Alteration of the growth hormone axis, visceral fat dysfunction, and early cardiometabolic risk in adults: the role of the visceral adiposity index

The aim of the study is to clarify the relationship between adipose tissue dysfunction, metabolic profile and growth hormone (GH)/insulin-like growth factor (IGF)-I secretion in healthy adult subjects. We investigated the metabolic profile in a cohort of 231 consecutive healthy subjects in relation to GH, IGF-I levels, and visceral adiposity index (VAI). Anthropometric measures, lipid profile, and glucose and insulin levels during oral glucose tolerance test, Homa-IR and ISI Matsuda, IGF-I and GH peak after GHRH plus Arginine test were analyzed. The subjects with high VAI showed lower GH peak (22.8 ± 11.1 vs. 42.2 ± 21.3 µg/L; p = 0.049) and lower IGF-I (presented as IGF-I under normal range, UNR) (0.54 ± 0.14 vs. 0.64 ± 0.12; p = 0.005) than group with normal VAI. ROC curve analysis identified the cut-off, able to detect subjects with high VAI, i.e., 31.8 µg/L for GH peak and 0.63 for IGF-1 UNR. The subjects with GH peak and IGF-I UNR under the cut-off showed significantly higher levels of VAI, systolic and diastolic blood pressure, glucose and insulin levels, Homa-IR, and lower ISI Matsuda, with a concomitant worse lipid profile (all p < 0.001). A strong relationship between GH axis, VAI and metabolic risk has been demonstrated. A percentage of apparently healthy subjects show a degree of visceral adipose dysfunction associated with GH and IGF-I levels that do not meet the criteria of overt GH deficiency (GHD). Long-term prospective studies could help to clarify and confirm whether a hypothetical condition of subclinical GHD could be taken into account as a new clinical entity.

Hyoid myotomy without suspension: a surgical approach to obstructive sleep apnoea syndrome

The aim of this study was to verify if hyoid myotomy without hyoid suspension is effective in surgical treatment of obstructive sleep apnoea syndrome (OSAS). We recruited six patients with OSAS, aged between 34 to 60 years, with retropalatal and retrolingual upper airway obstruction, non-obese (BMI < 27) and non-compliant to continuous positive airway pressure therapy. Pre-surgical clinical and instrumental evaluations included clinical examination, cephalometry, polysomnography (PSG) and sleep endoscopy. Surgical treatment included nasal surgery, uvulopalatopharyngoplasty, tonsillectomy and hyoid myotomy without hyoid suspension. Follow-up evaluations were performed with serial PSGs, performed early (one week after surgery), and at 1, 6 and 18 months after surgery. We observed that surgery was followed by immediate normalisation of breathing parameters evaluated by PSG that persisted after 18 months. Thus, hyoid myotomy without suspension combined with nasal and palatal surgery may be considered a valid treatment of non-obese OSAS patients with retrolingual and retropalatal collapse. Furthermore, we suggest that hyoid bone suspension, binding it to mandibular or to thyroid cartilage, might be unnecessary in selected cases.

Autophagic degradation of farnesylated prelamin A as a therapeutic approach to lamin-linked progeria

Farnesylated prelamin A is a processing intermediate produced in the lamin A maturation pathway. Accumulation of a truncated farnesylated prelamin A form, called progerin, is a hallmark of the severe premature ageing syndrome, Hutchinson-Gilford progeria. Progerin elicits toxic effects in cells, leading to chromatin damage and cellular senescence and ultimately causes skin and endothelial defects, bone resorption, lipodystrophy and accelerated ageing. Knowledge of the mechanism underlying prelamin A turnover is critical for the development of clinically effective protein inhibitors that can avoid accumulation to toxic levels without impairing lamin A/C expression, which is essential for normal biological functions. Little is known about specific molecules that may target farnesylated prelamin A to elicit protein degradation. Here, we report the discovery of rapamycin as a novel inhibitor of progerin, which dramatically and selectively decreases protein levels through a mechanism involving autophagic degradation. Rapamycin treatment of progeria cells lowers progerin, as well as wild-type prelamin A levels, and rescues the chromatin phenotype of cultured fibroblasts, including histone methylation status and BAF and LAP2α distribution patterns. Importantly, rapamycin treatment does not affect lamin C protein levels, but increases the relative expression of the prelamin A endoprotease ZMPSTE24. Thus, rapamycin, an antibiotic belonging to the class of macrolides, previously found to increase longevity in mouse models, can serve as a therapeutic tool, to eliminate progerin, avoid farnesylated prelamin A accumulation, and restore chromatin dynamics in progeroid laminopathies.

