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A POSSIBLE INTERRELATION BETWEEN GLUCOSE-6-PHOSPHATE DEHYDROGENASE AND DEHYDROEPIANDROSTERONE IN OBESITY
485 gen concentration in the recipient’s plasma, a hxmolytic anxmia, and possibly a fall in the prothrombin concentration. Hxmoglobinuria has been reported (McMillan et al. 1961). In our patient, the A.H.G. concentrates, though they gave rise to a hsemolytic anaemia and mild jaundice associated with a fall in the prothrombin concentration, nevertheless caused less trouble than was expected, and hxmoglobinuria did not occur. The management of this patient called for the preparation of cryoprecipitates from over 600 donors. Clearly, this considerable task can only be undertaken by a wellequipped and staffed laboratory, with adequate facilities not only for preparation of the cryoprecipitates but also for their storage. After the cryoprecipitates have been extracted, the blood can be used for ordinary transfusion purposes and is not wasted. Apart from the requisite laboratory equipment, it is also apparent that the management of this type of patient can only be undertaken in hospitals with the resources to cope with the formidable problems that may arise and where the medical and laboratory staffs are familiar with the treatment of hxmophiliacs (Biggs et al. 1967, Dalrymple-Champneys et al. 1967). The patient was initially admitted to hospital under the care of Prof. A. Kekwick, to whom we are grateful for permission to publish this case-report. We are indebted to Dr. R. Biggs, M.R.C. blood coagulation unit, Oxford, Dr. A. L. Bloom, Institute of Pathology, Royal Infirmary, Cardiff, and Mr. A. J. Gunning, Nuffield Department of Surgery, Radcliffe Infirmary, Oxford, for their helpful advice; to Dr. W. d’A. Maycock, Lister Institute, Elstree, Herts, Dr. W. J. Jenkins, director of The North-East Metropolitan Regional Blood Transfusion Service, Dr. R. A. Cumming, director of the Regional Blood Transfusion Centre, Royal Infirmary, Edinburgh, and Messrs. Kabi Pharmaceuticals, Bilton House, Uxbridge, for supplies of human A.H.G. concentrate; to Maws Pharmacy Supplies Ltd., Barnet, for supplies of porcine A.H.G.; to Dr. T. E. Cleghorn, director of the North-West Metropolitan Regional Blood Transfusion Service, for allowing us to bleed donors for the preparation of the cryoprecipitate; and to members of the laboratory and nursing staff, especially Mrs. B. Hume and Dr. J. Bridgman, whose unremitting care was a major contribution to the patient’s recovery. Requests for reprints should be addressed to J. W. S., BlandSutton Institute of Pathology, Middlesex Hospital, London W.1. REFERENCES
Abell, J. M., Bailey, R. W. (1960) Archs Surg., Chicago, 81, 569. Allison, P. R. (1965) Proc. R. Soc. Med. 58, 255. Biggs, R., Macfarlane, R. G., Rizza, C. R., Grant, J. (1967) Lancet, i, 1001. Dalrymple-Champneys, W., Hunter, J. R., Polton, K. R. (1967) Br. med. J. ii, 440. de Valderrama, J. A. F., Matthews, J. M. (1965) J. Bone Jt Surg. 47B, 256. Fraenkel, G. J., Taylor, K. B., Richards, W. C. D. (1959) Br. J. Surg. 46, 383. A. J. (1966) Treatment of Hæmophilia and other Coagulation Disorders (edited by R. Biggs and R. G. Macfarlane); chapt. 15. Oxford. Hall, M. R. P., Handley, D. A., Webster, C. U. (1962) J. Bone Jt Surg.
Gunning,
44B, 781. Kerr, C. B. (1963) The Management
of
Hæmophilia. Glebe,
New South
Wales.
Macfarlane, R. G., Mallam, P. C., Witts, L. J., Bidwell, E., Biggs. R., Fraenkel, G. J., Honey, G. E., Taylor, K. B. (1957) Lancet, ii, 252. Matthews, J. M. (1966) Treatment of Haemophilia and other Coagulation Disorders (edited by R. Biggs and R. G. Macfarlane); chapt. 4, p. 82. Oxford.
McMillan, C. W., Diamond, L. K., Surgenor, D. M. (1961) New Engl. J. Med. 265, 224, 277. Pool, J. G., Shannon, A. E. (1965) ibid. 273, 1443.
"... What are we to do with the under-fives ?
...
