.2+/-1.1 mm up to 46.8+/-1.2 mm (p<0.05) 10 days postoperative. LVEDD, EF changed from preoperative 51.1+/-0.9 mm, 73+/-2% to 54.5+/-1.2 mm, 65+/-4% 10 days postoperative. CONCLUSIONS: Threefold increase of ANP 10 days postoperative and return of TnT levels to normal under consideration of datas of echo show, that ANP is suitable to indicate the meanterm, functional, myocardial reduction. Increased ANP levels, atrial dilatation and dysfunction are important signs of cardial functional reduction after CAS.     

Activation of the coagulation system in the subarachnoid space after subarachnoid haemorrhage: Serial measurement of fibrinopeptide A and bradykinin of cerebrospinal fluid and plasma in patients with subarachnoid haemorrhage

Summary Fibrinopeptide A (FPA) levels as an indicator of thrombin activity in the cerebrospinal fluid (CSF) and plasma of 25 patients with subarachnoid haemorrhage (SAH) were measured serially by radioimmunoassay (RIA). FPA levels in CSF were extremely high on days 0–1 (1253±269 ng/ml, mean ± standard error) but decreased rapidly (11.3±3.9 ng/ml on days 2–4, 10.7±5.9 ng/ml on days 5–7, and 6.3±1.5 ng/ml on days 8–14). In the controls the FPA concentration in CSF was 1.2±0.9 ng/ml (mean ± standard deviation). Plasma FPA levels in patients with SAH showed no statistically significant changes with time.The bradykinin (BK) concentration in CSF and plasma in 27 patients with SAH was measured serially by RIA. The cocentrations in CSF were 122.7±22.7 pg/ml (mean ± standard error) on day 0, 38.6±6.1 pg/ml on day 1,22.7±6.3 pg/ml on day 2, and 17.1±3.0 pg/ml or less thereafter. Plasma BK levels in patients with SAH were higher than those in the control group, but there was no statistically significant change over time.From the measurement of FPA it was apparent that the coagulation system in the subarachnoid space is strongly activated in the early stage of SAH. The formation of BK in CSF after SAH is thought to be due to the contact activation of Hageman factor (intrinsic factor) in the subarachnoid space. Trabeculae as collagen bundles in the subarachnoid space were considered to have a possible role in activating the Hageman factor of the coagulation system in SAH.     

Predictors of Early Postoperative Hypocalcemia in Hemodialysis Patients With Secondary Hyperparathyroidism

We sought to investigate predictors of early development of postoperative hypocalcemia in secondary hyperparathyroidism. Thirty-six hemodialysis patients (21 men, 15 women; mean age, 39.6 ± 13.2 years; mean hemodialysis duration, 77.9 ± 47.1 months) underwent parathyroidectomy. We recorded preoperative adjusted serum calcium (Ca⁺²), phosphate, alkaline phosphatase, intact parathyroid hormone, and hemoglobin levels; mean systolic and diastolic blood pressure levels; parathyroid ultrasonography and scintigraphic data; and number and weight of the resected adenomas. Patients were divided into two groups based on Ca⁺² levels within 24 hours of parathyroidectomy: the hypocalcemia group (serum Ca⁺² levels ≤ 8 mg/dL; n = 26 patients) and the normocalcemia group (>8 mg/dL; n = 10 patients). A total parathyroidectomy with autotransplant was performed in 23 patients and a subtotal parathyroidectomy in 13 patients. Age (36.0 ± 9.7 vs 49.2 ± 16.6 years; P = .006); levels of preoperative serum Ca⁺² (9.6 ± 0.7 vs 10.4 ± 1.1 mg/dL; P = .01), alkaline phosphatase (346.7 ± 354.7 vs 653.3 ± 553.7 mg/dL; P = .05), and hemoglobin (10.5 ± 1.4 vs 12.3 ± 2.5 g/dL; P = .009); and number (2.0 ± 1.3 vs 2.9 ± 0.9; P = .04) and weight (1.9 ± 2.1 vs 3.2 ± 1.7; P = .01) of excised parathyroid adenomas were significantly lower among the hypocalcemia than the normocalcemia group. Among hemodialysis patients with secondary hyperparathyroidism, age, levels of preoperative serum Ca⁺² and alkaline phosphatase, and number and weight of adenomas were associated with early development of postoperative hypocalcemia.     

