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Aims: Metabolic disorders depend on genetic, hormonal and environmental factors, whose relations may differ between genders. Therefore, we compared the contribution of metabolic disorders to the metabolic syndrome in women and men. Methods: To this end, we used a hierarchical classification statistical method to classify subjects into similarity groups according to clinical and biological parameters. Data were collected from 3,508 men and women aged 35–64 years, from a cardiovascular disease survey. Results: In both women and men, hierarchical classification identified a cluster corresponding to the metabolic syndrome representing 14 and 15% of the women’s and men’s sample, respectively. In women, elevated body weight (women’s Z-score: 1.59 vs. men’s Z-score: 1.29; p < 0.005), waist girth (1.62 vs. 1.30; p < 0.001) and low HDL cholesterol (–0.95 vs. –0.75; p < 0.05) were significantly larger contributors to the metabolic syndrome than in men. In contrast, systolic (0.59 vs. 0.95; p < 0.0001) and diastolic (0.55 vs. 0.99; p < 0.0001) blood pressure and apolipoprotein B (0.51 vs. 0.71; p < 0.0001) contributed significantly less in women than in men. Finally, insulin (n.s.), glucose (n.s.), triglycerides (n.s.) and LDL-cholesterol (n.s.) contributions were not different between genders. Conclusion: These results are consistent with the concept that a clustering of metabolic disorders occurs frequently in both women and men. However, the contribution of several metabolic disorders to the metabolic syndrome is different in men and women. This finding supports the concept that different criteria are necessary to define the metabolic syndrome in women and men.

Aims. This study was to determine whether renal functional reserve (RFR) is present in patients who have suffered long-lasting Type I (insulin-dependent) diabetes mellitus.¶Methods. Renal functional reserve was elicited by a 3-h amino acid infusion (4.5 mg · kg–1· min–1) in 10 patients with nephropathy (DN +) and 10 patients without nephropathy (DN–) who had lived with diabetes for 24 ± 3 and 27 ± 3 years, respectively and in 15 healthy control subjects. Renal functional reserve was calculated as the difference between amino acid-stimulated and baseline glomerular filtration rates (GFR).¶Results. Baseline glomerular filtration rate in DN– patients (106 ± 8) and control subjects (112 ± 3 ml · min–1· (1.73m2)–1) was significantly higher (p < 0.01) than in DN + patients (79 ± 7 ml · min–1· (1.73m2)–1). Renal functional reserve was absent in DN + patients, whereas it represented 26 ± 4 % of the baseline in DN– patients and 23 ± 2 % in control subjects. Renal vascular resistance decreased statistically significantly during amino acid infusion in DN– patients and control subjects but not in DN + patients.¶Conclusions/hypothesis. These results indicate that very long-term Type I diabetic patients without diabetic nephropathy still have a normal renal functional reserve. In contrast, this reserve is suppressed in similarly long-term macroalbuminuric and hypertensive patients with overt nephropathy in spite of their remarkably maintained glomerular filtration rate. This opposite impairment supports the interpretation that glomerular hyperfiltration is a determining mechanism in human diabetic nephropathy. [Diabetologia (2000) 43: 227–230]

The aim of this study was to determine whether renal functional reserve (RFR) is altered in insulin-dependent diabetic (IDDM) patients according to the stage of diabetic nephropathy. RFR was examined in 33 IDDM patients in similar glycaemic and metabolic control and compared to 12 healthy control subjects, during eight 1 h clearance periods prior to, during and after a 3-h stimulation by amino acid infusion (4.5 mg x kg(-1) x min[-1]). RFR was calculated as the difference between stimulated and baseline glomerular filtration rates (GFR). In 14 early normotensive diabetic patients with normal urinary albumin excretion, mean baseline GFR (133 +/- 3 ml x min(-1) x 1.73 m[-2]) was higher whereas RFR (10 +/- 4 ml x min(-1) x 1.73 m[-2]) was lower (p0.05) than in control subjects (113 +/- 4 and 28 +/- 2 ml x min(-1) x 1.73 m(-2), respectively). In 10 normotensive patients who had lived with IDDM for 16 years and who had microalbuminuria, baseline GFR and RFR (109 +/- 7 and 24 +/- 6 ml x min(-1) x 1.73 m(-2), respectively) were similar to those in control subjects. In 9 patients who had suffered IDDM for 23 years and had developed macroalbuminuria and hypertension, baseline GFR (78 +/- 8 ml x min(-1) x 1.73 m[-2]) was lower than in control subjects (p0.05) and RFR (8 +/- 4 ml x min(-1) x 1.73 m[-2]) was not significant. In addition, renal vascular resistance decreased significantly during infusion (p0.05) in microalbuminuric normotensive patients as well as in control subjects (by 9 +/- 4 and 11 +/- 4 mmHg x l(-1) x min(-1) x 1.73 m(-2), respectively) but not in normoalbuminuric normotensive or macroalbuminuric hypertensive patients. These results indicate that microalbuminuric normotensive patients retain a normal RFR, whereas RFR is reduced or suppressed at two opposite stages of the disease: in normoalbuminuric normotensive patients with a high GFR and in macroalbuminuric hypertensive patients with a decreased GFR. This dissimilar impairment reveals permanent glomerular hyperfiltration in both early IDDM without nephropathy and IDDM with overt diabetic nephropathy, but not in IDDM with incipient nephropathy.