A POSSIBLE INTERRELATION BETWEEN GLUCOSE-6-PHOSPHATE DEHYDROGENASE AND DEHYDROEPIANDROSTERONE IN OBESITY A. LOPEZ-S. * M.D. Salamanca, Ph.D. Tulane ASSISTANT PROFESSOR OF MEDICINE
W. A. KREHL M.D. Yale, Ph.D. Wisconsin PROFESSOR OF MEDICINE
From the Clinical Research
Center, Department of Medicine, University of Iowa College of Medicine, Iowa City, Iowa, U.S.A. The
excretion of
urinary dehydroepianSummary drosterone (D.H.A.) and the glucose-6phosphate-dehydrogenase (G.-6-P.D.) activity of red blood-cells was measured in obese patients. Percentage excess body-weight was positively correlated with G.-6-P.D. activity. At the same time a negative correlation seemed to exist between the percentage excess body-weight and the urinary excretion of D.H.A. Higher urinary D.H.A. values were observed while the patients were losing weight. These findings suggest a possible relation between G.-6-P.D. and D.H.A. which could explain the pathogenesis of some types of obesity. Introduction ANIMAL work and clinical observation suggest the existof a delicate mechanism which regulates the balance between energy intake and energy output, and which seems to be influenced by neurological, physiological, metabolic, and hormonal factors. Several workers have described a possible relation between adrenocortical activity and obesity (Gray et al. 1956, Mlynaryk et al. 1962, Migeon et al. 1963). The urinary excretion of total 17-ketosteroids by obese individuals has been found to be elevated (Simkin 1961), normal (Gray et al. 1956, Gojate and Prunty 1963), or even diminished (Poisnick and DiRaimondo 1956, Jacobson et al. 1964). Lately attention has been directed to the urinary excretion of one specific 17-ketosteroid, dehydroepiandrosterone (D.H.A.). Sonka and Gregorova (1963) reported that the mean amount of D.H.A. excreted by obese people was lower than that found in urine from non-obese individuals. Sonka and Gregorova (1965) postulated that these decreased values of D.H.A. will result in a tendency toward increased lipogenesis because D.H.A., being an inhibitor of the enzyme glucose-6-phosphate dehydrogenase (G.-6-P.D.) could regulate the hexosemonophosphate shunt, and hence the synthesis of reduced N.A.D.P., which is required for the reductive synthesis of fatty acids. Hendrikx et al. (1965) have also reported abnormalities in the urinary excretion of D.H.A. in obesity, and similar findings have been noted in patients with gout (Sonka and Gregorova 1964a) and in obese diabetics (Sonka and Gregorova 1964b). We have investigated a possible in-vivo interrelation between G.-6-P.D. and D.H.A. in obese patients. ence
We should
clarify what we really want the state to do for this age-group ... As a society we lack any general philosophy of the responsibility of the state towards mothers and very young children. We are willing enough to approve educational provision from whatever age the experts think fit. But when it comes down to providing, in effect, the care of a mother-substitute, the state baulks and childminders flourish."-MAUREEN O’CONNOR, New Statesman, Aug. 25, 1967, p. 226.
Material and Methods G.-6-D. in red blood-cells and urinary excretion of D.H.A. were determined in fifty obese patients attending an outpatient obesity clinic (group A) and in young obese patients admitted to the Clinical Research Center (group B) who were placed in a diet characterised by rigid restriction of carbohydrate content * Present address: department of medicine, Louisiana State University Medical School, New Orleans 70112, U.S.A.
486 I-WEIGHT, G.-6-P.D. ACTIVITY, AND D.H.A. EXCRETION
TABLE
IN
FORTY-SEVEN OBESE PATIENTS IN GROUP A
less than 12 g. daily. G.-6-P.D. was determined by the method of Kornberg and Horecker (1955) by measuring the increase of absorbance of reduced N.A.D.P. at 340 m. per unit of time in a medium containing enzyme (red blood-cells), substrate (G.-6-P.), buffer (triethanolamine), and N.A.D.P. (as a cofactor). All these reagents were obtained from C. F. Boehringer and Soehne, G.M.B.H., Mannheim, Germany. 1 unit is that quantity of enzyme in 1 ml. of test solution which, at a temperature of 25°C, changes the reduced N.A.D.P. absorbance at a wavelength of 340 m. by 0.001 within 1 minute. Urinary D.H.A. was hydrolysed by the method of Burstein and Liebermann (1958), purified by thin-layer chromotography (silica gel, 0-30 mm. thick; solvent system 60% benzene, 40% ethylacetate), the trimethylsilyl ether was formed and quantitatively determined by gas-liquid chromotography (Barber ColemanModel 5000 ’ ; argon ionisation detector; U glass column, 6ft. long, 4 mm. internal diameter,’QF1,’ 3% coating andGasChrom Q’ support, 80-100 mesh; argon as carrier gas, inlet pressure 18 lb. per sq. in; colunm temperature 218°C; detector temperature 248°C; injector temperature 280°C; voltage to
1000
V.). Results
TableI shows the results found in forty-seven patients attending the outpatient clinic; these determinations were performed on specimens obtained at the time of first visit to the clinic. As the percentage excess weight increased, TABLE
II-WEIGHT, G.-6.P.D. ACTIVITY, AND D.H.A. EXCRETION GIRLS
IN
5
(GROUP B)
G.-6-P.D. in red blood-cells increased; on the other hand, percentage excess weight and/or the G.-6-P.D. activity were inversely correlated with urinary D.H.A. excreted in 24 hours. Group B consisted of five teenage girls, aged 15, 16, 17, 20, and 21, all of them significantly obese but otherwise healthy. Table 11 shows the tendency toward higher urinary D.H.A. values and lower G.-6-P.D. activity as the patients lost weight.
