Grasping the big picture: impact analysis of screening tools for timely referral for device-aided therapies.

Several screening tools are available to assist general neurologists in the timely identification of patients with advanced Parkinson's disease (PD) who may be eligible for referral for a device-aided therapy (DAT). However, it should be noted that not all of these clinical decision rules have been developed and validated in a thorough and consistent manner. Furthermore, only a limited number of head-to-head comparisons have been performed. Available studies suggest that D-DATS has a higher positive predictive value and higher specificity than the 5-2-1 criteria, while the sensitivity of both screening tools is similar. However, unanswered questions remain regarding the validity of the decision rules, such as whether the diagnostic performance measures from validation studies are generalizable to other populations. Ultimately, the question is whether a screening tool will effectively and efficiently improve the quality of life of patients with PD. To address this key question, an impact analysis should be performed. The authors intend to set up a multinational cluster randomised controlled trial to compare the D-DATS and 5-2-1 criteria on the downstream consequences of implementing these screening tools, with a particular focus on the impact on disability and quality of life.

Cytokine production of in vitro stimulated peripheral lymphocytes during the course of pregnancy and pseudopregnancy in the rat.

PROBLEM: Does maternal lymphocyte cytokine production after in vitro stimulation vary with the stage of pregnancy in the rat? METHOD OF STUDY: Blood samples were taken during the estrus cycle in rats (n = 11). Thereafter, rats were rendered pregnant (n = 6) or pseudopregnant (n = 5) and blood samples were taken at days 4, 8, 11, 15, and 20 of pregnancy and pseudopregnancy. White blood cell (WBC) count was measured and whole blood was stimulated with phorbol 12-myristate 13-acetate and calcium ionophore; interferon-gamma (IFNgamma) and interleukin-4 (IL-4) production as well as (sub)populations of lymphocytes were measured using flow cytometry. RESULTS: We observed an increase of WBC in the second week of pregnancy and a slowly decreasing percentage of lymphocytes during the course of pregnancy. The percentage IFNgamma producing T-lymphocytes after in vitro stimulation was increased during pregnancy (for Th-lymphocytes only in the second week of pregnancy, for Tc-lymphocytes at all days). This increased IFNgamma production in pregnant T-lymphocytes was accompanied by an increase during pseudopregnancy, and therefore may result from increased sex hormone concentrations. The percentage IFNgamma producing natural killer (NK) cells after in vitro stimulation was decreased on day 20 of pregnancy. No effect of pregnancy or pseudopregnancy was seen on percentage IL-4 producing lymphocytes after in vitro stimulation. CONCLUSION: In the rat the IFNgamma production after in vitro stimulation varies during pregnancy and is increased, rather than decreased, during pregnancy.

Monocyte activation, but not granulocyte activation, is inhibited in the presence of developing ovarian follicles.

This study was set up to evaluate the influence of ovarian factors on the acute phase of the endotoxin-induced glomerular inflammatory reaction. Six groups of rats with permanent jugular vein cannulas were used. This included three groups with increased progesterone and/or 17beta-oestradiol concentrations (day 14 pregnant rats, pseudopregnant rats and lactating rats), one group with the presence of developing ovarian follicles (cyclic rats), and two groups with both increased sex hormone concentrations and the presence of developing ovarian follicles (day 14 pregnant rats treated with FSH and day 21 pregnant rats). Rats were infused for 1h with either saline or endotoxin (1 microg/kg body weight) and sacrificed 4h after the infusion. Kidney sections were snap-frozen and prepared for immunohistochemistry. Endotoxin-induced glomerular granulocyte infiltration was increased only in the groups of rats with increased progesterone and/or 17beta-oestradiol concentrations. This could be due to endotoxin-induced ICAM-1 and/or VCAM-1 expression, which was observed in all endotoxin-treated groups and in all endotoxin-treated groups with increased sex hormone concentrations, respectively. It could also be due to an effect on granulocytes per se, since the number of endotoxin-induced CD11b-positive cells in the glomeruli was increased only in the groups with increased sex hormone concentrations. Endotoxin-induced glomerular monocyte infiltration, however, was seen only in those groups in which developing ovarian follicles were lacking (i.e. day 14 pregnant, pseudopregnant and lactating rats), suggesting that developing ovarian follicles produce anti-inflammatory factors. These factors did not have an effect on endothelial or leukocyte adhesion molecule expression. We hypothesize that the presence of elevated progesterone concentrations increased the endotoxin-induced glomerular granulocyte infiltration, while endotoxin-induced glomerular monocyte infiltration was inhibited in the presence of developing ovarian follicles.

