Transcervical endoscopic-assisted mediastinal parathyroidectomy with intraoperative parathyroid hormone monitoring.

Ectopic mediastinal parathyroid adenomas are rare lesions that typically necessitate either median sternotomy or thoracotomy. More recently, video-assisted thoracoscopy has been used to excise mediastinal parathyroid adenomas. Herein we describe a novel technique in which we used a minimally invasive transcervical endoscopic-assisted approach to excise an anterior mediastinal parathyroid adenoma in a young man with a history of spontaneous pneumothorax. Intraoperative parathormone monitoring confirmed the excision of all hypersecreting parathyroid tissue, thereby obviating the need for a conventional neck exploration.

Effect of standard vs extended Roux limb length on weight loss outcomes after laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Increasing the length of the Roux limb in open Roux-en-Y gastric bypass (RYGB) effectively increases excess weight loss in superobese patients with a body mass index (BMI) >50 kg/m2. Extending the RYGB limb length for obese patients with a BMI < 50 could produce similar results. The purpose of this study was to compare the outcomes of superobese patients undergoing laparoscopic RYGB with standard (< or =100-cm) with those undergoing the procedure with an extended (150-cm) Roux limb length over 1-year period of follow-up. METHODS: Retrospective data over 2.5 years were reviewed to identify patients with a BMI < 50 who underwent primary laparoscopic RYGB with 1-year follow-up ( n = 58). Forty-five patients (sRYGB group) received limb lengths < or = 100 cm, including 45 cm ( n = 1), 50 cm ( n = 2), 60 cm ( n = 6), 65 cm ( n = 1), 70 cm ( n = 1), 75 cm ( n = 3), and 100 cm ( n = 31). Thirteen patients (eRYGB group) received 150-cm limbs. Postoperative weight loss was compared at 3 weeks, 3 months, 6 months, and 1 year. RESULTS: Comparing the sRYGB vs the eRYGB group (average +/- SD), respectively: There were no significant differences in age (41.5 +/- 11.0 vs 38.0 +/- 11.9 years), preoperative weight (119.2 +/- 11.9 vs 127.8 +/- 12.5 kg), BMI (43.7 +/- 3.0 vs 45.2 +/- 3.5 kg/m2), operative time (167.1 +/- 72.7 vs 156.5 +/- 62.4 min), estimated blood loss (129.9 +/- 101.1 vs 166.8 +/- 127.3 cc), or length of stay (median, 3 vs 3 days; range, 2-18 vs 3-19). Body weight decreased over time in both groups, except in the sRYGB group between 3 and 6 months and 6 and 12 months after surgery and in the eRYGB group between 6 and 12 months. BMI also decreased over time, except in the eRYGB group between 6 and 12 months. Absolute weight loss leveled out between 6 and 12 months in both groups, with no increase after 6 months. Percent of excess weight loss did not increase in the eRYGB group after 6 months. An extended Roux limb did not significantly affect body weight, BMI, absolute weight loss, or precent of excess weight loss at any time point when the two groups were compared. A trend toward an increased proportion of patients with >50% excess weight loss ( p = 0.07) was observed in the extended Roux limb group. CONCLUSIONS: In this series, no difference in weight loss outcome variables were observed up to 1 year after laparoscopic RYGB. Thus, extending Roux limb length from < or =100 cm to 150 cm did not significantly improve weight loss outcome in patients with a BMI < 50 kg/m2.

The direct effects of catecholamines on hepatic glucose production occur via alpha(1)- and beta(2)-receptors in the dog.

