Thyrotropin secretion in thyrotoxic and thyroxine-treated patients: assessment by a sensitive immunoenzymometric assay.

A new TSH immunoenzymometric assay was found to be capable of discriminating between the serum TSH values of normal subjects [2.28 +/- 1.02 (+/-SD); range, 0.6-6.5 microU/ml] and those of clinically euthyroid, antithyroid drug-treated (n = 22) or clinically thyrotoxic (n = 34) patients. While a wide spectrum of basal TSH values was found in the antithyroid drug group [ranging from undetectable (less than 0.05 microU/ml: 57%) to 17.9 microU/ml], all clinically thyrotoxic patients had undetectable values. In 33 patients receiving chronic oral T4 therapy for treatment of goiter (n = 15) or thyroid cancer (n = 18), 48% (6 of 33) had undetectable basal TSH levels and no TSH response to TRH stimulation. Detectable TSH levels were found in 42% (14 of 33), and TRH responsiveness was found in 52% (17 of 33). The TSH response to TRH stimulation was less than 2.0 microU/ml in 7 patients. Serum free T4 index, free T3 index, and free T4 levels and oral T4 dosage were inferior predictors of TRH responsiveness compared to the basal TSH value. No patient receiving more than 0.2 mg T4 daily or having a free T4 index above 18, a free T3 index above 205 or a free T4 level above 3.0 ng/dl had a TSH response to TRH. Seventy-six percent (16 of 21) of the patients, when reevaluated 1-6 weeks after increased oral T4 dosage, had a significant reduction in their serum thyroglobulin level. This was true of both patients with initially detectable (11 of 14) as well as undetectable (5 of 7) basal serum TSH levels. These findings support the concept that subnormal and, for that matter, as yet undetectable levels of circulating TSH may exert stimulatory effects on thyroid tissue.

Rationale for effective treatment of hypercholesterolemia.

The primary objective of treating hypercholesterolemia is to reduce the patient's risk of developing coronary artery disease (CAD). Reducing low-density lipoprotein (LDL) cholesterol levels to achieve National Cholesterol Education Program (NCEP) goal lipid levels greatly reduces this risk. Treatment of additional risk factors for CAD (high blood pressure, diabetes, smoking) should be addressed and modified as part of appropriate patient management, but a high LDL cholesterol level is a major risk factor. Therefore, to effectively modify morbidity and mortality, reaching and maintaining NCEP target lipid levels should be the goal of lipid-lowering therapy. Epidemiologic data indicate that most adults in the United States need <30% reduction in LDL cholesterol level to achieve their NCEP goal. Regardless of the intervention or therapeutic agent used, the results of numerous studies have demonstrated that reducing LDL cholesterol levels to NCEP goals will result in significant reduction of CAD risk.

Safety of drugs commonly used to treat hypertension, dyslipidemia, and type 2 diabetes (the metabolic syndrome): part 1.

The benefits of blood pressure lowering, lipid lowering, and glycemic control on morbidity and mortality have been established in major long-term clinical trials. The most extensive information is available for diuretics or beta-blockers in hypertension, hepatic hydroxymethyl glutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins) in dyslipidemia, and insulin or sulfonylureas in diabetes. Other drug classes provide similar improvements in blood pressure, lipid profile, and glycemic control, and thereby might be expected to provide comparable long-term benefits. As a result, national guidelines advocate treating patients aggressively in order to achieve control of blood pressure low-density lipoprotein (LDL) cholesterol, and blood glucose. The risks associated with drug treatment are generally class-specific. Among antidiabetic agents, sulfonylureas and insulin are associated with risk for severe hypoglycemia, metformin with risk for lactic acidosis, and troglitazone with risk for idiosyncratic hepatocellular injury. Similarly, widely used antihypertensive and lipid-lowering agents are associated with risk for serious complications, such as angioedema with angiotensin-converting enzyme inhibitors, possible increased risk for myocardial infarction and cancer with calcium antagonists, and myositis and liver dysfunction with statins. Physicians must take an aggressive approach to patient management in order to achieve a level of disease control that optimally reduces risk for morbidity and mortality. Serious adverse events may occur rarely with most drug classes; these events can be minimized by appropriately monitoring or selecting patients for treatment.