Total white blood cell counts and LPS-induced TNF alpha production by monocytes of pregnant, pseudopregnant and cyclic rats.

Pregnancy in the rat may be associated with an activated innate immune system. Therefore, we investigated monocyte function as well as total white blood cell (WBC) counts during the follicular phase of the ovarian cycle, pregnancy and pseudopregnancy in the rat. Rats were equipped with a permanent jugular vein cannula, and 0.43 ml blood samples were taken from this cannula during the 4 days of the regular oestrus cycle of the rat (n=12). Thereafter, six rats were rendered pregnant, and the other six rats were rendered pseudopregnant according to standard methods. Blood samples were withdrawn from the cannula on days 4, 7 and 11 of pseudopregnancy and on days 4, 7, 11 and 20 of pregnancy. From each blood sample, 0.4 ml was stimulated with lipopolysaccharide (LPS) and monocyte intracellular cytokine production measured using flow cytometry. 30 microl of the blood was used to measure WBC counts and differential WBC counts. The results showed that the number of WBC was significantly increased only on day 11 of pregnancy compared with the follicular phase, and that this was due to the increased numbers of polymorphonuclear (PMN) cells. The percentage of TNF alpha-producing monocytes was increased on all days of pseudopregnancy and on day 11 of pregnancy. The fact that the percentage of monocytes producing TNF alpha upon an LPS stimulus was increased during the post-implantation phase of pregnancy and during pseudopregnancy as compared to the follicular phase may indicate that these conditions are proinflammatory conditions. For the post-implantation phase of pregnancy, this is once more stressed by the increased numbers of WBC and PMN.

Glomerular immunoglobulin deposits induce glomerular inflammation in pregnant but not in non-pregnant rats.

PROBLEM: Does an inflammatory stimulus evoke a more intense inflammatory response in pregnant rats as compared with non-pregnant rats? METHOD OF STUDY: Non-pregnant rats were injected with antibodies against the glomerular basement membrane (GBM), 14 days before pregnancy, to induce a subclinical glomerulonephritis. Part of the rats were rendered pregnant, the others remained non-pregnant throughout the experiment. Two experiments were performed: in experiment 1, pregnant and non-pregnant rats were killed at various intervals after the injection with antibody and parameters characteristic of a glomerular inflammation were evaluated using immunohistology on cryostat kidney sections and liver sections. In experiment 2, 24-hr urinary protein excretion was measured at various days after the injection in pregnant and non-pregnant rats. RESULTS: Experiment 1 revealed that a significant glomerular inflammation, as characterized by increased numbers of monocytes and LFA-1 positive cells per glomerulus, was only observed in pregnant rats with glomerulonephritis. Experiment 2 revealed that only pregnant rats with glomerulonephritis showed increased urinary protein excretion. CONCLUSION: The fact that glomerular inflammation coincides with proteinuria only in pregnant rats with glomerulonephritis, may suggest that these phenomena are causally related and promoted by the pregnant condition.

Association between macrophage activation and function of micro-encapsulated rat islets.

AIMS/HYPOTHESIS: Survival of microencapsulated islet grafts is limited, even when inflammatory reactions against the capsules are restricted to a small portion of less than 10%. METHODS: This study investigates both in vivo in rat recipients and in vitro whether cellular overgrowth on this minority of the capsules contributes to limitations in the functional survival of the 90% of the encapsulated islets which remain free of any cellular overgrowth. RESULTS: In successful rat recipients of an allogenic microencapsulated islet graft we found that the vast majority of cells in the capsular overgrowth were activated ED-1 and ED-2 positive macrophages which were found in numbers of approximately 1500 per capsule. Co-culture of encapsulated islets with 1500 (nr8383) rat-macrophages per capsule showed that the activation of macrophages was caused by islet-derived bioactive factors since TNF-alpha and IL-1beta secretion by macrophages was induced by islet-containing capsules and not by empty capsules. This activation of macrophages was associated with a decrease in function of the encapsulated islets as evidenced by a quantitatively reduced (35%) insulin response in static incubation and a slower response in perifusion. CONCLUSION/INTERPRETATION: Present research aims to design strategies for the temporary inhibition of macrophage activation since macrophages are predominantly present in the first two months after implantation. These strategies will serve as a pertinent basis for future clinical application of microencapsulated islets.

