Intra-operative quick insulin assay to confirm complete resection of insulinomas guided by selective arterial calcium injection (SACI)

Background and aims Insulinomas are rare endocrine disorders. Pre-operatively, conventional imaging techniques often fail to localise the tumor. In addition, due to the lack of quick insulin assays, intra-operative confirmation of complete resection was impossible until recently. Materials and methods Six patients with biochemical evidence of an insulinoma underwent pre-operative localisation studies and selective arterial calcium injection (SACI). In addition, insulin was measured before surgery and every 10–15 min after resection of the tumor using a quick insulin assay. Results Pre-operative localisation studies identified the tumor correctly as follows: endosonography: three of four, magnetic resonance imaging: two of four and SACI: six of six. Tumors in the head and body were enucleated while those in the tail were resected (n = 2, each). Those three patients, in whom magnetic resonance imaging and/or endosonography could localise the tumors pre-operatively, underwent laparoscopic surgery while the remaining three patients underwent open surgery. Intra-operatively, insulin dropped to normal levels within 20 min in all cases. After a follow-up of 0.8–3 years, all patients remained biochemically cured. Conclusions Pre-operatively, SACI appears to be a very sensitive localisation technique and may be most helpful in guiding the surgeon if conventional imaging techniques fail to localise the tumor. Complete removal of an insulinoma can be reliably predicted using a quick insulin assay. This paper was presented at the 2nd Biennial Meeting of the European Society of Endocrine Surgeons (ESES), May 18–20, 2006, Krakow, Poland.     

Optimal metabolite curve fitting for kinetic modeling of 11C-WAY-100635.

Many quantitative imaging protocols that make use of a metabolite-corrected arterial input function require the use of a mathematic model to describe the rate of metabolism of the radioligand. Commonly, parametric models are fit to metabolism data and then the fitted model is used to correct the plasma input function. (11)C-WAY 100635 is a rapidly metabolized radioligand used extensively in mapping the 5-hydroxytryptamine receptor 1A system. METHODS: To evaluate the adequacy of fit of 4 metabolite models, we examined data from 92 subjects who received an injection of (11)C-WAY 100635, were imaged with PET, and underwent measurement of total plasma concentration and metabolites. The performance of these models was assessed according to residual plots, as well as fit and information criteria. RESULTS: The study showed that the choice of model has a substantial effect on the resulting estimates of outcome measures. CONCLUSION: Among the models considered, the Hill model provides the best fit across all criteria.     

Physician assistants in academic radiology: the harborview experience

We describe a model of how physician assistants can be used in an academic medical center to expand radiologist productivity, and to enhance the departmental academic and educational missions. At Harborview Medical Center, following a training program and graduated responsibility under supervision, physician assistants provide initial interpretation of radiology studies, consultation to referring physicians, and perform less complicated interventional procedures. Acceptance of physician assistants by the radiologists, radiology residents, and referring physicians has been high. Although the impact of physician assistants on departmental clinical productivity is difficult to measure, our data suggest that radiologists are more efficient when physician assistants are assigned to service, both in terms of numbers of studies interpreted, and timeliness of reporting and billing. As a result of the success of our program, we believe that physician assistants can have an important role in radiology practice.     

A randomized trial of low-protein diet in type 1 and in type 2 diabetes mellitus patients with incipient and overt nephropathy.

OBJECTIVE: The efficacy of a low-protein diet in the secondary prevention of diabetic nephropathy is not established in patients with type 1 or type 2 diabetes mellitus. To determine whether a low-protein diet slows the decrease in glomerular filtration rate (GFR) and decreases the albumin excretion rate (AER) in diabetic patients with incipient and overt nephropathy, we performed a 2-year prospective, randomized controlled trial comparing the effects of a low-protein diet (0.8 g/kg/day) with a usual-protein diet. SETTING AND PATIENTS: The study was conducted in a University hospital and included 63 type 1 and type 2 diabetic patients with either incipient or overt nephropathy and mild renal failure (prestudy GFR, 80 +/- 20 mL/min). The primary outcome measures were decreased in GFR and 24-hour AER. RESULTS: In the low-protein-diet group, patients were younger (52 +/- 12 versus 63 +/- 9 years old) and more often were type 2 diabetic. During the follow-up period, according to dietary records the low-protein-diet group consumed 16% +/- 3% of total caloric intakes as compared with 19% +/- 4% in the usual-protein-diet group (P < .02), but 24-hour urinary urea excretions did not differ between the two groups. The 2-year GFR decrease was 7 +/- 11 mL/min in the low-protein-diet group and 5 +/- 15 mL/min in the usual-protein-diet group (P = not significant). AER did not increase significantly in the two diet groups during the follow-up period. Blood pressure and glycemic control were similar in the two groups all along the study. The decrease in GFR and AER were also similar in 6 compliant patients according to dietary records and to 24-hour urinary urea excretions from the low-protein-diet group and in 12 patients from the usual-protein-diet group. CONCLUSIONS: A 2-year low-protein diet did not alter the course of GFR or of AER in diabetic patients with incipient or overt nephropathy receiving renin-angiotensin blockers with strict blood pressure control.     

The 'Functional Muscle-Bone Unit': probing the relevance of mechanical signals for bone development in children and adolescents.

The present text deals with the relationship of muscle force and mass to bone mass and geometry in the developing skeleton of children and adolescents. Recent results of the last ten years are discussed with reflection on Harold Frost's 'mechanostat hypothesis'. Bone mass and geometry follow the development of body size and muscle force in children and adolescents. Thereby, bone is adapted to the tissue strain due to biomechanical forces. This process is modified by hormonal signals (i.e., estrogens and androgens). Therefore, the quantified relationship of muscle force to bone stability is a reasonable approach to distinguish between primary and secondary bone diseases. Primary bone diseases are characterized by a disturbed adaptation of bone to biomechanical forces. In contrast, secondary bone diseases show a correct adaptation of bone to loaded forces in combination with a decline of muscle force. Therefore, the 'Functional Muscle-Bone Unit' was introduced into the diagnostics of pediatric bone diseases. The ratio of two parameters--referred to bone strength on the one and to biomechanical forces on the other side--is a reasonable diagnostic approach to distinguish between primary and secondary bone diseases.     

The value of indices in the central and peripheral visual fields for the detection of glaucoma

We assessed 81 patients in four groups (normal, low- and high-risk ocular hypertension, and early glaucoma) with the standard Octopus G1 central visual field program in addition to two quantitative programs, PFN (peripheral field-nasal) and PFT (peripheral field-temporal), designed for this study to test the nasal and temporal periphery, respectively. Indices were calculated for each program for each subject in all groups. We then examined the behavior of the indices across the separate visual field areas within each group as well as the behavior of the indices of each field area among the different groups. We found that quantitative testing of the peripheral nasal visual field provided valuable information in the detection of glaucomatous visual dysfunction additional to that provided by quantitative testing of the central visual field. Quantitative testing of the temporal periphery was less valuable.