Biomedical subjects
Publications and source records attributed to A D Goodman.
We found anti-nuclear antibodies (ANA) in 26.7% of 150 relapsing-remitting and in 30.4% of 23 chronic progressive definite multiple sclerosis (MS) patients by retrospective chart review. These patients did not have systemic lupus erythematosus. Since ANA are not pathogenically relevant in MS, they are false-positive, and likely reflect systemic immune dysregulation in MS.
OBJECTIVE: Magnetic resonance imaging, computed tomography, cerebrospinal fluid analysis, and evoked potential testing are used to assist in the diagnosis of patients suspected to have multiple sclerosis (MS). The impact of these tests on a clinician's diagnosis of patients suspected to have MS has not been studied systematically. DESIGN: Clinicians made a diagnosis of each patient following clinical evaluation, again after reviewing the results of magnetic resonance imaging, and finally after reviewing information from other laboratory testing. These diagnoses were compared with the criterion standard of a masked "gold standard" panel reviewing all information after a mean follow-up of 0.9 year. SETTING: The General Neurology Clinic and Multiple Sclerosis Clinic of the University of Rochester (NY). PATIENTS: A consecutive sample of 62 patients diagnosed as having either possible or probable MS following clinical evaluation. MAIN OUTCOME MEASURE: Changes in diagnostic certainty of clinicians following incremental presentation of new laboratory data and the accuracy of such diagnoses. RESULTS: Clinicians used magnetic resonance imaging findings to diagnose definite MS or to eliminate MS from diagnostic consideration in 44% of cases. In these cases, further laboratory testing did not alter clinicians' decisions. In the remaining 56% of cases, in which magnetic resonance imaging did not lead to a diagnosis of definite MS or eliminate MS from diagnostic consideration, further laboratory testing led to such diagnoses in an additional 13% of cases. Gold standard diagnoses were in agreement with the clinician's assessments. CONCLUSIONS: Magnetic resonance imaging aids in the evaluation of patients suspected to have MS; other subsequent studies (computed tomography, cerebrospinal fluid analysis, and evoked potential testing) have less impact. After all studies are performed, about half of such patients still have a tentative diagnosis.
PURPOSE: To develop a strategy to identify cases of endogenous subclinical hyperthyroidism and free triiodothyronine (free T3) thyrotoxicosis in otherwise healthy ambulatory patients. PATIENTS AND METHODS: In a retrospective study we reviewed the records of ambulatory patients who had thyroid stimulating hormone (TSH) levels determined between October 1, 1991 and August 31, 1992. Each patient also had a simultaneous free thyroxine (free T4) measurement. Patients were excluded from consideration if they had active, concurrent non-thyroidal illness, psychiatric disease, known hypothalamic/pituitary lesions, were under treatment for hyper- or hypothyroidism, were on drugs known to affect TSH levels, or were pregnant. Patients without exclusions were diagnosed with free T3 toxicosis if they had: (1) a markedly subnormal TSH level (less than or equal to 0.1 mU/L), (2) a normal free T4, (3) a normal total T3, (4) evidence of a primary thyroid abnormality (e.g., autonomous function on a thyroid scan), and (5) an elevated free T3 level by tracer equilibrium dialysis. Patients meeting conditions 1-4, but with normal free T3 levels, were considered to have subclinical hyperthyroidism. RESULTS: One thousand twenty-five patients had TSH and simultaneous free T4 determinations, and 148 of these had markedly subnormal TSH but normal free T4 levels. Three patients met the criteria for free T3 toxicosis and three had subclinical hyperthyroidism. All six patients had either multinodular glands or a single nodule on thyroid exam. Four patients were treated with radioactive iodine or surgery, resulting in reversal of the TSH suppression in three cases. CONCLUSION: Apparently healthy ambulatory patients with subnormal TSH levels should be worked up with measurements of free T4 and total T3. If these are normal, a T3 level (by tracer equilibrium dialysis) be obtained to distinguish subclinical hyperthyroidism from overt free T3 toxicosis. A thyroid scan and radioiodine uptake measurement can be obtained to substantiate the diagnosis. Some patients with these conditions will benefit from treatment.