Serial changes over a longer period of time in a 19-yearold girl admitted to the Clinical Research Center revealed an inverse relation between the values of D.H.A. and G.-6-P.D., while the patient was losing weight (table III). Discussion The results reported here confirm the previous observations by Sonka and Gregorova (1963, 1964a and b, 1965), and Hendrikx et al. (1965) of an abnormal excretion of D.H.A. in patients with different forms of obesity. The reason why some obese persons excrete lower or practically no D.H.A. in their urines is not clear, but the biological implications are obvious. Several workers have investigated urinary D.H.A. and the G.-6-P.D. activity of different tissues in different physiopathological conditions including obesity (Sonka and Gregorova 1963, Fried and Antopol 1966), diabetes Rifkin et al. 1958, Sonka and Gregorova 1964b), atherosclerosis (Kittinger et al. 1960). In general, there is agreement that in those cases in which hyperlypogenesis is suspected, urinary D.H.A. tends to decrease while red blood-cell G.-6-P.D. activity increases. The inhibitory effect of D.H.A. on G.-6-P.D. in vitro has also been reported by Tsutsui et al. (1962) among others; all agree that D.H.A. is a potent inhibitor of G.-6-P.D. Such an inhibition in vivo could have interesting implications if changes in the level of enzymatic activity reflect alterations in the usage of the hexosemonophosphate shunt (Fitch and Chaikoff 1960). Changes in the activity of the enzyme G.-6-P.D. may result in changes in the activation of the shunt which may in turn result in changes in the availability of reduced N.A.D.P. which is an important cofactor in the synthesis of fatty acids. In animals, in conditions of adaptative hyperlypogenesis, adipose tissue apparently accounts for about 95% of the total fatty acids synthesised (Leveille 1967a). Perhaps the shunt is not as important a mechanism as it was once thought to be for the transfer of hydrogen for the reductive synthesis of fatty acids; the pyruvate cycle (Rognstad and Katz 1966) and the formation of oc-glycerophosphate (Leveille 1967b) have also been shown to make major contributions in the regulation of the synthesis of fatty acids by adipose tissue under conditions of rapid synthesis of fatty acids. Nevertheless Katz and Rognstad (1966) have reported quantitative data suggesting that while the operation of the hexosemonophosphate cycle is not likely to be an absolute requirement for fatty-acid synthesis, it is still essential for extensive synthesis. Although Fessler et al. (1967) have found that many of the characteristics of lipid synthesis previously ascribed to rat adipose tissue can be extended to human adipose tissue, the results of Shrago et al. (1967) demonstrated significant differences between adipose-tissue metabolism in man and lower animals: there seems to be a virtual absence of citriccleavage enzyme in human adipose tissue. Shrago et al. (1967) suggest that in human beings, enzyme adaptation is not as important as it once was thought to be on the basis of animal experiments. They suggest also that the control of multienzyme systems by substrate and cofactor concentrations and also allosteric stimulation or inhibition could serve as primary means of regulation. Whether or not D.H.A. can exert such a regulatory function is not known, but the mechanism of action of steroids have been suggested to be due to their allosteric effect and Marks and Banks (1960) postulated that D.H.A. is a noncompetitive inhibitor of G.-6-P.D. Adaptative hyperlipogenesis develops in various forms
487
of experimental obesity (Mayer et al. 1955) and, by analogy, in some types of human obesity carbohydrates could be preferentially disposed of through the hexosemonophosphate pathway; the additional lack of inhibition of G.-6-P.D. due to the absence of D.H.A. could, in some instances, be an important factor in the perpetuation of obesity. In this regard, the observation (table 11) that obese patients can reverse the G.-6-P.D. and D.H.A. patterns when losing weight is significant. We do not know if this is a direct effect of the changes in weight or not. Possibly exercise could influence the excretion of D.H.A.: Abbo (1966) reported changes in the urinary excretion of steroids as effect of exercise. The diet consumed by the patients could have influenced the observed changes in the D.H.A. and G.-6-P.D. values, and this is illustrated for one patient in table III. G.