[The Choosing Wisely Initiative of the German Society of Internal Medicine : Recommendations of the German Society for Endocrinology and the German Society for Geriatrics]. / Die Klug-entscheiden-Initiative der Deutschen Gesellschaft für Innere Medizin : Empfehlungen der Deutschen Gesellschaft für Endokrinologie und der Deutschen Gesellschaft für Geriatrie.

POSITIVE RECOMMENDATIONS: A. After osteoporotic fractures in the elderly, as a rule specific antiosteoporotic therapy should be initiated. a. Osteoporosis as a disease of the elderly should be diagnosed and treated (recommendation of the German Society for Geriatrics). B. All patients with diabetes mellitus should complete a specific diabetes training program when antidiabetic drug medication is initiated. C. In Germany, all pregnant women should be advised to undertake iodine supplementation. D. Endocrine causes of hypertension should be ruled out in younger patients and in patients on multiple antihypertensive drugs. E. All unclear cases of hypercalcemia should be clarified. NEGATIVE RECOMMENDATIONS: A. Testosterone substitution therapy should not be initiated on the basis of only one measurement of a reduced testosterone level without clinical signs and clarification of the underlying cause. B. Imaging procedures should only be used after the existence of hormonal disease has been confirmed. C. Sonographic screening for thyroid disease is not advised in the elderly. D. Long-term therapy with levothyroxine for nodular goiter should be avoided. E. In relevant stress situations hydrocortisone replacement therapy should not be continued without dose adjustment in patients with adrenal or pituitary insufficiency.

Characterization of a low pathogenic avian influenza H5N2 virus isolated from a turkey breeder flock in Manitoba, Canada.

In November 2010, an outbreak of avian influenza (AI) due to the H5N2 subtype virus occurred in a turkey breeder farm in northern Manitoba, Canada. The only clinical signs observed were depression, decrease in food consumption, and loss of egg production. The hemagglutinin (HA) cleavage (HA(0)) site of the isolated H5N2 virus was PQRETR/GLF, consistent with low pathogenic AI viruses. The intravenous pathogenicity index of this virus was zero. Whole-genome sequencing of two isolates that originated from two different barns was performed, and both isolates had 100% identical protein sequence in PB2, HA, NP, M1, M2, NS1, and NS2. The remaining gene segments (PB1, PA, and NA) had a single amino-acid difference when compared with each other. The nucleotide and protein sequences of eight gene segments from both isolates showed 99 or greater identity with other AI viruses that have been circulating in free-living aquatic birds in Canada and the United States within the last 10 yr. Phylogenetic analysis of the HA and neuraminidase (NA) gene segments showed that these viruses are closely related to other H5 strains that have been isolated from Manitoba and other parts of Canada. Serologic testing of archived serum samples collected from these turkeys a week before the outbreak showed no evidence of AI infection. In addition, other farms that were located within 3 km radius from the infected farm and farms that had epidemiologic connection with the farm also tested negative for the presence of H5N2 AI virus or antibody. This indicates that the virus might have been introduced to the farm from wild aquatic birds only a short time before detection. Results of this study highlight the importance of early detection and the significance of ongoing Canada-wide surveillance of AI in domestic poultry as well as in wild aquatic birds/ducks.

[Management of solid pulmonary nodules]. / Management solider pulmonaler Rundherde.

The increasing availability of computed tomography has meant that the number of incidentally detected solitary pulmonary nodules (SPN) has greatly increased in recent years. A reasonable management of these SPN is necessary in order to firstly be able to detect malignant lesions early on and secondly to avoid upsetting the patient unnecessarily or carrying out further stressful diagnostic procedures. This review article shows how the dignity of SPNs can be estimated and based on this how the management can be accomplished taking established guidelines into consideration.

Leptin and endocrine parameters in marathon runners.