IMAGING OF PSORIATIC ARTHRITIS

Imaging of psoriatic arthritis (PsA) is important for two reasons: the differential diagnosis from other arthritides and the assessment of structural damage that can be inhibited by the new drugs such as the anti-TNFalpha agents. Plain film radiographic findings of peripheral arthritis have been important in elaborating the concept of PsA as a separate disease entity. Characteristic aspects of psoriatic peripheral arthritis help the differentiation from rheumatoid arthritis. High-resolution ultrasonography (US), US combined with power Doppler (PDUS) and magnetic resonance imaging (MRI) can be used to image joint synovitis of PsA. Radiologic features of spondylitis associated with psoriasis are similar to spondylitis associated with reactive arthritis and differ from those of primary ankylosing spondylitis (AS) and the spondylitis associated with inflammatory bowel disease. MRI is very sensitive for the early diagnosis of sacroiliitis. There have been no MRI studies on the spine of patients with PsA. In primary AS bone oedema in the vertebral bodies is an indicator of active disease and can ameliorate during anti-TNFalpha therapy. Historically, plain film radiography have played a pivotal role in defining enthesitis lesions of SpA. However, entheseal bone changes appear late. US and MRI have proved to be a highly sensitive and non invasive tools. Recent US and MRI studies on both finger and toe dactylitis have established that dactylitis is due to flexor tenosynovitis and marked adjacent soft tissue swelling with a variable degree of small joint synovitis. There is no evidence of enthesitis of the insertion of the flexor digitorum tendons and of the attachment of the capsule of the digit joints.

Somatopause: state of the art

Aging is associated with decay in the somatotroph axis, that has been considered to cause many of the catabolic sequelae of normal aging. The physiological changes that the human body undergoes during aging are similar to those observed in GH deficiency (GHD). Changes of aging are represented by increased fat mass, increased cardiovascular risk, reduced muscle mass, reduced exercise tolerance, decreased strength and impaired quality of life. Some authors conjecture that the elderly could be GH deficient and would benefit from GH treatment. However, the endocrine pattern of aging is distinct from the decrease of GH/IGF-I levels associated with hypopituitarism, although there is not sufficient evidence for a clear therapeutic role of GH treatment during somatopause. So, further studies are needed to evaluate the real benefit of somatotropic treatment in aging. This review is focused on the effects of the somatopause and summarize the potentials for a therapeutic role of the recombinant human GH (rhGH) or of GH secretagogues in aging.

Auxological and anthropometric evaluation in skeletal dysplasias

Anthropometry is the technique of expressing body shape in quantitative terms. The measurements are compared with the standard growth curves for the general population and expressed as a SD score or percentiles. The comparison of the different parameters with normal standards requires: standardized landmarks on the body, standardized methods of taking measurements, and standard equipment. Skeletal dysplasias generally present with disproportionate short stature, that may be caused primarily by a short trunk or short limbs. If short limbs are observed, the reduction may affect the proximal (rhizomelic), the middle (mesomelic) or distal (acromelic) segments. Anthropometric measurements should include all the segments of the arms and the legs with a comparison with the normal standards for height age. Short stature homeobox- containing (SHOX) gene defects determine a highly variable phenotype, that includes an osteochondrodysplasia with mesomelic short stature and Madelung deformity, but also presentations without evident malformations. Anthropometric indicators of SHOX deficiency are: disproportionate short stature, reduction of lower limb, reduction of the ratio between arm span and forearm length with respect to height, increase in the sitting/ height stature ratio, increase in limb circumference (arm, forearm, thigh, and leg) with respect to height and increased body mass index. In some forms of skeletal dysplasias and in particular in SHOX gene anomalies that have many characteristics superimposable to idiopathic short stature, only an accurate auxo-anthropometric and dysmorphologic evaluation enable us to propose, fairly accurately, the subjects for the gene study.