-6-P.D. values progressively declined, and urinary D.H.A. increased between Oct. 24 and Nov. 22. During this time, the patient was consuming a diet restricted in calories, and very low in carbohydrates; on Nov. 22 the diet was changed, still restricted in calories but with equal distribution of calories derived from protein, fats, and carbohydrates. Although the patient continued losing weight, the interrelation between G.-6-P.D. and D.H.A. was not as consistent as previously. However, the general trend of lower G.-6-P.D. and higher D.H.A. values while losing weight continued. We have demonstrated changes in red blood-cell G.-6-P.D. activity in patients consuming diets of different carbohydrate compositions (Lopez-S., Krehl, and Hodges 1965). We have noted changes in the G.-6-P.D. activity of the red blood-cells after exogenous administration of D.H.A. to a healthy person (Lopez-S., Krehl, and Woon 1967). The therapeutic implications of this finding deserves further
CHAMPAGNE-CORK
INJURY
TO THE EYE
DESMOND ARCHER Belf., F.R.C.S.E., D.O.
M.B.
RESIDENT SURGICAL OFFICER
NICHOLAS GALLOWAY B.A. Cantab., M.B. Edin., F.R.C.S., D.O. LATE RESIDENT SURGICAL OFFICER
MOORFIELDS EYE HOSPITAL, HIGH HOLBORN, LONDON
W.C.1
of champagne-cork injury to the eye reported. In three of these cases traumatic cataract has developed, but none of the remaining patients have so far any serious residual visual impairment. All such injuries could be avoided by care in opening the bottle and by awareness of this particular hazard. Summary
Nine
cases
are
Introduction SINCE the invention of the champagne cork towards the end of the 17th century, there appear to have been very few records of injuries to the eye from flying champagne corks. In fact we have been able to find only one article, by Tiburtius (1962), on the subject. Cooper (1859), who wrote the first authoritative textbook on eye injuries, makes no mention of such an occurrence, although he describes numerous other bizarre misfortunes. It is interesting that the inventor of the champagne cork, a Benedictine monk by the name of Dom Perignon, was himself blind, although the cause is not known. The injuries described by Tiburtius were all due to plastic champagne corks. These have been used in Britain but have never been popular with the leading bottling houses. In all our cases the injuries were due to the traditional type of cork. The cork is laminated and covered by a metal cap which prevents indentation by the retaining wire cage. The weight of the cork is just short
investigation. Although the changes in D.H.A. and G.-6-P.D. can be explained on basis of the inhibitory effect of D.H.A. upon of an ounce. G.-6-P.D., other explanations are possible. D.H.A. might Material and Methods affect other enzyme systems similarly or it could be that We have seen eight of these injuries at Moorfields Eye D.H.A. acts by controlling the synthesis of other steroid Hospital in the past four years, and a search of the hospital hormones (Tsutsui et al. 1962). Any suggestions as to the records has revealed only one other case seen in 1936 (unforpossible action in vivo of D.H.A. in carbohydrate meta- tunately we have not been able to contact this last patient). bolism can only be speculative at the present time. This Of all the cases seen, all except one were considered serious effect may be an important factor in the development of enough to require admission to hospital. Routine examinations of the patients, including slit-lamp certain cases of obesity or it could contribute to the permicroscoDv and eonioscoov. were carried out relularlv. of more work to be needs petuation obesity. Obviously done-any minor addition to our understanding of metabolic derangements in obesity may help by providing points of departure for new and perhaps effective methods of managing this intractable condition " (Lancet 1964). Kittinger, G. W., Wexler, B. X., Miller, B. F. (1960) Proc. Soc. exp. Biol. "
We thank Mrs. Margarith Killen and Mr. Paul Woon for technical assistance. This work was supported by the U.S. Public Health Services (grant MO1-FR-59) and by the Edward Dalton Company, Evansville, Indiana. Requests for reprints should be addressed to A. L., University of Iowa College of Medicine, Iowa City, Iowa 52240, U.S.A. REFERENCES
Abbo, F. E. (1966) Geron. Clinica, 8, 184. Burstein, S., Liebermann, S. (1950) J. biol. Chem. 233, 331. Fessler, A., Beck, J. C., Rubinstein, D. (1967) Metabolism, 16, 438. Fitch, W. M., Chaikoff, I. L. (1960) J. biol. Chem. 235, 554. Fried, G. H., Antopol, W. (1966) Am. J. Physiol. 211, 1321. Gojate, A. N., Prunty, F. T. G. (1963) J. clin. Endocr. Metab. 23, 747. Gray, C. H., Lunnon, J. D., Pond, M. H., Simpson, S. L. (1956) ibid. 16, 473.