The role of alpha- and beta-adrenergic receptor subtypes in mediating the actions of catecholamines on hepatic glucose production (HGP) was determined in sixteen 18-h-fasted conscious dogs maintained on a pancreatic clamp with basal insulin and glucagon. The experiment consisted of a 100-min equilibration, a 40-min basal, and two 90-min test periods in groups 1 and 2, plus a 60-min third test period in groups 3 and 4. In group 1 [alpha-blockade with norepinephrine (alpha-blo+NE)], phentolamine (2 microg x kg(-1) x min(-1)) was infused portally during both test periods, and NE (50 ng x kg(-1) x min(-1)) was infused portally at the start of test period 2. In group 2, beta-blockade with epinephrine (beta-blo+EPI), propranolol (1 microg x kg(-1) x min(-1)) was infused portally during both test periods, and EPI (8 ng x kg(-1) x min(-1)) was infused portally during test period 2. In group 3 (alpha(1)-blo+NE), prazosin (4 microg x kg(-1) x min(-1)) was infused portally during all test periods, and NE (50 and 100 ng x kg(-1) x min(-1)) was infused portally during test periods 2 and 3, respectively. In group 4 (beta(2)-blo+EPI), butoxamine (40 microg x kg(-1) x min(-1)) was infused portally during all test periods, and EPI (8 and 40 ng x kg(-1) x min(-1)) was infused portally during test periods 2 and 3, respectively. In the presence of alpha- or alpha(1)-adrenergic blockade, a selective rise in hepatic sinusoidal NE failed to increase net hepatic glucose output (NHGO). In a previous study, the same rate of portal NE infusion had increased NHGO by 1.6 +/- 0.3 mg x kg(-1) x min(-1). In the presence of beta- or beta(2)-adrenergic blockade, the selective rise in hepatic sinusoidal EPI caused by EPI infusion at 8 ng x kg(-1) x min(-1) also failed to increase NHGO. In a previous study, the same rate of EPI infusion had increased NHGO by 1.6 +/- 0.4 mg x kg(-1) x min(-1). In conclusion, in the conscious dog, the direct effects of NE and EPI on HGP are predominantly mediated through alpha(1)- and beta(2)-adrenergic receptors, respectively.

The acute effect of metformin on glucose production in the conscious dog is primarily attributable to inhibition of glycogenolysis.

Although metformin has been used worldwide to treat type 2 diabetes for several decades, its mechanism of action on glucose homeostasis remains controversial. To further assess the effect of metformin on glucose metabolism, 10 42-hour-fasted conscious dogs were studied in the absence ([Con] n = 5) and presence ([Met] n = 5) of a portal infusion of metformin (0.15 mg x kg(-1) x min(-1)) over 300 minutes. Hepatic glucose production was measured by both arteriovenous-difference and tracer methods. All dogs were maintained on a pancreatic clamp and in a euglycemic state to ensure that any changes in glucose metabolism would result directly from the effects of metformin. The arterial metformin level was 21 +/- 3 microg/mL during the test period. Net hepatic glucose output (NHGO) decreased in Met dogs from 1.9 +/- 0.2 to 0.7 +/- 0.1 mg x kg(-1) x min(-1) (P < .05). NHGO remained unchanged in Con dogs (1.7 +/- 0.3 to 1.5 +/- 0.3 mg x kg(-1)min(-1)). Tracer-determined glucose production paralleled NHGO. The net hepatic glycogenolytic rate decreased from 1.0 +/- 0.2 to -0.3 +/- 0.2 mg x kg(-1) x min(-1) (P < .05) in Met dogs, but remained unchanged in Con dogs (0.8 +/- 0.2 to 0.8 +/- 0.3 mg x kg(-1) x min(-1)). No significant change in gluconeogenic flux was found in eitherthe Metgroup (1.2 +/- 0.3 to 1.3 +/- 0.3 mg x kg(-1) x min(-1)) or the Con group (1.3 +/- 0.4 to 1.0 +/- 0.3 mg x kg(-1) x min(-1)). No significant changes were observed in glucose utilization or glucose clearance in either group. In conclusion, in the normal fasted dog, (1) the primary acute effect of metformin on glucose metabolism was an inhibition of hepatic glucose production and not a stimulation of glucose utilization; and (2) the inhibition of glucose production was attributable to a decrease in hepatic glycogenolysis and not to an alteration in gluconeogenic flux.

A negative arterial-portal venous glucose gradient increases net hepatic glucose uptake in euglycemic dogs.

We investigated whether a negative arterial-portal venous (a-pv) glucose gradient, or "portal signal," can increase net hepatic glucose uptake (NHGU) and decrease muscle glucose uptake at euglycemia as it does at hyperglycemia. Twenty 42-h fasted dogs were studied during a basal and two 120-min euglycemic periods (period I and period II). Glucagon was maintained at basal levels, and insulin was raised 3-fold (3xIns, n = 10) or 15-fold (15xIns, n = 10). During period I, dogs received glucose only peripherally. During period II, one-half of the dogs continued the peripheral infusion; the other one-half received glucose intraportally (4 mg. kg(-1). min(-1) and reduced peripheral glucose infusion). A negative a-pv glucose gradient was present during intraportal glucose infusion. All 3xIns and 15xIns dogs had similar NHGU in period I. In period II, it was 2.1 +/- 0.3 (3xIns) and 2.5 (15xIns) mg. kg(-1). min(-1) greater in the presence than in the absence of the portal signal (P < 0.001). The net glucose fractional extraction data paralleled NHGU. In 3xIns, but not in 15xIns, whole body nonhepatic glucose uptake was lower in the presence of the portal signal than in its absence. In conclusion, in hyperinsulinemic, but not hyperglycemic conditions, the portal signal is effective in activating NHGU. The inhibition of nonhepatic glucose uptake, on the other hand, is minimal under euglycemic as opposed to hyperglycemic conditions.

