Erik Hägg

A low dose ACTH test to assess the function of the hypothalamic–pituitary–adrenal axis

OBJECTIVE The insulin tolerance test (ITT) has long been used to assess the hypothalamic–pituitary–adrenal axis, but may be hazardous. The standard synthetic ACTH (Synacthen) test has been advocated as a substitute but is sometimes insensitive. In this study the ITT has been compared to a low dose ACTH stimulation test (1 μg) and the standard ACTH stimulation test (250 μg).

A non-intensive stroke unit reduces functional disability and the need for long-term hospitalization.

In a prospective controlled trial we compared the clinical outcome for unselected acute stroke patients in a non-intensive stroke unit (n = 110) and in general medical wards (n = 183). The patients were comparable in age, marital state and functional impairment on admission. Case fatality rates over the first year after the stroke were similar in the two groups. By three months after the stroke, 15% of the survivors initially admitted to the stroke unit and 39% of those admitted to general medical wards remained hospitalized (p less than 0.001). The corresponding figures by one year after the cerebrovascular accident were 12% and 28%, respectively (p less than 0.05). A greater proportion of surviving stroke unit patients was independent in walking (0.10 greater than p greater than 0.05), personal hygiene (p less than 0.05) and dressing (p less than 0.001). Essential features of the stroke unit are team work headed by a stroke nurse, staff, patient and family education and very early onset of rehabilitation. We conclude that this strategy improves functional outcome and reduces the need for long-term hospital care.

The prognostic value of admission blood pressure in patients with acute stroke.

Background and Purpose Patients with acute stroke are often found to have high blood pressures at hospital admission. Previous studies have shown variable results regarding the prognostic value of high blood pressure in acute stroke. The aim of this study was to investigate the prognostic value of admission blood pressure in a population-based sample of patients with acute stroke. Methods Eighty-five patients with intracerebral hemorrhage and 831 with ischemic disease were included in the study. The relations between admission blood pressure and 30-day mortality were studied by logistic regression analyses. Results High blood pressure in patients with impaired consciousness on hospital admission was significantly related to 30-day mortality in patients with intracerebral hemorrhage (P=.037) and in patients with ischemic disease (P<.0001). In patients without impaired consciousness, high blood pressure at time of admission was not related to increased mortality at 30 days. Conclusions High admission blood pressure in alert stroke patients was not related to increased mortality. Stroke patients with impaired consciousness showed higher mortality rates with increasing blood pressure. However, this does not provide a basis for recommending antihypertensive therapy for such patients.

Value of basal plasma cortisol assays in the assessment of pituitary-adrenal insufficiency

A basal plasma Cortisol value taken in a physically unstressed state in 68 patients with or without hypothalamic‐pituitary‐adrenocortical disease was compared with the maximal plasma Cortisol concentration during an insulin tolerance test. There was a strong positive correlation between the values. Basal Cortisol levels above 300 nmol/1 (RIA method) almost excluded ACTH‐cortisol insufficiency and those below 100 nmol/1 strongly suggested dysfunction. A repeated basal Cortisol estimation within a month was especially valuable in categorizing patients with levels between 100 and 200 nmol/1. We suggest that a basal Cortisol measurement may be used as a first laboratory test in patients evaluated for possible hypothalamic‐pituitary‐adrenocortical insufficiency; in many patients, this approach obviates more sophisticated and expensive testing.

Factors influencing admission blood pressure levels in patients with acute stroke.

In clinical practice, patients with acute stroke often have high blood pressure. The aim of this study was to investigate factors correlated with blood pressure elevation in 843 consecutive stroke patients on hospital admission to a nonintensive stroke unit. Using a multivariate analysis model, we analyzed the influence on admission blood pressure of sex, age, previous hypertension, cardiac failure, diabetes, type of stroke, impaired consciousness, and latency between onset of symptoms and admission. Previous hypertension was the strongest predictor (p less than 0.001) of elevated blood pressure on admission, followed by the presence of intracerebral hemorrhage (p less than 0.001). The latency between onset of symptoms and admission showed no correlation with blood pressure levels at hospitalization. Previously, high blood pressure levels on hospital admission have been shown to decline within a few days in hospital. We therefore hypothesize that mental stress on hospital admission may be a major factor in the blood pressure elevation seen in acute stroke.

Prognosis after stroke in diabetic patients. A controlled prospective study.

