Effect of finasteride on human testicular steroidogenesis

We studied the testicular function and some androgen-mediated events in 22 males (16-30 years of age) with male pattern baldness that was treated with finasteride (10 mg once daily) for 2 years. Patients were evaluated every 3 months. Prostatic volume was determined in six subjects by endorectal ultrasound scans. Serum gonadotropin, prostate-specific antigen (PSA), and sex hormone levels were determined basally and periodically during the treatment period. Fourteen subjects underwent gonadal stimulation with human chorionic gonadotropin (hCG), and the gonadotropin response to gonadotropin releasing hormone (GnRH) was determined in eight subjects, prior to and after 2 years of therapy. Finasteride treatment resulted in an improvement in the male pattern baldness and prostatic shrinkage that was associated with an increase in serum testosterone levels (17.2 +/- 2.5 vs. 26.3 +/- 1.7 nmol/L) and a decrease in dihydrotestosterone (DHT) levels (1.45 +/- 0.41 vs. 0.38 +/- 0.10 nmol/L), causing a marked increase in that testosterone/DHT ratio. A significant increase in the serum levels of androstenedione (3.67 +/- 0.49 vs. 7.05 +/- 0.70 nmol/L) and estradiol (132 +/- 44 vs. 187 +/- 26 pmol/L) was also noted, whereas androstanediol glucoronide (33.3 +/- 6.4 vs. 10.7 +/- 4.5 pmol) and PSA (1.6 +/- 0.6 vs. 0.4 +/- 0.1 ng/ml) were significantly decreased. No changes in basal or stimulated levels of gonadotropin were observed. There was a significant increase in the testosterone response to hCG during finasteride therapy (delta: 16.7 vs. 35.5 nmol/L) that could be explained, at least in part, by the reduction of testosterone metabolism resulting from the blockage induced by finasteride. The decrease in the androstenedione to testosterone and estrone to estradiol ratios observed after hCG treatment, however, strongly suggests increased activity of the 17-ketosteroid reductase enzyme and an improvement of the testicular capacity for testosterone production.

Growth hormone secretion and effects of growth hormone therapy on growth velocity and weight gain in children with Prader-Willi syndrome

Obesity, short stature, decreased growth rate and delayed skeletal maturation are common features of children with Prader-Willi syndrome (PWS). In contrast to PWS, children with simple exogenous obesity have normal or increased growth rate and normal or advanced skeletal maturation. Decreased growth hormone (GH) secretion evaluated by pharmacological or physiological testing associated with increased plasma insulin-like growth factor (IGF-I) and GH-binding protein (GH-BP) levels are also characteristic of simple obesity. In order to understand whether the suboptimal GH secretion in PWS is an artifact of the obesity, we studied 33 obese and 11 non-obese PWS children, aged 2-16 years.GH secretion was evaluated with three pharmacological stimuli (insulin, clonidine and L-dopa) and by spontaneous 24-hour GH secretion. Skeletal maturation was delayed in 70% whereas plasma IGF-I and GH-BP were either low or normal. Forty subjects, including ten non-obese children, had GH deficiency by standard testing (failure to respond to two pharmacological stimuli), and all but one had blunted spontaneous 24-h GH secretion. No significant correlation between body mass index (wt/ht2) and spontaneous 24-h GH secretion (r = 0.145), p > 0.06) or GH-BP levels (r = 0.19, p > 0.07) was found. Thirty documented GH deficient children have completed at least two years of GH therapy. With treatment the overall mean height SD and weight SD changed from -2.2 to -0.8 and from 3.5 to 2.4 respectively (p < 0.0001). No patient has developed diabetes mellitus. In conclusion, growth velocity, skeletal maturation, GH secretion and GH dependent proteins in PWS resemble GH deficiency more than simple obesity. Our ongoing study suggests that GH deficiency in PWS is not an artifact of obesity. Although it is unlikely that GH deficiency is the only cause of decreased growth velocity and increased adiposity in PWS, it is a common feature and significant contributory factor. Long term observation will be required until achievement of adult height to determine whether GH therapy actually improves final height.

