Urinary bone resorption markers (deoxypyridinoline and C-terminal telopeptide of type I collagen) in healthy persons, postmenopausal osteoporosis and patients with type I diabetes.

PURPOSE: Deoxypyridinoline (DPD) is a derivative of hydroxypyridinium, which is released during bone resorption into the blood stream and is eliminated unmodified with urine. A further collagen-derived marker of bone resorption is the C-terminal telopeptide of type I collagen (beta-CTX-I, here abbreviated as CTX), which is released in bone resorption and almost entirely excreted by the kidneys. The aim of our study was to investigate different well-described patient groups as well as normal probands in view of differences and expected correlations of these two parameters: patients with insulin-dependent diabetes mellitus, postmenopausal women with osteoporosis and healthy control persons. MATERIALS AND METHODS: We used a solid-phase chemiluminescence enzyme immunoassay (Pyrilinks D-IMMULITE) for urinary DPD measurement and for the assessment of urinary CTX we used a quantitative ELISA (Osteometer Biotec A-S, CrossLaps ELISA). RESULTS: We found a highly significant correlation between both parameters in the group of healthy persons (r = 0.75, p < 0.05, n = 28) as well as in the group of patients with diabetes mellitus type I (r = 0.79, p < 0.05, n = 65). Also, a significant correlation was observed between DPD and CTX (r = 0.583, p < 0.05, n = 88) in the group of female osteoporotic patients. CONCLUSIONS: Despite good correlations between DPD and CTX in all of the investigated groups, these urinary markers were of limited diagnostic significance in the group of postmenopausal osteoporosis due to a wide spread (few patients showed concentrations above the range of healthy persons) in this newly diagnosed drug-naïve patient collective.

Pre-meal insulin aspart compared with pre-meal soluble human insulin in type 1 diabetes.

Insulin aspart has been shown, in medium-term studies, to achieve reductions in HbA(1c) without increasing the risk of major hypoglycaemia compared with pre-meal human insulin. The aim of the present 3-year study was to evaluate the long-term safety and efficacy of insulin aspart in people with type 1 diabetes. This was a 30-month extension of a multinational, multicentre, open-label, parallel-group study of 753 people with type 1 diabetes, originally randomly allocated to treatment with insulin aspart or unmodified human insulin before meals, with NPH insulin as basal insulin. Main outcomes measures were hypoglycaemia (major or minor), adverse events and HbA(1c). As insulin aspart became commercially available in some countries before the end of the trial, analyses of HbA(1c) used 30-month data to maintain statistical power. The relative risk estimate of major hypoglycaemia was similar between treatment groups (relative risk [RR] 1.00 [95% CI 0.72, 1.39]). The risk of having a minor hypoglycaemic episode was higher with insulin aspart than with human soluble insulin (RR 1.24 [1.09, 1.39] p=0.024). Insulin aspart was significantly superior to human insulin with respect to overall glycaemic control, with a baseline-adjusted HbA(1c) difference of -0.16 (-0.32, -0.01)% (p=0.035). Insulin aspart was well tolerated and effective during long-term treatment. The HbA(1c) advantage was maintained with insulin aspart without any adverse impact on the rate of major hypoglycaemia.

Telerobotic-assisted laparoscopic spleen-preserving partial resection of the pancreatic tail for insulinoma.

Laparoscopic pancreatic resection is rarely described. Telerobotic-assisted laparoscopy may offer some advantages for resection of the pancreatic tail. A 49-year-old woman was diagnosed with insulinoma located in the pancreatic tail. Telerobotic-assisted laparoscopic spleen-preserving resection of the pancreatic tail was performed. Operation time was 195 minutes. The postoperative course was uneventful. The previously described advantages of a telerobotic approach with extended range of motion and three-dimensional view make more complex operations like pancreatic resection possible and may offer extended indications for laparoscopic surgery.

Bone mineral density changes and bone turnover in thyroid carcinoma patients treated with supraphysiologic doses of thyroxine.