Hendrikx, A., Heyns, W., Steeno, O., de Moor, P. (1965) Excerpta med. int. Congr. Ser. no. 101. Jacobson, G., Seltzer, C. C., Bondy, P. K., Mayer, J. (1964) New Engl. J. Med. 271, 651. Katz, J., Landau, B. R., Bartsch, G. E. (1966) J. biol. Chem. 241, 727. Rognstad, R. (1966) ibid. p. 3600. -
References continued at foot of next
column
Med. 104, 616. Kornberg, A., Horecker, B. L. (1955) Meth. Enzym. 1, 323. Lancet (1964) i, 593. Leveille, G. A. (1967a) Proc. Soc. exp. Biol. Med. 125, 85. (1967b) Can. J. Physiol. Pharmac. 45, 201. Lopez-S., A., Krehl, W. A., Hodges, R. E. (1965) Fedn Proc. Fedn Am. Socs exp. Biol. 24, 314. Woon, P. (1967) ibid. 26, 473. Marks, P. A., Banks, J. (1960) Proc. natn. Acad. Sci. U.S.A. 46, 447. Mayer, J., Hagman, N. C., Marshall, N. B., Stoops, A. J. (1955) Am. J. Physiol. 181, 501. Migeon, C. H., Green, O. C., Eckert, J. P. (1963) Metabolism, 12, 718. Mlynaryk, P., Gillies, R. R., Murphy, B., Patte, C. J. (1962) J. clin. Endocr. -
-
-
Metab. 22, 587. Poisnick, J., DiRaimondo, V. (1956) ibid. 16, 957. Rifkin, H., Solomon, S., Liebermann, S. (1958) Diabetes, 7, 9. Rognstad, R., Katz, J. (1966) Proc. natn. Acad. Sci. U.S.A. 55, 1148. Shrago, E., Glennon, J. S., Gordon, E. S. (1967) J. clin. Endocr. Metab.
27, 679. Simkin, B. (1961) New Engl. J. Med. 264, 974. Sonka, J., Gregorovà, J. (1963) Acta Univ. Carolinœ, 1, 1. (1964a) Lancet, ii, 671. (1964b) ibid. p. 44. (1965) J. Physiol., Paris, 56, 650. Tsutsui, E. A., Marks, P. A., Reich, P. (1962) J. biol. Chem. 237, 3009. -
-
-
-
-
-
Abell, J. M., Bailey, R. W. (1960) Archs Surg., Chicago, 81, 569. Allison, P. R. (1965) Proc. R. Soc. Med. 58, 255. Biggs, R., Macfarlane, R. G., Rizza, C. R., Grant, J. (1967) Lancet, i, 1001. Dalrymple-Champneys, W., Hunter, J. R., Polton, K. R. (1967) Br. med. J. ii, 440. de Valderrama, J. A. F., Matthews, J. M. (1965) J. Bone Jt Surg. 47B, 256. Fraenkel, G. J., Taylor, K. B., Richards, W. C. D. (1959) Br. J. Surg. 46, 383. A. J. (1966) Treatment of Hæmophilia and other Coagulation Disorders (edited by R. Biggs and R. G. Macfarlane); chapt. 15. Oxford. Hall, M. R. P., Handley, D. A., Webster, C. U. (1962) J. Bone Jt Surg.
Gunning,
44B, 781. Kerr, C. B. (1963) The Management
of
Hæmophilia. Glebe,
New South
Wales.
Macfarlane, R. G., Mallam, P. C., Witts, L. J., Bidwell, E., Biggs. R., Fraenkel, G. J., Honey, G. E., Taylor, K. B. (1957) Lancet, ii, 252. Matthews, J. M. (1966) Treatment of Haemophilia and other Coagulation Disorders (edited by R. Biggs and R. G. Macfarlane); chapt. 4, p. 82. Oxford.
McMillan, C. W., Diamond, L. K., Surgenor, D. M. (1961) New Engl. J. Med. 265, 224, 277. Pool, J. G., Shannon, A. E. (1965) ibid. 273, 1443.
"... What are we to do with the under-fives ?
...
