Metastatic pheochromocytoma and paraganglioma: focus on therapeutics

Metastatic pheochromocytomas and paragangliomas are rare and challenging tumors. The tumor burden, combined with excessive catecholamine production, predispose to a broad spectrum of complications that range from spinal cord compression to any organ damage, all of which may lead to decreased quality of life and overall survival. Current therapies include surgery, systemic chemotherapy and radiopharmaceutical agents. Surgery is often a preferred therapy because it may cure or allow a long-term remission in patients with locoregional or isolated resectable distant metastases. Additionally, surgery can palliate symptoms related to tumor burden or catecholamine excess. However, in patients for whom surgery is not an option, systemic chemotherapy and radiopharmaceutical agents are preferred options. Systemic chemotherapy and radiopharmaceutical agents such as 131I-Metaiodobenzylguanidine (131I-MIBG) may cause partial responses or stabilization of disease with better blood pressure control and symptomatic and performance status improvement. However, as these therapies are only palliative, patients' quality of life and personal preferences should always be considered. The recognition of molecular pathways involved in the pheochromocytoma and paraganglioma tumorigenesis has driven the development of new therapeutic options. Agents such as tyrosine kinase, MAPK, PI3K, or hypoxia inducible factor inhibitors, alone or in combination, may represent novel therapeutic strategies that could be evaluated in prospective clinical trials. Transcriptional profiling and the development of personalized cancer medicine will help to pave the way for more specific therapeutic approaches and combinations.

Similarly increased congenital anomaly rates after intrauterine insemination and IVF technologies: a retrospective cohort study

BACKGROUND

While intrauterine insemination (IUI), a simple, inexpensive and non-invasive technique, is the most used assisted reproduction technology (ART) worldwide, the risk of major birth defects following IUI is paradoxically not well documented.

METHODS

Retrospective cohort study performed in Burgundy, France, over a 9-year period which consisted of the cross analysis of two prospective databases, the Burgundy perinatal network database and the database of the assisted conception units in Burgundy. A total of 1348 ART singletons [in vitro fertilization technologies (IVFT): n= 903; IUI: n= 445] matched with 4044 infants conceived naturally, 552 ART twins (IVFT: n= 362; IUI: n= 190) matched with 1656 twins who were conceived naturally. The major birth defects were categorized according to the European Surveillance of Congenital Anomalies classification EUROCAT.

RESULTS

Compared with naturally conceived singletons, singletons born after IUI and IVFT had a higher prevalence of major congenital malformations, with adjusted odd ratios (AOR) of 2.0 [95% confidence interval (CI) 1.0-3.8] and 2.0 (CI 1.3-3.1); 3.6 and 4.2% of infants born, respectively. All twins and unlike-sex twins born after IVFT but not IUI, have an increased prevalence of major birth defects compared with naturally conceived twins; AOR of 3.0 (CI 1.6-5.6) and 3.7 (CI 1.1-16.9), respectively. When comparing IUI with IVFT, no differences were observed for singletons (AOR 1.0; CI 0.4-2.2), all twins (AOR 0.4; CI 0.1-1.2) and unlike-sex twins (AOR 0.3; CI 0.1-4.5).

CONCLUSIONS

The risk of major birth defects in singletons conceived through IUI was increased over naturally conceived singletons. This risk was no different from that observed after IVFT.

Asthma programmes in diverse regions of the world: challenges, successes and lessons learnt

International surveys have demonstrated that asthma is still underdiagnosed and undertreated in many parts of the world. Despite improvements in the standard of asthma care delivered in many areas, as evidenced by improved global asthma mortality data, much information on projects and programmes undertaken in resource-limited regions of the world is not in the public domain. The aim of this report is to review projects and programmes in diverse regions around the world so that health care providers, planners and consumers may draw on the successes, failures and lessons learnt. Such real world experiences may contribute to achieving Global Initiative for Asthma goals of asthma control. Asthma projects and programmes in Argentina, Australia, Brazil, China, Japan, Mexico, Philippines, Russia, South Africa and Turkey were discussed by a group of experts in asthma care, the Advancing Asthma Care Network, from their respective countries, over a course of three satellite meetings in 2010. Collective analyses consistently identified low rates of dissemination and implementation of national and international treatment guidelines, low levels of continuing medical education and training of primary health care professionals and access and distribution of inhaled corticosteroids to be major barriers that are critical to the overall success of a national asthma management programme. In the less developed asthma programmes, under-recognition and undertreatment further limited the success of the programmes. Evidence from well-established national asthma management programmes suggests that establishment of a successful programme entails a logical progression through specific developmental stages, starting with political/stakeholder endorsement and commitment, followed by epidemiological evaluation, evaluation of disease burden, evaluation of access to care and best therapy, and finally optimisation and maintenance therapy for individual patients.