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Purpose. Magnetic resonance imaging (MRI) has come to assume a position of major importance in the diagnostic process for multiple sclerosis (MS). The authors believe that a tendency toward overreliance on MRI results in isolation from clinical findings continues to result in both false-positive and false-negative diagnostic errors. Methods. To evaluate this, MRI results in newly referred patients with clinical findings suggestive, but not diagnostic, for MS, were studied prospectively. Results. Of 99 consecutive referrals for suspected MS, there were 3 false-positive diagnoses of MS and 7 false-negatives, when the MRIs were read in isolation from specific clinical data. None of the scans in the false-negative groups were normal. Representative images of both groups are provided. Conclusion. In newly referred patients who fall short of criteria for definite MS, it remains dangerous for both clinicians and radiologists to rely too heavily only on MRI results.
It is rare for young diabetic patients to develop severe complications in the first years of their disease. We describe three patients, aged 14-23 years who developed cataracts and severe retinopathy within one to five years of diagnosis of diabetes. During the same period, one patient developed peripheral neuropathy and a second severe autonomic neuropathy. Rapid development of chronic complications in these patients raises the possibility that there may be a subset of patients with unusual susceptibility to complications. We re-emphasize the need for vigilant monitoring for complications in young diabetic patients, even in the first few years of their disease. In particular, young patients with visual complaints should be evaluated carefully for evidence of treatable eye disease.
In an attempt to elucidate the physiologic role of the hepatic receptors for prolactin (PRL), we studied the effect of changes in diet on the specific binding of 125I-ovine prolactin (oPRL) by membranes from female rat liver. Specific binding of PRL (SBP) was decreased by over 50% in rats fed 15% glucose ad lib for 2 days, as compared with fasted rats (P less than .01), while serum PRL was similar in both groups. Feeding 20% glucose by tube decreased SBP significantly, but tube-feeding equicaloric amounts of fat or protein-amino acid solution did not. Glucose feeding did not decrease the specific binding of 125I-bovine growth hormone (bGH) to liver, or decrease SBP to membranes of nitrosomethylurea (NMU)-induced mammary carcinomas, indicating that the effect of glucose on hepatic SBP is selective. Administration of glucose decreased SBP significantly in adrenalectomized-ovariectomized rats, in adrenalectomized-chemically sympathectomized rats, and in hypophysectomized rats receiving replacement therapy, including bovine prolactin (bPRL), bGH, hydrocortisone, estrogen, and thyroid hormones. Thus, the effect of glucose is not mediated by a factor from the adrenals, ovaries, or pituitary, and probably not by catecholamines. Administration of insulin to fasted diabetic rats did not alter SBP. Infusion of glucagon for 1 day, at a rate that did not alter serum glucose, increased hepatic SBP 29% (P less than .01). Since glucose administration decreases plasma glucagon, we hypothesize that glucagon may contribute to the maintenance of the hepatic PRL receptors, and that the suppressive effect of glucose on hepatic SBP may be mediated at least in part by suppression of plasma glucagon.(ABSTRACT TRUNCATED AT 250 WORDS)
GTP, in physiologic concentration (10(-4) mol/L), enhances cAMP binding to an Mr 57,000 binding protein (BP) in hepatic cytosol, which probably is the phosphorylated receptor subunit of protein kinase II (PK II). When we attempted to separate PK II from other hepatic cytosol proteins by DEAE-cellulose chromatography, we observed that GTP caused little stimulation of [3H]cAMP binding in an eluate fraction (110 to 170 mmol/L KCI), which was rich in PK II but did stimulate cAMP binding to the 210 to 325 mmol/L KCI fraction, which also contains PK II. This suggested that the latter fraction might contain a cofactor necessary for GTP stimulation of cAMP binding, which was lacking in the 110 to 170 mmol/L KCI fraction. Cyclic AMP BP in the 210 to 325 mmol/L fraction was removed by absorption onto cAMP agarose in the presence of 325 mmol/L KCI. When an aliquot of the BP-poor fraction, containing the putative cofactor, was added to the 110 to 170 mmol/L fraction containing PK II, the addition of 10(-4) mol/L GTP to the mixture increased [3H]cAMP binding by more than 80%. Cofactor activity could be extracted from the 210 to 325 mmol/L eluate by adsorption onto cAMP agarose in the presence of 10 mmol/L K phosphate, and eluted with 100 mmol/L KCI, suggesting that the cofactor may bind to the cAMP BP under appropriate circumstances. Addition of this eluted cofactor fraction to the 110 to 170 mmol/L fraction in the presence of 10(-4) mol/L GTP, increased the specific binding of [3H] cAMP more than twofold. Pretreatment of the cofactor fraction with trypsin eliminated this effect.(ABSTRACT TRUNCATED AT 250 WORDS)
An impairment of the measles virus-specific cytotoxic T lymphocyte response in multiple sclerosis was previously reported. This response is predominantly mediated by HLA class II-restricted CD4+ cells. In the present report, virus-specific cytotoxic T lymphocyte responses in multiple sclerosis were further studied by examining the response to mumps virus. No significant difference was detected in the generation of mumps virus-specific cytotoxic T lymphocyte responses between normal individuals and multiple sclerosis patients with impaired measles virus-specific cytotoxicity. A portion of the mumps virus-specific cytotoxic T lymphocyte response could be mediated by HLA class II-restricted CD4+ cells generated from both normal controls and MS patients. This CD4+ cell-mediated portion of the response was similar in both groups. These findings support the view that there is a distinct measles virus-specific impairment in cell-mediated cytotoxicity in multiple sclerosis.