A POSSIBLE INTERRELATION BETWEEN GLUCOSE-6-PHOSPHATE DEHYDROGENASE AND DEHYDROEPIANDROSTERONE IN OBESITY A. LOPEZ-S. * M.D. Salamanca, Ph.D. Tulane ASSISTANT PROFESSOR OF MEDICINE
W. A. KREHL M.D. Yale, Ph.D. Wisconsin PROFESSOR OF MEDICINE
From the Clinical Research
Center, Department of Medicine, University of Iowa College of Medicine, Iowa City, Iowa, U.S.A. The
excretion of
urinary dehydroepianSummary drosterone (D.H.A.) and the glucose-6phosphate-dehydrogenase (G.-6-P.D.) activity of red blood-cells was measured in obese patients. Percentage excess body-weight was positively correlated with G.-6-P.D. activity. At the same time a negative correlation seemed to exist between the percentage excess body-weight and the urinary excretion of D.H.A. Higher urinary D.H.A. values were observed while the patients were losing weight. These findings suggest a possible relation between G.-6-P.D. and D.H.A. which could explain the pathogenesis of some types of obesity. Introduction ANIMAL work and clinical observation suggest the existof a delicate mechanism which regulates the balance between energy intake and energy output, and which seems to be influenced by neurological, physiological, metabolic, and hormonal factors. Several workers have described a possible relation between adrenocortical activity and obesity (Gray et al. 1956, Mlynaryk et al. 1962, Migeon et al. 1963). The urinary excretion of total 17-ketosteroids by obese individuals has been found to be elevated (Simkin 1961), normal (Gray et al. 1956, Gojate and Prunty 1963), or even diminished (Poisnick and DiRaimondo 1956, Jacobson et al. 1964). Lately attention has been directed to the urinary excretion of one specific 17-ketosteroid, dehydroepiandrosterone (D.H.A.). Sonka and Gregorova (1963) reported that the mean amount of D.H.A. excreted by obese people was lower than that found in urine from non-obese individuals. Sonka and Gregorova (1965) postulated that these decreased values of D.H.A. will result in a tendency toward increased lipogenesis because D.H.A., being an inhibitor of the enzyme glucose-6-phosphate dehydrogenase (G.-6-P.D.) could regulate the hexosemonophosphate shunt, and hence the synthesis of reduced N.A.D.P., which is required for the reductive synthesis of fatty acids. Hendrikx et al. (1965) have also reported abnormalities in the urinary excretion of D.H.A. in obesity, and similar findings have been noted in patients with gout (Sonka and Gregorova 1964a) and in obese diabetics (Sonka and Gregorova 1964b). We have investigated a possible in-vivo interrelation between G.-6-P.D. and D.H.A. in obese patients. ence
We should
clarify what we really want the state to do for this age-group ... As a society we lack any general philosophy of the responsibility of the state towards mothers and very young children. We are willing enough to approve educational provision from whatever age the experts think fit. But when it comes down to providing, in effect, the care of a mother-substitute, the state baulks and childminders flourish."-MAUREEN O’CONNOR, New Statesman, Aug. 25, 1967, p. 226.
Material and Methods G.-6-D. in red blood-cells and urinary excretion of D.H.A. were determined in fifty obese patients attending an outpatient obesity clinic (group A) and in young obese patients admitted to the Clinical Research Center (group B) who were placed in a diet characterised by rigid restriction of carbohydrate content * Present address: department of medicine, Louisiana State University Medical School, New Orleans 70112, U.S.A.