Low plasma insulin-like growth factor (IGF)-I despite high circulating growth hormone (GH) in insulin-dependent diabetes mellitus (IDDM) indicate a hepatic GH resistance. This state may be reflected by the reduction of the circulating GH binding protein (GHBP), corresponding to the extracellular domain of the GH receptor, and the reduction of insulin-like growth factor binding protein (IGFBP)-3, major IGF-I binding protein, upregulated by GH. We carried out two studies. In the first, plasma GHBP activity was compared in patients with IDDM on continuous subcutaneous insulin infusion (CSII) or on conventional therapy and in healthy subjects. In the second study, the 18 patients on CSII at baseline were then treated by continuous intraperitoneal insulin infusion with an implantable pump (CPII) and prospectively studied for GH-IGF-I axis. Although HbA1 c was lower in patients on CSII than in those on conventional therapy, GHBP was similarly reduced in both when compared to control subjects (10.2 ± 0.8 and 11.6 ± 0.9 % vs 21.0 ± 1.3, p < 0.01). CPII for 12 months resulted in: a slight and transient improvement in HbA1 c (Time (T)0: 7.6 ± 0.2 %, T3:7.1 ± 0.2 %, T12: 7.5 ± 0.2 %, p < 0.02), improvement in GHBP (T0: 10.2 ± 0.8 %, T12: 15.5 ± 1.5, p < 0.0001), near-normalization of IGF-I (T0: 89.4 ± 8.8 ng/ml, T12: 146.9 ± 15.6, p < 0.002) and normalization of IGFBP-3 (T0: 1974 ± 121 ng/ml, T12: 3534 ± 305, p < 0.0001). The hepatic GH resistance profile in IDDM does not seem to be related to glycaemic control, but partly to insufficient portal insulinization. Intraperitoneal insulin delivery, allowing primary portal venous absorption, may influence GH sensitivity, and improve hepatic IGF-I and IGFBP-3 generation. [Diabetologia (1996) 39: 1498–1504]

Treatment of acromegaly with intermittent sc injections of octreotide is associated with an increased incidence of cholelithiasis. We investigated the incidence of gallstone formation, the occurrence of gallbladder disease, and the response of gallstones to ursodeoxycholic acid in 30 acromegalic patients who were treated with a continuous sc infusion of octreotide at doses between 200 and 800 micrograms/day for 3-70 months. Of the 30 patients, 28 had pretretment ultrasonography of the biliary tree performed, and all had frequent follow-ups. Nine patients underwent pre- and posttreatment bile sampling. No patient treated for less than 6 months and 18.5% of patients treated for more than 6 months developed new gallstones. No patient developed symptomatic cholelithiasis while receiving octreotide therapy. Of six patients who developed gallstones, four were treated with ursodeoxycholic acid, which dissolved all gallstones. One patient with gallstones experienced an episode of biliary colic when octreotide was withdrawn; however, no cholecystitis was found at subsequent cholecystectomy. Bile sampling showed that 8 (75%) of the 12 patients who were assessed demonstrated microcrystals, whereas in 3 (50%) of 6 patients who were closely analyzed thereafter, microcrystals disappeared once octreotide therapy was stopped. Our results show that continuous sc infusion octreotide therapy increases the incidence of cholelithiasis over normal values, as is the case with intermittent sc injections. Although higher octreotide levels are sustained with continuous sc infusion, this is not associated with an increased risk of gallstone formation compared with intermittent sc octreotide therapy.

Basic fibroblast growth factor (bFGF) is a potent mitogen for various cell types. We report here the first study of the effects of bFGF on a digestive tract-derived cell line. The effect of bFGF on the proliferation of AR4-2J cells, tumor cells of acinar pancreatic origin, was investigated together with modulation of ornithine decarboxylase (ODC) activity, an intracellular event involved in cell proliferation. bFGF caused a concentration-dependent stimulation of AR4-2J cell growth, with a half maximal effect (EC50) at 22 +/- 2 pM. ODC activity, assayed by the CO2-trapping method, was also increased by bFGF in a dose-dependent manner, reaching half-maximal stimulation at 20 pM. We conclude that bFGF is a very potent growth promoting factor for cells of pancreatic origin, already effective at picomolar concentrations. The parallelism between the growth assay and the ODC activity assay implicates the involvement of ODC activity in the pathway of the mitogenic effect of bFGF. The stimulation of ODC activity therefore seems to be a reliable early marker for cell proliferation in this model.