Proteomics of saliva: personal experience

The salivary proteome is a complex protein mixture resulting from the activity of salivary glands with the contribution of other components that form the oral environment such as oral tissues and micro-organisms. For diagnosis purposes, saliva collection has the great advantage of being an easy and non-invasive technique. Human saliva proteomics have proven to be a novel approach in the search for protein biomarkers for detection of different local and systemic diseases. Currently, more than 1400 salivary proteins have been identified. In the last few years, our research group has extensively studied the salivary proteomics in order to analyse the salivary composition, investigating the major families of proteins present in human and mammalian saliva, the post-translational modifications, the different contributions of glands, the physiological and pathological modifications of saliva. The aim of this report is to present our personal experience in salivary proteomics. In conclusion, salivary proteome analysis represents an important field both for diagnosis and monitoring of various diseases and could be considered a novel approach to prevention of various pathological conditions.

Role of IGF-I on PTH effects on bone

IGF-I and PTH have synergistic actions on bone and some effects of the anabolic actions of PTH are mediated by local production of IGF-I, as has been shown in vitro and in vivo studies both in animals and humans. PTH can induce skeletal IGF-I expression both in vitro and in vivo. In chondrocytes, IGF-I synthesis is under GH control, whereas in osteoblasts its synthesis is fundamentally under the control of PTH. PTH stimulates the synthesis of IGF-I via a cAMP-dependent mechanism, and this factor has pro-differentiating and prosurvival effects on osteoblasts. In in vitro studies, IGF-I and PTH have shown a synergistic action on the osteoblasts of bone marrow. Human clinical data confirm the interactions between PTH and GH-IGF-I axis on bone. PTH is involved in the development of osteoporosis in adult patients with GH deficiency (GHD). In fact, patients with GHD show renal, skeletal, and intestinal cell insensitivity to PTH, leading to a mild state of PTH resistance and increased serum PTH levels. In addition, GH replacement in these patients restores PTH secretory rhythm, increases bone turnover markers, 1,25-dihydroxy vitamin D concentration, and Ca absorption/reabsorption, thus contributing to the positive effects of GH on bone. On the other hand, in post-menopausal women with primary hyperparathyroidism a reduced secretion of GH is observed, in association with a greater impairment of bone mass. GH administration resulted in increased IGF-I concentration, decreased PTH concentration, and increased nephrogenous cAMP. In conclusion, the anabolic action of PTH requires paracrine and autocrine effects of IGF-I.

Postural control in patients with total hip replacement

AIM

The aim of this study was to investigate the balance of the standing position and the motor responses by means of dynamic posturography (DP) in patients affected by hip osteoarthritis and treated by total hip replacement (THR).

METHODS

Data obtained from THR patients were compared with those of control adult groups ofage-matched subjects with normal hearing and no history of audio-vestibular symptoms. The statistical tests used were paired and unpaired Student's t-test. Significance was set for P<0.05. The study was carried out at the Department of Otorhinolaryngology and Department of Physiatrics and Rehabilitation of the A. Gemelli University Hospital of Rome (Italy). Twenty-three consecutive patients, without cochleo-vestibular or neurological pathologies (screened by accurate case-history), affected by hip osteoarthritis and treated by THR were enrolled. The main outcome measure were Sensory Organization Test (SOT), Motor control test (MCT) and Adaptation test (AT) obtained by means of Equi-Test Dynamic Posturography System by NeuroCom (Int. Inc., Clackamas, OR, USA).

RESULTS

When analysing the SOT and MCT, no statistically significant differences were observed between patients and controls. In the AT, the sway energy score decreased in the course of the test in an up and down perturbation both in healthy and in THR patients.

CONCLUSIONS

These data confirm a normal postural control and symmetrical responses in THR patients and confirm the absence of a detectable relationship between balance problems and fall risk. These results could be justified by an irrelevant role of intracapsular proprioceptors in maintaining balance. Moreover DP could be useful in osteo-articular diseases for understanding balance, evaluating surgical outcome and monitoring the rehabilitation program.