486 I-WEIGHT, G.-6-P.D. ACTIVITY, AND D.H.A. EXCRETION
TABLE
IN
FORTY-SEVEN OBESE PATIENTS IN GROUP A
less than 12 g. daily. G.-6-P.D. was determined by the method of Kornberg and Horecker (1955) by measuring the increase of absorbance of reduced N.A.D.P. at 340 m. per unit of time in a medium containing enzyme (red blood-cells), substrate (G.-6-P.), buffer (triethanolamine), and N.A.D.P. (as a cofactor). All these reagents were obtained from C. F. Boehringer and Soehne, G.M.B.H., Mannheim, Germany. 1 unit is that quantity of enzyme in 1 ml. of test solution which, at a temperature of 25°C, changes the reduced N.A.D.P. absorbance at a wavelength of 340 m. by 0.001 within 1 minute. Urinary D.H.A. was hydrolysed by the method of Burstein and Liebermann (1958), purified by thin-layer chromotography (silica gel, 0-30 mm. thick; solvent system 60% benzene, 40% ethylacetate), the trimethylsilyl ether was formed and quantitatively determined by gas-liquid chromotography (Barber ColemanModel 5000 ’ ; argon ionisation detector; U glass column, 6ft. long, 4 mm. internal diameter,’QF1,’ 3% coating andGasChrom Q’ support, 80-100 mesh; argon as carrier gas, inlet pressure 18 lb. per sq. in; colunm temperature 218°C; detector temperature 248°C; injector temperature 280°C; voltage to
1000
V.). Results
TableI shows the results found in forty-seven patients attending the outpatient clinic; these determinations were performed on specimens obtained at the time of first visit to the clinic. As the percentage excess weight increased, TABLE
II-WEIGHT, G.-6.P.D. ACTIVITY, AND D.H.A. EXCRETION GIRLS
IN
5
(GROUP B)
G.-6-P.D. in red blood-cells increased; on the other hand, percentage excess weight and/or the G.-6-P.D. activity were inversely correlated with urinary D.H.A. excreted in 24 hours. Group B consisted of five teenage girls, aged 15, 16, 17, 20, and 21, all of them significantly obese but otherwise healthy. Table 11 shows the tendency toward higher urinary D.H.A. values and lower G.-6-P.D. activity as the patients lost weight.
Serial changes over a longer period of time in a 19-yearold girl admitted to the Clinical Research Center revealed an inverse relation between the values of D.H.A. and G.-6-P.D., while the patient was losing weight (table III). Discussion The results reported here confirm the previous observations by Sonka and Gregorova (1963, 1964a and b, 1965), and Hendrikx et al. (1965) of an abnormal excretion of D.H.A. in patients with different forms of obesity. The reason why some obese persons excrete lower or practically no D.H.A. in their urines is not clear, but the biological implications are obvious. Several workers have investigated urinary D.H.A. and the G.-6-P.D. activity of different tissues in different physiopathological conditions including obesity (Sonka and Gregorova 1963, Fried and Antopol 1966), diabetes Rifkin et al. 1958, Sonka and Gregorova 1964b), atherosclerosis (Kittinger et al. 1960). In general, there is agreement that in those cases in which hyperlypogenesis is suspected, urinary D.H.A. tends to decrease while red blood-cell G.-6-P.D. activity increases. The inhibitory effect of D.H.A. on G.-6-P.D. in vitro has also been reported by Tsutsui et al. (1962) among others; all agree that D.H.A. is a potent inhibitor of G.-6-P.D. Such an inhibition in vivo could have interesting implications if changes in the level of enzymatic activity reflect alterations in the usage of the hexosemonophosphate shunt (Fitch and Chaikoff 1960). Changes in the activity of the enzyme G.-6-P.D. may result in changes in the activation of the shunt which may in turn result in changes in the availability of reduced N.A.D.P. which is an important cofactor in the synthesis of fatty acids. In animals, in conditions of adaptative hyperlypogenesis, adipose tissue apparently accounts for about 95% of the total fatty acids synthesised (Leveille 1967a). Perhaps the shunt is not as important a mechanism as it was once thought to be for the transfer of hydrogen for the reductive synthesis of fatty acids; the pyruvate cycle (Rognstad and Katz 1966) and the formation of oc-glycerophosphate (Leveille 1967b) have also been shown to make major contributions in the regulation of the synthesis of fatty acids by adipose tissue under conditions of rapid synthesis of fatty acids. Nevertheless Katz and Rognstad (1966) have reported quantitative data suggesting that while the operation of the hexosemonophosphate cycle is not likely to be an absolute requirement for fatty-acid synthesis, it is still essential for extensive synthesis. Although Fessler et al. (1967) have found that many of the characteristics of lipid synthesis previously ascribed to rat adipose tissue can be extended to human adipose tissue, the results of Shrago et al. (1967) demonstrated significant differences between adipose-tissue metabolism in man and lower animals: there seems to be a virtual absence of citriccleavage enzyme in human adipose tissue. Shrago et al. (1967) suggest that in human beings, enzyme adaptation is not as important as it once was thought to be on the basis of animal experiments. They suggest also that the control of multienzyme systems by substrate and cofactor concentrations and also allosteric stimulation or inhibition could serve as primary means of regulation. Whether or not D.H.A. can exert such a regulatory function is not known, but the mechanism of action of steroids have been suggested to be due to their allosteric effect and Marks and Banks (1960) postulated that D.H.A. is a noncompetitive inhibitor of G.-6-P.D. Adaptative hyperlipogenesis develops in various forms