Monocyte intracellular cytokine production during human endotoxaemia with or without a second in vitro LPS challenge: effect of RWJ-67657, a p38 MAP-kinase inhibitor, on LPS-hyporesponsiveness.

In the present study, we investigated the effect of RWJ-67657, a p38 MAP kinase inhibitor, upon in vivo LPS-induced monocyte cytokine production and upon monocyte LPS-hyporesponsiveness. Thirty minutes before a single injection of LPS (4 ng/kg BW), healthy male volunteers received a single oral dose of RWJ-67657 at increasing dosages (0-1400 mg). Blood samples (pre-medication, 3, 6 and 24 h after LPS) were immediately incubated with LPS (reflecting LPS-hyporesponsiveness) or without LPS (reflecting in vivo monocyte stimulation) for 4 h at 37 degrees C. Following red blood cells lysis and white blood cell permeabilization, cells were labelled with alpha-CD14-FITC and alpha-IL-1beta, alpha-IL-12 or alpha-TNFalpha (PE-labelled), fixed, and analysed using flow cytometry. In vivo LPS injection resulted in an increased percentage of circulating monocytes producing IL-1beta, TNFalpha and IL-12 only at 3 h after the LPS injection. This was dose-dependently inhibited by RWJ-67657 treatment. LPS-hyporesponsiveness to in vitro LPS treatment was most prominent at 3 and 6 h after the in vivo LPS injection; compared with pre-medication monocytes, at these intervals a reduced percentage of monocytes produced IL-1beta, TNFalpha or IL-12 after the in vitro LPS stimulus. At t = 6 h, this LPS-hyporesponsiveness could dose-dependently be inhibited by RWJ-67657 treatment of the volunteers. We therefore conclude that p38 MAP kinase inhibition with RWJ-67657 inhibited monocyte production of cytokines following in vivo LPS injection. Treatment with RWJ-67657 also reversed the LPS-hyporesponsiveness. Whether this result can be extended to the clinical situation remains to be elucidated. Patients with sepsis or an otherwise high risk for multi-organ failure are potential study groups.

The immune response during the luteal phase of the ovarian cycle: increasing sensitivity of human monocytes to endotoxin.

OBJECTIVE: To test the hypothesis that during the luteal phase of the human ovarian cycle, as compared with the follicular phase, the percentage of cytokines producing peripheral monocytes after in vitro stimulation with endotoxin is increased. DESIGN: Prospective study. SETTING: Academic research institution. PATIENT(S): Women with regular menstrual cycles. INTERVENTION(S): Blood samples were collected between days 6 and 9 of the menstrual cycle (follicular phase) and between days 6 and 9 of the menstrual cycle following the LH surge (luteal phase). MAIN OUTCOME MEASURE(S): Percentages of tumor necrosis factor (TNF)-alpha-, interleukin (IL)-1 beta-, and IL-12-producing monocytes as well as total white blood cell (WBC) count, differential WBC counts, and plasma 17 beta-estradiol and progesterone concentrations. RESULT(S): Mean plasma 17 beta-estradiol and progesterone concentrations, percentage of TNF-alpha- and IL-1 beta-producing monocytes, WBC counts, and granulocyte cell count were significantly increased in the luteal phase as compared with the follicular phase of the ovarian cycle. The percentage of IL-12-producing monocytes, monocyte count and lymphocyte count did not vary between the 2 phases of the ovarian cycle. CONCLUSION(S): Together with an increase in progesterone and 17 beta-estradiol during the luteal phase, there is an increase in percentage TNF-alpha- and IL-1 beta-producing peripheral monocytes after in vitro stimulation with endotoxin as compared with the follicular phase of the ovarian cycle. Whether this increased sensitivity of monocytes for proinflammatory stimuli during the luteal phase is due to increased plasma levels of progesterone or 17 beta-estradiol needs further investigation.

Cytokine production by natural killer lymphocytes in follicular and luteal phase of the ovarian cycle in humans.

PROBLEM: The aim of this study was to test the hypothesis that, during luteal phase of the ovarian cycle, as compared with follicular phase, the cytokine productive capacity of peripheral natural killer (NK)-lymphocytes in humans is shifted towards a "Th2-type"-like response. METHOD OF STUDY: Intracellular Th1 and Th2 cytokine production by in vitro activated peripheral NK-lymphocytes in a whole blood preparation of the follicular and the luteal phase of the ovarian cycle was measured by flow cytometry. RESULTS: There was no difference in interferon (IFN)-gamma, interleukin (IL)-2, IL-4, and IL-10 cytokine production in activated NK-lymphocytes when comparing luteal phase with follicular phase of the ovarian cycle. However, there was a significant increase in peripheral NK-lymphocyte number in luteal phase compared with follicular phase. CONCLUSION: The cytokine productive capacity of peripheral NK-lymphocytes is not shifted towards a "Th2-type"-like response in the luteal phase as compared with the follicular phase of the ovarian cycle in humans.