Type 1 diabetes treatment requires not only an intensive insulin regimen, but also intensive management, which daily involves participation of the patient. Our aim was to prospectively evaluate the efficacy on patient skills and metabolic control of our routine 5-day in-patient education programme.Over one year, each type 1 diabetic patient undertaking the programme for the first time, and able to complete a 2, 6, and 12 month follow-up, participated in the study (n=76). At baseline (T0), 61 patients had intensified insulin treatment and 15 increased from 2 to 3 daily insulin injections during the hospital stay. Using questionnaires and analysis of a glycaemia logbook, we evaluated at T0, T2, T6 and T12 patient skills related to diet, physical exercise, self-monitoring of blood glucose (SMBG), adjustment of insulin doses, and treatment of hypoglycaemia. Metabolic control was evaluated at the same time.At one year, the following skills improved: Intake of carbohydrates (T0: 59%, T12: 90% of patients, p0.001) and snacks (p0.001), appropriate physical exercise (p0.001), frequency of SMBG (T0: 3.3 +/- 1.5/day, T12: 4.5 +/- 1/day, p0.001), frequency of post-prandial tests (p0.001) and adjustment of insulin doses (T0: 18%, T12: 53% of patients, p0.001). More patients always carried sugar (T0: 61%, T12: 97%, p0.001) and appropriately treated hypoglycaemia (T0: 48%, T12: 79%, p0.001). Concurrently, HbA(1c) decreased (T0: 8.6 +/- 1.5%, T12: 7.7 +/- 0.9%, p0.001), and the frequency of hypoglycaemia was reduced (p0.001). There was a correlation between the decrease of HbA(1c) and the frequency of SMBG (p0.001, r2=0,24).Education led to positive changes in patient skills, which were maintained over one year and were associated with improved metabolic control.

We evaluated in a prospective study microcomputer nutritional teaching games and their contribution to the children's acquisition of nutritional knowledge and improvement of eating habits.One thousand eight hundred seventy-six children aged 7-12 years took part in this study at school. All 16 schools of the same school district were randomized into two groups: games group and control group, both receiving conventional nutritional teaching by their teachers. The children in the games group played computer games during the conventional nutritional teaching period (2 hours a week for 5 weeks). At completion of the study, dietetic knowledge and dietary records were evaluated in both groups.Dietary knowledge tests results were better in the games group (p0.001). The children in the games group had a significantly better balanced diet for an energy intake of about 1900 kilocalories: more carbohydrate (46.4 +/- 0.2% vs 45.7 +/- 0.2%, p0.05), less fat (37.1 +/- 0.1% vs 37.6 +/- 0.2%, p0.05), less protein (16.5 +/- 0.1% vs 16.7 +/- 0.1%, p0.05), less saccharose (11.5 +/- 0.1% vs 12.2 +/- 0.2%, p0.001), more calcium (p0.001) and more fiber (p0.05). The games group had a better snack at 10 a.m., a less copious lunch and less nibbling (p0.001).The children in the games group had slightly but significantly better nutritional knowledge and dietary intake compared to children in the control group. Using our micro computer nutritional teaching games at school provides an additional and modern support to conventional teaching.

To study the efficacy of the nutritional education software, Nutri-Expert, in the management of obese adult patients.Two groups of obese patients were followed up over one year in a randomized study: the first group received close traditional management (seven nutritional visits over the year, with physicians and dietitians conjointly) and the second one also used at home by Minitel the Nutri-Expert system. 557 patients were enrolled in the study by 16 French centers of diabetology and nutrition. Body mass index (BMI), tests of dietetic knowledge, dietary records and centralized biological measurements were assessed at inclusion, 6 and 12 months. 341 patients were evaluable at the end of the year.The group using Nutri-Expert scored significantly better in the tests of dietetic knowledge than the control group. For all patients, nutritional education led to a significant improvement in BMI, dietary records and biological measurements, without significant difference between the two groups. Five years after the end of the study, the weight of 148 patients was recorded; mean BMI was significantly lower than the initial value but there was no significant difference between the two groups.In the management of obese patients, Nutri-Expert system has a role to play in reinforcing nutritional knowledge; if regular follow-up is not possible, or if a large series of obese patients is to be treated, Nutri-Expert could partly replace traditional management, for example between visits.

Long-term experience of growth hormone (GH) replacement therapy in a large population of hypopituitary adults with GH deficiency (GHD) is limited, and safety surveillance is clearly essential. KIMS, the PharmaciaUpjohn International Metabolic Database, is a long-term, open, outcomes research programme of hypopituitary adult patients with GHD who are treated in a conventional clinical setting.The present analysis encompasses data from 1034 hypopituitary adult GHD patients treated with GH for a total of 818 patient years.Prior to GH therapy, the KIMS patient population exhibited an increased prevalence of obesity, diabetes mellitus (in females) and hyperlipidaemia, compared with normal populations described in published studies. Quality of life, assessed using a disease-specific questionnaire (QoL-AGHDA), was also reduced in KIMS patients. The maintenance dose of GH was significantly higher in patients who were receiving GH prior to enrolment into KIMS (non-naive patients) compared with patients who commenced GH at the time of enrolment (naive patients). In addition, dose of GH correlated significantly with body weight in the former group of patients. Analysis of serum levels of IGF-I indicated that overtreatment with GH was markedly more common in non-naive than in naive patients. The frequency of adverse events in KIMS patients was no higher than that reported in patients receiving placebo in previous clinical trials. Recurrence of pituitary or CNS tumours was reported in six patients, a rate consistent with data from control series. Three deaths were reported, none of which was obviously associated with GH treatment.Our data, drawn from a large population of hypopituitary adults treated with GH for a total of more than 800 patient years, confirm previous reports that untreated GHD in hypopituitary adults is associated with a number of important clinical problems. In addition, the results suggest that there has been a shift in recent years from determination of GH dose on the basis of body weight to dose titration of individual patients, and indicate that the latter technique has important advantages. The data provide further evidence that GH replacement therapy is well-tolerated in adults. However, it is possible that some adverse events may not become evident over the time scale covered by the present analysis, and continued surveillance therefore remains mandatory.