Dactylitis, a term for different digit diseases

Dorland's Illustrated Medical Dictionary gives the following definition of dactylitis (deltaalphachitauupsilonlambdaomicronsigma = digit): 'inflammation of a finger or toe'. Although any inflammatory process involving the fingers or toes may be called dactylitis, the term has entered in current use only in some well-defined entities. These differ in the involved tissue of the digit and in the type of involvement. Tuberculous dactylitis is the variant of tuberculous osteomyelitis affecting the short tubular bone of the hands and feet. Radiographs typically show a central, lytic, cystic, and expansive lesion known as spina ventosa. Syphilitic dactylitis is a manifestation of congenital syphilis. Radiological findings mimic those of tuberculous dactylitis but the involvement is bilateral and symmetric. Sarcoid dactylitis is due to typical non-caseating granulomas invading the phalanges and the adjacent soft tissue. Blistering distal dactylitis is an infection of the anterior fat pad on the volar surface of the distal portion of a single finger or more rarely a toe, mostly caused by group A beta-haemolytic streptococci. Sickle cell dactylitis, also known as 'hand-foot syndrome', is due to localized bone marrow infarction of the carpal and tarsal bones and phalanges. Spondyloarthritis dactylitis, also called 'sausage-like' digit, is a diffuse painful swelling of the fingers and toes. Recent ultrasonography (US) and magnetic resonance imaging (MRI) studies on both finger and toe dactylitis have established that dactylitis is due to flexor tenosynovitis and that the enlargement of the joint capsule is not an indispensable condition for the 'sausage-like' feature. There is no evidence of enthesitis of flexor digitorum tendons and joint capsule.

Preoperative bevacizumab combined with letrozole and chemotherapy in locally advanced ER- and/or PgR-positive breast cancer: clinical and biological activity

The antiangiogenic agent bevacizumab showed synergistic effects when combined with chemotherapy in advanced breast cancer. We presently investigated the activity of bevacizumab in combination with chemotherapy, including capecitabine and vinorelbine, and endocrine therapy, including letrozole (+triptorelin in premenopausal women), as primary therapy for patients with ER and/or PgR ⩾10% T2–T4a-c, N0–N2, M0 breast cancer. Biological end point included the proliferative activity (Ki67), whereas clinical end points were clinical response rate, pathological complete response (pCR) and tolerability. Circulating endothelial cells (CECs) and their progenitors, as surrogate markers of antiangiogenic activity, were measured at baseline and at surgery.Thirty-six women are evaluable. A clinical response rate of 86% (95% CI, 70–95) and no pCR were observed; Ki67 was significantly decreased by 71% (interquartile range, −82%, −62%). Toxicity was manageable: two grade 3 hypertension, four grade 3 deep venous thrombosis and no grade >2 proteinuria were observed. Treatment significantly decreased the percentage of viable CECs and prevented the chemotherapy-induced mobilisation of circulating progenitors. Basal circulating progenitors were positively associated with clinical response. In conclusion, bevacizumab is feasible and active in association with primary chemoendocrine therapy for ER-positive tumours in terms of proliferation inhibition, clinical response and antiangiogenic activity.

Giant deep lobe parotid gland pleomorphic adenoma involving the parapharyngeal space. Report of three cases and review of the diagnostic and therapeutic approaches

Aim of the present report is to discuss and underline the diagnostic algorithm and the surgical approach to giant parotid pleomorphic adenomas arising in the deep lobe and growing in the parapharyngeal space. Three cases are described and a review is made of the international literature concerning giant deep lobe parotid gland pleomorphic adenoma. Diagnosis was based on imaging, computed tomography scan and magnetic resonance imaging and upon cytology, by means of fine needle aspiration biopsy. The surgical approach varied according to the location of the tumour. All patients were discharged without complications and no cases of permanent facial nerve palsy were observed. An exhaustive pre-operative diagnostic algorithm is required before approaching this lesion. Fine needle aspiration biopsy is, in our opinion, mandatory to avoid histological surprises. The surgical approach should provide excellent visibility with wide surgical exposure to secure local neurovascular structures.

Hearing loss in Turner syndrome: results of a multicentric study

The purpose of this article was to evaluate otological diseases in 173 patients (pts) with Turner syndrome (TS).