Previous experimental observations have suggested to us that PRL and GH may be involved in regulating the metabolism of carnitine, a factor that plays a critically important role in fatty acid oxidation and ketogenesis. In the present study we administered bovine PRL (bPRL) or bovine GH (bGH) at a physiologic rate to hypophysectomized female rats for 2-3 days, and observed that bPRL caused a small (16%) increase (P less than 0.01), and bGH a 36% increase (P less than 0.01), in hepatic carnitine, bPRL decreased serum carnitine by 24% (P less than 0.05), and bPRL and bGH each increased the liver/serum carnitine ratio by 58% (P less than 0.01), suggesting that these hormones enhance the active uptake of carnitine from plasma. bPRL and bGH, alone or in combination, did not affect the carnitine content of cardiac or skeletal muscle, but in combination they increased the heart/serum and muscle/serum carnitine ratios by 45-76% (P less than 0.01), thus allowing maintenance of normal cardiac and skeletal muscle carnitine despite a decreased plasma level. In hypophysectomized male rats, bPRL did not affect liver or epididymal carnitine. We hypothesize that PRL and GH may play a role in the regulation of the carnitine concentration of female liver by enhancing hepatic uptake of carnitine from plasma, and through this mechanism may affect hepatic fatty acid oxidation and ketogenesis. The effect of lactogenic and somatogenic hormones on hepatic carnitine and ketogenesis could be of particular physiological importance in late pregnancy and during lactation.
GTP, in physiologic concentration, enhances the binding of cAMP to a protein in the hepatic cytosol that may be the regulatory subunit of protein kinase II. Ingestion of carbohydrate suppresses hepatic gluconeogenesis and glycogenolysis, two processes that are stimulated by cAMP. In this study, we have examined the possibility that carbohydrate inhibits these processes partly by decreasing the sensitivity of the GTP-responsive cAMP-binding protein to the effect of GTP. We found that 100 muM GTP was much less effective in enhancing cAMP binding in the hepatic cytosol of rats given 15% glucose for 2 days than in the cytosol of fasted rats [21 +/- 3% (mean +/- SE) increase vs. 67 +/- 6%, P less than .01]. Corresponding results were noted in diethylaminoethyl (DEAE)-cellulose extracts of the hepatic cytosol of these rats. GTP stimulation of cAMP binding was also diminished in the hepatic cytosol of diabetic rats treated for 7 days with insulin compared with that of untreated diabetic rats (29 +/- 10 vs. 81 +/- 11% increase, P less than .01), but this could have been due to increased food intake in the treated rats. We conclude that GTP stimulation of hepatic cAMP binding is decreased in the carbohydrate-fed state and that this effect may be mediated by the increase in plasma insulin induced by carbohydrate. Our observations suggest that some of the cellular effects of cAMP may be regulated by modulation of the stimulatory effect of GTP on the GTP-responsive cAMP-binding protein.
