Randall G. Sprague

Adult-onset vitamin-D-resistant hypophosphatemic osteomalacia. Effect of total parathyroidectomy.

Abstract A 27-year-old man with disabling adult-onset hypophosphatemic osteomalacia was studied in 1947. Because of the failure of large doses of vitamin D, with oral calcium and phosphate supplements, to induce calcium retention on prolonged metabolic balance studies, total parathyroidectomy was performed. Bone healing ensued and subsequently tetany has been easily controlled with modest doses of vitamin D. On restudy in 1968 (after vitamin D had been discontinued) both serum phosphate and renal phosphate clearance were in the range expected in hypoparathyroidism. Intravenous administration of parathyroid hormone reproduced the high phosphate clearance that had been present before parathyroidectomy. The data indicate a causal or permissive role of parathyroid hormone in the renal phosphate leak, hypophosphatemia and osteomalacia in this patient.

Steatorrhea Complicating Diabetes Mellitus with Neuropathy: Report of Cases without Apparent External Pancreatic Insufficiency

Disturbances of gastrointestinal function have frequently been observed in association with diabetes mellitus. The disorders which have been reported include gastric atony and dilatation, postprandial abdominal cramping, severe constipation, and intractable diarrhea characterized by watery stools, nocturnal exacerbations and fecal incontinence. These disturbances have been attributed by many investigators to alterations in gastrointestinal motility secondary to visceral diabetic neuropathy. The purpose of the present report is to call attention to a group of patients with diabetes mellitus and neuropathy who exhibited diarrhea and steatorrhea which apparently could not be attributed to external pancreatic insufficiency.

Control of Diabetic Diarrhea with Antibiotic Therapy

The ability of oral antibiotic treatment to control diabetic diarrhea was documented by a double-blind study involving a patient with this condition. When the patient was given Mysteclin-F, the diarrhea subsided promptly, only to recur when a placebo was substituted,. The erratic behavior of diabetic diarrhea is indicated, however, by the fact that a remission eventually occurred, and no further treatment was required. Although not all patients with diabetic diarrhea respond to antibiotic treatment, its trial merits consideration forthose patients who are refractory to the simpler forms of treatment.

Cardiovascular and Renal Complications of Cushing's Syndrome

CARDIOVASCULAR and renal changes are frequently important features of Cushings syndrome. Of the 12 cases reported by Cushing1 in 1932, hypertension occurred in 9, and cardiac hypertrophy in 4. Fri...

Effects of cortisone and ACTH.

Publisher Summary This chapter describes the effects of cortisone and adrenocorticotropic hormone (ACTH). The early investigations on the dog and rat, employing single doses of cortisone, suggested that its characteristic effect might be to increase urinary excretion of sodium and chloride. It was shown further in the partially depancreatized rat, and in the dog that cortisone and 17-hydroxycorticosterone may cause an increase in excretion of sodium and chloride. The physiological effects of ACTH depend on its ability to stimulate the adrenal cortices to increase their output of steroid hormones, some of them closely related to cortisone. Consequently, cortisone and ACTH have many effects in common. In many instances there is no definite line of demarcation between actions of the two agents. In this chapter, the effects of cortisone and ACTH are considered together, except in certain situations in which significant differences are apparent. Relation of glutathione to effects of ACTH and cortisone on carbohydrate metabolism is described. Effects on lymphoid tissue, blood lymphocytes, and eosinophils are discussed. Infections, bacterial allergic reactions and other inflammatory reactions are also described.

The Effects of Adrenalectomy and of Hypophysectomy on the Degenerative Complications of Diabetes

In this issue of DIABETES appear three papers which report studies of the effects of total adrenalectomy or hypophysectomy on patients suffering from the degenerative complications of diabetes. In addition to the small number of patients whose cases are reported in these papers, a few other diabetic patients in this country and abroad suffering from retinopathy and intercapillary glomerulosclerosis have been treated by either adrenalectomy or hypophysectomy. Perhaps it is not too early to comment on the rationale and justification for the use of these radical measures in the study and treatment of the degenerative complications of diabetes. There is good reason to believe that both diabetic retinopathy and intercapillary glomerulosclerosis are manifestations of the same degenerative vascular disease of diabetes. However, the pathogenesis of these complications is poorly understood, and most observers will concede that the rationale for their treatment by extirpation of the pituitary or adrenal glands is not entirely clear or well established. The two procedures are based in part on the hypothesis that certain hormones, particularly some of those secreted by the adrenal cortex, play either an active or a permissive role in the development of the degenerative complications. It has further been suggested that there are differences in adrenal cortical function of diabetics who have such complications as compared to those who do not. The evidence in support of these hypotheses has recently been reviewed in DIABETES by Becker and associates. Most of it is indirect or circumstantial in character, and supporting evidence in the field of clinical diabetes is still rather meager. Some clinical evidence is provided by a case reported by Poulsen which has attracted wide attention. The patient was a young woman with diabetic retinopathy which healed completely following the development of pituitary insufficiency due to postpartum pituitary necrosis (Sheehans syndrome). On the other hand, clinical evidence against a role of the adrenal cortex in the pathogenesis of the degenerative complications is the infrequency with which patients suffering from Cushings syndrome, a condition characterized by chronic hyperfunction of the adrenal cortex, have anything resembling diabetic retinopathy or intercapillary glomerulosclerosis. Without reviewing all the available evidence, it appears that at present the conception that the anterior pituitary or adrenal cortex plays an active role in the development of the degenerative complications needs further support, although the possibility remains that the presence of these glands is a necessary condition for the development of the complications. Regardless of what role the adrenal cortex and pituitary may play in the pathogenesis of the renal lesions of diabetes, the increased renal excretion of sodium chloride which uniformly follows adrenalectomy and sometimes follows hypophysectomy, might be of some benefit to patients with intercapillary glomerulosclerosis associated with hypertension and edema. Such benefit, however, does not imply a favorable modification of the underlying renal lesion. It is to be hoped that some day a better understanding of the pathogenesis of the degenerative complications of diabetes will lead to methods for their prevention. In the meantime, the problem posed by these complications is of such great magnitude that further study of the role of the anterior pituitary and adrenal cortex is in order, and in selected otherwise hopeless cases exploration of such radical treatment as hypophysectomy and adrenal-

Fluids and Electrolytes in the Therapy of Diabetic Acidosis: Panel Discussion

MODERATOR HOWARD: Dr. Osier used to say that anyone who knew syphilis knew medicine because the wide variations in the late complications required the physician to know something about nearly every field of medicine. Since late complications of syphilis are now relatively rare, I think diabetes has taken its place and the physician who tries to take care of diabetics must know something about all the medical specialties. The most serious disturbances of water and electrolyte metabolism occur in association with diabetic acidosis, and result directly from the metabolic defect of insulin deficiency. Many patients in acidosis present coincident abnormalities in other areas, such as renal disease, heart failure, septicemia and the like, which must be given due consideration in planning the course of therapy. In order to highlight the water and electrolyte problems, we have felt it wise to eliminate such complications, at least