Effect of a selective rise in hepatic artery insulin on hepatic glucose production in the conscious dog.

In the present study we compared the hepatic effects of a selective increase in hepatic sinusoidal insulin brought about by insulin infusion into the hepatic artery with those resulting from insulin infusion into the portal vein. A pancreatic clamp was used to control the endocrine pancreas in conscious overnight-fasted dogs. In the control period, insulin was infused via peripheral vein and the portal vein. After the 40-min basal period, there was a 180-min test period during which the peripheral insulin infusion was stopped and an additional 1.2 pmol. kg-1. min-1 of insulin was infused into the hepatic artery (HART, n = 5) or the portal vein (PORT, n = 5, data published previously). In the HART group, the calculated hepatic sinusoidal insulin level increased from 99 +/- 20 (basal) to 165 +/- 21 pmol/l (last 30 min). The calculated hepatic artery insulin concentration rose from 50 +/- 8 (basal) to 289 +/- 19 pmol/l (last 30 min). However, the overall arterial (50 +/- 8 pmol/l) and portal vein insulin levels (118 +/- 24 pmol/l) did not change over the course of the experiment. In the PORT group, the calculated hepatic sinusoidal insulin level increased from 94 +/- 30 (basal) to 156 +/- 33 pmol/l (last 30 min). The portal insulin rose from 108 +/- 42 (basal) to 192 +/- 42 pmol/l (last 30 min), whereas the overall arterial insulin (54 +/- 6 pmol/l) was unaltered during the study. In both groups hepatic sinusoidal glucagon levels remained unchanged, and euglycemia was maintained by peripheral glucose infusion. In the HART group, net hepatic glucose output (NHGO) was suppressed from 9.6 +/- 2.1 micromol. kg-1. min-1 (basal) to 4.6 +/- 1.0 micromol. kg-1. min-1 (15 min) and eventually fell to 3.5 +/- 0.8 micromol. kg-1. min-1 (last 30 min, P < 0.05). In the PORT group, NHGO dropped quickly (P < 0.05) from 10.0 +/- 0.9 (basal) to 7.8 +/- 1.6 (15 min) and eventually reached 3.1 +/- 1.1 micromol. kg-1. min-1 (last 30 min). Thus NHGO decreases in response to a selective increase in hepatic sinusoidal insulin, regardless of whether it comes about because of hyperinsulinemia in the hepatic artery or portal vein.

Hepatic and gut clearance of catecholamines in the conscious dog.

Our aim was to assess hepatic and gut catecholamine clearance under normal and simulated stress conditions. Following a 90-minute saline infusion period, epinephrine ([EPI] 180 ng/kg x min) and norepinephrine ([NE] 500 ng/kg x min) were infused peripherally for 90 minutes into five 18-hour fasted, conscious dogs undergoing a pancreatic clamp (somatostatin plus basal insulin and glucagon). Arterial plasma levels of EPI and NE increased from 44 +/- 9 to 2,961 +/- 445 and 96 +/- 6 to 6,467 +/- 571 pg/mL, respectively (both P < .05). Portal vein plasma levels of EPI and NE increased from 23 +/- 8 to 1,311 +/- 173 and 79 +/- 10 to 3,477 +/- 380 pg/mL, respectively (both P < .05). Hepatic vein plasma levels of EPI and NE increased from 5 +/- 2 to 117 +/- 33 and 48 +/- 10 to 448 +/- 59 pg/mL, respectively (both P < .05). Net hepatic and gut EPI uptake increased from 0.5 +/- 0.1 to 30.0 +/- 3.0 and 0.4 +/- 0.1 to 26.3 +/- 4.0 ng/kg x min, respectively (both P < .05). Net hepatic and gut NE uptake increased from 1.5 +/- 0.4 to 74.7 +/- 8.4 and 0.8 +/- 0.2 to 57.9 +/- 7.6 ng/kg x min, respectively (both P < .05). Neither the net hepatic (0.86 +/- 0.05 to 0.93 +/- 0.02) nor gut (0.45 +/- 0.10 to 0.55 +/- 0.04) fractional extraction of EPI changed significantly during the simulated stress condition. Net hepatic and gut spillover of NE increased from 0.8 +/- 0.2 to 3.5 +/- 1.3 and 0.6 +/- 0.2 to 8.8 +/- 2.0 ng/kg x min, respectively, during catecholamine infusion (both P < .05). These results indicate that (1) approximately 30% of circulating catecholamines are cleared by the splanchnic bed (16% and 14% by the liver and gut, respectively); (2) the liver and gut remove a large proportion (approximately 86% to 93% and 45% to 55%, respectively) of the catecholamines delivered to them on first pass; and (3) high levels of plasma catecholamines increase NE spillover from both the liver and gut, suggesting that the percentage of NE released from the presynaptic neuron that escapes the synaptic cleft is increased in the presence of high circulating catecholamine levels.