Endurance training may lead to different hormonal alterations e. g., exercised induced hypothalamic ovarian/testicular dysfunction. The aim of this study was to reveal new connections between physical exercise, leptin and hormonal responses. 36 male participants of the Berlin-Marathon had their blood samples taken 2 days before the marathon. Hormones of the hypothalamic-pituitary axis and leptin were correlated with the training status and the achieved marathon time. Leptin correlated with the achieved marathon time after being adjusted for age and BMI (r=0.607, p<0.001) and was lowest in the best trained runners. Additionally, when the group was divided into quartiles of their achieved marathon time, significantly increased cortisol, fT4, cortisol/DHEAS ratio and decreased IGF-1 levels were observed in the slowest group. In the better trained group, a decrease of testosterone/DHT ratio and an increase of testosterone/cortisol ratio were observed. Our study supports the thesis of a linear relationship between physical fitness and leptin variations in the physiological range. We found an increased anabolic hormonal response in well trained marathon runners and hormonal reactions of increased stress in less trained runners. As the stress-induced neuroendocrine adaptations in our study group are associated with more higher leptin values, the pathophysiological role of decreased leptin values seems to be limited to overtrained athletes.

[Tumors and pseudotumors of the mediastinum]. / Tumoren und Pseudotumoren des Mediastinums.

Space occupying lesions of the mediastinum are relatively common. They represent a wide spectrum of diseases including highly malignant tumors requiring immediate further diagnostic and therapeutic procedures as well as clinically insignificant findings and normal variants. This review provides an overview of different mediastinal tumors and pseudotumors. Furthermore, it aims at enabling the reader to classify mediastinal lesions according to the pathogenesis and clinical significance. Localization of the lesion within a specific mediastinal compartment may suggest the etiology and thus the differential diagnosis. Also, morphological imaging criteria may suggest the diagnosis. The reader of this review should be able to reliably classify mediastinal lesions which exhibit these specific features without histological examination.

In vivo activity of 11ß-hydroxysteroid dehydrogenase type 1 in man: effects of prednisolone and chenodesoxycholic acid.

The 11ß-hydroxysteroid dehydrogenases (11ß-HSDs) play a pivotal role in glucocorticoid (GC) action. 11ß-HSD1 is a predominant reductase, activating GCs from inert metabolites, whereas 11ß-HSD2 is a potent dehydrogenase inactivating GCs. Knowing the metabolic effects of GCs, a selective inhibition of 11ß-HSD1 represents a potential target for therapy of impaired glucose tolerance, insulin insensitivity and central obesity. In vitro, 11ß-HSD1 is selectively inhibited by chenodesoxycholic acid (CDCA) and upregulated under GC exposure. Therefore, we aimed to investigate the effects of CDCA and prednisolone on hepatic 11ß-HSD1 activity in vivo by measuring 11-reduction of orally given cortisone (E) acetate to cortisol (F). CDCA or placebo was given to 5 male healthy volunteers within a randomised cross-over trial before and after oral administration of 12.5 mg E acetate at 8:00 h. For measurement of in vivo effects of GCs on 11ß-HSD1 activity, hepatic reduction of 25 mg E acetate before and after treatment with prednisolone (30 mg for 6 days) was determined in 7 healthy males. Serum GC levels were determined using a fully automated liquid chromatographic system. CDCA had no effect on the activity of 11ß-HSD1 in vivo. Prednisolone therapy leads to a marked rise in serum F concentrations and an elevated F/E serum ratio. This proves GC-induced activation of hepatic 11ß-HSD1, which could not be extinguished by a parallel increase of IGF-1 under prednisolone. CDCA does not affect in vivo activity of 11ß-HSD1 when given in therapeutic dosages. During GC treatment, increased hepatic activation of E to F may aggravate metabolic side effects of GCs such as seen in the metabolic syndrome.

[High resolution computed tomography of the lungs: ground glass opacity and its differential diagnosis]. / Hochauflösende computertomographie der lunge: milchglas und seine differenzialdiagnosen.

Ground glass opacity (GGO) is defined as diffuse pulmonary infiltration which does not obscure vessels and bronchial walls and is due to intra-alveolar or interstitial processes of pulmonary parenchyma which only partially replace air. The etiology is variable including edema, airspace and interstitial pneumonia due to different organisms, non-infectious pneumonitis as well as tumor manifestations. Physiological processes, such as poor ventilation of dependent lung areas and effects of expiration can also present as ground glass opacity.This review describes the physiology and pathophysiology of GGO, illustrates different examples of common diseases presenting with GGO and reviews how GGO may be used for diagnosis and differential diagnosis of pulmonary disease.

Intravenous lipid and heparin infusion-induced elevation in free fatty acids and triglycerides modifies circulating androgen levels in women: a randomized, controlled trial.