Type II diabetes includes various pathophysiologic entities. Glycoregulatory disorders are due to multiple mechanisms, associated to different degrees. Identical response to treatment is not observed among patients or at different times of treatment, early or later in the disease. Until very recently, the treatment available was insufficient. It now has gained new classes of drugs that act on the secretion of insulin, the sensitivity to insulin and the rate of intestinal glucide absorption. Approaches to treatment are often complementary and oral antidiabetic drugs can be associated. Hygienic and dietary measures remain indispensable to reinforce drug efficacity and to prevent complications in these patients.

In diabetes, the links between long-term complications and chronic hyperglycaemia and the risk of hypoglycaemia during intensive treatment have been well-documented. However, the potential short- or long-term benefits of glycaemic control on quality of life and cognitive functions have generally been reported as minimal or nil. Patients do not perceive the connection between better glycaemic control and quality of life. The potential advantages of Ozidia, whether in terms of glycaemic control, tolerance or ease of use, suggest that this treatment may provide improved quality of life. Two studies have investigated this possibility. The first, carried out over a 16-week period in the United States, was a randomised double-blind Ozidia vs placebo study in 594 non-insulin-dependent (NIDDM) diabetic patients to evaluate the respective influences of glycaemic control, symptoms of hyperglycaemia and side-effects of treatment on quality of life. The results were important, indicating a decrease in short-term clinical symptoms and an improvement in the quality of life, in correlation with decreased HbA1C. The quality of life of NIDDM patients can be improved by stricter glycaemic control, and thus can modify in the choice of therapeutic strategies and cost-benefit evaluation of intensive glycaemic control. The second study now under way in France concerns an evaluation of the quality of life of NIDDM patients before and after treatment with Ozidia. More than 600 diabetologists are involved, and the study should include 1,500 patients. The purpose is to show that Ozidia effectively improves quality of life by encouraging treatment compliance and improving treatment effectiveness. Thanks to self-monitoring of glycaemia, patients can measure the efficacy of their treatment regularly at various times of the day. A dose 5 to 15 mg/day of Ozidia is administered in this open 12-week study. The results will not be available before the end of 1997.

Humalog is the first analog of human insulin to be evaluated on a large scale in clinical conditions by discontinuous subcutaneous administration. Eight international multicentric studies have investigated the efficacy and tolerance of Humalog in protocols with 3 daily insulin injections (3 preprandial injections of Humalog associated with 1 or 2 injections of Umuline NPH or Umuline Zinc). A total of 2834 patients participated in these studies, including 2,277 who used Humalog. In addition to these trials, more than 5,000 patients had used Humalog by 1996, in some cases for more than 3 years. In insulin-dependent diabetes (IDDM), glycaemic control at the time of inclusion of patients in these protocols, as evaluated by HbA1C, was generally moderate (8 to 9%) despite 3 daily injections. This did not constitute intensive care since basal insulin for half of these patients was ensured by only a single daily injection. In these conditions, the results obtained showing significant postprandial improvement in glycaemic control and a significant reduction of the number of hypoglycaemic episodes, particularly at night, are important even though HbA1C levels were not significantly decreased. In a more recent crossover study (1996), 199 well-controlled IDDM patients (HbA1C = 7.3%) were treated intensively by multiple injections. The number of severe hypoglycaemic episodes with coma was only one-fifth that of the group treated by Humalog (equivalent to a reduction of 26 comas per 100 patients/year) in the absence of any significant modification of HbA1C. No differences were noted for lipids, adverse side effects or severe events (except hypoglycaemic episodes) and immunogenicity. In non-insulin-dependent diabetes, the results were similar but less impressive concerning the improvement in postprandial glycaemic control and the reduction in hypoglycaemic episodes. In addition to the significant results obtained in these studies, Humalog was favoured by the vast majority of patients. It is likely that Humalog will allow intensified treatment of diabetes in very favourable conditions, and that more patients will achieve the difficult goal of normalising glycaemia. However, a single injection of NPH or prolonged insulin is not sufficient for that purpose. Two daily injections will generally be necessary.