Basal hepatic glucose production is regulated by the portal vein insulin concentration.

The ability of portal vein insulin to control hepatic glucose production (HGP) is debated. The aim of the present study was to determine, therefore, if the liver can respond to a selective decrease in portal vein insulin. Isotopic ([3H]glucose) and arteriovenous difference methods were used to measure HGP in conscious overnight fasted dogs. A pancreatic clamp (somatostatin plus basal portal insulin and glucagon) was used to control the endocrine pancreas. A 40-min control period was followed by a 180-min test period. During the latter, the portal vein insulin level was selectively decreased while the arterial insulin level was not changed. This was accomplished by stopping the portal insulin infusion and giving insulin peripherally at half the basal portal rate (PID, n=5). In a control group (n=5), the portal insulin infusion was not changed and glucose was infused to match the hyperglycemia that occurred in the PID group. A selective decrease of 120 pmol/l in portal vein insulin was achieved (basal, 150+/-36 to last 30 min, 30+/-12 pmol/l) in the absence of a change in the arterial insulin level (basal, 30+/-3 to last 30 min, 36+/-4 pmol/l). Neither arterial nor portal insulin levels changed in the control group (30+/-6 and 126+/-30 pmol/l, respectively). In response to the selective decrease in portal vein insulin, net hepatic glucose output (NHGO) increased significantly, from 8+/-1 (basal) to 30+/-6 and 14+/-2 micromol x kg(-1) x min(-1) by 15 min and the last 30 min (P < 0.05) of the experimental period, respectively. Arterial plasma glucose increased from 5.9+/-0.2 (basal) to 10.5+/-0.4 micromol/l (last 30 min). Three-carbon gluconeogenic precursor uptake fell from 11.2+/-2.9 (basal) to 5.9+/-0.7 micromol x kg(-1) x min(-1) (last 30 min), and thus a change in gluconeogenesis could not account for any of the increase in NHGO. With matched hyperglycemia (basal, 5.5+/-0.3 to last 30 min, 10.5+/-0.8 micromol/l) but no change in insulin, NHGO decreased from 12+/-1 (basal) to 0 (-1+/-6 micromol x kg(-1) x min(-1), last 30 min, P < 0.05) and hepatic gluconeogenic precursor uptake did not change (basal, 8.0+/-1.7 to last 30 min, 8.9+/-2.2 micromol x kg[-1] x min[-1]). Thus, the liver responds rapidly to a selective decrease in portal vein insulin by markedly increasing HGP as a result of increased glycogenolysis. These studies indicate that after an overnight fast, basal HGP (glycogenolysis) is highly sensitive to the hepatic sinusoidal insulin level.

Effect of a selective rise in sinusoidal norepinephrine on HGP is due to an increase in glycogenolysis.

To determine the effect of a selective rise in liver sinusoidal norepinephrine (NE) on hepatic glucose production (HGP), norepinephrine (50 ng.kg-1.min-1) was infused intraportally (Po-NE) for 3 h into five 18-h-fasted conscious dogs with a pancreatic clamp. In the control protocol, NE (0.2 ng.kg-1.min-1) and glucose were infused peripherally to match the arterial NE and blood glucose levels in the Po-NE group. Hepatic sinusoidal NE levels rose approximately 30-fold in the Po-NE group but did not change in the control group. The arterial NE levels did not change significantly in either group. During the portal NE infusion, HGP increased from 1.9 +/- 0.2 to 3.5 +/- 0.4 mg.kg-1.min-1 (15 min; P < 0.05) and then gradually fell to 2.4 +/- 0.4 mg.kg-1.min-1 by 3 h. HGP in the control group did not change (2.0 +/- 0.2 to 2.0 +/- 0.2 mg.kg-1.min-1) for 15 min but then gradually fell to 1.1 +/- 0.2 mg.kg-1.min-1 by the end of the study. Because the fall in HGP from 15 min on was parallel in the two groups, the effect of NE on HGP (the difference between HGP in the two groups) did not decline over time. Gluconeogenesis did not change significantly in either group. In conclusion, elevation in hepatic sinusoidal NE significantly increases HGP by selectively stimulating glycogenolysis. Compared with the previously determined effects of epinephrine or glucagon on HGP, the effect of NE is, on a molar basis, less potent but more sustained over time.

