Rudolf Gasser

Low Bone Mineral Density and Impaired Bone Metabolism in Young Alcoholic Patients Without Liver Cirrhosis : A Cross-Sectional Study

BACKGROUNDnOsteoporosis is regularly mentioned as a consequence of alcoholism. Ethanols direct effect on bone-modeling cells as well as alcoholism-related life-style factors such as malnutrition, lack of exercise, hormonal changes, and liver cirrhosis are discussed as potential causative factors.nnnMETHODSnIn a cross-sectional study, we have examined 57 noncirrhotic alcoholic patients (37 male, 20 female) aged 27 to 50 years. Patients suffering from comorbid somatic diseases and with co-medication known to have an influence on bone mineral density (e.g., glucocorticoids, heparin, anticonvulsant agents, oral contraceptives) were excluded. We determined bone mineral density (BMD) by dual x-ray absorptiometry (DXA) in the lumbar spine (L1-L4) and the proximal right femur (femoral neck, total hip) as well as parameters of bone metabolism.nnnRESULTSnIn males but not females, BMD was significantly reduced in the lumbar region, as well as in the proximal femur (femoral neck, total hip). Nine male patients (24.3% of men) and 1 female patient (5% of women) had low BMD (defined as Z-score < or = -2.0). As expected, there was a positive correlation between body mass index (BMI) and BMD. Alcohol-related factors (e.g., duration of abuse, consumed amount of alcohol per day) as well as smoking were not associated with a significant effect on BMD. All of the 20 women examined showed elevated estradiol levels, which may have served as a protective factor. In this study, 75.7% of the men and 90% of the women had vitamin D insufficiency or deficiency (plasma levels of 25-hydroxy-vitamin D < 30 ng/ml).nnnCONCLUSIONSnOur study indicates that younger alcoholic patients without other diseases may suffer from an increased risk to develop low BMD and a disturbance of vitamin D metabolism. Nutritional factors or less exposure to sunlight may play an important role in bone loss in young alcoholic patients. BMD measurement and assessment of bone metabolism should be considered in all patients with chronic alcoholism.

Pheochromocytoma and sub-clinical Cushing's syndrome during pregnancy: diagnosis, medical pre-treatment and cure by laparoscopic unilateral adrenalectomy.

The coexistence of pheochromocytoma and primary adrenal Cushing’s syndrome of the same adrenal gland has rarely been reported. We describe here the case of a female patient presenting with mild Cushing’s stigmata, hypertension and diabetes mellitus in whom we diagnosed a pheochromocytoma of the left adrenal gland with coexisting non-ACTH-dependent cortisol hypersecretion. While hormonal work-up was still in progress, the patient became pregnant and wanted to carry her pregnancy to full-term. A laparoscopic adrenalectomy in the 17th week of gestation was decided upon and the patient accordingly prepared for surgery by pre-treatment with phenoxybenzamine. Successful surgery — the first ever reported laparoscopic resection of a pheochromocy-toma in pregnancy — without perioperative complications was performed under general anesthesia, with the patient receiving peri- and post-operative hydrocortisone substitution. Pathohistological examination revealed a pheochromocytoma with positive immunostaining for interleukin-6 (IL-6) and negative immunostaining for ACTH, vasoactive intestinal polypeptide (VIP) and cytochrome P450, and with no signs of malignancy. A paracrine stimulation of the ipsilateral adrenal cortex by IL-6 produced by the pheochromocytoma, leading to cortical hyperplasia and subclinical Cushing’s syndrome, is suggested by the positive immunostaining for IL-6 and the MRI findings. Post-operatively, secondary adrenal insufficiency ensued, necessitating continuing hydrocortisone replacement over 12 months. Hypertension resolved after surgery, and diabetes after the uncomplicated vaginal delivery at term.

Technique and results of laparoscopic adrenalectomy.