Inhibition of growth hormone receptor activation by pegvisomant may increase bone density in acromegaly

Treatment of acromegaly with pegvisomant lowers serum IGF-1 and raises serum growth hormone. As both IGF-1 and GH are important for bone growth and remodeling, we were concerned that lowering of IGF-1 could cause loss of bone. To evaluate the effects of treatment of acromegaly with pegvisomant on bone mineral density (BMD) we developed an observational, prospective study. 7 acromegaly patients participated in the study. Male and female subjects aged 18 years or more were eligible to participate. Patients were eugonadal or on adequate gonadal replacement therapy for at least 3 years before participating in the study. These patients were treated with a mean dosage of 20 mg of pegvisomant daily for up to 7 years. Bone mineral density (BMD) was evaluated by dual X-ray absorbtiometry (DXA) at baseline, 8, and 18 months as a part of a prospective trial and periodically thereafter. Baseline mean serum insulin-like growth factor-1 (IGF-1) concentration±SD was elevated in all patients (679.86±138.21 ng/ml). The IGF-1 concentrations at 18 months decreased significantly from baseline (p=0.016). Wilcoxon signed-rank tests showed significant increases in the spine BMD from baseline to 18 months (p=0.016) and significant increases in the right hip BMD from baseline to 18 months (p=0.032). The range of the increases was 4.3-17.8% at 7 years. It is concluded that successful treatment of acromegaly with pegvisomant increases BMD.

A current review of the etiology, diagnosis, and treatment of pediatric pheochromocytoma and paraganglioma

CONTEXT

Pheochromocytomas and paragangliomas (PHEO/PGL) are neuroendocrine tumors that arise from sympathetic and parasympathetic paraganglia. Diagnosed rarely during childhood, PHEO/PGL are nonetheless important clinical entities, particularly given our evolving understanding of their pathophysiology.

EVIDENCE ACQUISITION

We identified articles through the U.S. National Library of Medicine by using the search terms pheochromocytoma and paraganglioma. Results were narrowed to manuscripts that included children and studies related to the genetics of PHEO/PGL. Web-based resources for genetic disorders were also used. For all articles, we performed subsequent reference searches and verification of source data.

EVIDENCE SYNTHESIS

Up to 20% of PHEO/PGL are diagnosed in children. Most are functional tumors, and clinical presentation includes symptoms related to catecholamine hypersecretion and/or tumor mass effect. Increasingly, PHEO/PGL are identified during presymptomatic screening in children with genetic syndromes associated with PHEO/PGL (multiple endocrine neoplasia type 2, von Hippel-Lindau disease, and the paraganglioma syndromes). Plasma and/or urine metanephrines are the best diagnostic test for a functional tumor, and the management of pediatric patients is similar to adults. Genetic counseling should be undertaken in all cases. Although most pediatric PHEO/PGL are benign, these tumors can occasionally metastasize, a condition for which no curative treatment exists.

CONCLUSIONS

Although PHEO/PGL are rarely diagnosed during childhood, the pediatric provider should be able to recognize and screen for such tumors, particularly in the context of a known genetic predisposition. Optimal care of these children includes a multidisciplinary team approach at centers experienced in the evaluation and treatment of these uncommon yet fascinating endocrine neoplasms.

How to demonstrate that eSET does not compromise the likelihood of having a baby?

BACKGROUND

In several randomized studies, elective single embryo transfer (eSET) has proven its effectiveness in reducing twin pregnancy rates while obtaining acceptable overall pregnancy rates. However, there is no outcome measurement consensus to evaluate the effectiveness of eSET versus double-embryo transfer (DET).

METHODS

This study evaluated whether or not adopting an eSET strategy instead of a DET strategy lowers the probability of having at least one live-born infant in good prognosis couples. Seven hundred and twenty-six couples were divided into two groups. The retrospective arm of the study was undertaken on the first group of couples (n = 483, DET group) and the prospective arm performed on the second group of couples (n = 243, SET group). In these specific populations, the probability of a woman having at least one live-born infant and the probability that one embryo utilized leads to a child were the main outcome measures.

RESULTS

The probability of a woman having at least one live-born infant was 60.5% in the DET group compared with 60.8% in the SET group. The probability of a live-born child per embryo utilized was not significantly different between the SET and the DET groups, 18.9% and 17.6%, respectively. In addition, the cumulative multiple live birth rate was significantly lower in the SET compared with the DET group.

CONCLUSIONS

In this observational study, using appropriate cryopreservation techniques, the chance of delivering a live baby, per utilized embryo, in an elective SET strategy is as good as that for DET.

Factors related to withholding life-sustaining treatment in hospitalized elders

OBJECTIVES

To look for predictors in the clinical records of orders for "limitation of life sustaining treatment" (LLST) or "do not attempt resuscitation" (DNAR) in hospitalized elders and to assess the relationship between the presence of these orders and the quality of end-of-life (EOL) care.

DESIGN

Retrospective clinical record review.

SETTING

Inpatients of an inner city elderly acute care unit (EACU) in Spain.

PARTICIPANTS

Of 103 hospitalized patients who died in the EACU during one year, 90 dying an expected death either from acute or chronic disease were included.

MEASUREMENTS

Demographic, functional, cognitive, clinical, and end-of-life (EOL) parameters. The influence of identifying closeness to death and the number of LLST suborders on the quality of EOL-management were considered simultaneously using structural equation modelling with LISREL 8.30 software.

RESULTS

LLST and specific DNAR orders were registered in 91.1% and 83.3% of patients, respectively. Failure of acute treatment, discussions with the patient/family, recognizing the presence of common EOL symptoms, and prescribing specific symptomatic treatment were recorded in 88.9%, 93.3%, 94.4%, and 86.7% of patients, respectively. LLST-orders were more likely to be documented if there was severe functional impairment prior to admission (p < 0.001), advanced organ disease criteria were met (p=0.006), or closeness to death was acknowledged in writing (p < 0.001). The quality of the EOL-management was better in patients for whom there were LLST-orders (p =0.01) and written acknowledgement of closeness to death (p < 0.001).