Interaction of late pregnancy and lactation in rats.

The effect of pregnancy on lactation was studied during the third week of lactational pregnancy in postpartum pregnant rats with a delay in implantation of only 1 day (1d-LP rats). In an experimental design in which the suckling litter was prevented from consuming solid food, lactational performance was estimated by weighing the ten-pup suckling litters on days 16-21 of lactation or by measuring maternal weight loss after a nursing spell on day 21. In 1d-LP rats, food consumption as well as lactational performance was lower than it was in nonpregnant lactating rats (L rats) and pregnant-lactating rats with a normal long delay of implantation of at least 6 days (LP rats). The time spent by the pups sucking at the nipples was not different among the three groups, but the number of milk ejections was diminished in 1d-LP dams. Restriction of daily food supply during days 16 to 21 of lactation diminished lactational performance more strongly in 1d-LP rats than it did in L rats; 1d-LP rats conserved protein stores and mobilized fewer minerals than did L rats. The weight and composition of the litter in vitro were not affected by the food restriction. In pregnant-lactating rats (LP and 1d-LP rats), the number of early resorptions was increased in comparison with pregnant rats, showing that lactation can affect the earlier stages of pregnancy. It was concluded that late pregnancy does not affect nursing behaviour, but suppresses lactation by restricting maternal food intake and mobilization of maternal stores. Measurements in serum indicate a causative role for oestradiol, but not for leptin.

Progesterone stimulates pancreatic cell proliferation in vivo.

Treatment of cyclic and pregnant rats with progesterone stimulates cell proliferation within the islets of Langerhans. It was investigated whether this effect of progesterone depends on sex and/or the presence of the gonads or the presence of oestradiol. For this purpose, Silastic tubes containing progesterone were inserted s.c. in intact and gonadectomized male and female rats, and in gonadectomized female rats treated with oestradiol. After 6 days of progesterone treatment, rats were infused for 24 h with 5-bromo-2'-deoxyuridine (BrdU) and dividing cells were identified in pancreatic sections by immunostaining for BrdU. Progesterone treatment increased islet-cell proliferation in intact male and female rats (P < 0.05), but not in gonadectomized male and female rats or in gonadectomized female rats supplemented with oestradiol. Furthermore, in intact male and female rats, progesterone treatment also stimulated cell proliferation in extra-islet pancreatic tissue (P < 0.05). Identification of the proliferating cells, by double-immunocytochemistry, revealed that progesterone treatment stimulated proliferation of both alpha and beta cells within the pancreatic islets. In extra-islet pancreatic tissue, progesterone treatment stimulated proliferation in both duct (cytokeratin 20-immunoreactive) and non-duct cells. Progesterone treatment did not increase the number of single glucagon or insulin-containing cells outside the pancreatic islets, nor that of cytokeratin 20/insulin double-positive cells, suggesting that progesterone treatment did not stimulate differentiation of duct cells into endocrine cells. Progesterone treatment did not affect insulin responses to an i.v. glucose load (0.5 g/kg body weight). It is concluded that progesterone stimulates pancreatic cell proliferation indirectly; gonadal factor(s), not identical to oestradiol, is (are) probably involved.

Effects of food restriction on glucose tolerance, insulin secretion, and islet-cell proliferation in pregnant rats.

Pregnancy is associated with increased glucose-stimulated insulin secretion and increased pancreatic islet-cell proliferation. In the present study it was investigated whether increased food intake, as occurs during pregnancy, is involved in the regulation of these phenomena. From Day 0 of pregnancy, rats received each day the mean amount of food they consumed daily during the estrous cycle prior to conception. This food restriction regime resulted in lower maternal body weight, and in lower fetal weight on Day 20 of gestation, but did not affect fetal survival. Food-restricted rats showed decreased insulin responses to an i.v. glucose challenge on Day 13, and lower islet-cell replication rates on Day 14 of pregnancy than pregnant rats fed ad lib. Plasma lactogenic activity in food-restricted animals was increased on Days 11 and 13; plasma progesterone levels were unchanged, but plasma leptin concentrations declined progressively during food restriction. Glucose tolerance was normal, suggesting that food restriction improved insulin action. On Day 20 of pregnancy, insulin responses were similar in food restricted and ad lib-fed rats; glucose tolerance was still unchanged. It thus seems that the improved insulin action as present on Day 13 had disappeared on Day 20. Also on Day 20, lactogenic activity as well as progesterone concentrations were similar in food-restricted and ad lib-fed rats. It was concluded that increased food intake plays an important role in the stimulation of islet-cell proliferation and insulin secretion, as well as in the diminished insulin action during the second week of rat pregnancy.