Interaction of equal increments in arterial and portal vein insulin on hepatic glucose production in the dog.

We have previously shown that a selective increase of 84 pmol/l in either arterial or portal vein insulin (independent of a change in insulin in the other vessel) can suppress tracer-determined glucose production (TDGP) and net hepatic glucose output (NHGO) by approximately 50%. In the present study we investigated the interaction between equal increments in arterial and portal vein insulin in the suppression of TDGP and NHGO. Isotopic ([3-3H]glucose) and arteriovenous difference methods were used in conscious overnight fasted dogs. A pancreatic clamp was used to control the endocrine pancreas. A 40-min basal period was followed by a 180-min test period, during which arterial and portal vein insulin levels were simulataneously and equally increased 102 pmol/l. Hepatic sinusoidal glucagon levels remained unchanged, and euglycemia was maintained by peripheral glucose infusion. TDGP was suppressed approximately 60% by the last 30 min of the experimental period. In contrast, NHGO was suppressed 100% by that time. Coincidentally, hepatic glucose uptake (net hepatic [3H]glucose balance) increased significantly (approximately 4 mumol.kg-1.min-1). The effects of simultaneous equal increases in peripheral and portal venous insulin were not additive in the suppression of TDGP. However, they were additive in decreasing NHGO as a result of an increase in the uptake of glucose by the liver.

Portal adrenergic blockade does not inhibit the gluconeogenic effects of circulating catecholamines on the liver.

This study was undertaken to determine the impact of portal adrenergic blockade on the gluconeogenic effects of epinephrine (EPI) and norepinephrine (NE). Experiments were performed on 18-hour fasted conscious dogs and consisted of a 100-minute equilibration, a 40-minute basal, and two 90-minute test periods. A pancreatic clamp was used to fix insulin and glucagon levels at basal values. Propranolol (1 microgram/kg.min) and phentolamine (2 micrograms/kg.min) were infused intraportally during both test periods. Portal infusion of alpha- and beta-adrenergic blockers alone (first test period) slightly increased hepatic glucose production from 2.4 +/- 0.4 to 2.8 +/- 0.5 mg/kg.min (nonsignificant [NS]) NE (500 ng/kg.min) and EPI (180 ng/kg.min) were infused peripherally during the second test period. Arterial NE and EPI increased from 186 +/- 63 to 6,725 +/- 913 pg/mL and 76 +/- 25 to 2,674 +/- 344 pg/mL, respectively. Portal NE and EPI increased from 135 +/- 32 to 4,082 +/- 747 pg/mL and 28 +/- 8 to 1,114 +/- 174 pg/mL, respectively. Hepatic glucose production, the maximal gluconeogenic rate, and gluconeogenic efficiency increased from 2.8 +/- 0.5 to 3.8 +/- 0.4 mg/kg.min (P < .05), 0.7 +/- 0.3 to 2.1 +/- 0.6 mg/kg.min (P < .05), and 21% +/- 8% to 60% +/- 13% (P < .05), respectively, in response to catecholamine infusion. Net hepatic lactate balance changed from output (1.5 +/- 3.3 mumol/kg.min) to uptake (-11.0 +/- 3.8 mumol/kg.min, P < .05). Net hepatic glycerol uptake increased from -1.5 +/- 0.7 to -5.5 +/- 2.0 mumol/kg.min (P < .05). Net hepatic uptake of gluconeogenic amino acids did not change significantly. Similarly, hepatic glycogenolysis did not increase during catecholamine infusion. In conclusion, portal delivery of adrenergic blockers selectively inhibits the glycogenolytic effects of EPI and NE on the liver, but allows a marked gluconeogenic response to the catecholamines.

Comparison of the direct and indirect effects of epinephrine on hepatic glucose production.