In Type 1 diabetes, high circulating growth hormone (GH) in conjunction with low plasma insulin-like growth factor-I (IGF-I) is indicative of a hepatic GH-resistance profile since the liver is the main source of circulating IGF-I. The reduction in specific growth hormone binding protein (GHBP), corresponding to the extracellular domain of the GH receptor, provides an indirect indication of the hepatic density of GH receptors, as does the reduction in IGFBP-3, the major IGF binding protein, which is GH-dependent. Type 1 diabetes is also associated with high levels of IGFBP-1, a binding protein down-regulated by insulin. Although most of these abnormalities have been described in situations of poor glycaemic control, hyperglycaemia does not seem to be the predominant factor in their pathogenesis. Even intensified subcutaneous insulin therapy does not normalize GH, IGF-I, GHBP and IGFBP-3 plasma levels. Some indirect evidence suggests that portal insulinopenia plays a role in the hepatic GH-resistance profile of Type 1 diabetes, i.e. discrepancies between the abnormalities reported in Type 1 and Type 2 diabetes, and the inverse relationship between residual insulin secretion in Type 1 diabetes and some of these abnormalities. Intraperitoneal insulin therapy administered to Type 1 diabetic patients by implantable pumps (without modification of glycaemic control) can improve GHBP activity, practically normalize plasma IGF-I and normalize IGFBP-3. The improvement in GH-IGF-I axis disorders obtained with intraperitoneal insulin therapy (which allows primary portal insulin absorption) provides direct evidence of the central role of portal insulin in the regulation of this system.

GH deficiency impairs lipid metabolism in adults, but little is known about the direct effect of GH on adipose tissue in humans. First, the in vitro response of fat cells to GH in five GH-deficient adults was studied; second, it was investigated whether 6-month recombinant human GH (rhGH) administration modifies this response. Biopsies of fat were obtained from the periumbilical region before and after rhGH administration. The response of the collagenase-isolated fat cells to various concentrations of GH was assessed by glycerol release, measured by bioluminescence. Before treatment, GH induced a lipolytic activity from the adipocytes, which became significantly higher after 6 months of treatment. Thus, this study provides evidence for an intrinsic lipolytic activity of GH in GH-deficient adults and for its improvement after long term rhGH administration.

The mouse pituitary cell line AtT-20 was found to secrete two low MW IGFBPs into conditioned medium (CM). The major IGFBP migrated at approximately 29 kDa and a minor IGFBP of 24 kDa was also present on western ligand blots (WLB). Both IGFBPs were purified from CM by IGF-affinity chromatography followed by reverse phase-FPLC. N-terminal analysis revealed that the first 10 amino acids of the 29 kDa and the 24 kDa IGFBPs were homologous to corresponding sequences of both human and rat IGFBP-5 and IGFBP-4, respectively. The 24 kDa IGFBP also crossreacted with a new antiserum specific for rodent IGFBP-4. The concentrations of both IGFBPs were increased by the addition of IGF-I, IGF-II, or insulin to the cell cultures, with IGFBP-5 demonstrating the greatest hormonal stimulation. The effects of IGF-I on IGFBP-5 expression were both time and dose dependent, with IGF-I being more potent than IGF-II, and IGF-II more potent than insulin. The relative potencies of these hormones in stimulating IGFBP-5 production were consistent with the peptides acting through the type-I IGF receptor. Similarly, the IGF-II analog [Leu 27]-IGF-II, which has very low affinity for the type-I receptor, only slightly stimulated an increase in IGFBP-5. Addition of dexamethasone to the cultures decreased both basal and IGF-stimulated IGFBP-5 production. Northern blotting demonstrated that IGF-I increased the expression of the mRNA for IGFBP-5, whereas dexamethasone decreased it. Together, these data suggest that the IGFs can increase IGFBP-5 production at both the protein and mRNA level.

Besides exerting its own lipolytic effect, growth hormone (GH) has been reported to potentiate the lipolytic response of adipose tissue to epinephrine. It was thought interesting to find out whether long-term recombinant human growth hormone (rhGH) administration modifies epinephrine-induced lipolysis in isolated adipocytes of GH-deficient adults. In a double-blind protocol, GH-deficient subjects received either 6 mo placebo (controls, n = 5) or 6 mo rhGH (treated, n = 5). Biopsies of fat were obtained from the periumbilical region before and after placebo or rhGH administration. The response of the collagenase-isolated fat cells to various concentrations of epinephrine was assessed by glycerol release, measured by bioluminescence. Epinephrine-induced lipolysis was not altered by 6 mo placebo, while it was significantly increased by 6 mo rhGH. A similar response was obtained with isoproterenol, but no significant differences occurred in either group with UK 14304, an alpha 2-adrenoreceptor agonist. Thus, in GH-deficient adults, long-term rhGH administration improves the lipolytic response of isolated adipocytes to epinephrine, essentially by increasing the efficiency of the beta-adrenergic pathway.

