Biomedical subjects
Publications and source records attributed to J W Elte.
A male patient is described who presented with thyrotoxicosis, and a large painful neck mass. From the excised mass and stomach aspiration Mycobacterium tuberculosis was cultured and a diagnosis of miliary tuberculosis was made. The thyrotoxicosis was attributed to tuberculous thyroiditis.
In this communication data on the natural history of euthyroid multinodular goitres are presented. From a total group of 140 patients (mean age 54.6 years, 14 men and 126 women; 88 with autonomous, 52 with non-autonomous function), follow-up data were available for 90 patients (mean age 54.0 years, 11 men and 79 women; 64 with autonomous, 26 with non-autonomous function). During follow-up (means: 5.0 years, maximum 12.2 years) transitions in function were seen 15 times; 8 autonomous patients became hyperthyroid after less than 1-7 years. There were 6 transitions from non-autonomy to autonomy and 1 from autonomy to non-autonomy. One patient who demonstrated the whole cycle from non-autonomy through autonomy up to hyperthyrodism is described in more detail. In one patient operated upon because of hyperparathyroidism a follicular carcinoma was found by chance. Mechanical problems were the reason for surgery in 6 patients only, 16 patients were operated upon because of cosmetic reasons (mostly in the early years of the study). Finally, results from 19 TRH tests in 16 autonomous patients suggest that TRH tests in patients with autonomously functioning euthyroid multinodular goitres are not yet redundant.
Since the effectiveness of 30 mg methimazole in a single daily dose in gaining initial control of hyperthyroidism may depend largely on patient characteristics, 52 patients (34 with diffuse and 18 with nodular goitre) were investigated in an attempt to determine the relative importance of a number of pretreatment variables. Return to normal thyroid hormone levels after 2 to 6 weeks of treatment appeared to be the rule, although eight of these patients formed notable exceptions (6-20 weeks). The individual duration of treatment until achievement of biochemical euthyroidism correlated with the initial free thyroxine index (r = 0.75, P less than 0.001) and the free triiodothyronine index (r = 0.70, P less than 0.001). For patients with a diffuse goitre it was also related to the thyroid volume estimated by ultrasound (r = 0.73, P less than 0.001). According to multiple linear regression analysis however these variables were found to have no independent prognostic value. The decrease in thyroid volume during initial therapy, the nature of the goitre, a medication compliance score and various other patient variables did not correlate with the effect of treatment. In 12 cases perchlorate discharge tests were performed. The results suggest continued hormone synthesis in patients with highly active iodine trapping as an important mechanism of the postponed attainment of euthyroidism.
An anonymous questionaire concerning diabetes type I was circulated through (Young) AEMIE members. Questions were asked regarding available facilities, diagnosis, follow-up and therapy. One hundred and six completed questionaires were available for study: most were from 5 countries, i.e. 20 from the Netherlands (NL), 26 from Great Britain (GB), 16 from France (F), 16 (+2) from Belgium (B) (+ Luxemburg = LUX) and 19 from Ireland (IRL). There was a preponderance of general internists and internist/diabetologists. In Great Britain significantly more participants were internist/diabetologists and they treated significantly more patients than other participants. They also had access to more facilities, especially diabetes nurses. Most patients appeared to perform bloodglucose measurements; only 10 p. 100 of the patients did not measure glucose in blood or urine at all. There is general acceptance that bloodglucose regulation should be as tight as possible. The allowance of sugar under certain conditions was mostly permitted in the Benelux countries. The use of insulin pens exceeded that of insulin pumps. The preference for pens was primarily related to convenience for patient and doctor and low cost. The main indication for their use was bad regulation. This study confirms the impression that there is an increased interest in patient education (i.e. diabetes nurses, educational programmes and home blood glucose monitoring) amongst European physicians and a trend towards using new devices such as insulin pens and pumps in an effort to achieve a tighter blood sugar control.
131 patients with osteolytic metastases from breast cancer were randomised to receive long-term oral treatment with aminohydroxy-propylidene-bisphosphonate (APD), 300 mg daily (n = 70), or to act as controls (n = 61) in a multicentre trial. Specific antitumour therapy was at the discretion of the clinician and variable. An interim analysis was made after a median follow-up of 13 months in the APD group and 14 months in the controls. There was a significant reduction in pathological fractures and severe bone pain in the APD group, and hypercalcaemia was prevented. Consequently the necessity for radiotherapy for skeletal complications was more than halved; the number of systemic therapy changes was also reduced. Gastrointestinal side-effects of APD led to a drop-out of 8% of patients. Oral supportive APD therapy is simple and convenient, and significantly reduced skeletal morbidity in advanced breast cancer.