To determine the extent to which the effect of a physiologic increment in epinephrine (EPI) on glucose production (GP) arises indirectly from its action on peripheral tissues (muscle and adipose tissue), epinephrine was infused intraportally (EPI po) or peripherally (EPI pe) into 18-h-fasted conscious dogs maintained on a pancreatic clamp. Arterial EPI levels in EPI po and EPI pe groups rose from 97 +/- 29 to 107 +/- 37 and 42 +/- 12 to 1,064 +/- 144 pg/ml, respectively. Hepatic sinusoidal EPI levels in EPI po and EPI pe were indistinguishable (561 +/- 84 and 568 +/- 75 pg/ml, respectively). During peripheral epinephrine infusion, GP increased from 2.2 +/- 0.1 to 5.1 +/- 0.2 mg/kg x min (10 min). In the presence of the same rise in sinusoidal EPI, but with no rise in arterial EPI (during portal EPI infusion), GP increased from 2.1 +/- 0.1 to 3.8 +/- 0.6 mg/kg x min. Peripheral EPI infusion increased the maximal gluconeogenic rate from 0.7 +/- 0.4 to 1.8 +/- 0.5 mg/ kg x min. Portal EPI infusion did not change the maximal gluconeogenic rate. The estimated initial increase in glycogenolysis was approximately 1.7 and 2.3 mg/kg x min in the EPI pe and EPI po groups, respectively. Gluconeogenesis was responsible for 60% of the overall increase in glucose production stimulated by the increase in plasma epinephrine (EPI pe). Elevation of sinusoidal EPI per se had no direct gluconeogenic effect on the liver, thus its effect on glucose production was solely attributable to an increase in glycogenolysis. Lastly, the gluconeogenic effects of EPI markedly decreased (60-80%) its overall glycogenolytic action on the liver.

The role of fatty acids in mediating the effects of peripheral insulin on hepatic glucose production in the conscious dog.

We investigated the mechanism by which a selective increase in arterial insulin can suppress hepatic glucose production in vivo. Isotopic (3-3H-glucose) and arteriovenous difference methods were used in overnight-fasted, conscious dogs. A pancreatic clamp (somatostatin, basal portal insulin, and glucagon infusions) was used to control the endocrine pancreas. Equilibration (100 min) and basal (40 min) periods were followed by a 180-min test period. In control dogs (n = 5), basal insulin delivery was continued throughout the study. In the other two groups, peripheral insulin was selectively increased at the beginning of the test period by stopping the portal insulin infusion and infusing insulin peripherally at twice the basal portal rate. One group (INS + FAT; n = 6) received an infusion of 20% intralipid + heparin (0.5 U x kg(-1) x min(-1)) to clamp the nonesterified fatty acid (NEFA) levels during hyperinsulinemia; the other group (INS; n = 7) received only saline during the experimental period. In the INS group, a selective increase in peripheral insulin of 84 pmol/l was achieved (36 +/- 6 to 120 +/- 24 pmol/l, last 30 min) while portal insulin was unaltered (84 +/- 18 pmol/l). In the INS + FAT group, a similar increase in peripheral insulin was achieved (36 +/- 6 to 114 +/- 6 pmol/l, last 30 min); again, portal insulin was unaltered (96 +/- 12 pmol/l). In the control group, basal insulin did not change. Glucagon and glucose remained near basal values in all protocols. In the INS group, NEFA levels dropped from 700 +/- 90 (basal) to 230 +/- 65 micromol/l (last 30 min; P > 0.05), but in the INS + FAT group changed minimally (723 +/- 115 [basal] to 782 +/- 125 micromol/l [last 30 min]). In the INS group, net hepatic glucose output dropped by 6.7 micromol x kg(-1) x min(-1) (P < 0.05), whereas in the INS + FAT group it dropped by 3.9 micromol x kg(-1) x min(-1) (P < 0.05). When insulin levels were not increased (i.e., in the control group), net hepatic glucose output dropped 1.7 micromol x kg(-1) x min(-1) (P < 0.05). In all groups, the net hepatic glucose output data were confirmed by the tracer-determined glucose production data. In the INS group, net hepatic gluconeogenic substrate uptake (alanine, glutamine, glutamate, glycerol, glycine, lactate, threonine, and serine) fell slightly (10.4 +/- 1.3 [basal] to 7.2 +/- 1.3 micromol x kg(-1) x min(-1) [last 30 min]), whereas in the INS + FAT group it did not change (7.3 +/- 1.5 [basal] to 7.4 +/- 0.6 micromol x kg(-1) x min(-1) [last 30 min]), and in the control group it increased slightly (9.6 +/- 1.3 [basal] to 10.3 +/- 1.4 micromol x kg(-1) x min(-1) [last 30 min). These results indicate that peripheral insulin's ability to regulate hepatic glucose production is partially linked to its inhibition of lipolysis. When plasma NEFA levels were prevented from falling during a selective arterial hyperinsulinemia, approximately 55% of insulin's inhibition of net hepatic glucose output (NHGO) was eliminated. The fall in NEFA levels brings about a redirection of glycogenolytically derived carbon within the hepatocyte such that there is an increase in lactate efflux and a corresponding decrease in NHGO.