It has been suggested that elevated levels of insulin or insulin-like growth factors (IGFs) play a role in the development of diabetic vascular complications. Previously, we have shown a differential response to insulin between vascular cells from retinal capillaries and large arteries with the former being much more insulin responsive. In the present study, we have characterized the receptors and the growth-promoting effect of insulinlike growth factor I (IGF-I) and multiplication-stimulating activity (MSA, an IGF-II) on endothelial cells and pericytes from calf retinal capillaries and on endothelial and smooth muscle cells from calf aorta. We found single and separate populations of high affinity receptors for IGF-I and MSA with respective affinity constants of 1 X 10(-9) M-1 and 10(-8) M-1 in all four cell types studied. Specific binding of IGF-I was between 7.2 and 7.9% per milligram of protein in endothelial cells and 9.1 and 10.4% in the vascular supporting cells. For 125I-MSA, retinal endothelial cells bound only 1.7-2.5%, whereas the aortic endothelial cells and the vascular supporting cells bound between 5.6 and 8.5% per milligram of protein. The specificity of the receptors for IGF-I and MSA differed, as insulin and MSA was able to compete with 125I-IGF-I for binding to the IGF-I receptors with 0.01-0.1, the potency of unlabeled IGF-I, whereas even 1 X 10(-6) M, insulin did not significantly compete with 125I-MSA for binding to the receptors for MSA. For growth-promoting effects, as measured by the incorporation of [3H]thymidine into DNA, confluent retinal endothelial cells responded to IGF-I and MSA by up to threefold increase in the rate of DNA synthesis, whereas confluent aortic endothelial cells did not respond at all. A similar differential of response to insulin between micro- and macrovascular endothelial cells was reported by us previously. In the retinal endothelium, insulin was more potent than IGF-I and IGF-I was more potent that MSA. In the retinal and aortic supporting cells, no differential response to insulin or the IGFs was observed. In the retinal pericytes, IGF-I, which stimulated significant DNA synthesis beginning at 1 X 10(-9) M, and had a maximal effect at 5 X 10(-8) M, was 10-fold more potent than MSA and equally potent to insulin. In the aortic smooth muscle cells, IGF-I was 10-100 times more potent than insulin or MSA. In the retinal and aortic supporting cells, no differential response to insulin or the IGFs was observed. In the retinal pericytes, IGF-I, which stimulated significant DNA synthesis beginning at 1 X 10(-9) M, and had a maximal effect at 5 X 10(-8) M, was 10-fold more potent than MSA and equally potent to insulin. In the aortic smooth muscle cells, IGF-I was 10-100 times more potent than insulin or MSA. In addition, insulin and IGF-I at 1 X 10(-6) and 1 X 10(-8) M, respectively, stimulated these cells to grow by doubling the number of cells as well. In all responsive tissues, the combination of insulin and IGFs were added together, no further increase in effect was seen. These data showed that vascular cells have insulin and IGF receptors, but have a differential response to these hormones. These differences in biological response between cells from retinal capillaries and large arteries could provide clues to understanding the pathogenesis of diabetic micro- and macroangiopathy.
We have found that in female rats a variety of stressful stimuli, including sc inflammation, skin incision, endotoxin injection, and cold exposure, cause a significant decrease (30-86%) in the capacity of the hepatic cell membranes to specifically bind [125I]ovine PRL. Stress-induced decrease in food intake was not a factor in these studies, as nourishment was given only by tube feeding. Neither sc inflammation nor cold exposure affected hepatic binding of [125I]insulin. Further, the induction of inflammation in lactating rats and rats bearing 7,12-dimethylbenz[a]anthracene-induced mammary carcinomas did not affect the binding of PRL by the lactating or malignant mammary tissue. The suppressive effect of inflammation on hepatic binding of PRL was demonstrable in adrenalectomized-ovariectomized rats, in hypophysectomized rats receiving hormone replacement, and in adrenalectomized rats that had undergone partial chemical sympathectomy. We conclude that sc inflammation, as well as other forms of stress, decreases hepatic binding of PRL, but does not affect hepatic binding of insulin or mammary binding of PRL. The decrease in hepatic PRL binding is not mediated by a hormone secreted by the adrenals, ovaries, or pituitary, or by catecholamines, but could be mediated by another plasma factor or by peripheral dopaminergic neurons. Stress-induced decrease in hepatic PRL binding, or a related decrease in the binding of other polypeptide hormones, could play a role in the physiological response to stress.