CONCLUSIONS

LLST-orders were more likely to be written in an EACU for patients with previous severe impairment, co-morbidity, or advanced disease. Written acknowledgement of closeness to death and LLST-orders were predictors of better EOL-management.

Zoledronic acid for the prevention of bone loss in patients with previously untreated lymphoma undergoing chemotherapy

e20611

Background: Treatment of lymphoma with alkylating agents and steroids causes bone loss and increased fracture risk. In addition, over half of all untreated lymphoma patients are osteopenic or osteoporotic at diagnosis. Pamidronate reduces bone loss and risk of vertebral fractures in lymphoma patients undergoing chemotherapy (CT). However, the effects of the more potent bisphosphonate (BP) zoledronic acid (ZA) in this setting are unknown. Therefore, we report on a phase III trial evaluating the effect of ZA on bone mineral density (B) in patients with newly-diagnosed lymphoma undergoing CT. Methods: In total, 72 patients will be randomized to either the control arm [calcium carbonate (1,200 mg orally/day) plus vitamin D (400 IU orally/day)], or the BP arm [calcium carbonate and vitamin D as in the control arm plus ZA (4 mg IV at baseline and at 6 months)]. The primary endpoint is the absolute change in B of the lumbar spine (LS) and femoral neck (FN) at baseline and 12 months. Results: Thus far, 112 patients have been screened for enrollment. Twenty-seven patients (24.1%) failed screening due to periodontal disease, a predetermined exclusion criterion of the study. To date, 14 patients in the control arm and 9 patients in the BP arm have completed the one-year follow up period including baseline and one-year B evaluations. Comparing patients in the control arm to those in the BP arm, the average absolute change in B at the LS was -0.048 g/cm2 vs. 0.0093 g/cm2 (p=0.005), at the left FN was -0.039 g/cm2 vs. 0.0074 g/cm2 (p=0.01), and at the right FN was -0.043 g/cm2 vs. 0.0211 g/cm2 (p<0.001), respectively. There have been no therapy-related serious adverse events or skeletal fractures in either arm. Conclusions: ZA in combination with calcium carbonate and vitamin D improves the B of patients with lymphoma undergoing CT. Given the incidence of below-average pre-treatment B and the known deleterious effects of lymphoma therapy on bone density, baseline B evaluation is warranted in all lymphoma patients. The high rate of periodontal disease in this patient population emphasizes the need for careful dental evaluation prior to BP therapy given the well-described, albeit rare, risk of osteonecrosis of the jaw from ZA.

[Table: see text]

[Spermiogenesis: histone acetylation triggers male genome reprogramming]

During their post-meiotic maturation, male germ cells undergo an extensive reorganization of their genome, during which histones become globally hyperacetylated, are then removed and progressively replaced by transition proteins and finally by protamines. The latter are known to tightly associate with DNA in the mature sperm cell. Although this is a highly conserved and fundamental biological process, which is a necessary prerequisite for the transmission of the male genome to the next generation, its molecular basis remains mostly unknown. We have identified several key factors involved in this process, and their detailed functional study has enabled us to propose the first model describing molecular mechanisms involved in post-meiotic male genome reprogramming. One of them, Bromodomain Testis Specific (BRDT), has been the focus of particular attention since it possesses the unique ability to specifically induce a dramatic compaction of acetylated chromatin. Interestingly, a mutation was found homozygous in infertile men which, according to our structural and functional studies, disrupts the function of the protein. A combination of molecular structural and genetic approaches has led to a comprehensive understanding of new major actors involved in the male genome reprogramming and transmission.

Fertilisation and pregnancy outcome after ICSI in globozoospermic patients without assisted oocyte activation

The successful outcome of intracytoplasmic sperm injection (ICSI) with globozoospermic sperm and non-activated oocytes is reported. Three couples underwent ICSI treatment and two of the patients were siblings. Forty-four non-activated oocytes were injected, 26 oocytes fertilised normally and 17 good quality embryos were obtained. Six embryo transfers were carried out, three with fresh embryos and three with frozen-thawed embryos. Three pregnancies resulted from the fresh embryo transfers and additionally two pregnancies were obtained after the transfer of frozen-thawed embryos. Two healthy babies were born. One twin pregnancy is ongoing. Our case reports demonstrate that in some ICSI attempts undertaken with globozoospermic sperm cells from two of our patients, high fertilisation rates, pregnancies and live births can be achieved, without artificially activated oocytes. Our data also suggest that in some cases, round-headed spermatozoa lack the capacity to activate the oocyte. Therefore, it cannot be excluded that artificial oocyte activation could be of help in globozoospermic patients with complete fertilisation failure.