[Colorectal cancer: its clinical picture and survival]

Retrospectively collected information on 77 patients who had undergone resection for colorectal cancer at Belén Hospital, Trujillo, Perú, from 1966 to 1993, was analyzed to establish their clinical features and the importance of both clinical and pathological factors affecting outcome. Common presenting features in right colon cancer were abdominal pain, pallor, and palpable mass; in left colon cancer were symptoms of obstruction, and in rectal carcinoma predominated bleeding. The diagnostic accuracy of barium enema (n = 25) and proctosigmoidoscopy (n = 18) was 72 and 100% respectively. In 54.5% (n = 42) curative resection and in 45.5% (n = 35) palliative resection was performed The surgical procedures performed were right hemicolectomy (n = 29), transverse colectomy (n = 6), left hemicolectomy (n = 11), sigmoid resection (n = 14), low anterior resection (n = 5), and abdominoperineal resection of the rectum (n = 12). The total perioperative mortality rate was 18%. The 5 year survival rate in this series was 28% (53% for curative resection and 0% for palliative resection). An univariate analysis of survival time using long-rank test revealed that presence of bowel obstruction or perforation, macroscopic appearance, tumor size, depth of invasion, lymph node status, number of lymph node metastasis, distant metastasis, and clinical stage had and individual prognostic significance. Age, sex, length of disease, serum hemoglobin level, blood transfusions, location of tumor, histologic type, and tumor grade did not affect the prognosis. Improvement in the survival probably depends on development of better adjuvant therapy in association with surgery.

MR of the pituitary in patients with Prader-Willi syndrome: size determination and imaging findings

Prader-Willi syndrome (PWS) is an unusual genetic disorder characterized by short stature, obesity, hypogonadism, hypotonia, cognitive impairment, and dysmorphic facies. There is an interstitial deletion of the proximal long arm of chromosome 15 in about 70 % of patients. Some of these clinical features suggest a central hypothalamic/pituitary dysfunction, and recent investigations have demonstrated a marked impairment in spontaneous growth hormone (GH) secretion. We studied 15 GH-deficient PWS patients by magnetic resonance imaging (MRI) to determine whether there was a diminution in the gross morphological size of the anterior pituitary gland, the site of GH synthesis. We also set out to catalog the pertinent imaging findings in this patient population. Our results indicate that this is the first report documenting pituitary size by MRI in PWS patients. No statistically significant difference was found in the height of the anterior pituitary gland in PWS patients compared with either normal children or children with isolated GH deficiency. An interesting imaging finding is that three of 15 patients (20 %) demonstrated complete absence of the posterior pituitary bright spot (PPBS), and a fourth patient demonstrated a small PPBS. These observations reflect an objective physiologic disturbance in the hypothalamus. The clinical and radiologic implications of these findings are discussed.

Disinfection and sterilization practices in Mexico

We evaluated antisepsis, disinfection, and sterilization procedures at 22 hospitals in the state of Yucatan, Mexico, which provide services for approximately 80% of the population. The percentage of hospitals that followed standard recommendations for diverse antisepsis procedures were as follows: surgical scrub, 41%; surgical site preparation, 68%; central intravenous (iv) catheters, 61%; peripheral iv catheters, 86%; urinary catheters, 41%, and umbilical cord care, 5%. Inappropriate procedures typically involved the use of benzalkonium chloride and mercury compounds. Adequate sterilization procedures were observed for sharp surgical instruments in 9%, for blunt surgical instruments in 81%; for linen in 90%; for surgical brushes in 9%; for metal prostheses in 100%; for plastic prostheses in 57%; and for disinfection of endoscopes in 30%. The most common errors were the use of too short an exposure time in steam sterilizers or dry heat sterilizers, and the use of benzalkonium chloride as a sterilizing agent. Only 14% of hospitals used commercial spore preparations for autoclave monitoring. For the reuse of disposables, 50-94% of hospitals employed inappropriate sterilization or low-level disinfection procedures. Similar conditions are likely to exist in hospitals throughout the country. The establishment of strict regulations and hospital training programmes for disinfection and sterilization procedures, and the reuse of disposable devices is urgently needed in Mexico.