BACKGROUND: The polycystic ovarian syndrome (PCOS) is characterized by hyperandrogenism and associated with obesity and impaired glucose metabolism. Despite the high prevalence of PCOS and the considerable clinical impact, the precise interplay between metabolism and hyperandrogenemia is not entirely clear. OBJECTIVE: The objective of the study was to analyze the effects of iv lipid and heparin infusion on circulating androgen levels in healthy women. DESIGN: This was a randomized, controlled, crossover trial. SETTING: The study was conducted at an endocrinology center. PATIENTS: Patients included 12 healthy young women during the early follicular phase of two subsequent cycles. INTERVENTION: After an overnight fast, a 20% lipid/heparin or a saline/heparin infusion was administered in random order for 330 min. MAIN OUTCOME MEASURES: A detailed characterization of androgen metabolism was performed. RESULTS: Elevations in free fatty acids and triglycerides, induced by lipid/heparin infusion, elevates the levels of androstenedione, dehydroepiandrosterone (DHEA), dehydroepiandrosterone sulfate (DHEAS), testosterone, 5alpha-dihydrotestosterone, estrone, and 17beta-estradiol. Urinary excretion of DHEA, DHEAS, 5-androstene-3beta,17beta-diol, and the sum of urinary excreted DHEA and its 16-hydroxylated downstream metabolites, 16alpha-hydroxy-DHEA and 5-androstene-3beta,16alpha,17beta-triol, were reduced. CONCLUSION: The mechanism of iv lipid and heparin infusion-induced elevation of circulating androgens described here might contribute to the development of hyperandrogenism in women with PCOS and suggests that lowering of hyperlipidemia might be a potential therapeutic target in patients with PCOS to treat hyperandrogenemia.

[Lung cancer screening: status in 2007]. / Screening des Lungenkarzinoms: Stand 2007.

Thoughts on screening for lung cancer are based on the very poor prognosis of this tumor when the diagnosis is made because of symptoms (<15% 5-year survival), the markedly better prognosis if it is detected in asymptomatic early stages (up to 80% 5-year survival), the high sensitivity of unenhanced low-dose CT in the detection of small tumors, and the clear definition of persons at risk. Feasibility studies using well-defined diagnostic algorithms for management of detected pulmonary nodules have demonstrated a high proportion (>50 to >90%) of small, resectable non-small-cell lung carcinomas in the early stages, with a good prognosis for the patients affected and a low rate of unnecessary biopsies. However, biases such as overdiagnosis, length-time and lead-time could hamper potential reduction of mortality from lung cancer, and the results of large prospective randomized trials are therefore awaited. At the same time, other techniques for early diagnosis of lung cancer are under evaluation, such as sophisticated methods of sputum analysis, molecular markers in the blood and analysis of exhaled air.

The simultaneous measurement of plasma-aldosterone- and -renin-concentration allows rapid classification of all disorders of the renin-aldosterone system.

OBJECTIVE: The determination of the plasma aldosterone (PAC) to the plasma renin concentration (PRC) ratio is an accepted screening tool for primary hyperaldosteronism (PHyperA). DESIGN: To assess the diagnostic significance of this ratio for other disorders of the renin-aldosterone-system (RAS), we examined 60 patients with different adrenal diseases, 32 patients with essential hypertension and 76 normotensive healthy volunteers. The aldosterone (pmol/L) and renin (mU/L) concentrations were measured in one plasma sample by an automated chemiluminescence assay (Nichols Advantage). RESULTS: Patients with PHyperA (n=31) had a PAC/PRC ratio between 105 and 2328 and could be distinguished without overlap from the essential hypertension group (ratio: range 2.7-49) and normal healthy volunteers (ratio: range 0.9-71). Fourteen patients with primary hypoaldosteronism showed low PAC/PRC ratios (range 0.21-0.98) and low PAC values (range: 42-100). Seven patients with secondary hypoaldosteronism had normal PAC/PRC ratios (range 2.8-23.2) and low PAC values (range: 42-116). Eight patients with secondary hyperaldosteronism had normal PAC/PRC ratios (range 7.8-67.9) and elevated PAC values (range: 803-2917). The graphic presentation of these data allowed the differentiation of all major disorders of the RAS. CONCLUSIONS: The measurement of PAC/PRC ratios using this automated system provides a sensitive and rapid screening method for PHyperA. Moreover, the measurement of both the PAC and the PAC/PRC ratio allows differentiation of other disorders of the RAS.