A comparison of the effects of selective increases in peripheral or portal insulin on hepatic glucose production in the conscious dog.

We investigated the mechanisms by which peripheral or portal insulin can independently alter liver glucose production. Isotopic ([3-3H]glucose) and arteriovenous difference methods were used in conscious overnight-fasted dogs. A pancreatic clamp (somatostatin plus basal insulin and basal glucagon infusions) was used to control the endocrine pancreas. After a 40-min basal period, a 180-min experimental period followed in which selective increases in peripheral (PERI group, n = 5) or portal-vein (PORT group, n = 5) insulin were induced. In control dogs (CONT group, n = 10), insulin was not increased. Glucagon levels were fixed in all studies, and basal euglycemia was maintained by peripheral glucose infusion in the two experimental groups. In the PERI group, arterial insulin rose from 36 +/- 12 to 120 +/- 12 pmol/l, while portal insulin was unaltered. In the PORT group, portal insulin rose from 108 +/- 42 to 192 +/- 42 pmol/l, while arterial insulin was unaltered. Neither arterial nor portal insulin changed from basal in the CONT group. With a selective rise in peripheral insulin, the net hepatic glucose output (NHGO; basal, 11.8 +/- 0.7 micromol x kg-1 x min-1) did not change initially (11.8 +/- 2.1 micromol x kg-1 x min-1, 30 min after the insulin increase), but eventually fell (P < 0.05 ) to 6.1 +/- 0.9 micromol x kg-1 x min-1 (last 30 min). With a selective rise in portal insulin, NHGO dropped quickly (P < 0.05) from 10.0 +/- 0.9 to 5.6 +/- 0.6 micromol x kg-1 x min-1 (30 min after the insulin increase) and eventually reached 3.1 +/- 1.1 micromol x kg-1 x min-1 (last 30 min). When insulin levels were not increased (CONT group), NHGO dropped progressively from 10.1 +/- 0.6 to 8.3 +/- 0.6 micromol x kg-1 x min-1 (last 30 min). Conclusions drawn from the net hepatic glucose balance data were confirmed by the tracer data. Net hepatic gluconeogenic substrate uptake (three carbon precursors) fell 2.0 micromol x kg-1 x min-1 in the PERI group, but rose 1.2 micromol x kg-1 x min-1 in the PORT group and 1.2 micromol x kg-1 x min-1 in the CONT group. A selective 84 pmol/l rise in arterial insulin was thus associated with a fall in NHGO of approximately 50%, which took 1 h to manifest. Conversely, a selective 84 pmol/l rise in portal insulin was associated with a 50% fall in NHGO, which occurred quickly (15 min). From the control data, it is evident that in either case approximately 30% of the fall in NHGO was due to a drift down in baseline and that 70% was due to the rise in insulin. In conclusion, an increment in portal insulin had a rapid inhibitory effect on NHGO, caused by the suppression of glycogenolysis, while an equal increment in arterial insulin produced an equally potent but slower effect that resulted from a small increase in hepatic sinusoidal insulin, from a suppression of gluconeogenic precursor uptake by the liver, and from a redirection of glycogenolytic carbon to lactate rather than glucose.

Direct effects of catecholamines on hepatic glucose production in conscious dog are due to glycogenolysis.