Immune cells from pleural fluids of patients with inflammatory breast cancer are immunocompetent

Abstract #5044

Background: Malignant pleural effusion is a debilitating complication of metastatic breast cancer (MBC), including inflammatory breast cancer (IBC). The cellular components in pleural effusion are important indicators of pathologic process. Although pleural fluids from patients with IBC contain tumor cells and immune cells, little is known about the phenotype and function of the immune cell infiltrate. The objective of the study was to determine the immunophenotype and function of the cellular immune cells in pleural effusion of patients with pleural metastases.&#x2028; Methods and Patients: Pleural effusions from 9 women with MBC, 6 with IBC, median age 56 years (range 44-75 yrs), were submitted for pathological review. Mononuclear cells (MNC) were reacted with a cocktail of monoclonal antibodies to detect surface antigens by 8-parameter flow cytometry. In addition, MNC were activated through the T-cell receptor (TCR) with immobilized anti-CD3 and soluble anti-CD28 to assess intracytoplasmic syntheses of pro-inflammatory [interleukin (IL)-2, tumor necrosis factor (TNF)-a and interferon-gamma (IFN-γ)] and anti-inflammatory (IL-10) cytokines by TCR-activated CD4+ and CD8+ T cells. Data are presented as the mean (±SEM) of TCR-activated CD4+ and CD8+ T-cells that synthesized inflammatory and anti-inflammatory cytokines.&#x2028; Results: Upon pathological review, the mean (±SEM) number of tumor cells, MNC, and neutrophils were 20.2% ± 7.4% (range, 2%-72%), 62.4% ± 7.7% (range, 25%-96%), and 17.3% ± 5.9% (range, 0%-50.0%), respectively. The MNC consisted of 83.1% ± 8.2% CD3+ pan-T, 58.2% ± 7.0% CD4+ T, 24.2% ± 5.2% CD8+ T, 2.8% ± 0.9% CD19+ B, 4.0% ± 0.7% natural killer (NK), 3.4% ± 1.8% NKT, and 0.9% ± 0.2% dendritic cells, respectively. The CD4/CD8 T-cell ratio was 3.62 ± 0.78. The percentages of CD4+ and CD8+ T cells that synthesized inflammatory and anti-inflammatory cytokines following activation through the TCR-activated are listed in Table 1.&#x2028; &#x2028; Conclusion: There were no statistically significant differences between pleural fluids of IBC and non-IBC subjects with respect to tumor cell involvement, MNC phenotype, or T-cell function. Moreover, the function of pleural fluid T cells of MBC patients were similar to that of normal peripheral blood T cells (historical data, not shown). These data suggest that T-cells in the pleural fluids of patients with MBC are immune competent and can be activated through the TCR to synthesize pro- and anti-inflammatory cytokines.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5044.

Psychiatric Family History in Juvenile Psychiatric Patients

Introduction:

The presence of mental illness in any of the parents can be a stressful factor in the child and be in certain way generator of disease. AIMS describe and quantify the psychiatric family history in patients who were consecutively referred to the outpatient department of children and adolescent psychiatry,mental health community center of collado villalba, Madrid

Material and method:

Obtain data of a series of cases filing a card of the 18-year-old minor patients who in September, October, November and December, 2007 come for the first time to our mental health community center.

Results:

The total number of patients were 114. There were psychiatric family history in 36,8% (N=42), the mother was or had been in psychiatric treatment in 28% (N=31)) of the cases, the father in 15% (N=17) and the brothers in 7 % (N=8), the most frequent diagnoses in mothers it were neurosis in 21 % (N=24), toxic abuse in 3,5% (N=4) and personality disorder in 1,8% (N=2), toxic abuse was the most frequent with 8,8% (N=10) in parents, followed by neurosis diagnosed in 4,4% (N=5), the most frequent diagnoses in brothers was the emotional disorder in 4,4,% (N=5). The mean age of parents was 41,34 (SE =6,34), in mothers was 38,43 (SE=6,59).

Conclusions:

We have to consider the existence of some kind of psychiatric family history in the therapeutic plan of the patient.

Prospective evaluation of the threat related to the use of seminal fractions from hepatitis C virus-infected men in assisted reproductive techniques

BACKGROUND

The risk of hepatitis C virus (HCV) transmission during assisted reproductive techniques (ARTs) is still disputed and no report concerning its prospective evaluation is available.

METHODS

The aim of this 4-year follow-up multicentre study that enrolled 86 HCV-serodiscordant couples was to determine whether a sperm-processing method was able to reduce levels of HCV in semen and the risk of HCV transmission to the newborn. All the men were chronically infected by HCV and 10 of them by human immunodeficiency virus. A total of 181 seminal plasmas and 153 sperm fractions were tested for the presence of HCV RNA.

RESULTS

HCV RNA tested positive in 20.4% of the seminal samples. All of the 153 final sperm fractions tested negative for HCV. The detection of HCV RNA in semen was significantly correlated with a high viral load in blood (P < 0.05). The presence of HCV RNA in seminal plasma impaired neither semen parameters nor ART issue. From the 58 couples enrolled effectively in an ART programme, 24 pregnancies and 28 newborns were obtained. All of them tested negative for HCV RNA in blood.

CONCLUSION

These results emphasize the safety of the semen-processing method. The negligible risk of transmitting HCV reduces the value of the systematic analysis of HCV RNA in seminal fractions prior to ART. Since use of this analytical procedure involves the freezing of semen, its avoidance would result in an increase in sperm quality and reduce the need to perform intracytoplasmic sperm injection techniques.

Starting a new program of split liver transplantation after a low learning curve: a reality in centers with large experience in liver surgery and whole liver transplantation

BACKGROUND/AIMS

Split liver transplantation (SLT) is nowadays, considered an adequate surgical solution to expand the grafts from the existing pool of cadaveric donors.