Role of increased insulin demand in the adaptation of the endocrine pancreas to pregnancy.

During gestation the demand for insulin increases due to a decrease in insulin sensitivity of the maternal tissues. Simultaneously, pancreatic islet-cell proliferation, as well as insulin production and secretion increase. Both phenomena appear to be caused by the actions of pregnancy hormones. We studied the relationship between the two phenomena by investigating whether the supply of exogenous insulin affects the secretion of pregnancy hormones and islet function during gestation. For that purpose rats were treated with high doses of insulin (4.8 IU day-1 by sub-cutaneous osmotic mini pumps) so that the endogenous demand for insulin was fully satisfied from day 8-14 of gestation. Euglycaemia (5.0 mM) was maintained by intra venous infusion of glucose. The treatment suppressed insulin synthesis, as measured by in situ hybridization, in both pregnant and cyclic rats. In addition, in pregnant rats the increments in insulin secretion and in islet-cell proliferation were partly prevented. Furthermore, the data also suggest that in pregnant rats the treatment partly prevented the decrease in insulin sensitivity. Finally, the treatment did not affect the plasma concentrations of progesterone, prolactin and placental lactogen, but prevented the rise in growth hormone concentrations in pregnant rats. The present data suggest that, next to direct effects of pregnancy hormones and growth hormone on the pancreatic islets, a decreased insulin sensitivity in the maternal tissues, induced by actions of the same hormones, is involved in the regulation of islet function during gestation.

Effect of insulin on endocrine pancreas function during late pregnancy in the rat.

To partly or completely satisfy the increasing demand for insulin, pregnant rats were infused SC with human insulin (2.4 or 4.8 IU/day) from day 14 to day 20 of gestation. Cyclic control rats underwent the same procedure of 6 days of insulin-treatment. During the treatment all groups of rats were hypoglycaemic, but foetal survival was not affected. The low dose treatment prevented the characteristic rise of the insulin response to a glucose challenge during pregnancy, both in vivo and in vitro, while the high dose treatment suppressed the insulin response, as well as the pancreatic insulin content. The insulin responses and insulin contents of pregnant rats were higher than those of the corresponding cyclic control rats. These results support the hypothesis that during gestation the increased insulin demand, due to the actions of placental hormones, is the cause of the increased insulin secretion. However, it cannot be excluded that direct effects of placental hormones on the islets of Langerhans are also involved.

Pancreatic beta-cell function and islet-cell proliferation: effect of hyperinsulinaemia.

Pancreatic beta-cell function was studied in adult female rats, in which endogenous insulin demand was fully met by SC infusion of human insulin (4.8 IU/24 h) for 6 days, resulting in hyperinsulinaemia and severe hypoglycaemia. The amount of pancreatic endocrine tissue declined by 40%, (pro)insulin mRNA, as determined by in situ hybridisation by 95%, and the amount of stored insulin by 90%. Islet-cell proliferation as determined by 24 h of BrdU infusion declined by 60%. Basal glucose levels normalized within 2 days after the insulin treatment was ended, whereas about 1 week was needed to restore the amount of pancreatic insulin, glucose-induced insulin release, and glucose tolerance to normal values. The amount of endocrine tissue recovered within 48 h and mRNA abundance within 96 h after discontinuation of the insulin infusion, whereas at that time islet-cell proliferation still showed a sixfold increase, before returning to control levels after 1 week. These results show that after a period of suppression of beta-cell function, recovery of insulin synthetic capacity does not immediately result in normalization of insulin stores and insulin release. Under these conditions, episodes of hyperglycaemia may occur, which may act as a stimulus for islet-cell proliferation.

Arginine stimulated glucagon and insulin secretion by islets of Langerhans of pregnant and lactating rats.