AR4-2J, a rat pancreatic acinar-tumor cell line, was used to investigate long-term effects of basic fibroblast growth factor (bFGF) and somatostatin on pancreatic cancer cells. We observed that bFGF stimulated cell proliferation when cells were cultured in serum-free medium. The effect was dose-dependent with half-maximal and maximal effects at 25 pM and I nM bFGF, respectively. The somatostatin analog SMS 201-995 (SMS) decreased the growth-promoting effect of bFGF. The maximal effect was observed at I nM SMS and the half-maximal effect at 20 pM SMS. Characterization of bFGF receptor-binding properties with [125I]bFGF revealed that AR4-2J cells exhibited 2 classes of bFGF binding site with respective KD values of 47 pM and 3 nM and binding capacities of 14 fmol and 0.9 pmol/10(6) cells. High-affinity receptors correlated with bFGF stimulation of AR4-2J cell growth, suggesting that the effects of bFGF are receptor-mediated.

The authors report 35 cases of implantation of a programmable implantable insulin pump, under local anesthesia. This technique allows creation of an subcutaneous pocket and introduction of an intraperitoneal catheter for insulin delivery. The morbidity is mainly due to the catheter which becomes thrombosed by a fibrotic pannus at its tip. We observed only one case of mechanical dysfunction of the pump. Subcutaneous migration is secondary to reoperation without new fixation. With a mean follow-up of 7 months, 75% of the patients are doing well.

This study was performed to evaluate the risk of gallstone formation during long-term treatment with the long-acting somatostatin analog octreotide (SMS 201-995). Twelve patients (8 men, 4 women--mean age 43 years) treated with continuous subcutaneous octreotide infusion for acromegaly (mean duration 26.5 months, mean dose 541 micrograms/day) were included. Bile collection by duodenal intubation was performed before, during, and 45 days after octreotide treatment in 3, 12, and 8 patients, respectively. Abdominal ultrasonography and/or oral cholecystrography were also performed before (n = 9 patients), during (n = 12), and after treatment (n = 10). Bile examination was normal in the 3 patients controlled before treatment but showed that 58.3 percent of the treated patients had cholesterol monohydrate crystals. After discontinuation of octreotide only 25 percent of patients had cholesterol crystals. In 3 patients (25 percent) treated longer than 6 months, cholesterol crystals occurred prior to the occurrence of small radiolucent gallstones: one patient underwent cholecystectomy because of biliary colic, while in the two others, complete dissolution of stones was obtained after 10 months of treatment with ursodeoxycholic acid given in association with octreotide. None of the 9 other acromegalic patients (including 7 treated more than 20 months) developed stones. Cholesterol gallstone formation seems to be increased in acromegalic patients during long-term octreotide treatment but the exact incidence remains to be determined in larger series of patients.

Ten adolescents (four boys and six girls) aged 11.5 to 17 years, presenting with constitutionally tall stature were treated with twice daily subcutaneous injections of 250 micrograms of SMS 201-995 (Sandostatin). Results are reported after 6 and 12 months of therapy. Reduction of growth rate was obtained in 9 patients and correlated with the reduction of 24-hour growth hormone pulsatility and with the decrease of plasma Somatomedin-C values. Moreover, acceleration of bone maturation on SMS 201-995 therapy occurred in seven patients, and mean bone age increased from 13.3 years to 14.5 and 15.8 years after 6 and 12 months of SMS therapy. The mean reduction of predicted adult height was 4.9 cm at the last evaluation after 6 or 12 months of therapy. The dual effect of SMS 201-995 on growth rate and bone maturation suggests that it may be an alternative treatment to reduce adult height.

Low density vascular smooth muscle (VSM) cell cultures maintained on extracellular-matrix(ECM)-coated dishes and plated in the presence of either plasma or serum will proliferate actively when serum-containing medium is replaced by a synthetic medium supplemented with three factors: high density lipoprotein (HDL, 250 micrograms protein/ml); insulin (2.5 micrograms/ml) or somatomedin C (10 ng/ml); and fibroblast growth factor (FGF, 100 ng/ml) or epidermal growth factor (EGF, 50 ng/ml). The omission of any of these three factors from the synthetic medium results in a lower growth rate of the cultures, as well as in a lower final cell density once cultures reach confluence. When cells are plated in the total absence of serum, transferrin (10 micrograms/ml) is also required to induce optimal cell growth. The effects of the substrate and medium supplements on the life span of VSM cultures have also been analyzed. Cultures maintained on plastic and exposed to medium supplemented with 5% bovine serum underwent 15 generations. However, when maintained on ECM-coated dishes the serum-fed cultures had a life span of at least 88 generations. Likewise, when cultures were maintained in a synthetic medium supplemented with HDL and either FGF or EGF, an effect on the tissue culture life span by the substrate was observed. Cultures maintained on plastic underwent 24 generations, whereas those maintained on ECM-coated dishes could be passaged repeatedly for 58 generations. These experiments demonstrate the influence of the ECM-substrate only in promoting cell growth but also in increasing the longevity of the cultures.