OBJECTIVESnOur technique of laparoscopic adrenalectomy as well as the results of this method are presented.nnnMETHODSnTransperitoneal laparoscopic adrenalectomy was performed in 18 consecutive patients (10 right side, 8 left side) for Conns disease (7 patients), pheochromocytoma (6 patients), Cushings syndrome (1 patient), and large inactive adenoma (4 patients). The tumor size ranged between 1 and 8 cm (mean 4.2). One of the patients, who presented with Conns disease and bilateral adenoma, underwent enucleation of the larger adenoma on the right side leaving the uninvolved portion of the adrenal gland intact.nnnRESULTSnThe mean operative time was below 3 h; blood loss was minimal in all cases except 2. Hypertensive crisis was not encountered in this series. The only postoperative complication seen was transient diabetes insipidus which occurred in 1 patient. Analgesics were required only on the first 2 postoperative days. Oral intake and ambulation were resumed within 24 h. Mean postoperative hospitalization was 4.6 days.nnnCONCLUSIONSnIn our hands, laparoscopic adrenalectomy proved to be associated with a low morbidity and few complications. In addition, it is one of the few procedures where laparoscopy can compete with open surgery in terms of operative time.

ELEVATED LEVELS OF SERUM SECRETONEURIN IN PATIENTS WITH THERAPY RESISTANT CARCINOMA OF THE PROSTATE

PURPOSEnThe majority of prostate cancers show some degree of neuroendocrine differentiation. It was previously demonstrated that chromogranin A, a constituent of large dense core vesicles of neuroendocrine cells, is frequently elevated in patients with metastatic prostate cancer. We evaluate the expression of secretoneurin, which is generated by proteolytic processing of secretogranin II (chromogranin C), in patients with prostate disease.nnnMATERIALS AND METHODSnSecretoneurin was measured in sera of 16 healthy men whose blood was drawn for prostate cancer screening (controls), and in 9 patients with prostatitis, 19 with benign prostate hyperplasia and 54 with prostate cancer detected by radioimmunoassay. Therapy resistant disease (clinical stage D3) was noted in 20 prostate cancer cases. Serum prostate specific antigen was measured in all patients and controls. In addition, chromogranin A, prostate acid phosphatase and interleukin-6 were determined in patients with D3 prostate cancer. Molecular properties of secretoneurin immunoreactivity were analyzed by gel filtration chromatography followed by radioimmunoassay.nnnRESULTSnMean secretoneurin was 58.9+/-8 fmol./ml. in patients with therapy resistant prostate cancer. Levels were significantly higher than those measured in sera from controls and patients with prostatitis, benign prostatic hyperplasia and pT2 or pT3 prostate cancer. There was a statistically significant correlation between secretoneurin and chromogranin A in patients with endocrine therapy failure (r = 0.543, p<0.05). There was no correlation between serum secretoneurin and prostate specific antigen, prostate acid phosphatase or interleukin-6. Gel filtration chromatography analysis of sera of 3 patients with D3 prostate cancer revealed a peak of secretoneurin immunoreactivity where intact secretoneurin elutes, thus showing that the processed peptide is circulating in the blood.nnnCONCLUSIONSnSecretoneurin is elevated in sera of patients with endocrine therapy refractory prostate cancer. Our results support the concept that neuroendocrine differentiation is associated with prostate cancer progression.

Operation for N2 small cell lung carcinoma

Of 48 patients with limited small cell lung carcinoma treated by different modes, but always including radical operation, a series of 25 patients with N2 lymph node metastases is reported. In a first period (1970 to 1977) treatment consisted solely of radical resection in 3 patients; chemotherapy was added to operation in 6, and local radiotherapy was added in 2. Since 1977, 14 patients were treated according to a comprehensive therapy protocol including radical resection (six pneumonectomies, one bilobectomy, seven lobectomies), chemotherapy, local radiotherapy, and prophylactic cranial irradiation. Eleven patients, in whom N2 disease was confirmed preoperatively, received chemotherapy as the first step, followed by adjuvant resection. Projected 5-year survival rate is 25% for the entire N2 group and 47% for the comprehensively treated group. Seven patients of this latter group are alive 12, 19, 30, 48, 66, 73, and 74 months after comprehensive therapy, equivalent to an observed 2-year survival rate of 38%. This is the largest reported series of patients with resected small cell lung carcinoma in the N2 stage treated at a single institution; the results are so encouraging that we can no longer advocate general refusal of radical lung resection for small cell lung carcinoma in the N2 stage if it is part of a multimodal therapeutic protocol.