487
of experimental obesity (Mayer et al. 1955) and, by analogy, in some types of human obesity carbohydrates could be preferentially disposed of through the hexosemonophosphate pathway; the additional lack of inhibition of G.-6-P.D. due to the absence of D.H.A. could, in some instances, be an important factor in the perpetuation of obesity. In this regard, the observation (table 11) that obese patients can reverse the G.-6-P.D. and D.H.A. patterns when losing weight is significant. We do not know if this is a direct effect of the changes in weight or not. Possibly exercise could influence the excretion of D.H.A.: Abbo (1966) reported changes in the urinary excretion of steroids as effect of exercise. The diet consumed by the patients could have influenced the observed changes in the D.H.A. and G.-6-P.D. values, and this is illustrated for one patient in table III. G.-6-P.D. values progressively declined, and urinary D.H.A. increased between Oct. 24 and Nov. 22. During this time, the patient was consuming a diet restricted in calories, and very low in carbohydrates; on Nov. 22 the diet was changed, still restricted in calories but with equal distribution of calories derived from protein, fats, and carbohydrates. Although the patient continued losing weight, the interrelation between G.-6-P.D. and D.H.A. was not as consistent as previously. However, the general trend of lower G.-6-P.D. and higher D.H.A. values while losing weight continued. We have demonstrated changes in red blood-cell G.-6-P.D. activity in patients consuming diets of different carbohydrate compositions (Lopez-S., Krehl, and Hodges 1965). We have noted changes in the G.-6-P.D. activity of the red blood-cells after exogenous administration of D.H.A. to a healthy person (Lopez-S., Krehl, and Woon 1967). The therapeutic implications of this finding deserves further
CHAMPAGNE-CORK
INJURY
TO THE EYE
DESMOND ARCHER Belf., F.R.C.S.E., D.O.
M.B.
RESIDENT SURGICAL OFFICER
NICHOLAS GALLOWAY B.A. Cantab., M.B. Edin., F.R.C.S., D.O. LATE RESIDENT SURGICAL OFFICER
MOORFIELDS EYE HOSPITAL, HIGH HOLBORN, LONDON
W.C.1
of champagne-cork injury to the eye reported. In three of these cases traumatic cataract has developed, but none of the remaining patients have so far any serious residual visual impairment. All such injuries could be avoided by care in opening the bottle and by awareness of this particular hazard. Summary
Nine
cases
are
Introduction SINCE the invention of the champagne cork towards the end of the 17th century, there appear to have been very few records of injuries to the eye from flying champagne corks. In fact we have been able to find only one article, by Tiburtius (1962), on the subject. Cooper (1859), who wrote the first authoritative textbook on eye injuries, makes no mention of such an occurrence, although he describes numerous other bizarre misfortunes. It is interesting that the inventor of the champagne cork, a Benedictine monk by the name of Dom Perignon, was himself blind, although the cause is not known. The injuries described by Tiburtius were all due to plastic champagne corks. These have been used in Britain but have never been popular with the leading bottling houses. In all our cases the injuries were due to the traditional type of cork. The cork is laminated and covered by a metal cap which prevents indentation by the retaining wire cage. The weight of the cork is just short
investigation. Although the changes in D.H.A. and G.-6-P.D. can be explained on basis of the inhibitory effect of D.H.A. upon of an ounce. G.-6-P.D., other explanations are possible. D.H.A. might Material and Methods affect other enzyme systems similarly or it could be that We have seen eight of these injuries at Moorfields Eye D.H.A. acts by controlling the synthesis of other steroid Hospital in the past four years, and a search of the hospital hormones (Tsutsui et al. 1962). Any suggestions as to the records has revealed only one other case seen in 1936 (unforpossible action in vivo of D.H.A. in carbohydrate meta- tunately we have not been able to contact this last patient). bolism can only be speculative at the present time. This Of all the cases seen, all except one were considered serious effect may be an important factor in the development of enough to require admission to hospital. Routine examinations of the patients, including slit-lamp certain cases of obesity or it could contribute to the permicroscoDv and eonioscoov. were carried out relularlv. of more work to be needs petuation obesity. Obviously done-any minor addition to our understanding of metabolic derangements in obesity may help by providing points of departure for new and perhaps effective methods of managing this intractable condition " (Lancet 1964). Kittinger, G. W., Wexler, B. X., Miller, B. F. (1960) Proc. Soc. exp. Biol. "
We thank Mrs. Margarith Killen and Mr. Paul Woon for technical assistance. This work was supported by the U.S. Public Health Services (grant MO1-FR-59) and by the Edward Dalton Company, Evansville, Indiana. Requests for reprints should be addressed to A. L., University of Iowa College of Medicine, Iowa City, Iowa 52240, U.S.A. REFERENCES
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