Results of transsphenoidal microsurgery for growth hormone-secreting pituitary adenoma in a series of 214 patients

Of 214 patients with acromegaly who underwent transsphenoidal microsurgical resection of a pituitary adenoma, 54% had growth hormone (GH) levels below 5 ng/ml and 74% had levels less than 10 ng/ml immediately after surgery. Among the 174 patients who could be contacted for long-term follow-up review (average duration 76 months), most recent GH determinations were available for 165. Of these 165 patients, 131 (79.4%) have a GH level less than 5 ng/ml and 153 (92.7%) have a level below 10 ng/ml; these represent 75.3% and 87.9%, respectively, of the total 174 patients reviewed. Fifty-two patients received postoperative radiation therapy. Nine patients underwent reoperation. There were five cases of tumor recurrence following an apparent surgical cure (4.3%), nine new instances of anterior pituitary hypofunction (5%), and five failures of multimodality therapy (2.3%). There were no perioperative deaths, five cases of cerebrospinal fluid leak requiring surgical repair (2.2%), and four cases of postoperative meningitis (1.8%). Permanent diabetes insipidus did not occur. Two of 52 patients who were irradiated postoperatively had severe complications; 23 (54.8%) of 42 patients who were available for follow-up evaluation had developed panhypopituitarism; and eight (19%) of 42 had normal pituitary function an average of 44 months postirradiation.     

Effects of naloxone on prolactin-secreting pituitary adenomas.

The investigators assessed the effects of the opioid antagonist naloxone on anterior pituitary hormone release in hyperprolactinemic females with pituitary microadenoma (n = 6) and macroadenoma (n = 7). In those with microadenoma, intravenous bolus injection of naloxone significantly increased serum luteinizing hormone (LH) concentrations but had no significant effect on serum prolactin (PRL), follicle-stimulating hormone, and thyroid-stimulating hormone concentrations. In patients with macroadenoma, naloxone significantly decreased serum LH and serum PRL concentrations. The response of LH to naloxone differed considerably between the two groups of patients. The results suggest that LH and PRL secretion is influenced by changes in endogenous opiates and in gonadotropin-releasing hormone and PRL inhibitory factor due to hypothalamic dysfunction.     

Cerebral salt wasting syndrome distinct from the syndrome of inappropriate secretion of antidiuretic hormone (SIADH)

Summary Two cases with pituitary tumour developed postoperative hyponatraemia which was not caused by inappropriate secretion of antidiuretic hormone. The one case with non-functioning macro-adenoma showed severe hyponatraemia (116 mEq/1) on day 11 after trans-sphenoidal surgery in association with diabetes insipidus (DI). The patient was treated by aqueous pitressin and saline administration to control urinary output and keep positive salt balance at the same time. The other case with GH-producing macro-adenoma showed progressive negative sodium balance with the total loss of 644 mEq resulting in hyponatraemia of 133 mEq/1. This was corrected by additional salt intake. The plasma atrial natriuretic polypeptide (ANP), antidiuretic hormone (ADH) as well as aldosterone levels were normal in the latter case. These patients were considered to manifest primary salt wasting disorder, which should be clearly differentiated from the syndrome of inappropriate secretion of antidiuretic hormone (SIADH).     

A comparative evaluation of effectiveness of medical and surgical therapy in patients with macroprolactinoma

BACKGROUND: The surgical success rate in macroprolactinomas is quite low, while medical treatment is more effective in reducing PRL levels and tumour mass. In this study the effectiveness of surgical, medical and radiant approaches on clinical symptoms, PRL levels and tumour size were compared in a large series of patients with macroprolactinomas. METHODS: One hundred and thirty-two patients (63 males and 69 females) were followed-up. Eighty-three patients were operated by trans-sphenoidal (TSS) approach: 18 underwent only TSS, 10 were operated and then irradiated; 30 patients underwent TSS and dopamine agonists, 25 were treated by TSS, radiotherapy and dopamine agonists. One hundred and four patients were treated by medical therapy: 49 patients were only administered dopamine agonists and 55 were given dopamine agonists after unsuccessful surgery and/or radiotherapy. RESULTS: In 83 patients serum PRL levels decreased from 1873+/-319.9 ng/ml to 831.6+/-297.8 ng/ml after trans-sphenoidal surgery: a significant PRL reduction was obtained in 18 cases (22%) and a full PRL normalization was found in 15 patients (18%). The pituitary adenoma was completely removed in the 15 cases, in whom serum PRL normalized. Sexual function was restored in 57 percent; of women and in 29 percent; of men. In contrast, dopaminergic drugs normalized PRL levels (from 1590.5+/-232.7 to 19.2+/-4.8 ng/ml) in 93/104 patients (89 percent;). Sexual function was restored in 74 percent; of women and in 75 percent; of men. Radiotherapy, performed after unsuccessful TSS, was ineffective in normalizing PRL levels. CONCLUSIONS: Medical therapy should be considered the first choice treatment in macroprolactinomas, while the surgical approach is recommended when neurological compressive symptoms are present and in patients resistant or intolerant to dopamine agonists. Radiotherapy may be indicated only in the patients in whom medical and surgical therapy have not been successful.     