Glucagon secretion by isolated pancreatic rat islets was not affected by an increase of the glucose concentration from 2.5 to 5.0 mM, but was stimulated by 25 mM arginine. This stimulation was only slightly increased by pregnancy and lactation. Insulin secretion increased, when the glucose concentration was raised from 2.5 to 5.0 mM, especially in pregnant islets and was also stimulated by arginine. The arginine stimulated insulin release was greatly augmented during late pregnancy and lactation. Islet content did not reflect the changes in secretion: glucagon content increased in the course of pregnancy and lactation, while insulin content was increased during late pregnancy, but not during lactation. It is concluded that, unlike insulin, glucagon is only marginally involved in the increase in anabolism during pregnancy and lactation.

Dopamine and TRH-induced prolactin secretion in pseudopregnant rats.

The stimulatory effect of TRH on prolactin (Pr1) secretion by the anterior pituitary gland (APG) of the pseudopregnant (PSP) rat was studied in vivo and in vitro. TRH, 500 micrograms, did not increase Pr1 release during the Pr1 peaks which are generated daily between 01.00 and 12.00 for about 10 days (mean height of the peaks: 302 +/- 99 ng mL-1), nor did TRH induce Pr1 secretion during the phase of low (12 +/- 1 ng Pr1 mL-1) secretion (the "interphase", between 20.00 and 01.00 h). 25 mg/kg b.w. of the dopamine- (DA) release blocking drug, 1-hydroxy-3-amino-pyrrolidone-2 (HA 966) did not itself induce peaks of Pr1 during the interphase, but in 1 animal out of 6 which were treated with this dose of HA 966, TRH (500 micrograms) induced a peak of Pr1 with a height of 264 ng mL-1 x 100 mg HA 966/kg b.w. induced during the interphase peaks of Pr1 which were as high as spontaneous Pr1 peaks (343 +/- 95 ng mL-1). TRH increased these Pr1 peaks to 844 +/- 48 ng mL-1. Apparently, HA 966 not only lowers DA concentrations but also somehow increases the TRH-responsiveness of the lactotrophs. In vitro, the secretion of Pr1 by incubated pituitary glands was suppressed to the same extent by 5 x 10(-8) and 10(-6) M DA. TRH stimulated Pr1 secretion in the presence of 5 x 10(-8) M DA, but not in the presence of 10(-6) M DA or in the absence of DA. It is concluded that in vitro TRH acts as a physiological antagonist of DA. It is suggested that in vivo the effectivity of TRH as a Pr1-releasing factor may be modulated by DA and that this effect of DA is independent from its Pr1-release suppressing effect.

Effect of the TRH analogue, CG 3703, on prolactin secretion in the pseudopregnant rat.

The effect of the TRH analogue, CG 3703 (AG), on secretion of prolactin (Prl) was studied in pseudopregnant rats. AG stimulated Prl secretion of incubated pituitary glands in the presence of 5.10(-8) M dopamine (DA) but not in the presence of 0 or 10(-6) M DA. AG did not inhibit the in vitro secretion of Prl. AG postponed the peaks of Prl which were generated between 0100 and 1200 h (delay after 500 micrograms AG: 3-4 h); the height of these nocturnal Prl peaks was not affected by AG. AG did not induce Prl secretion during the phase of low Prl secretion (the interphase) between 2000 and 0100 h. The DA-release blocking drug, HA 966, induced peaks of Prl during the interphase. These peaks were as high as spontaneous nocturnal Prl peaks and were blocked by AG. The results show that AG has two opposite effects on Prl secretion: a direct, stimulating effect, which is modulated by DA, and an indirect inhibitory effect, which is probably executed by DA, released by AG from the tuberoinfundibular DA neurons.

Metabolism of pregnant-lactating rats is adapted to pregnancy rather than to lactation.

In pregnant-lactating rats implantation was induced on day 4 of lactation so that, as an exception, lactation coincided with the period of high fetal growth. The already present suckling litters of these animals lagged behind in growth, but the "second" litters were at birth normal in size and weight. Such pregnant-lactating rats were tested in vivo with intravenous glucose loads and compared with cyclic and lactating rats. Glucose tolerance was unaffected by the reproductive state. Pregnant-lactating rats showed, just as during their first pregnancy, low basal glucose levels. Their basal insulin levels and insulin responses, however, were decreased in comparison with the first pregnancy and resembled those of lactating rats. This may be due to an increased insulin turnover, because in vitro insulin responsiveness and insulin content of both "pregnant-lactating" and "pregnant" islets were increased in comparison with "cyclic" and "lactating" islets. It was concluded that the metabolism of pregnant-lactating rats is adapted to the pregnant rather than to the lactational state.