Mononeuropathy multiplex and mixed sensorimotor neuropathy are known complications of systemic vasculitis and related autoimmune disorders. Autonomic dysfunction is not generally considered a neurologic complication of these diseases. We report two patients who came to neurologic attention because of autonomic dysfunction and were then discovered to have autoimmune disease. Autonomic dysfunction may be the presenting sign of autoimmune disorders, which should be considered in the differential diagnosis of acquired autonomic disturbances.
In the present study we have demonstrated specific binding of 3H-labeled adenosine 3',5'-cyclic monophosphate (cAMP) to a nuclear extract from rat liver. GTP, GDP, and low concentrations of ATP and ADP increased nuclear binding of [3H]cAMP, and AMP inhibited [3H]cAMP binding. Photoaffinity labeling studies employing [32P]cAMP revealed four nuclear binding proteins [relative molecular weight (Mr) 36,000, 49,000, 54,000 and 57,000]. Unlabeled cAMP decreased [32P]cAMP binding to all four proteins, whereas GTP increased binding to the 57,000 protein. We also observed specific binding of [3H]cAMP in the liver cytosol, which was stimulated by GTP but not by ADP or ATP. Photoaffinity labeling studies of the cytosol in the absence of unlabeled nucleotides revealed three cAMP-binding proteins (Mr 36,000, 49,000, and 54,000). Unlabeled cAMP inhibited binding of [32P]cAMP to all three proteins, whereas in the presence of GTP there was binding of [32P]cAMP to a Mr 57,000 protein. Using DEAE-cellulose, we isolated from the nuclear extract and cytosol a cAMP-binding protein that responded to GTP with an increase in cAMP binding but was unaffected by GDP, ATP, ADP, and AMP. Guanosine imidodiphosphate did not affect cAMP binding, suggesting that the stimulatory effect of GTP may be mediated by phosphorylation. We speculate that alterations in intracellular GTP in vivo may modulate the binding of cAMP to a protein in the nucleus and cytosol.
We have measured plasma von Willebrand factor (VWF) as the factor VIII-related antigen, plasma fibronectin, and two of the serum somatomedins, insulin-like growth factor I (IGF I) and IGF II, in 51 diabetic patients and 25 nondiabetic control subjects. VWF was significantly higher in the diabetic group than in the controls (173 +/- 9% SEM versus 101 +/- 9%, P less than 0.001), as has been reported by others. However, within the diabetic group there was no significant difference in VWF between those patients without retinopathy, those with background or proliferative retinopathy, or those with macular edema. There was also no difference in VWF between the diabetic subjects with and those without proteinuria. These results rule against a previously advanced hypothesis that the increase in VWF in patients with diabetes is secondary to microangiopathy. No significant difference was observed in fibronectin, IGF I, or IGF II between the diabetic and control groups, between the diabetic group without retinopathy and the retinopathic subgroups, and between the diabetic subjects with and without proteinuria. In the diabetic patients, there was no correlation between diabetic control as assessed by glycosylated hemoglobin and glycosylated serum protein, and the plasma levels of VWF, fibronectin, IGF I, or IGF II. The results of this study strongly suggest that neither plasma VWF, fibronectin, IGF I, nor IGF II plays an important primary role in the pathogenesis of diabetic microvascular disease, although one or more of these factors might play a permissive role.
In a retrospective study of 120 patients with surgically proved primary hyperparathyroidism, 71 patients who were normotensive and 49 patients (41 percent) who were either hypertensive at the time of parathyroidectomy or had a history of hypertension were compared. The mean serum calcium levels in the normotensive and hypertensive patients were very similar (11.6 +/- 0.1 [SEM] mg/dl, and 11.8 +/- 0.1), ruling against the hypothesis that hypercalcemia per se is the dominant cause of the hypertension of hyperparathyroidism. The mean serum creatinine levels in the two groups were also very similar (1.02 +/- 0.05 and 1.09 +/- 0.05 mg/dl), indicating that the hypertension of hyperparathyroidism is not the consequence of advanced renal parenchymal damage. The hypertensive patients did not have a significantly higher prevalence of urolithiasis. A review of the data in this and related studies leads to the conclusion that the hypertension of hyperparathyroidism is heterogeneous in origin. The mean serum phosphate level in the hypertensive patients was significantly lower than that in the normotensive patients (2.20 +/- 0.06 mg/dl versus 2.69 +/- 0.09 mg/dl, p less than 0.02), which may be due to a decrease in renal tubular phosphate reabsorption secondary to hypertension.
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