Developmental trends of sleep-disordered breathing in Prader-Willi syndrome: the role of obesity

Polysomnographic recordings of 43 children and adults with Prader-Willi syndrome (PWS) were inspected and classified into 5 age groups. The effect of age and body mass index (BMI) on measures of breathing, oxygen saturation, and sleep efficiency were analyzed. Body mass index (BMI) increased significantly between early childhood and preadolescent groups. Subjecting the data to analysis of variance showed an overall significant effect of BMI but no age effect on breathing parameters and oxygen saturation. Increased BMI was associated with decreased oxygen saturation and with higher apnea/hypopnea index. Sleep efficiency index was significantly lower in adults than in young children, preadolescent, and adolescent groups. These findings emphasize the role of obesity in the development of sleep-related breathing abnormalities and nocturnal oxygen desaturation in patients with PWS.

Caries incidence, effect of preventive measures, and caries prediction in Uruguayan children

In 1988, 100 12- to 13-year-old children from two neighborhoods in Montevideo with different standards of living were examined. Twenty-three children with large numbers of mutans streptococci, lactobacilli, or decayed surfaces or a combination of these factors were considered to be at high risk of developing caries. Twelve of these 23 children were selected for special preventive measures. A second examination was made 18 months later, at which 81 of the originally 100 children were studied. The clinical and microbiologic variables were tested for their ability to predict caries by calculating their sensitivity, specificity, the positive and negative predictive values. The incidence of new DMFS was significantly higher in the children from the low than in those from the high socioeconomic area. It was also significantly higher in the children considered being at high risk than in those at low risk at the start of the study. Preventive measures reduced the caries risk. The highest sensitivity was obtained with the clinical test, whereas the highest specificity was obtained with the combined clinical and microbiologic tests. The findings indicate that methods for identifying children at risk which started to be used in Scandinavia 20 years ago could be applied in the Uruguayan population of today. It is valuable to know this, as the resources for both treatment and prevention are very limited.

Characterization of zona glomerulosa function in patients with classic and non-classic forms of congenital adrenal hyperplasia due to 11 beta-hydroxylase deficiency

The function of the adrenal zona glomerulosa was studied in 18 patients with 11-hydroxylase deficiency confirmed by elevated plasma levels of 11-deoxycortisol. Patients were divided into two groups. Group I (4 males, 7 females; aged 1.2-2.8 yrs) had symptoms at birth or shortly after (classic form), and Group II (4 males, 3 females; aged 7.3-20.1 yrs) had their first clinical manifestation during childhood (non-classic form). To study zona glomerulosa function, patients were given dexamethasone p.o. 2 mg/m2/day x6 days, thus suppressing the zona fasciculata. Six hours after the last dose of dexamethasone, the zona glomerulosa was stimulated by i.v. administration of furosemide 1.0 mg/kg as a single dose. Blood was drawn 2 h later. In the untreated state, all patients had striking elevation of ACTH (Group I: 1,070 +/- 380 pg/ml; Group II: 764 +/- 180 pg/ml), 11-deoxycortisol (Group I: 63,000 +/- 22,000 ng/dl; Group II: 17,200 +/- 5,200 ng/dl) and deoxycorticosterone (Group I: 1,100 +/- 67 ng/dl; Group II: 499 +/- 27 ng%) while plasma renin activity (< 0.5 ng/ml/h in both groups) and aldosterone (Group I: 3.0 +/- 1.8 ng/dl; Group II: 2.3 +/- 1.8 ng/dl) were markedly suppressed. After the administration of furosemide 4 patients in Group I were unable to increase aldosterone (2.8 +/- 0.9 ng/dl) secretion in spite of marked elevation of plasma renin activity (28 +/- 7 ng/ml/h), suggesting an impairment of 11-hydroxylase in the zona glomerulosa.(ABSTRACT TRUNCATED AT 250 WORDS)

Dental caries and microbial and salivary conditions in Uruguayan children from two different socioeconomic areas