The efficacy of intravenous aminohydroxypropylidene bisphosphonate as treatment for the hypercalcemia of malignancy was examined in a phase II multicenter study in 132 patients with a large variety of primary tumors. This provided an opportunity for an analysis of the separate influences of bone resorption and renal calcium handling on the genesis and maintenance of hypercalcemia. The results demonstrated that increased bone resorption is the major contributory factor and that inhibition with bisphosphonate normalizes the serum calcium concentration within five days in more than 90 percent of patients. Hypercalcemia is sustained by an inability of the kidney to deal efficiently with a chronically increased calcium load. This is influenced by the requirements of volume regulation in the presence of a sodium diuretic effect of hypercalcemia and is very sensitive to induced variations of sodium load. In addition, in a minority of patients, direct renal actions of tumor-derived humoral factors adversely reduce the ability to excrete calcium. For optimal treatment of tumor-induced hypercalcemia, bisphosphonate treatment should be combined with intravenous administration of saline solution.
In this overview various aspects concerning internal medicine in the Netherlands are discussed. Special attention is given to training, which is likely to be increased from 5 to 6 years in the near future. Current problems in internal medicine are mostly related to under-funding of health care and include unemployment (which necessitates reduction of training facilities), disagreement with the government about finances and an argument with the sickness funds concerning professional responsibility and the termination of free enterprise. Also the issue of task definition of the general internist is reviewed. Funding of research used to be mainly the task of the government. Problems with the national economy, however, have resulted in a reduction of the governmental contribution. Private research foundations related to patients' associations, (pharmaceutical) companies and non-university hospitals have increased in importance.
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In this review different aspects of osteolytic bone metastasis of breast carcinoma including morbidity, pathogenesis, accompanying hypercalcaemia and treatment, are discussed. Bone metastases occur in many patients with breast cancer (percentages of up to 85% have been reported); although patients seldom die of bone metastases morbidity is pronounced. Literature data point out that humoral factors, such as prostaglandins and the recently described growth factors are of importance beside cell interactions between monocytes, lymphocytes, osteoclasts and tumour cells. Nowadays, no significance is attributed to parathyroid hormone (PTH) overproduction in this respect. The differential diagnosis between primary hyperparathyroidism and tumour-induced hypercalcaemia is not always easy biochemically; combinations of both do occur less frequently than has been assumed in the past. A new and promising line of investigations involves the growth factors, which can increase osteolytic bone resorption and may bind to epidermal growth factor (EGF) or PTH receptors, thus inducing some of the biological effects of PTH (including hypercalcaemia). Until recently it was exceedingly difficult to treat tumour-induced hypercalcaemia (TIH) (the acute condition). Since the availability of the bisphosphonates dichloromethylidene bisphosphonate (Cl2MDP) and 3-amino-1-hydroxypropylidene-1, l-bisphosphonate (APD) this treatment has become very simple. Preliminary results, derived from the literature, point out that bisphosphonate treatment might also be effective in providing long-term control.
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Thyroid-stimulating immunoglobulins (TSIs) were measured by radioreceptor assay in serum from 51 patients with a multinodular goitre, divided into four groups according to thyroid function, and in 30 normal people. In 9 patients who were euthyroid and had non-autonomous thyroid function and in 6 patients who were hyperthyroid, TSI index was normal . Of 21 euthyroid patients with autonomous function only 2 had a slightly abnormal TSI index (66 in both, normal greater than or equal to 68). Another series of 15 clinically euthyroid patients also had a normal TSI index. These results suggest that TSIs do not contribute to the pathogenesis of multinodular goitre, as has been suggested by others.
Twelve female patients (mean age 60 years, range 41--74) with euthyroid multinodular goitre and a flat TRH test (median delta TSH 0.9 muIU/ml, range 0--3.5) had normal prolactin responses to TRH (median data prolactin 48 ng/ml, range 6--115). The results are comparable with those in euthyroid patients receiving full substitution doses of thyroid hormone without increasing T3 and/or T4 levels beyond the normal range.
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