METHODOLOGY

A total of 897 liver transplantations were performed between 1986 and 2002; 20 were SLTs (2.3%). A 30% were children.

RESULTS

Mean follow up of 15.15 months +/- 13.85. Median age was 42.27 +/- 25.65 yrs. Median recipient weight was 52.29 +/- 20.87 Kg. Mean donor weight was 76.1 +/- 13.11. The majority was "in situ" SLT (65%). There was no primary graft dysfunction. Two patients developed biliary complications (none in situ SLT). Early HAT occurred in 2 patients and delayed HAT in one. Four patients were retransplanted but none were performed because of primary graft dysfunction. Five patients died in the hospital. Fifteen patients (75%) survived the postoperative period and 3 patients died during follow-up. Mean patient survival time was 42 months (95% CI: 31-52). Actuarial patient survival was 93.3%, 84.4%, 84.4% at 6 months, 1 year and 3 years. Mean graft survival was 36 months (95% CI: 25-48). Actuarial graft survival was 87%, 72%, 72% at 6, 12, 36 months. Univariate analysis of risk factors for graft loss showed that the type of splitting technique (p=0.019), and the UNOS (1 and 2a) status of the recipient (p=0.001) were significantly associated with graft loss.

CONCLUSIONS

In the context of large volume full cadaveric liver transplantation, split liver can provide adequate results (even after a short learning curve) mainly in elective cases and with the in situ technique.

Single-point acupuncture and physiotherapy for the treatment of painful shoulder: a multicentre randomized controlled trial

OBJECTIVE

Evaluate the efficacy of acupuncture associated with physiotherapy for patients with painful shoulder.

METHODS

In a multicentre controlled randomized study, participants were recruited with a clinical diagnosis of unilateral subacromial syndrome from six rehabilitation medicine departments belonging to the Public Health System in two Spanish regions. All participants received 15 sessions of physiotherapy during the 3 weeks that the treatment lasted and were randomized to additionally receive, once a week, acupuncture or mock TENS (transcutaneous electrical nerve stimulation). The primary outcome measure was the change in the Constant-Murley Score (CMS) for functional assessment of the shoulder, at 4 weeks after randomization. This study is registered as an International Standard Randomized Controlled Trial, number ISRCTN28687220.

RESULTS

A total of 425 patients were recruited. The mean score (s.d.) on the CMS had increased by 16.6 (15.6) points among the acupuncture group, compared with 10.6 (13.5) points in the control group, and the mean difference between the two groups was statistically significant (6.0 points; 95% CI 3.2, 8.8 points; P < 0.001). By the end of the treatment, 53% of the patients in the acupuncture group had decreased their consumption of analgesics, compared with a corresponding 30% among the control group (P < 0.001).

CONCLUSIONS

Single-point acupuncture in association with physiotherapy improves shoulder function and alleviates pain, compared with physiotherapy as the sole treatment. This improvement is accompanied by a reduction in the consumption of analgesic medicaments.

Pulmonary arteriovenous fistula in a patient with renal cell carcinoma

Arteriovenous (AV) fistulas are common in renal cell carcinoma. These are usually small and asymptomatic. Case reports have previously described symptomatic fistulas in primary renal cell tumour or, less commonly, bone metastases. The current study describes a patient with lung metastases from renal cell carcinoma who developed a symptomatic pulmonary AV fistula. The patient presented with debilitating progressive shortness of breath, which resolved after coiling of the pulmonary AV fistula. Supporting radiographs include a unique ventilation-perfusion finding of perfusion tracer in the kidney that is diagnostic of a pulmonary shunt. This is the first report of a pulmonary fistula from renal cell carcinoma. This rare complication of renal cell carcinoma reflects its diverse clinical presentations and unique tumour biology.

Predictive factors for an increased risk of sperm aneuploidies in oligo-astheno-teratozoospermic males

Patients with severe spermatogenesis impairment can now successfully father a child thanks to the use of intracytoplasmic sperm injection (ICSI). In oligozoospermic patients, many studies have reported significantly higher sperm aneuploidy rates and therefore an increased risk of transmitting a chromosomal abnormality via the injection of abnormal spermatozoa. However, the frequency of aneuploidy is highly variable between patients. The aim of the present work was to identify clinical and biological factors, which, together with non-obstructive oligozoospermia, could be predictive of elevated sperm aneuploidies. The sperm aneuploidy rates for chromosomes X, Y, 13, 18 and 21 were assessed in 31 infertile men with well-characterized spermatogenesis impairment, and in a population of control men with proven fertility. The frequency of sperm aneuploidy was compared between several patient subgroups according to their clinical and biological factors. Nearly half of the oligozoospermic males (15/31) had a significantly increased disomy rate for at least one of the five chromosomes compared with that observed in the control population (mean disomy rates + 1.96 standard deviation). Factors significantly associated with higher numbers of aneuploid sperm were cigarette smoking, an elevated follicle-stimulating hormone level, a sperm concentration less than 1 m/mL, and a severe teratozoospermia. Hence, several factors predictive of an increased risk of sperm aneuploidy rates were identified in ICSI male candidates with a non-obstructive oligozoospermia.