A study of interleukin-8 and defensins in urine and plasma of patients with pyelonephritis and glomerulonephritis

Background: Interleukin-8 (IL-) plays a crucial role in the recruitment and activation of polymorphonucleated leukocytes (PMN) in the site of inflammation. Defensins are specific cationic proteins from azurophil PMN granules which exert antimicrobial, cytotoxic and proinflammatory activities. Methods: Urine and plasma levels of IL-8 and defensins were studied using specific enzyme-linked imunosorbent assays. IL-8 was determined in 107 patients, including 45 with chronic glomerulonephritis (GN) and 62 with chronic pyelonephritis (PN). Urine and plasma levels of defensins were studied simultaneously in 29 patients with GN and 29 with PN. None of the patients examined showed any evidence of renal insufficiency. A group of 24 healthy volunteers was used as a control. Results: Urinary IL-8 was significantly increased in all groups of patients comparing with healthy control (<30 pg/ml). The level of IL-8 in the urine of patients with PN (477±114 pg/ml, mean±SEM) was significantly (P <0.001) higher than in patients with GN (53±7 pg/ml). The concentration of defensins in urine of patients with GN was slightly increased in comparison with the normal level (21±3.5 ng/ml versus 15.7±2.8 ng/ml). Urinary defensins were significantly elevated in patients with PN (134±118 ng/ml, P<0.001),and were significantly higher than in the GN group (P <0.001). A close correlation was observed between IL-8 and defensin concentrations in urine (r=0.62), and between the urinary leukocyte count and IL-8 level (r=0.72). The highest levels of IL-8 were observed in patients with PN, associated with nephrolithiasis 914 patients, 822±219 pg/ml versus 367±72 pg/ml in patients with PN alone, P <0.05). IL-8 and defensin levels increased in older patients with PN, but not in older patients with GN. Conclusions: The levels of IL-8 and defensins in urine were 7-10-fold higher in patients with PN than in patients with GN. Thus, there is a significant difference in IL-8 production between septic and aseptic chronic inflammatory processes in kidney. It is possible to speculate that the timing and progression of kidney inflammation is mediated by an IL-8 dependent mechanism at least in the case of PN.     

Safety and efficacy of pulse and daily calcitriol in patients on CAPD: a randomized trial

Background: Calcitriol therapy is the mainstay of therapy for the treatment of secondary hyperparathyroidism. Oral administration of calcitriol is necessary in CAPD patients, but no studies have directly compared different routes of administration in this patient population. Methods: To determine if the peak serum calcitriol level (pulse therapy) is more important than the total delivered dose, we randomized CAPD patients with mild to moderate secondary hyperparathyroidism to receive either pulse (3.0 &mgr;g twice a week, n=10) or daily (0.75 &mgr;g a day, n=8) oral calcitriol in comparable weekly doses. The main comparison was the rate of decline of serum intact parathyroid hormone (PTH) levels to reach the desired end-point of 100 pg/ml. The patients were dialysed with low-calcium dialysate and received only calcium-containing phosphate binders. Results: Pharmacokinetic analysis after a single dose of 3.0 &mgr;g (pulse) vs 0.75 &mgr;g (daily) revealed 1,25(OH)2-vitamin D levels to be higher in the pulse group at 3 and 6 h, but equivalent by 12 h. The area under the curve for 1 week of daily and 1 week of pulse therapy was equal. The patients in the 2 arms had equivalent basal serum levels of PTH (pulse=562±291 vs daily=454±113 pg/ml), calcium (pulse=2.32±0.20 vs daily=2.32±0.12 mmol/l) and phosphorus (pulse=1.32±0.52 vs daily=1.35±0.26 mmol/l). The time required for the PTH to decrease to 100 pg/ml and rate of decline in PTH were similar (time: pulse=14.2±6.8 weeks, daily=12.2±7 weeks; rate: pulse=7.4±4.2 vs daily=8.4±4.2% PTH/week; P=NS). The serum calcium increased similarly in both groups. Hypercalcaemia (>2.9 mmol/l) was rare (pulse=3, daily=2 episodes). Conclusions: This study demonstrates that pulse and daily calcitriol are similarly effective and safe for the treatment of mild to moderate secondary hyperparathyroidism in CAPD patients despite higher peak levels of 1,25(OH)2-vitamin D with pulse therapy. Key words: calcitriol; calcium balance; CAPD; dialysis; hyperparathyroidism; renal osteodystrophy      