Generalized Large Vessel Arteritis Visualized by 18Fluorodeoxyglucose-Positron Emission Tomography

This previously healthy 81-year-old man with recurrent fever up to 38.8°C and an erythrocyte sedimentation rate of more than 85 mm/h had no pain and did not respond to empirical treatment with antibiotics. Imaging by computerized tomography, thyroid and whole body 99mTc-MIBI scintigraphy (because of pre-diagnosed hyperparathyroidism), gastroscopy, colonoscopy, and bone marrow aspiration were …

Hypokalemia, Hyperreninemia and Osteoporosis in a Patient Ingesting Large Amounts of Cider Vinegar

Accessible online at: http://BioMedNet.com/karger Dear Sir, Regular ingestion of cider vinegar is becoming an increasingly popular habit in Austria and Germany. Cider vinegar is described as a prophylaxis and cure for almost any disease or complaint. Doses from one teaspoon to six soupspoons per day have been recommended. A local bookshop offered nine different specialist books on the benefits of cider vinegar. Here we describe the case of a woman, in whom chronic ingestion of excessive amounts of cider vinegar caused serious health problems. The 28-year-old patient was admitted because of muscle cramps and unexplained hypokalemia of 2.8–3.2 mval/l. Blood pressure was 100/80 mm Hg. Her serum and urine chemistries are shown in table 1. The patient showed urinary potassium wasting and inappropriately high sodium excretion in correlation to the stimulated plasma renin activity. The most surprising finding was the extremely high positive urinary anion gap, which together with the high pH suggested massive bicarbonate excretion. Further questioning revealed that the patient had ingested large amounts of cider vinegar regularly for 6 years. She consumed about 250 ml of vinegar per day diluted in water and as salad dressing. Assuming an acetate concentration of vinegar of 5%, she had ingested around 200 mmol of acetic acid. The vinegar had a pH of 3.25 and contained 28 mval of potassium/l without detectable sodium. To our knowledge the consequences of ingestion of large amounts of acetic acid have not been described in detail. Acetate is rapidly metabolized to bicarbonate in the liver [1]. Therefore, the net effect of acetic acid ingestion on acid base balance shoud be zero. There is, however, probably a time lag between the acute hydrogen ion load and delayed bicarbonate formation that may cause disturbances in acid base status. Based on the findings in our patient, we propose the following mechanism. Metabolization of acetate to bicarbonate yielded a bicarbonate load of about 200 mmol. The high urinary anion gap and pH suggest that the bicarbonate load was excreted in the urine. Her plasma bicarbonate level was also slightly increased. Renal bicarbonate excretion is necessarily accompanied by urinary sodium and potassium excretion. Renal sodium loss caused effective arterial blood volume depletion and stimulation of her renin angiotensin aldosterone system. Potassium wasting resulted in mild hypokalemia. Renal excretion of bicarbonate implies that the acute acid load must have been buffered somewhere. Otherwise metabolic acidosis would be expected. An acute acid load is predominantly buffered by bone. This occurs in exchange with sodium and potassium ions and liberation of calcium carbonate [2]. Acid also diminishes osteoblast activity and stimulates osteoclast activity, thereby provoking loss of bone mass [3]. Our patient had low levels of osteocalcin, a finding attributable to acid buffering by bone. Her bone mineral density was drastically reduced and in the osteoporotic range (quantitative CT L2–L4 119.9 mg/cm3, T-score –3.0). However, urinary free deoxypyridinoline excretion was also very low, and the patient hypocalciuric rather than hypercalciuric. AlkalTable 1. Serum and urine chemistry