The aim of this one-year prospective study was to determine whether longterm thyroxine treatment is a risk factor for elevated bone turnover, loss of bone mass and subsequent development of osteoporosis. Premenopausal women (N = 19), and men (N = 9) suffering from differentiated thyroid gland carcinoma in the mean age of 39.0 +/- 8.0 years and 41.8 +/- 10.0 years were investigated. All of them had undergone a total thyroidectomy and subsequent thyroxine therapy. The duration of the TSH-suppressive therapy prior to the the beginning of our study was 9.4 +/- 6.4 years in the female and 8.1 +/- 6.0 years in the male group. The prospective observation was performed by dual X-ray absorptiometry (DXA) at the spine and the femoral neck and by single-photon absorptiometry (SPA) at the distal radius. Laboratory testings included thyroid hormones T3, T4 and TSH, serum calcium, phosphate and PTH, and urinary calcium and phosphate from spontaneous and 24-hour urine samples. Markers of bone formation (osteocalcin, alkaline phosphatase and PICP) and resorption (Ca/Cr and ICTP) were determined. Statistically significant loss of bone mass was observed only on the distal radius in males (p<0.05). At the lumbar spine and femoral neck, only a minor bone loss was registered in a small number of patients. Almost 50 % of the females showed values above the reference range. In more than 30 % of the females, and smaller number of male patients, ICTP values ranged above the reference range, corresponding to elevated bone turnover. These two variables exhibited a slight correlation with bone density at the measured skeletal areas, mostly considering the male group. The results are a proof that accelerated bone turnover and subsequent bone loss occurs during TSH-suppressive thyroxine therapy. In future prospective studies a prolonged time of observation will be necessary, as well as to increase the number of studied patients, in order to better assess the relative risk of osteoporosis in patients undergoing TSH-suppressive treatment more precisely.

Isolation of thyroid cells obtained by fine-needle aspiration biopsy.

Usually thyroid cells isolated from tissue obtained by surgery or thyroid cell lines are used to investigate the pathogenesis of autoimmune thyroid diseases. Isolation and cultivation of thyrocytes from fine-needle aspiration biopsy (FNAB) has not yet been published. The aim of this study was to isolate and cultivate thyrocytes from samples of FNAB. FNAB samples were obtained from nine adults and nine children with Hashimoto's thyroiditis (HT). The aspiration material was filtered resulting in small samples of tissue on the surface of the filter membrane. These tissue fragments were digested by collagenase I and dispase II. The yielding cells were cultivated for 3 weeks in Ham's F12 Kaighn's Modification medium in presence of 1 mU/mL bovine thyrotropin (TSH), 10 microg/mL human insulin, 6 microg/mL transferrin, and 10(-8) M hydrocortisone. Finally, isolated thyroid cells were characterized by determination of gene expression of thyrotropin receptor (TSHR), thyroperoxidase (TPO), and thyroglobulin (Tg) using a nested reverse transcriptase-polymerase chain reaction (RT-PCR). Thyroid cells obtained by FNAB can be maintained over a time period of approximately 3 weeks. Depending on the sample size a final number of 1000-14,000 cells was gained per FNAB. In addition, all cells isolated by the described method expressed TPO mRNA. TSHR mRNA was found in 4 samples, whereas 15 samples were Tg mRNA-positive. There were no differences with respect to the expression TSHR and TPO mRNA between samples from adults and children. The isolation and cultivation of thyroid cells obtained by FNAB has been established. In contrast to surgical specimen, this technique provides an easy access to thyrocytes derived from individual patients allowing repeated sampling to investigate the time progression of the chronic disease or the effect of treatment over time.

Lymphocyte homing in xenotransplanted human thyroid tissue can be inhibited by LFA-1 and ICAM-1 antibodies.

OBJECTIVES: Homing of lymphocytes is an important factor with respect to the initiation of the autoimmune process in Graves' disease (GD). As previously shown, human lymphocytes, particularly of intrathyroidal origin, derived from patients with GD, are able to migrate into normal xenotransplanted thyroid tissue and induce functional and histological changes. The aim of this study was to investigate the effect of LFA-1 and ICAM-1 antibodies on the homing of lymphocytes of different origin into xenografted human thyroid tissue. METHODS: Eighty-five nude mice bearing 8-week-old xenografts of normal human thyroid tissue were treated twice with anti-CD 54 (anti-ICAM-1), anti-CD 11a (anti-LFA-1), a combination of both, or, serving as controls, iso-antibodies without specific binding capacity or saline. Thereafter, intrathyroidal (ITL) or peripheral blood lymphocytes (PBL) obtained from 4 patients with GD or saline were injected into the animals (i.v., 0.2 mL, 10(6) cells). After 48 hours the mice were sacrificed and transplants as well as mice thyroids were examined by immunohistochemical staining with Ki67, CD3, HLA-II (DAKO, Hamburg), IgG, CD44, ICAM-1, and VCAM-1 (Immunotech, Hamburg). RESULTS: Pretreatment with anti-ICAM-1 and anti-LFA-1 decreased lymphocyte homing (CD3-staining), and expression of HLA-II, IgG, CD44, and VCAM-1 in the transplants. CONCLUSION: Our data show that [ICAM-1/LFA-1 stimulated (induced)] lymphocyte homing and subsequently thyrocyte proliferation are inhibited by ICAM-1 and LFA-1 antibodies in xenotransplanted thyroid tissue. This suggests that ICAM1 and LFA-1 play an important role in the early steps of autoimmune thyroid disease. The inhibition/suppression of ICAM-1 and LFA-1 interaction by respective antibodies, as demonstrated in the present study, may provide a new concept for prophylaxis and therapy.