The effects of catecholamines (CATS) infused into the hepatic portal vein were studied in ten 18-h-fasted conscious dogs. Glucose production (GP) and gluconeogenesis (GNG) were assessed using tracer ([3H]glucose, [14C]alanine) and arteriovenous difference techniques. Each experiment consisted of a 100-min equilibration, a 40-min basal, and two 90-min test periods. A pancreatic clamp (somatostatin + basal portal insulin and glucagon) was used to fix insulin and glucagon at basal levels. Propranolol (1 microgram.kg-1.min-1) and phentolamine (2 micrograms.kg-1.min-1) were infused intraportally during both test periods of the blockade group while a carrier solution was infused in the control group. Norepinephrine (NE; 100 ng.kg-1.min-1) and epinephrine (Epi; 40 ng.kg-1.min-1) were infused intraportally during the second test period of both protocols. Portal NE (70 +/- 46 to 8,404 +/- 674 and 162 +/- 57 to 6,530 +/- 624 pg/ml, respectively) and portal Epi (21 +/- 11 to 3,587 +/- 309 and 29 +/- 6 to 2,989 +/- 406 pg/ml, respectively) rose in the control and adrenergic blockade groups, respectively. The increases in arterial NE and Epi were modest in both groups. Intraportal infusion of CATS increased GP from 2.1 +/- 0.2 to 6.2 +/- 1.0 mg.kg-1.min-1 in the control group but did not change it (2.7 +/- 0.4 to 2.7 +/- 0.3 mg.kg-1.min-1) in the blockade group. Portal CATS had no effect on GNG in the presence or absence of adrenergic blockade (GNG rose from 0.7 +/- 0.2 to 0.9 +/- 0.2 and 0.8 +/- 0.2 to 1.0 +/- 0.2 mg.kg-1.min-1 in the control and blockade groups, respectively). In conclusion, portal infusion of catecholamines significantly augmented GP by selectively stimulating glycogenolysis. The increase in hepatic GP could be completely inhibited by intraportal adrenergic blockade.

Identification of a gene encoding a novel protein-tyrosine kinase containing SH2 domains and ankyrin-like repeats.

Using the polymerase chain reaction with primers corresponding to conserved regions in the kinase domain of protein-tyrosine kinases, we amplified segments of several protein-tyrosine kinase genes from Hydra vulgaris, a member of the ancient metazoan phylum Cnidaria. Characterization of cDNA clones for one of these genes, HTK16, revealed that it encodes a non-receptor protein-tyrosine kinase with two SH2 domains but no SH3 domain. In this regard the predicted HTK16 protein resembles two mammalian non-receptor protein-tyrosine kinases, the products of the ZAP-70 and syk genes. However, the HTK16 protein contains five ankyrin-like repeats, a structural motif which has not previously been found in protein-tyrosine kinases. The HTK16 protein also contains a potential tyrosine phosphorylation site in its carboxyl-terminal tail which resembles the phosphorylation site in members of the src family. RNA hybridization analysis indicates that the HTK16 gene is expressed in epithelial cells, cells which also express the Hydra homologue of the src protein. Our finding of the HTK16 gene in Hydra indicates that diversification of genes encoding non-receptor protein-tyrosine kinases was a very early event in metazoan evolution.

In vivo evidence that ethosuximide is a substrate for cytochrome P450IIIA.

The role of various subfamilies of rat hepatic cytochrome P450 in the oxidation of ethosuximide was evaluated by comparing ethosuximide clearance in control rats and those pretreated with relatively selective P450 inducers and/or inhibitors. Clotrimazole pretreatment increased ethosuximide clearance threefold (p less than 0.005). Dexamethasone increased ethosuximide clearance twofold (p less than 0.001), and the dexamethasone effect was completely abolished by a single dose of triacetyloleandomycin. These results suggest a prominent role for cytochrome P450IIIA in ethosuximide metabolism in the rat. Isoniazid increased ethosuximide clearance twofold (p less than 0.001), and this effect was abolished by a single dose of diallylsulfide, suggesting that ethosuximide is also processed by cytochrome P450IIE1 in rats. Phenobarbital pretreatment increased ethosuximide clearance 2-2.7 fold (p less than 0.001); an effect that was only partially reversed by orphenadrine, an inhibitor of cytochrome P450IIB/IIC enzymes. This suggests a quantitatively less important role for the IIB/IIC subfamilies in processing ethosuximide, since phenobarbital is an inducer of P450 subfamilies IIB, IIC, IIE, and IIIA. Neither the cytochrome P450IA inducer, beta-naphthoflavone, nor the inhibitor, alpha-naphthoflavone altered ethosuximide clearance. Ajmaline, an inhibitor of cytochrome P450IID, had no effect on ethosuximide clearance. Together, these findings suggest that ethosuximide is principally oxidized by cytochrome P450IIIA, and that cytochrome P450IIE may play an important role. Cytochromes P450IIB/C play less prominent roles in ethosuximide oxidation, and neither cytochrome P450IA nor cytochrome P450IID is involved.