Free fatty acids increase androgen precursors in vivo.

CONTEXT: There is considerable evidence that metabolic factors such as insulin resistance may induce hyperandrogenemia in polycystic ovary syndrome. However, other metabolic factors such as free fatty acids (FFAs) may also contribute to androgen excess. OBJECTIVE: The objective was to study effects of FFAs on adrenal production of androgen precursors in vivo. DESIGN AND PARTICIPANTS: We investigated eight healthy young men, because male individuals produce the androgen precursors dehydroepiandrosterone (DHEA), DHEA sulfate, and androstenedione predominantly in the adrenal gland. A randomized controlled crossover trial was performed. INTERVENTION: After a 10-h overnight fast, 20% lipid/heparin or saline/heparin infusion was given at a rate of 1.5 ml/min. Four hours after start of lipid infusion, a euglycemic hyperinsulinemic clamp was performed. MAIN OUTCOME MEASURES: DHEA, androstenedione, 17-OH-progesterone, testosterone, estrone, LH, FSH, ACTH, and cortisol were measured. RESULTS: The adrenal androgen precursors DHEA and androstenedione showed a circadian decline during saline/heparin infusion (P < 0.05 vs. baseline, respectively), whereas no significant changes were observed during lipid/heparin infusion (P = not significant vs. baseline, respectively). Correspondingly, DHEA and androstenedione values were significantly elevated during lipid compared with saline infusion (P < 0.05, respectively), and areas under curve of both androgen precursors were significantly increased with lipid compared with saline infusion. Notably, all changes were detected before induction of insulin resistance. CONCLUSIONS: This study demonstrates that FFAs increase production of androgen precursors in vivo in men. These data tentatively suggest that hyperandrogenemia in polycystic ovary syndrome may be induced, at least in part, by elevated FFAs.

Solitary pulmonary nodule with growth and contrast enhancement at CT: inflammatory pseudotumour as an unusual benign cause.

Small (< or =10 mm) pulmonary nodules are frequently detected at modern chest CT. As most of these nodules are benign, non-invasive classification is required--usually based on assessment of growth and perfusion. Absence of growth and no evidence of perfusion, as demonstrated by lack of enhancement at contrast-enhanced CT or MRI, strongly suggest a benign nodule. On the other hand, growth with a doubling of the nodule's volume between 20 days and 400 days or enhancement suggest a malignant nature of the lesion. We present an example of a nodule with strong contrast enhancement and a doubling time of approximately 260 days, which histologically represented a benign inflammatory pseudotumour.

Glucagon inhibits ghrelin secretion in humans.

OBJECTIVE: It is well known that i.m. glucagon administration stimulates GH and cortisol release in humans, although the mechanisms are unclear. These effects are similar to those described for ghrelin on somatotroph and corticotroph function. The aim of the present study was to investigate the role of ghrelin in mediating the stimulatory effects of glucagon and to evaluate the effect of glucagon on ghrelin secretion. DESIGN AND METHODS: We studied the endocrine and metabolic response to i.m. glucagon administration in 24 subjects (14 men, 10 women; age 19-65 years; body mass index, 25.3 +/- 1 kg/m(2)), who were shown to have an intact anterior pituitary function as evaluated before enclosure. RESULTS: Serum ghrelin concentrations fell significantly at 30, 60, 120 and 180 min after glucagon administration (means +/- s.e.m.; baseline, 377.9 +/- 34.5 pg/ml; nadir, 294.6 +/- 28.3 pg/ml (60 min); P < 0.01). Conversely, i.m. glucagon elicited an increase in GH (baseline, 1.5 +/- 0.4 microg/l; peak, 14.2 +/- 2.7 microg/l (180 min); P < 0.01) and cortisol concentrations (baseline, 452.6 +/- 35.2 nmol/l; peak, 622.1 +/- 44 nmol/l (180 min); P < 0.01). The changes in ghrelin concentration at both 120 and 180 min were still significant after correction for glucose and insulin (P < 0.05). CONCLUSIONS: We show that i.m. glucagon decreases ghrelin significantly. Therefore, the already known stimulatory effects of i.m. glucagon on cortisol and GH are not mediated by a change in ghrelin concentrations. The mechanisms underlying the ghrelin suppression after i.m. glucagon are unlikely to include glucose or insulin variations and need to be further elucidated.