Dental caries, microbial and salivary conditions, dietary habits, and socioeconomic conditions were studied in 100 12- to 13-year-old children from 2 different socioeconomic areas in Montevideo: Pocitos and Piedras Blancas. The residents of Pocitos had a higher educational level, better housing conditions, and occupations involving higher earnings than those of Piedras Blancas. The caries prevalence in the two areas was about the same, but the children in Piedras Blancas had more decayed surfaces and fewer filled surfaces than the children in Pocitos. The mean values for caries in Piedras Blancas and Pocitos were, DMFT, 4.2 and 4.2; DMFS, 8.1 and 7.8; DS, 4.7 and 2.5; and FS, 1.7 and 4.7, respectively. The differences in DS and FS were statistically significant. The frequency of sugar intake and the salivary secretion rate were similar, but the buffer capacity was significantly higher in Pocitos than in Piedras Blancas. The plaque index was the same, but the distribution of cariogenic microorganisms differed significantly. Fifty-eight per cent of the children in Piedras Blancas had more than 10(6) CFU of mutans streptococci per milliliter saliva, compared with 17% of the children in Pocitos. Similar differences were found with regard to the lactobacilli. The percentage of children with high numbers of mutans streptococci was higher in Piedras Blancas and lower in Pocitos than in previous epidemiologic studies in Scandinavia. It was, however, higher than that recently noted in Finland.

Sleep and breathing patterns in patients with Prader Willi syndrome (PWS): effects of age and gender

Patients with Prader Willi syndrome (PWS) often complain of daytime hypersomnolence. Because of reported daytime sleepiness and high prevalence of morbid obesity, these patients have been considered at risk for sleep related disordered breathing, but polysomnographic studies have been limited. We evaluated sleep and breathing polysomnographically in 24 PWS patients including 15 adults and 9 children. All adult patients completed MSLT testing on the day following the nocturnal sleep study. Both adult and children groups showed little or no sleep apnea, but REM related oxygen desaturation was quite common, its severity significantly correlated with increased obesity. Sleep patterns in both groups showed abnormal REM sleep cycles with variable REM latency (at times significantly shortened) and fragmented REM sleep with multiple brief REM periods. REM sleep abnormalities were still present in some patients without REM related desaturation. As a group, patients with PWS demonstrated pathological somnolence as measured by MSLT, which correlated with nocturnal sleep efficiency but not with nocturnal REM latency. It is hypothesized that the abnormal sleep findings in PWS reflect an underlying hypothalamic dysfunction characteristic of this syndrome.

Male hypogonadism with gynecomastia caused by late-onset deficiency of testicular 17-ketosteroid reductase

BACKGROUND

17-Ketosteroid reductase deficiency results in male pseudohermaphroditism because conversion of the weak androgen androstenedione to the more potent androgen testosterone is impaired. If a late-onset form exists, hypogonadism and gynecomastia caused by decreased testosterone production and increased estrogen production, respectively, would be expected as the major clinical manifestations in men.

METHODS

We studied 48 male subjects, ranging from 14 to 26 years of age, who had idiopathic pubertal gynecomastia. Serum concentrations of gonadal and adrenal steroid hormones were measured before and after the administration of corticotropin and after the combined administration of chorionic gonadotropin and dexamethasone for three days.

RESULTS

We identified three unrelated subjects (ages, 16, 17, and 26 years) with results indicative of a partial deficiency of testicular 17-ketosteroid reductase. The three subjects had gynecomastia as well as decreased libido and impotence. Their mean (+/- SD) base-line serum androstenedione and estrone concentrations were elevated as compared with the levels in the 45 subjects without this enzyme deficiency (androstenedione, 380 +/- 70 vs. 110 +/- 70 ng per deciliter [13 +/- 2 vs. 4 +/- 2 nmol per liter]; estrone, 138 +/- 12 vs. 46 +/- 9 pg per milliliter [511 +/- 44 vs. 170 +/- 33 pmol per liter]). After the administration of chorionic gonadotropin, the mean serum androstenedione concentration in these three subjects was 910 +/- 48 ng per deciliter (32 +/- 2 nmol per liter) and the mean serum estrone concentration was 260 +/- 16 pg per milliliter (962 +/- 59 pmol per liter). The mean serum testosterone concentration at base line was 210 +/- 80 ng per deciliter (7.4 +/- 2.8 nmol per liter) in the 3 subjects, as compared with a value of 410 +/- 12 ng per deciliter (14.4 +/- 0.42 nmol per liter) in the 45 other subjects, and it did not increase in response to the administration of chorionic gonadotropin. The concentrations of androstenedione and estrone in spermatic venous serum were 19 times higher and 73 times higher, respectively, than in normal men. The serum concentrations of follicle-stimulating hormone and luteinizing hormone in these three subjects were inappropriately low, suggesting the presence of hypogonadotropic hypogonadism.