SMS 201-995, a long-acting somatostatin analog, was given as the initial treatment to an acromegalic patient. SMS 201-995 (200 micrograms, sc, three times daily) reduced, but did not normalize, serum GH levels. Complete and prolonged control of GH secretion was obtained with a 600-micrograms daily continuous sc infusion (CSI), and the patient was treated in this way for 6 months. Rapid improvement of clinical signs and symptoms of acromegaly occurred, as did major tumor shrinkage. The other pituitary functions did not change. After 6 months, the daily SMS 201-995 dose was progressively reduced; GH secretion remained suppressed. After 12 months of treatment, GH secretion was controlled with a CSI of 100 micrograms SMS 201-995 daily, but not with two daily sc 100-micrograms injections. Further significant reduction in tumor size occurred. We conclude that CSI of SMS 201-995 resulted in constant GH normalization and marked clinical and morphological improvement. This form of treatment should be considered as an alternative to ablative treatment of acromegaly.

Bovine vascular endothelial cells maintained on dishes coated with an extracellular matrix and exposedto medium supplemented with lipoprotein-deficient serum (LPDS) require the presence of lipoprotein to proliferate optimally. High density lipoprotein (HDL) seems to be the major factor involved in the proliferation of vascular endothelial cells. This is mostly due to its lack of toxicity when added at high concentration, as well as to its nondependence on LPDS to exhibit its mitogenic properties. Therefore, HDL at physiological concentrations (1,000--1,500 microgram protein/ml) can fully replace serum. Low density lipoprotein, unlike HDL, has a biphasic effect. Although mitogenic for vascular endothelial cells when added at low concentration, once physiological concentrations are reached it becomes toxic for the cells. Moreover, and in contrast with HDL, the mitogenic effect of low density lipoprotein was found to be a function of the LPDS concentration to which cultures were exposed. The substrate upon which cultures are maintained has been found to be an important factor if a mitogenic effect of HDL is to be observed. When maintained on plastic, cells proliferate poorly in response to HDL unless fibroblast growth factor is added to the medium. In contrast, when maintained on extracellular matrix, an optimal growth rate is induced by HDL, even in the absence of fibroblast growth factor. This suggests that, in vivo, the integrity of the basement membrane upon which endothelial cells rest and migrate is an important factor in determining the cells response to lipoproteins present in plasma.

The marked pituitary tumor shrinkage achieved by continuous sc infusion (CSI) of the long-acting somatostatin analog octreotide in one acromegalic patient led us to treat 16 other acromegalic patients for up to 24 months by CSI. This therapy, given in doses ranging from 100-600 micrograms/day, resulted in normalization of the mean daily serum GH (mGH) and insulin-like growth factor I levels in 9 of the 17 patients (53%). In 7 patients, mean daily serum GH decreased but not to normal; 3 of these patients had hyperprolactinemia which was not influenced by octreotide. One patient was completely unresponsive. In contrast to the biochemical results, 80% of the patients had marked clinical improvement. Side-effects consisted of slightly impaired carbohydrate tolerance in 2 patients and cholelithiasis in 2 patients. Pituitary tumor size decreased in only 3 patients; in 1 of them visual field defects disappeared rapidly. These results suggest that octreotide treatment may prove beneficial before surgery in patients with macroadenomas, although its efficacy varies widely. Potential responsivity can usually be determined by a short course (24 h) of CSI of octreotide.

The culture of retinal capillary endothelial cells involves certain problems concerning contamination by pericytes, the maintenance of differentiation and the duration of culture viability. A procedure for the isolation and culture of capillary endothelial cells from bovine retina which overcomes these difficulties, is described. Microvessel fragments isolated by mechanical dispersion and filtration techniques adhere strongly to dishes coated with extracellular matrix produced by bovine corneal endothelial cells. The first migrating cells emerge from the original microvessel fragments two days after plating. This technique and subsequent cloning provides migrating and proliferating cells derived only from the retinal capillaries and uncontaminated by other cell types such as pericytes. Endothelial cells were grown on gelatin coated dishes in a serum supplemented medium (10% calf serum). Cell proliferation was significantly enhanced by the addition of basic fibroblast growth factor (1 ng/ml) to the culture medium. In these culture conditions, retinal capillary endothelial cells can be repeatedly passing without the loss of their principal morphological characteristics and some of the differentiated properties of endothelial cells. Primary cultures and subcultures, at least up to the 8th passage, formed a monolayer of small, elongated, tightly-packed, contact inhibited cells which expressed Factor VIII-related antigen. Ultrastructural examination by transmission electron microscopy of confluent bovine retinal capillary endothelial cells showed many tight junctions and Webel Palade granules. These studies provide new means for the isolation and culture of retinal capillary endothelial cells and presents evidence for growth factor requirements for the ability of cells to be repeatedly passing.