Neuron-specific enolase (NSE) in small-cell lung cancer: longitudinal tumor marker evaluation

Abstract A study of 362 serum samples from 57 patients with small-cell lung cancer (SCLC) limited disease, enabled the validity of neuron-specific enolase (NSE) to be redefined as a serum parameter for therapy control. In contrast to standard calculation of sensitivity and specificity, the dynamics of marker development were incorporated in calculations by longitudinal evaluation of NSE values in the course of the disease. In this way, it was shown that sensitivity of the marker at 87% and specificity at 94% are clearly higher than reported to date. Longitudinal evaluation of the marker prevents interpretation errors that distort the outcome of sensitivity/specificity calculations for an early increase or decrease during remission or progression. Isolated false positive values are rare, solitary in the course of the disease and never exceed 35 μg/1. After radical surgery for so far untreated SCLC, the marker drops to normal values within nine to 14 days. Following chemotherapy NSE falls to normal values in 66% of all cases, even when radiologically there is only a partial remission. A correlation of changes of NSE level with certain types of therapy, for example NSE increase due to enhanced release by nervous tissue during cerebral irradiation, was not established.

Markers of bone resorption and formation during abstinence in male alcoholic patients.

BACKGROUNDnReduced bone mineral density (BMD) is commonly found in alcohol-dependent patients. Many risk factors have been reported, yet the course of markers of bone formation and resorption in abstinent alcoholic patients have not received much attention.nnnMETHODSnIn a prospective longitudinal study, we investigated BMD in male abstinent inpatients of an alcohol rehabilitation clinic aged 21 to 50xa0years at baseline and after 8xa0weeks of treatment. At baseline and at week 8, all patients had blood drawn for the analysis of liver function tests, calcium, phosphate, parathormone, 25-hydroxyvitamin D, osteocalcin (OC), serum crosslaps, sex hormones, and prolactin. BMD was determined by dual X-ray absorptiometry in the lumbar spine and the proximal right femur. We also determined the amount of physical activity prior to inpatient treatment by using the International Physical Activity Questionnaire (IPAQ).nnnRESULTSnLow BMD was found in 15.1% of the patients for the lumbar spine, in 5.7% for the femoral neck, and in 1.9% for the total hip. BMD differed significantly from normal values, in the lumbar spine and in the femoral neck. At baseline, crosslaps were elevated in 34% of the patients, while OC levels were lowered in 17%. Over the course of the 8xa0weeks, we found a significant increase in OC plasma levels, indicating a higher rate of bone formation during continuous abstinence. There were also positive correlations between IPAQ scores and BMD as reflected by Z-scores in all regions, pointing to a protective effect of physical activity.nnnCONCLUSIONSnIn summary, this report confirms earlier cross-sectional studies of lowered BMD in alcoholic noncirrhotic men. We could also demonstrate that the initial imbalance between bone formation and resorption seems to adjust toward a balance between the two during abstinence.

[Lymph node tuberculosis in a patient with polymyalgic symptoms: value of 18F-fluorodeoxyglucose positron emission tomography (18F-FDG-PET)].

Zusammenfassung. Bei einer 60-jährigen Patientin mit corticosteroid-resistenter Polymyalgia rheumatica und einer erhöhten Blutsenkungsgeschwindigkeit wurde eine 18F-FDG-PET-Untersuchung durchgeführt. Diese zeigte einen cervicalen Focus, der histologisch und mikrobiologisch als Lymphknotentuberkulose identifiziert wurde.Summary.18F-FDG-PET studies were performed in a 60-year-old female patient with polymyalgia rheumatica resistant to prior corticosteroid treatment. PET studies showed a cervical focus, which was identified histologically and microbiologically as lymph node tuberculosis.