CONCLUSIONS

A late-onset form of testicular 17-ketosteroid reductase deficiency can cause gynecomastia and hypogonadism in men.

Elevated serum estradiol associated with increased androstenedione-testosterone ratio in adolescent males with varicocele and gynecomastia

OBJECTIVE

To investigate the testicular function in adolescents with pubertal gynecomastia associated with varicocele before and after varicocelectomy.

DESIGN AND PATIENTS

We have studied six male adolescents 15 to 19 years of age with bilateral gynecomastia. They were selected among other adolescents with gynecomastia because of the presence of visible varicoceles. All of them had normal physical examination and secondary sexual characteristics. This was prospective study of 3 months' duration. All the patients that were included finished the study.

SETTING

All the patients were evaluated in the Endocrine Clinic of Winthrop-University Hospital, a tertiary care unit.

INTERVENTION

Serum testosterone (T), androstenedione (A), and estradiol (E2) responses to the administration of human chorionic gonadotropin (hCG) 2,000 IU for 3 consecutive days before and 3 months after varicocelectomy were determined.

RESULTS

Varicocelectomy did not cause any significant changes in the basal (pre-hCG) levels of the steroid. However, the increase in T levels achieved with hCG was significantly (P less than 0.005) higher after varicocelectomy (before T, 925 +/- 212 ng%; after T, 1,649 +/- 406 ng%). Simultaneously, the stimulated levels of E2 and A were significantly lower (P less than 0.005) after varicocelectomy (E2, 62 +/- 12 pg/mL; A, 326 ng% +/- 80 ng%) than before (E2, 106 +/- 13 pg/mL; A, 580 ng% +/- 95 ng%).

CONCLUSION

The reciprocal effect on the levels of T and its immediate precursor, A, suggests an impairment of the 17-ketoreductase enzyme activity. The increased levels of E2 after hCG and its normalization after varicocelectomy suggests that varicoceles may play a pathogenetic role in the development of gynecomastia.

[Comparative study of the adherence test and the Petry plaque count test of Streptococcus mutans in saliva]

The Streptococcus mutans counts--added to lactobacili depicting test--are an useful instrument in cariology when determining the risk groups. In studies concerning a large number of patients the S. Mutans count in saliva test are the most accesible. Nevertheless, they are very expensive and also complicate to carry out. Simplified techniques which depict S. Mutans on the basis of adherence tests have been perfected. The most suitable from them, taking into account our working conditions, is the Matsukubo test. We deemed it interesting to correlate this test and the Gold medium count. The study has been carried out with three different populations using both techniques at the same time. As per the correlation indices obtained we conclude that the Matsukubo technique and the count have a significant correlation between them. Due to its low cost, the simplicity of its realization, as well as its easy reading it can be effectively used as a primary procedure when studying populations large in number. Through this method selection will be made of the patients to be studied applying more precise microbiological techniques.

[Evaluation of oral health status of a preschool group with a predictive test based on mutans group and clinical studies]

A children's population, aged from 2 to 5 years, was studied for three years. Bacteriological and clinical criteria were followed, with a determination of the M. st level in non-stimulated saliva in the age-groups of 3, 4 and 5 years. We found, as Alaluusua did, a correlation between the M. st level in saliva and the number of caries. With this study, a large number of caries-free children had a low M. st level. The largest amount of caries appears in children with a high M. st level. The highest caries incidence in this population appears at the 4 year children group. It has to be remembered that this is an age-group with specific characteristics. Caries is a disease depending on many factors and the M. st level would be very significant to an early detection of risks, but should be evaluated considering all the parameters as a whole. Its predictive value is not sufficient by itself but it has an unquestionable value when detecting risk patients of an early age. Therefore, treatment has to be the result of an etiological diagnosis addressed to prevention after an evaluation of all the factors related with the caries disease.