STUDY DESIGN

One hundred and seventy-three pts, mean chronological age (CA) 12+/-6.2 yr. Patients were submitted to different therapies: GH, estrogen therapy (EE), no therapy (no tx). Seventy-nine pts (CA 11 yr) had no otological diseases. Conductive hearing loss (CHL) occurred in 38.7% (CA 11 yr) and otoscopy was: persistent secretory otitis media in 55.2%, chronic otitis media in 10.4%, pars flaccida retraction pocket in 19.4%, mostly bilateral. Cholesteatoma was present in 15%. Sensorineurinal hearing loss (SNHL) occurred in 15.6% (CA 16 yr), 11 of whom were affected by high tone loss, and 15 by loss in midfrequencies (dip between 0.5-3 kHz), bilateral in 93%. Degree of hearing loss (HL) was mild [20-40 decibel hearing level (dBHL)] in 15%, moderate (45-60 dBHL) in 31%, severe (65-80 dBHL) in 8%, profound (dBHL>85) in 2%. We found a significant association between CHL and karyotype 45, X (p<0.025), congenital cranio-facial abnormalities, prevalently with low-set ears (p<0.04), narrow and/or high arched palate (p<0.018), and micrognathia (p<0.004). Our study confirms that the high prevalence of middle ear infections and CHL in TS are probably due to growth disturbances of the structures from the first and second branchial arches. We did not find any association between EE, GH, and HL. We recommend a regular audiological follow-up, especially during childhood, to prevent important middle ear anatomic sequele and to identify HL at an early stage, as the impact on social functioning may be significant.

Concomitant localization of a myxopapillary ependymoma at the middle thoracic part of the spinal cord and at the distal part of the filum terminale. Case report

Myxopapillary ependymomas represent the most frequent type of ependymomas found at the conus medullaris-cauda equina-terminal filum level. In this article the authors describe the clinical presentation, radiographic findings, operative details, and pathological features of a patient with a concomitant presentations of a thoracic spinal cord myxopapillary ependymoma and a filum terminale myxopapillary ependymoma. A 16-year-old man presented to the Neurosurgery Department of the S. Maria delle Grazie Hospital (Naples, Italy) with an increased weakness of both the legs with great difficulties with walking and with bowel and bladder dysfunction. In a few minutes he becomes paraplegic. Magnetic resonance (MR) imaging revealed two ependymomas: the first one was localized in the middle thoracic part of the spinal cord and, the second one was localized in the cauda at sacral level. Two operations were performed for gross total resection of the masses. The first operation was performed at thoracic level and the second one was performed at the sacral level after two months. The examination demonstrated in both cases a myxopapillary ependymoma. The patient experienced complete resolution of her preoperative symptoms. This article reports an unusual case of a concomitant presentations of a thoracic spinal cord myxopapillary ependymoma and a filum terminale myxopapillary ependymoma myxopapillary. To the best of the authors' knowledge, this association has not yet been reported. This raises the interesting question of a possible associative or causative relationship between these pathologies. The authors considered dissemination to be the spread of tumor along the neuraxis to a location separate from the primary site. They do not believe that the lesion at the cauda level was a drop metastase. As the entire spinal cord and the brain were imaged, and as the tumor in the thoracic spinal cord area was we well capsulated, a disseminated ependymoma was confidently excluded.

Diffuse idiopathic skeletal hyperostosis may give the typical postural abnormalities of advanced ankylosing spondylitis

OBJECTIVES

To describe a case-series of patients who presented with the typical postural abnormalities of long-standing advanced ankylosing spondylitis (AS) but were instead found to suffer from diffuse idiopathic skeletal hyperostosis (DISH).

METHODS

We enrolled consecutive patients who showed postural abnormalities, which at first suggested to us the diagnosis of long-standing advanced AS, although the diagnostic process led us to the correct diagnosis of DISH. Each patient had a complete physical examination and radiographs of the spine and pelvis, and was investigated for HLA-B27 locus typing.

RESULTS

From 15 June 1998 to 15 June 2006, 15 patients with DISH were seen who presented with the typical postural abnormalities of long-standing advanced AS. All patients were males with a median age of 69 yrs (range 51-91). All lacked HLA-B27 and denied personal or family history of spondyloarthritis. All measurements assessing cervical, thoracic and lumbar spinal movement were abnormal.

CONCLUSIONS

Patients suffering from DISH can occasionally have severe limitations of spinal mobility, along with postural abnormalities that resemble long-standing advanced AS. Thus, the differential diagnosis between DISH and advanced AS is not limited to the radiological findings and can also extend to the clinical findings in the two diseases, as is highlighted by our report.