Substrate utilization during prolonged exercise with ingestion of 13C-glucose in acute hypobaric hypoxia (4,300 m)

Energy substrate oxidation was measured using indirect respiratory calorimetry combined with tracer technique in five healthy young male subjects, during a 80-min exercise period on ergocycle with ingestion of 140 g of (13)C-labelled glucose, in normoxia and acute hypobaric hypoxia (445 mmHg or 4,300 m), at the same relative [77% V(.-)((O)(2)(max))] and absolute workload (161+/-8 W, corresponding to 77 and 54% V(.-)((O)(2)(max)) in hypoxia and normoxia). The oxidation rate of exogenous glucose was not significantly different in the three experimental situations: 21.4+/-2.9, 20.2+/-1.2 and 17.2+/-0.6 g over the last 40 min of exercise at approximately 77 and approximately 54% V(.-)((O)(2)(max)) in normoxia and in hypoxia, respectively, providing 12.5+/-1.5, 16.8+/-1.1 and 14.9+/-1.1% of the energy yield, although ingestion of glucose during exercise resulted in a higher plasma glucose concentration in hypoxia than normoxia. The contribution of carbohydrate (CHO) oxidation to the energy yield was significantly higher in hypoxia (92.0+/-2.1%) than in normoxia for both a given absolute (75.3+/-5.2%) and relative workload (78.1+/-1.8%). This greater reliance on CHO oxidation in hypoxia was entirely due to the significantly larger contribution of endogenous glucose oxidation to the energy yield: 75.9+/-1.7% versus 66.6+/-3.3 and 55.2+/-3.7% in normoxia at the same relative and absolute workload.

Is the CAG repeat of mitochondrial DNA polymerase gamma (POLG) associated with male infertility? A multi-centre French study

BACKGROUND

Recent data emphasized the implication of polymerase gamma (POLG) CAG repeats in infertility, making it a very attractive gene for study. A comparison of POLG CAG repeats in infertile and fertile men showed a clear association between the absence of the usual 10-CAG allele and male infertility, excluding azoospermia. It has also been suggested that the POLG gene polymorphism should be considered as a possible contributing factor in unexplained couple infertility where semen parameters are normal. In this study, we investigated the POLG CAG repeats, in a well-defined population of patients with severe male factor infertility.

METHODS

We conducted a large study of POLG CAG repeats in 433 infertile and 91 fertile, normozoospermic and healthy males. In all subjects, phenotypic data, including semen parameters, hormonal status and clinical profiles, were available.

RESULTS

Thirteen 'homozygous mutants' (3%) were found among the 433 idiopathic infertile patients. The follow-up of the 13 'homozygous mutant' resulted in pregnancy for more than half of the couples, through assisted reproductive techniques or even spontaneously. In addition, one 'homozygous mutant' was identified in 91 fertile men (1.1%)

CONCLUSION

Under our conditions, our study does not confirm any relationship between the polymorphic CAG repeat in the POLG gene and male infertility.

Simultaneous liver-kidney transplantation for adult recipients with irreversible end-stage renal disease

HYPOTHESIS

Combined liver-kidney transplantation is safe (low morbidity and acceptable mortality) and effective in patients with end-stage liver disease. Although refinements in surgical technique have resulted in better patient and allograft outcomes, the negative impact of renal insufficiency on survival in patients undergoing liver transplantation has been widely reported, although some aspects are controversial.

DESIGN

Analysis of the clinical characteristics and outcome in the management of patients undergoing combined liver-kidney transplantation. The end points were operative mortality, morbidity, and long-term survival.

SETTING

University Hospital 12 de Octubre.

PATIENTS

Between May 1986 and December 2001, 820 liver transplantations were performed. There were 16 cases (1.96%) of combined liver-kidney transplantations, which represent the sample of this study.

RESULTS

Mean +/- SD follow-up of 42.2 +/- 29 months: 6 patients died (37.5% mortality rate). There were 4 (25%) hospital deaths within 6 months following surgery and 2 after 6 months (4 sepsis, 1 refractory heart failure, and 1 recurrent hepatitis C virus disease). Univariate analysis related to mortality included age, sex, etiology, preoperative creatinine level, United Network for Organ Sharing status, Child-Pugh score, type of hepatectomy (piggyback), intraoperative blood product administration, and the presence of postoperative complications. The only 2 significant factors were the presence of postoperative complications (P = .01) and the United Network for Organ Sharing status (P = .02). Crude survival rate was 62.5%. Actuarial survival rates were 80%, 71%, and 60% at 1, 3, and 5 years, respectively.

CONCLUSION

Because end-stage renal disease is not a formal contraindication for liver transplantation, a combined liver-kidney transplantation for adults with end-stage renal disease can be done safely and effectively.

Liver recipients undergoing hepatic transplantation and subsequent retransplantation: a comparison between clinical characteristics

BACKGROUND/AIMS

In order to establish a rational strategy for organ distribution and optimal patient management, we postulate it is mandatory not only to understand the pathophysiology of failing grafts but also to better recognize the baseline clinical characteristics of the recipients shortly before receiving a second liver allograft.

METHODOLOGY

Between March 1986 and December 1997, 1061 patients underwent 1087 orthotopic liver transplantation at three Hospitals in Madrid (122 retransplants).