[Hereditary medullary thyroid carcinoma--genotype-phenotype characterization]. / Hereditäres medulläres Schilddrüsenkarzinom--Genotyp-Phänotyp Charakterisierung.

BACKGROUND AND OBJECTIVE: Hereditary medullary thyroid carcinoma (MTC) is caused by germline mutations of the RET proto-oncogene. A genotype - phenotype correlation has been established, showing clustering of mutations in exons 10 and 11 in classical MEN 2 A syndrome, in exon 16 codon 918 in MEN 2 B syndrome and in exons 13-15 in familial MTC. A line of evidence suggested that the development and the aggressiveness of MTC in the different cancer syndromes is variable. Aim of this study was to compare the phenotype of exon 13-15 mutations with that of exon 11 mutation and possibly draw therapeutical consequences. PATIENTS AND METHODS: We compared the phenotype of 47 patients with mutations in exon 13-15 with 66 patients with exon 11, codon 634 mutation, the classical MEN2A. Patients were further subdivided as index and screening patients. RESULTS: Mean age of 19 index patients with codon 790, 791, 804 or 891 mutation was significant higher compared with 18 index patients with codon 634 mutation (mean age at diagnosis 50+/-12 years; range 30-69 y vs mean age 31+/-9 years; range 17-49 y), tumor stage at operation was favourable (C-cell hyperplasia n = 1; stage I n = 8; II n = 3; III n = 2; IV n = 2; no operation n = 1; no information n = 2 vs stage I n = 3; stage II n = 6; stage III n = 4, no information n =5), cure rate was better (56 % vs 38 %) and the death rate was lower (n = 2 vs n = 4). In screening patients no differences concerning the age, tumor stage, cure and death rate between patients with exons 13-15 and codon 634 mutations were seen. CONCLUSIONS: MTC in patients with exon 790, 791, 804, 891 mutations displayed a late onset and an indolent course compared to codon 634 mutation, this has to be taken into account when recommending timing and extent of prophylactic surgery.

[Optimal recurrence prevention of iodine deficiency related goiter after thyroid gland operation. A prospective clinical study]. / Optimale Rezidivprophylaxe der Jodmangelstruma nach Schilddrüsenoperation. Eine prospektive klinische Studie.

In summary the data of our study show: (1) Sonographically determined thyroid volume of patients with euthyroidism after surgery is found to be significantly lower with a combination therapy (iodide 150 microgram +Levothyroxine 75 microgram) compared to patients with iodide monotherapy (200 microgram). (2) Thyroid volume of patients with hypothyroidism after surgery is found to be significantly lower during a combination therapy (150 microgram iodide + 75 microgram L-thyroxine) compared to patients with a Levothyroxine monotherapy. (3) Patients with hypothyroidism and Levothyroxine monotherapy, however present with a significant increase of thyroid volume after surgery. (4) Urinary iodide excretion in the treatment groups with iodide or combination therapy increases significantly during therapy, however, patients with Levothyroxine monotherapy do not show changes. (5) Thyroid function is well stabilized in all treatment groups with adequate controls and adjustment of Levothyoxine dosage. There data clearly demonstrate that the combination therapy with Levothyoxine and iodide significantly improves prophylaxis of goiter recurrence.

[Autoimmune thyroiditis. Treatment with thyroid gland hormones in subclinical hypothyroidism or already in euthyroid state?]. / Autoimmunthyreoiditis. Behandlung mit Schilddrüsenhormonen bei subklinischer Hypothyreose oder schon bei Euthyreose?