SummaryCohorts of diabetic (n=121) and non-diabetic (n=584) patients were prospectively followed for up to ten years after having suffered from a stroke. All but six of the diabetic patients had Type 2 (non-insulin-dependent) diabetes mellitus. The diabetic patients had more risk factors associated with stroke: heart failure (p<0.001) and angina pectoris (p<0.001), than the non-diabetic patients. Neither body mass index nor blood pressure levels differed between the groups at admission. Haematocrit levels were higher in the diabetic group (p<0.01). The diabetic patients were more commonly afflicted by cerebral embolism and to a lesser extent by transient ischaemic attacks than the nondiabetic patients. When calculated by log-rank tests, the diabetic group had an increased risk of death (p<0.001), recurrent stroke (p=0.001), and of myocardial infarction (p=0.001) after the initial stroke. Autopsy-verified causes of death between the groups did not differ significantly, although half of all deaths during the period one to six months after stroke were caused by pulmonary embolism in the diabetic group. Thus, diabetes increases the risk of death after a stroke, and it also increases among stroke survivors the risk of recurrent stroke and myocardial infarction.

Cardiovascular risk factors in young snuff-users and cigarette smokers

Abstract. We studied cardiovascular risk factors in 21 young men who were habitual snuff‐users, and compared them with the same risk factors in 18 non‐tobacco‐users and 19 cigarette smokers of the same age and body mass index. Both snuff‐users and smokers showed increased levels of alcohol and coffee consumption and a decreased level of physical exercise compared to non‐users. Both groups of tobacco‐users showed increased serum insulin levels compared to the control group at similar blood glucose concentrations. In contrast to the smokers, snuff‐users showed no significant elevation of diastolic blood pressure, haemoglobin concentrations, white cell count, serum cholesterol or triglyceride levels. Snuff users had higher plasma fibrinogen levels than non‐users (P = 0.07). The use of snuff by young men appears to have less impact than smoking on cardiovascular risk factors, with the possible exception of elevated serum insulin and plasma fibrinogen levels.

Glutamate decarboxylase (GAD65) and tyrosine phosphatase-like protein (IA-2) autoantibodies index in a regional population is related to glucose intolerance and body mass index.

Aims/hypothesis. Our aims were to investigate the concentrations and prevalence of autoantibodies against the Mr 65.000 isoform of glutamate decarboxylase (GAD65) and the tyrosine phosphatase-like protein (IA-2) in adults and to test the hypothesis that GAD65 and IA-2 autoantibodies in a regional population are related to abnormal oral glucose tolerance. Methods. We analysed serum from 2157 Swedish subjects aged either 30, 40, 50 or 60 years old who, in 1988–1992, participated in the Västerbotten County Health Project and were subjected to the World Health Organisation (WHO) standard oral glucose tolerance test at entry into the study. Results. We found 23 of 2157 (1.1 %) and 17 of 2152 (0.8 %) subjects exceeded the 99th centile of GAD65 autoantibody index and IA-2 autoantibody index, respectively. In 18 subjects with diabetic oral glucose tolerance test, GAD65 autoantibody concentrations were higher than in those with normal oral glucose tolerance test (p = 0.02). Subjects with IGT (n = 416) and diabetes (n = 18), i. e. abnormal OGTT (n = 434), had a higher IA-2Ab index compared with those with normal OGTT (p = 0.008). A stepwise multiple logistic regression test showed that the odds ratios for subjects in the highest BMI group to exceed the 95th or 99th GAD65 autoantibody centile were 3.6 (CI 1.4–8.9) and 17.6 (CI 2.6–121.6), respectively. Conclusion/interpretation. GAD65 and IA-2 autoantibodies, are associated with impaired or diabetic glucose tolerance in an adult regional population. This observation together with the association between GAD65 autoantibody concentrations and body mass index indicate a possible relation between islet autoimmunity and beta-cell function abnormalities with obesity and insulin resistance. [Diabetologia (1999) 42: 555–559]

Acute confusional state (delirium) soon after stroke is associated with hypercortisolism

Acute confusional state (ACS), or delirium according to DSM-III-R, and the function of the hypothalamic-pituitary-adrenal-axis were studied in 83 patients soon after an ischemic supratentorial stroke.

Fracture incidence in GH-deficient patients on complete hormone replacement including GH

Fracture risk in GHD patients is not definitely established. Studying fracture incidence in 832 patients on GH therapy and 2581 matched population controls, we recorded a doubled fracture risk in CO GHD women, but a significantly lower fracture risk in AO GHD men.