Pilot Study on Early Postoperative Discharge in Pituitary Adenoma Patients: Effect of Socioeconomic Factors and Benefit of Specialized Pituitary Centers

Introduction Pituitary neoplasms are benign entities that require distinct diagnostic and treatment considerations. Recent advances in endoscopic transsphenoidal surgery have resulted in shorter lengths of stay (LOS). We implemented a postoperative day (POD) 1 discharge paradigm involving a multidisciplinary approach and detailed preoperative evaluation and review of both medical and socioeconomic factors. Methods The experience of a single neurosurgeon/ears, nose, throat (ENT) team was reviewed, generating a preliminary retrospective database of the first 30 patients who underwent resection of pituitary lesions under the POD 1 discharge paradigm. We assessed multiple axes from their preoperative, in-house, and postoperative care. Results There were 14 men and 16 women with an average age of 53.8 years (range: 27–76 years). There were 22 nonsecretory and 8 secretory tumors with average size of 2.80 cm (range: 1.3–5.0 cm). All 30 patients underwent preoperative ENT evaluation. Average LOS was 1.5 ± 0.7 days. A total of 18 of 30 patients were discharged on POD 1. The insurance status included 15 with public insurance such as emergency Medicaid and 15 with private insurance. Four patients had transient diabetes insipidus (DI); none had permanent DI. Overall, 28 of 30 patients received postoperative steroids. Factors that contributed to LOS > 1 day included public insurance status, two or more medical comorbidities, diabetes mellitus, transient panhypopituitarism, and DI. Conclusion The implementation of a POD 1 discharge plan for pituitary tumors is feasible and safe for elective patients. This implementation requires the establishment of a dedicated Pituitary Center model with experienced team members. The consistent limitation to early discharge was socioeconomic status. Efforts that incorporate the analysis of social disposition parameters with proper management of clinical sequelae are crucial to the maintenance of ideal LOS and optimal patient outcomes.     

Preoperative high CEA level in lung cancer patients: significant of measurement of serum CEA level among preoperative and postoperative course in long time observed patient]

We measured pre- and postoperative CEA level in 330 patients who underwent resection for lung cancer at Kyushu Cancer Center Hospital between 1983 and 1986 using RIA method. There were 93 patients with high preoperative serum CEA level above 5 ng/ml. The interrelationships among preoperative serum CEA level, prognostic factors, outcome, and postoperative change of CEA level were investigated in the 93 patients. Five-year survival rate of patients with preoperative serum CEA level ranging from 5.0 to 10.0 ng/ml (N = 53) was 60.0%, while that of patients with preoperative CEA level over 10.1 ng/ml (N = 40) was 24.6% (P less than 0.05). Recurrent rate was higher in patients with preoperative CEA level over 10.1 ng/ml, especially in those with lung cancer at stages I or II. However, patients with preoperative CEA level about 50 ng/ml, showed good outcome after curative resection. All 12 patients in whom postoperative serum CEA level did not return to normal died within 4 years, indicating that normalization of CEA level is an important factor in prognosis. This study indicates that among lung cancer patients with high serum CEA level, the preoperative CEA level and postoperative change of CEA level are apparently prognostic factors.     

Management of prolactinomas associated with very high serum prolactin levels

The authors have reviewed the results of transsphenoidal microsurgical management in 69 patients with prolactin-secreting pituitary adenomas who had preoperative serum prolactin levels over 200 ng/ml. The patients were divided into three groups based on their preoperative serum prolactin levels: over 200 to 500 ng/ml (Group A); over 500 to 1000 ng/ml (Group B); and over 1000 ng/ml (Group C). The percentage of successful treatment ("control rate") was 68%, 30%, and 14%, respectively, in these three groups of patients. Based on these results, the authors offer guidelines for the management of patients with prolactin-secreting pituitary adenomas associated with exceptionally high serum prolactin levels. The surgical control rate of 68% in Group A seems to justify surgery for these patients, while primary medical care with bromocriptine is recommended for most patients with serum prolactin levels over 500 ng/ml.