In patients with subclinical hypothyroidism thyroid hormone therapy should be recommended more often with respect to analysis of effectiveness and risks. There is no cost-difference between treated patients and those who undergo thyroid hormone controls only, but thyroid hormone therapy probably induces improvement of clinical and laboratory parameters and reduction of cardiovascular risk factors. These therapeutic effects have to be elucidated in clinical prospective studies. Thyroid hormone therapy of patients with autoimmune thyroiditis and still euthyroid function obviously inhibits the autoimmune process and development of hypothyroidism. A final recommendation, however, can be given after the data of clinical studies with larger populations are available.

Effects of pioglitazone in nondiabetic patients with arterial hypertension: a double-blind, placebo-controlled study.

Hypertension is often associated with insulin resistance, dyslipidemia and obesity, which indicate a prediabetic state and increased risk of cardiovascular disease. Pioglitazone treatment of patients with type 2 diabetes reduces insulin resistance and improves lipid profiles. The present double-blind placebo-controlled study is the first study to report effects of pioglitazone in non-diabetic patients with arterial hypertension. Following a one week run-in, 60 patients were randomized to receive either pioglitazone (45 mg/day) or placebo for 16 weeks. Insulin sensitivity (M-value) increased by 1.2 +/- 1.7 mg/min/kg with pioglitazone compared with 0.4 +/- 1.4 mg/min/kg (P = 0.022) with placebo. HOMA index was decreased (-22.5 +/- 45.8) by pioglitazone but not by placebo (+0.8 +/- 26.5; P < 0.001). Decreases in fasting insulin and glucose were significantly (P = 0.002 and P = 0.004, respectively) greater with pioglitazone than placebo. Body weight did not change significantly with either treatment. HDL-cholesterol was increased and apolipoprotein B was decreased to a significantly greater extent with pioglitazone. There was a significantly (P = 0.016) greater decrease from baseline in diastolic blood pressure with pioglitazone. These changes would suggest improved glucose metabolism and a possible reduction in risk of cardiovascular disease with pioglitazone treatment of non-diabetic patients with arterial hypertension.

Detection of thyroid peroxidase mRNA in peripheral blood of patients with malignant and benign thyroid diseases.

The aim of this study was to evaluate thyroid peroxidase (TPO) mRNA expression in peripheral blood of patients with benign and malignant thyroid disease. Included were 120 thyroid cancer patients, 85 patients with goitre or Graves' disease (GD) and 54 healthy volunteers. TPO mRNA expression was analysed in peripheral blood by nested RT-PCR. In cancer patients, RT-PCR results were compared with staging, grading and serum thyroglobulin (TG) measurement. TPO transcripts were detected in 7/10 (70%) patients with known metastases of thyroid cancer and in 39 of 110 (36%) patients without metastases (P<0.05), in 15/44 (34%) patients with goitre, in 17/41 (41%) cases with GD and in 4/54 (7.4%) subjects in the control group (P<0.05, controls vs all patients with thyroid disease). Among cancer patients without metastatic disease, RT-PCR results correlated positively with lymph node status (P=0.05), grading (P=0.01) and elevated serum thyroglobulin levels (P=0.03). This is the largest study investigating the use of the TPO-RT-PCR assay. Positivity in TPO-RT-PCR correlates significantly with metastatic disease in cancer patients and with the presence of thyroid disease in general. To date, TPO-RT-PCR cannot substitute for standard techniques in the diagnosis of local recurrence or metastatic spread in thyroid cancer patients. However, as results of TPO-RT-PCR correlate significantly with lymph node status, grading and serum TG measurements in patients with non-metastatic disease, TPO seems to be an interesting molecular marker to look at in follow-up studies.

Unbalanced amounts of HLA-DQA1 allele mRNA: DQA1*03 shows high and DQA1*0501 low amounts of mRNA in heterozygous individuals.

Genes of the HLA-DR, DQ region confer strong susceptibility to type 1 diabetes mellitus (IDDM). A possible mechanism of susceptibility is a difference in the amounts of transcripts of predisposing and neutral or protective haplotypes. In this study we developed an assay to compare the amounts of mRNA of two distinct HLA-DQA1 alleles in peripheral blood lymphocytes (PBLs) of heterozygous individuals, using a quantitative RT-PCR with an internal standard covering all HLA-DQA1 specifities. We also developed an algorithm to calculate the amounts of mRNA for two distinct alleles in heterozygous individuals based on the comparison to the same internal standard. In total, 37 HLA-DQA1 heterozygous individuals were analysed, including patients with IDDM (n = 14) and healthy controls (n = 23). Intra-individually, we observed different amounts of mRNA for different HLA-DQA1 alleles in the order: HLA-DQA1*03 > *01 > *0201 > *05. This order was observed in all individuals. We also observed a variation in the ratio of these unbalanced amounts of mRNA in individuals with the same HLA-DQA1 allele combinations. In all allele combinations the average ratio was increased in patients with IDDM compared to the control samples. HLA-DQA1*03 positive and DQA1*03, *05 heterozygous patients had the highest average ratios. Nevertheless, based on limited sample numbers, these differences did not reach significance. We therefore conclude that variations between HLA-DQA1 alleles are not limited to the nucleotide sequence but are also found at the level of amounts of mRNA.