The implication of protein phosphorylation in the mitogenic action of high density lipoproteins (HDL) on bovine vascular endothelial cells was investigated by incubating endothelial cell cultures in the presence of 32P-labeled phosphoric acid. The incorporation of 32P into proteins was measured after fractionation by polyacrylamide gel electrophoresis in the presence of sodium dodecyl sulfate and autoradiography of the gel. In endothelial cells seeded at low density and made quiescent by serum starvation, HDL markedly and consistently enhanced the degree of phosphorylation of a Mr 27,000 protein in a time- and dose-dependent manner. Using 500 micrograms/ml HDL, 32P labeling of the 27-kDa protein was already measurable after 10 min of incubation and reached a maximum at 20-30 min. Minimal effective dose of HDL during a 30-min incubation period was in the range of 5-10 micrograms/ml. While the apolipoprotein moiety of HDL was able to mimic the effect of total HDL, the lipid part of HDL was not. Furthermore, fibroblast growth factor appeared to potentiate the effect of HDL on 27-kDa protein phosphorylation, in agreement with the synergism observed between fibroblast growth factor and HDL on endothelial cell proliferation. Two activators of protein kinase C, 12-O-tetradecanoylphorbol 13-acetate and 1-oleoyl-2-acetylglycerol also induced the phosphorylation of the 27-kDa protein. These results suggest that the 27-kDa protein may be a physiological substrate for protein kinase C and that HDL could exert their mitogenic effect on endothelial cells through activation of protein kinase C and subsequent protein phosphorylation.

A 6.75-kilobase human hepatoma-derived basic fibroblast growth factor (bFGF) cDNA was cloned and sequenced. An amino-terminal sequence generated from a purified hepatoma bFGF was found to correspond to the nucleotide sequence and to begin 8 amino acids upstream from the putative methionine start codon thought to initiate a 154-amino acid bFGF translation product. This sequence suggests that a form of bFGF of at least 163 amino acids exists. The hepatoma cDNA was transcribed in vitro into RNA; in vitro translation of this RNA generated three forms of bFGF with molecular masses of 18, 21, and 22.5 kDa. By use of in vitro mutagenesis, it was found that the 22.5-kDa bFGF and possibly the 21-kDa form were initiated with CUG start codons. The 18-kDa bFGF was initiated with an AUG codon. By transfecting into COS cells human hepatoma bFGF cDNA and a construct from which the AUG initiator was eliminated, it was found that the higher molecular mass forms of bFGF were as biologically active as the 18-kDa form.

TOULMED is an inference engine, capable of accomodating imprecision and uncertainty, which is developed and experimented in medical applications. The illustrative examples in this paper are taken from the application to the treatment of diabetes. The paper emphasizes the importance of the management of imprecision and uncertainty in order to take into account all the nuances of the medical knowledge. More particularly, a comparative example is provided where the same medical knowledge is processed with and without a treatment of imprecision and uncertainty (which is dealt with in the mathematical framework of possibility theory).

8 toll adolescents (4 boys and 4 girls) had accepted to bo treated by SMS 201-995 for 12 Months in order to reduce their growth velocity and therefore their adult height. This treatment had been submitted to the local ethical committee. Afc present time 5 patients had undergone 3 months treatment (4 boys and one girl), mean chronological age was 14 years 6 months ± 1 year 2 months, mean SD for height was + 3.1 ± 0.42 SD, mean bone age was 14 years 6 Months ± 1 year 3 months, pubertal development was scored Tanner stage III (n=l) and IV (n=4). Before treatment, physiological 24 hour GH secretion, GH response to TRH and GHRH stimulation tests, SmC levels and others pituitary functions were evaluated. SMS 201-995 was given twice daily using 2 subcutaneous injection of 250 ug at 8.00 AM and 8.00 PM. For the whole group, growth velocity had strongly decreased (2 ± 2.82 cm/y versus 6.9 ± 2.35 cm/y), growth was completely blocked in 3 patients. One boy aged 15 years 9 months had the same growth velocity before and after treatment. The last patient had previously been treated unsuccessfully by bromocryptine during one year and after 3 months of SMS 201-995 therapy growth velocity had decreased (6cm/y versus 10 cm/y before treatment). Tolerance of this therapy was good however transient diarrhea and nausea during the first ten days had occured in all cases. Routine biological parameters remained normal. CONCLUSION : These preliminary results suggest the efficacy of SMS 201–995 in reducing growth velocity in children with constitutional tall stature without major side effects.

Basic Fibroblast growth factor (FGF) is a polypeptide of 17.000 PM, isolated from various bovine and human tissues. This factor has a strong mitogenic activity and maintains differenciation of mesodermic cells in vitro, but its physiological role remains unknown. We used a radioimmunoassay (RIA) developped by Guillemin et al. Using antibodies raised against a synthetic replicate of |Tyr10| FGF (1-10). Our RIA intraassay and interassay coefficients of variation were 14% and 7% respectively. 83 children, 44 boys and 39 girls aged from 1 year 1 month to 15 years 10 months (m : 6 years 6 months) were studied. FGF mean value was 20,01 ± 6,18 pmol|ml. A great disparity of individual values was found. No significative difference was found between boys (18,76 ± 6,28 pmol/ml) and girls (20,87 ± 5,84 pmol/ml). FGF values did not correlated with chronological age, but analysis of the results showed a slightly increase of FGF values with a maximum peak in prepubertal stage (10-12 years) followed by a slow decrease in pubertal children (12-16 years). We had previously studied 135 adults men and women. Adult FGF levels were lower than in children (m : 18,34 ± 4,44 pmol/ml, p