RESULTS

Mean follow-up was 36 months (range, 1-90), 40.6% of the recipients were alive and survival at 1, 3 and 5 years was 62%, 53%, and 46%. Almost 50% of the recipients were UNOS 1 before retransplantation. In comparison to p-OLT (15% UNOS 1), it is clearly shown that the retransplants have been performed in the sickest patients with more adverse prognostic indicators (higher AST, bilirubin, creatinine serum levels, higher Child-Pugh score, higher rate of ascites and lower serum levels of albumin and prothrombin activity).

CONCLUSIONS

Liver retransplantation is acceptable and significant differences in recipients' baseline characteristics suggest an impact on lower survival.

Muscle magnetic resonance imaging in patients with congenital muscular dystrophy and Ullrich phenotype

The aim of this study was to evaluate muscle magnetic resonance imaging findings in patients with congenital muscular dystrophy and Ullrich phenotype. Fifteen children with congenital muscular dystrophy and Ullrich phenotype were included in the study. All patients had collagen VI studies in muscle and, when family structure was informative, linkage studies to the collagen 6 loci. Three of the 15 patients had reduced collagen in muscle. One of the three was from an informative family and linked to one of the collagen 6 loci. Another patient was linked to one of the collagen 6 loci but had normal expression of collagen in muscle. The remaining 11 all had normal collagen expression in muscle. Only two of these 11 were from informative families and linkage to collagen 6 loci was excluded in them. All patients had muscle magnetic resonance imaging of their leg muscles using transverse T1 sequences. With the exception of the two patients in whom linkage to the collagen 6 loci was excluded, the other 13 patients showed the same pattern of selective involvement on magnetic resonance imaging of thigh muscles. This consisted of relative sparing of sartorius, gracilis, adductor longus and rectus. This pattern was also found in the case linked COL6A1/A2 locus but with normal collagen. This finding, and the striking clinical and magnetic resonance imaging concordance between patients with normal and reduced collagen VI in muscle suggest that collagen VI could still be the culprit in several cases with normal collagen expression, or alternatively a primary defect in a protein that closely interacts with collagen VI. Mutation analysis of the collagen 6 genes in cases with normal collagen VI expression is needed to resolve this issue.

Live liver donation: a prospective analysis of exclusion criteria for healthy and potential donors

INTRODUCTION

Living donor liver transplantation represents a controversial option to increase the donor pool.

DESIGN

Prospective and descriptive clinical study.

OBJECTIVE

(1) To identify risk factors (exclusion criteria) for live donation; (2) to determine the rate of recipients that benefit from a living donor.

METHODS

Between May 1995 (first adult-to-adult living donor liver transplantation in Spain) and November 2002, we evaluated 74 healthy volunteers and performed 12 living donor liver transplants (no donor mortality).

RESULTS

All actual donors and volunteers are alive and healthy. After a mean time of 3.2+/-0.5 weeks, 72% of potential donors were considered unsuitable for live donation. Exclusion criteria were grouped in three categories: (primary) donor safety reasons (68%); (secondary): ABO mismatch (17%) and (tertiary): cadaveric graft transplantation (15%). Consequently, just 43.7% of the recipients presenting to us with a potential living donor, did finally benefit from these organs. The mortality rate was 8.3% for 43 recipients presenting with a living donor in comparison to 15% for those who did not (321 recipients between May 1995 and November 2001).

CONCLUSIONS

ALDLT can benefit a significant number of recipients on the waiting list (43.7% of those presenting with a donor). The most frequent exclusion criteria concern donor safety, namely, unsuspected chronic liver diseases and unsuspected thrombophilic disorders.

Results in split liver transplantation

INTRODUCTION

The shortage in cadaveric grafts has prompted the development of alternative surgical techniques to expand the donor pool.

OBJECTIVE

To evaluate the feasibility of split liver transplantation using an observational, retrospective, and longitudinal study.

MATERIALS AND METHODS

Between April 1986 and October 2002 we performed 875 liver transplants. From April 1991 to date, we performed 18 split liver transplantations in patients of mean age 42.27+/-25.65 years; five children and 13 adults; and 83.3% women. Urgent transplants accounted for 38.9%. Mean patient weight was 52.29+/-20.87 kg. Ex situ splitting was performed in 33%. The mean cold ischemia time was 460+/-265.69 minutes with a mean warm time of 64.33+/-11.78 minutes. Mean consumption of packed blood was 5.59+/-4.87 units; of frozen fresh plasma, 11.56+/-7.42 units; and of platelets 4.89+/-4.99 units.

RESULTS

After a mean follow-up of 10.83+/-12.51 months, 55.56% of the recipients are alive. Actuarial patient and graft survival rates at 1 year are 55.6% and 44.12%, respectively. Actuarial patient and graft survival rates at 1 year, excluding operative mortality were 77% and 68%, respectively. Actuarial patient and graft survival rates at 1 year, comparing urgent and elective transplantations are: 14.29 and 14%, respectively, for urgent cases and 90.91 and 90% for elective ones. Operative mortality was 16.6% while mortality during follow-up was 26.6%. The late complications included arterial thrombosis (n=2): of whom the first needed liver retransplantation 4 months after split liver transplantation; chronic rejection (n=2), recurrence of hepatitis (n=1).

CONCLUSIONS

Split liver transplantation is a useful way to expand the graft pool and shows better results in elective liver transplantation.