A recently described polymorphism in the CD28 gene on chromosome 2q33 is not associated with susceptibility to type 1 diabetes.

Type 1 diabetes mellitus is an autoimmune disease with a strong genetic background. The CTLA4 gene region (IDDM12) has been implicated in genetic susceptibility to type 1 diabetes by genome scanning and both family- and population-based analyses. As the genes encoding the costimulatory molecules CTLA4 and CD28, which compete for the receptor B7, reside close together on chromosome 2q33 and have high sequence homology, we investigated a recently described polymorphism in intron 3 of the CD28 gene and the CLTA4 codon 17 polymorphism in 176 patients with type 1 diabetes and 220 healthy controls. Whereas CTLA4 was found to be associated with type 1 diabetes, the frequency of the CD28 polymorphism did not differ between patients and controls, either in the entire sample or after stratification for CTLA4 genotype. Thus, the CD28 intron 3 polymorphism does not appear to be associated with susceptibility to type 1 diabetes.

Long-term cisapride treatment improves diabetic gastroparesis but not glycaemic control.

BACKGROUND: In patients with diabetic gastroparesis, delayed food delivery to the intestine may become a major obstacle to post-prandial glycaemic control. AIM: To investigate whether cisapride accelerates gastric emptying in the long term or improves diabetes control in patients with diabetic gastroparesis. METHODS: Eighty-five patients with long-standing insulin-dependent diabetes mellitus (glycosylated haemoglobin (HbA1c) > 7.0%), dyspepsia and diabetic neuropathy were tested for impaired gastric emptying of solids by the 13C-octanoate breath test. Nineteen of these patients with severe diabetic gastroparesis (i.e. t1/2 > 170 min) were randomly treated with 10 mg cisapride t.d.s. (n=9) or placebo (n=10) for 12 months. Thereafter, the breath test, dyspeptic symptoms and HbA1c values were reassessed. RESULTS: Half emptying times in nine patients with diabetic gastroparesis were significantly shortened by cisapride (175 +/- 46 min vs. 227 +/- 40 min; P < 0.03). Half emptying times in the 10 patients taking placebo did not change (205 +/- 37 min vs. 211 +/- 36 min, P=0.54). Cisapride significantly reduced dyspepsia (score: 4.1 +/- 1.6 vs. 2.0 +/- 0.5, P=0.002). HbA1c values after 12 months of treatment were not different (cisapride: 7.7 +/- 0.4% vs. 7.6 +/- 0.9%, P=0.76; placebo: 7.5 +/- 0.6% vs. 7.6 +/- 1.5%, P=0.89). CONCLUSIONS: Prokinetic treatment with cisapride accelerates gastric emptying of solids and improves dyspeptic symptoms in diabetic gastroparesis. Glycaemic control, however, is not affected by cisapride.

Nateglinide improves glycaemic control when added to metformin monotherapy: results of a randomized trial with type 2 diabetes patients.

AIMS/HYPOTHESIS: This study evaluated the addition of nateglinide, a d-phenylalanine derivative that restores early phase insulin release, to metformin in type 2 diabetes patients stabilized on high-dose metformin. METHODS: This multicentre, double-blind, parallel group trial included 467 metformin-treated patients with glycosylated haemoglobin (HbA1c) between 6.8% and 11%. Patients were randomized to add nateglinide 60 mg, 120 mg or placebo before three meals to metformin 1000 mg b.i.d. for 24 weeks. RESULTS: HbA1c was significantly reduced with nateglinide 60 mg and 120 mg plus metformin compared with metformin control (-0.36%, p = 0.003; -0.59%, p < 0.001 respectively). Greater benefits occurred if patients had elevated HbA1c at baseline (-1.38% with nateglinide 120 mg in patients with HbA1c > 9.5%). A modest fasting plasma glucose reduction was observed. Most symptoms suggestive of hypoglycaemia occurred in patients with low HbA1c levels (