Safety of drugs commonly used to treat hypertension, dyslipidemia, and Type 2 diabetes (the metabolic syndrome): part 2.

It is becoming increasingly acknowledged that people with Type 2 Diabetes represent what can be termed "an enriched population": a group that has the greatest risk of morbidity and mortality from cardiovascular diseases such as myocardial infarcts and strokes. Due to the tremendous toll, both human and financial, that these cardiovascular diseases result in, major efforts are being put forth to decrease their occurrence. It is clear that success in this endeavor is optimized by achieving target levels of glucose, blood pressure, and cholesterol. Analysis of the individual drugs used to treat these comorbidities of the cardiovascular dysmetabolic syndrome has brought an understanding that frequently monotherapy is ineffective, and a clear appraisal of the benefits of available pharmaceuticals can result in a successful decision about which agents to include in regimens of combination therapy. This success translates into ultimately reducing the untimely death and disability that is unfortunately all too common among the people with these illnesses. As diabetes continues to be increasing alarmingly among all segments of the population, there is an urgency for this need. The knowledge is present; only the application is not.

Optochiasmatic arachnoiditis with treatment by surgical lysis of adhesions, corticosteroids, and cyclophosphamide: report of a case.

A 24-year-old woman presented with progressive optochiasmatic arachnoiditis causing progressively worsening visual loss associated with headache and amenorrhea. Treatment with the standard initial therapy of dexamethasone, warfarin, and dipyridamole was unsuccessful at halting her disease process. Surgical lysis of adhesions led to a temporary improvement and then deterioration. A course of therapy with cyclophosphamide was initiated and her response to this therapy resulted in resolution of her headaches, return of her vision to normal, and resumption of her normal menstrual cycles.

Lipid disorders in patients with type 2 diabetes. Meeting the challenges of early, aggressive treatment.

Because patients with type 2 diabetes are at high risk for cardiovascular events, lipid abnormalities in these patients should be aggressively and efficiently treated. What is the rationale behind such an approach, and what are the goals of therapy? Dr Marcus addresses these questions and provides up-to-date recommendations for lipid-lowering treatment.

Insulin pump therapy: acceptable alternative to injection therapy.

Initiation of insulin therapy is an exhilarating although anxiety-provoking experience for diabetic patients. It is, in a metaphysical sense, a time of rebirth. Patients are no longer victims of their diabetes but truly masters of it. No statement better illustrates how basic this change is than that of a patient who says, "What a difference it has made in my life to eat a meal because I want to, not because I have to." This article examines a means of insulin delivery that is growing in acceptance--insulin pump therapy.

Optimizing off-pump coronary artery bypass graft: technical and metabolic aspects.

PURPOSE: Our purpose was to determine if complete revascularization could be successfully performed off bypass in the majority of coronary artery bypass graft (CABG) patients. METHODS: Using a metabolic protocol and the Medtronic Octopus stabilizer device (Medtronic, Inc., Minneapolis, MN), 285 consecutive patients between July 1, 1997 and July 31, 1999 were successfully revascularized off pump via median sternotomy. A relative contraindication for off bypass CABG was cardiogenic shock. The metabolic protocol was designed to enhance systolic and diastolic cardiac function during surgery. RESULTS: Of 298 patients on whom we attempted off-pump revascularizations, 96% (285/298) were successful. The mean number of grafts per case was 3.3. The mean age of patients was 69.5 years, and 38% (109/285) were 75 years of age or older. Perioperative myocardial infarction (MI) occurred in two patients (0.7%) and operative mortality was 2.8% (8/285). Average Parsonnet score was 4.8. Cost savings were realized through minimal blood product utilization (average 1.5 units per case) and decreased cardiopulmonary bypass supplies. CONCLUSION: Complete revascularization can be performed off bypass in the majority of CABG patients. The concomitant use of the Octopus off-bypass technique with aggressive metabolic support ensures manual manipulation of a beating heart and results in a low incidence of postoperative complications and significant cost savings.