Human seminal plasma displays significant phospholipid transfer activity due to the presence of active phospholipid transfer protein

The lipid composition of germ cell membranes is considerably modified during spermatogenesis, sperm maturation and capacitation. Some of these modifications are caused by exchanges between soluble lipid donors or acceptors and cell membranes. The aim of this study was to assess whether significant lipid transfers between lipoprotein structures are detectable in human seminal plasma. Phospholipid and cholesteryl ester (CE) transfer activities were measured by specific fluorescence and isotopic assays. Seminal plasma samples did not display significant CE transfer. Substantial levels of phospholipid transfer activity were detected in all samples studied, levels were approximately 25% of the phospholipid transfer activity measured in human blood plasma. Concordantly, CE transfer protein was not detected in seminal plasma, while the presence of the phospholipid transfer protein (PLTP) was confirmed by Western blot analysis. Enzyme-linked immunosorbent assay indicated that seminal PLTP concentrations represented 25% of the concentration measured in blood plasma. Blockade of phosphatidylcholine and phosphatidyl-ethanolamine transfer by a 60 min, 56 degrees C heating step or with anti-PLTP antibody revealed that PLTP accounts for almost 80% of the phospholipid transfer activity present in seminal plasma. As shown by gel-permeation chromatography and Western blot analysis, seminal PLTP activity was partially associated with prostasomes. Significantly higher PLTP activity levels were measured in seminal plasma samples with low seminal vesicle secretions. The latter observation may reflect the sustained secretion of active PLTP that is diluted in a variable volume of PLTP-free seminal vesicle secretion. In conclusion, human seminal plasma displays significant phospholipid transfer activity due to the presence of active PLTP.

Predictive factors in smoking cessation with combined therapy with bupropion and nicotine patches

The association of bupropion and nicotine is a good choice in the treatment of smoking cessation. However, not all patients actually give up smoking.

STUDY OBJECTIVES

This work was undertaken with the aim of finding out the functional or clinical variables that could be associated with the success of the cessation therapy.

DESIGN

In one year, 88 patients who were treated with bupropion 300 mg/day and nicotine patches were followed-up, for 1 month and 3 months, respectively. They were all questioned about the number of cigarettes per day, the years they have been smoking, the number of quitting attempts, and concurrent pulmonary conditions were sought for. The Fageström Test, forced spirometry (FVC, FEV-1, FEF25-75), and exhaled carbon monoxide (by co-oxymetry) were also assessed. For the statistical analysis, a logistic regression model allowing to predict the response of new subjects to the treatment, with the lowest error possible, was applied. To choose the working model, the highest and lowest value of each variable were found, drawing the correlation matrix between dependent and independent variables, by means of the box-plot procedure. Then, the model's application conditions were analysed: linearity, homoscedasticity, independence of the applications, and normality of the distributions. To assess the discrimination of the model, a ROC curve was used.

RESULTS

Showed that at the end of the follow-up year, 59.1% of the patients quitted smoking. The multivariate analysis with logistic regression showed that no previous history of chronic obstructive pulmonary disease (COPD), a FEF25-75 value and effectively quit after the first week of treatment were independent prognostic factors of treatment success. When the diagnosis precision of our model was analysed by means of the ROC curve, it showed a 78% value, with the 95% confidence interval ranging from 68.5% to 86.9%. At the optimal cut-off point of our model, sensitivity and specificity for quitting smoking were found to be 66.7% and 80%, respectively.

CONCLUSIONS

We conclude that with a diagnosis precision of 78.8% patients with no history of COPD, who quitted at the first week of therapy with bupropion and with low FEF25-75, will remain non-smokers after one year follow-up. Contrarily, COPD patients who still smoke after one week of therapy, will not achieve quitting smoking.

Comparison of passive heat or exercise-induced dehydration on renal water and electrolyte excretion: the hormonal involvement

The effects of hydromineral hormones and catecholamines on renal water and electrolyte excretion were examined during and after dehydration induced by either passive heat or exercise. Eight healthy young Caucasian subjects participated in three separate trials, each including three consecutive phases. Phases 1 and 3 involved a 90-min period at rest in a thermoneutral environment, while phase 2 involved a 120-min period designed to provide: (1) euhydration (control trial), (2) passive heat-induced dehydration of 2.8% body mass, or (3) exercise-induced dehydration of 2.8% body mass. During the two dehydration procedures, the decreases in urine flow and sodium excretion were more marked during exercise (P < 0.05). An increase in plasma catecholamines occurred only during exercise, together with a reduction in creatinine clearance and more marked increases in plasma renin and aldosterone than during passive heat exposure (P < 0.05). Although plasma vasopressin was elevated during the two dehydration procedures, urine osmolality did not change and, moreover, free water clearance increased during exercise (P < 0.05). Plasma levels of atrial natriuretic peptide increased markedly only during exercise compared to the other trials (P < 0.05). After the dehydration procedures, urine flow decreased again and urine osmolality increased markedly (P < 0.05), while plasma vasopressin remained elevated. These results suggest that sympathoadrenal activation during exercise plays a major role in the more marked reduction in diuresis and natriuresis than during passive heat exposure. Despite high plasma vasopressin concentrations during the two dehydrating events, the observed antidiuresis was not due to an increased renal concentrating ability, and the vasopressin was more effective after the dehydration procedures.