Adrenocortical suppression tests, based on the fall in urinary 17-hydroxy\x=req-\ corticosteroid excretion during the oral administration of dexamethasone, were found to be of value in the diagnosis of Cushing's syndrome, but less useful in differentiating bilateral adrenal hyperplasia from adrenal tumour. Such tests have the disadvantage of requiring accurate urine collections and of taking several days to perform. A test is described, based on the decrease in plasma cortisol concentration during i.v. infusion of dexamethasone at a rate of 1 mg./hr. The results obtained in 12 patients with Cushing's syndrome and bilateral adrenal hyperplasia differed from those found in control subjects in that there was a delay between the start of the infusion and the fall of plasma cortisol, and the rate of fall was less rapid. The values found after 180 min., expressed either as \g=m\g./100 ml. or as a percentage of the resting level, differed significantly (P < 0\m=.\001) in the two groups. The test proved valuable as an aid to the diagnosis of Cushing's syndrome, was easy to perform, and could be completed in 3 hr.In some patients with Cushing's syndrome, the administration of synthetic glucocorticoids appeared to result in an increased urinary steroid excretion. A transient increase in plasma cortisol levels was also observed in some of these patients during the early period of dexamethasone infusion. It is thought that this finding reflects an alteration in steroid metabolism induced by dexamethasone and fluorocortisol.

Background-Surgery in patients with malignant bile duct obstruction is associated with high postoperative morbidity and mortality. Tumour necrosis factor (TNF-) plays a key role in the pathogenesis of these complications. Aims-To determine the eVect of biliary drainage on plasma concentrations of TNF-, its soluble circulating receptors (sTNFr), and other proinflammatory cytokines. Methods-Plasmaconcentrations of TNF-, sTNFr-P75, interleukin 6 (IL-6), and IL-1 were measured in 25 patients with malignant bile duct obstruction before and after endoscopic stent insertion. Results-Mean serum bilirubin was 157 µmol/l before stent insertion and 35.2 µmol/l one week post stent insertion. There was complete relief of jaundice in 77% of patients by four weeks. Plasma concentrations of TNF-and IL-1 were below the detection limit of the assays in all samples. Median plasma sTNFr-P75 in the cancer patients was 960 ng/l (range 400-6600) before stent insertion and remained unchanged at one and four weeks after stenting. Plasma sTNFr-P75 in cancer patients was significantly higher (p<0.01) than in healthy controls (250 (200-650) ng/l). Before stent insertion, plasma IL-6 concentrations were detectable (above 5 ng/l) in 17 (68%) patients. After relief of biliary obstruction IL-6 levels fell from a prestent median of 13.2 to less than 5 ng/l at one week after stent insertion. Plasma concentrations of IL-6 were undetectable in 76% of patients at this time. Conclusion-Activation of the TNF/sTNFr complex is unchanged after biliary drainage in patients with malignant bile duct obstruction. This may explain why preoperative drainage does not influence the high morbidity and mortality associated with surgery in these patients. (Gut 1998;42:555-559)

No abstract

Little has appeared about this condition in recent years in Great Britain, but our experience suggests that it may be more common than supposed, and may need to be considered in a differential diagnosis of chest pain. Tietze (1921) described a condition of painful non-suppurative swelling of the costochondral or sternoclavicular joints. The following criteria should be met:( The latest review is that of Karon, Achor, and Janes (1958), who reported their findings in six females and seven males, in whom the symptoms of swelling had persisted for from 3 days to more than 3 years. Present InvestigationsThree cases recently studied are described below: Case 1, a previously fit but slightly obese male aged 25, complained of pain in the right anterior region of the chest for 2 months. This had followed an upper respiratory tract infection and unproductive cough. Shortly after this, he had noticed tender swellings over the right second, third, and fourth costosternal junctions. These had persisted despite local application of heat and a course of achromycin.At this time the patient was in normal health apart from the swellings. The erythrocyte sedimentation rate was 54 mm./hr (Westergren), and the total white cell count 14,700/c.mm., with 43 per cent. lymphocytes.There was a pyrexia of 99. 40 F. An oval, tender swelling, 3 in. by 2 in., was fixed to the deep structures over the second right costochondral junction, and these changes were found to a lesser degree over the third and fourth costosternal junctions. A diagnosis of Tietze's syndrome was made, but in view of a persistent slight pyrexia and raised erythrocyte sedimentation rate not previously found in this condition, a full series of investigations were carried out.Laboratory Tests.-A chest radiograph and tomography of the costochondral junction showed no abnormality. The Wassermann reaction and Kahn test were negative. The blood cholesterol, uric acid, and electrolytes were normal. The agglutination tests for Brucella abortus and B. melitensis, typhoid, and paratyphoid showed no rise in the antibodies to these infections. The Paul Bunnell reaction was negative. There was no increase in the cold agglutinins. The Rose-Waaler test was negative, and the antistreptolysin titre was only 90 Todd units/c.mm.Therapy.-Local pain and swelling persisted, and continued to be accompanied by a mild pyrexia with a raised erythrocyte sedimentation rate and lymphocytosis. Because of this, oral prednisolone 5 mg. three times daily was prescribed, and within 3 days there was a marked improvement, with disappearance of pain, diminution of the swelling, and a fall in the temperature and erythrocyte sedimentation rate.Biopsy.-A biopsy of the third costal cartilage was taken through a transverse anterior chest incision. The

No abstract