Leydig cell function in adolescent boys with varicoceles

The incidence of varicoceles in adolescent boys ranges from 5% to 19.5%. We studied five adolescent boys aged 17 to 20 years with visible left-sided varicoceles. All of them had public hair and testicular volumes between 20 to 25 mL and had achieved stage V of pubertal development. Serum gonadotropin response to the intravenous administration of 100 micrograms of gonadotropin-releasing hormone (GnRH) and testosterone response to the administration of 2,000 IU human chorionic gonadotropin (hCG) daily for 3 days before and 3 months after varicocelectomy were measured. Basal levels of both gonadotropins were in the pubertal range, and there was no significant difference between serum levels before and after varicocelectomy. Both gonadotropins, however, showed increased responses to the administration of GnRH (luteinizing hormone [LH]: basal, 12.0 +/- 5.1 mIU/mL; peak, 105.0 +/- 36.0 mIU/mL; follicle-stimulating hormone [FSH]: basal, 11.6 +/- 4.2 mIU/mL, peak, 60.0 +/- 18.0 mIU/ml) that decreased after varicocelectomy (LH: basal, 14.3 +/- 6.0 mIU/mL; peak, 58.6 +/- 12.0 mIU/mL; FSH: basal, 6.8 +/- 4.6 mIU/mL; peak, 38.0 +/- 8.1 mIU/mL). Serum testosterone response to hCG was also significantly improved by varicocelectomy (testosterone peak: before, 780 +/- 210 ng/dL; after, 1850 +/- 170 ng/dL). Testicular biopsy specimens showed no histologic abnormalities and normal spermatogenesis. Endocrine evaluation in adolescent boys with varicoceles could detect an early Leydig cell dysfunction that could be corrected by varicocelectomy.

Leukocyte alkaline phosphatase in hypothyroidism and hyperthyroidism. Response to initiation of thyroxine replacement therapy

Leukocyte alkaline phosphatase (LAP) activity was determined in normal subjects, and in untreated, symptomatic patients with primary hypothyroidism or thyrotoxicosis. The means +/- 1 SD of (n) subjects were, respectively: 61.7 +/- 27.5 (16), 149.9 +/- 56.3 (9) and 96.9 +/- 27.7 (9). The mean LAP values of the hypothyroid and thyrotoxic groups were significantly different from that of the normal group (P less than .01). Values were above the normal range (20 to 120) in seven of the nine hypothyroid patients. LAP values were in the upper half of the normal range in eight of the nine thyrotoxic patients. In the two hypothyroid patients studied at 24-hour intervals, LAP activity was altered markedly within 48 hours of initiation of thyroxine therapy, 25 micrograms daily. In five hypothyroid patients followed for several months after initiating thyroxine replacement, LAP levels were essentially normal within 1 to 2 months. In the thyrotoxic patients, LAP values declined within the first month of medical management, but tended to remain within the normal range.

Hypothalamic-pituitary gonadal axis in boys with primary hypothyroidism and macroorchidism

Nine of 15 boys with severe long-standing primary hypothyroidism were found to have macroorchidism. All 15 patients had elevated thyroid-stimulating hormone levels. However, only those patients with testicular enlargement had striking elevations of serum prolactin and gonadotropin values. The response to gonadotropin-releasing hormone in our patients was blunted, in contradistinction to that of children with true precocious puberty. In spite of the elevated levels of luteinizing hormone, the serum testosterone levels were in the prepubertal range, explaining the lack of peripheral manifestations of androgenic effect. Improvement of testosterone secretion followed decreasing prolactin levels with bromocriptine administration, suggesting an inhibitory effect of prolactin on luteinizing hormone action at the Leydig cell. We conclude that testicular enlargement is the result of continuous follicle-stimulating hormone stimulation and that the term "true precocious puberty" is not appropriate in children with hypothyroidism and macroorchidism unless the hypothalamic-pituitary gonadal axis is shown to be at the pubertal stage.

Effect of prolonged clonidine administration on growth hormone concentrations and rate of linear growth in children with constitutional growth delay

Sixteen prepubertal children with constitutional growth delay (10 boys and six girls, mean age 7.2 +/- 2.1 years) were administered a daily dose of clonidine (0.15 mg/m2) for a period of 1 year. Growth hormone levels, plasma somatomedin C, and linear growth rate were significantly increased at the end of the treatment. Six of the children maintained the higher growth rate even 6 months after treatment. These and other studies suggest that prolonged stimulation of the hypothalamus by clonidine may ameliorate the impairment of growth hormone release seen in some children with constitutional growth delay. Because of the low cost and the convenience of the oral route, administration of clonidine could be a mode of treatment in some children with poor growth.