Arginine but not pyridostigmine, a cholinesterase inhibitor, enhances the GHRH-induced GH rise in patients with anorexia nervosa

Pirenzepine, a muscarinic antagonist probably acting via stimulation of hypothalamic somatostatin release, abolishes the growth hormone releasing hormone (GHRH)-stimulated growth hormone (GH) rise in normal subjects but only blunts it in patients with anorexia nervosa (AN). This finding suggested the existence in AN of an alteration of cholinergic system and/or somatostatinergic tone. To further investigate these mechanisms, in 11 AN women patients (age 18.8 +/- 0.9 years; BMI 13.4 +/- 0.4) we studied the GH response alone (1 microgram/Kg IV as a bolus at 0 min) and combined with pyridostigmine (PD, 120 mg orally, 60 min before GHRH administration), a cholinesterase inhibitor, or arginine (ARG 30 g infused over 30 min starting at 0 min), two compounds probably acting via inhibition of hypothalamic somatostatin (SS) release. The GH response to GHRH preceded by a previous (120 min before) neurohormone administration also was studied. All these tests also were performed in 20 normal age-matched women (age 22.0 +/- 1.8 yrs; BMI20.1 +/- 2.4). Basal serum GH levels were higher in AN patients than in normal volunteers (NV) (10.3 +/- 3.4 versus 2.8 +/- 0.3 microgram/L; p < 0.001), whereas plasma IGF-I levels were lower in AN patients than in NV (43.3 +/- 10.6 versus 172.4 +/- 13.9 micrograms/L; p < 0.00001). In AN patients, GHRH administration induced a GH rise higher, though not significantly, than that in NV [delta area under the curve (AUC) 1173.6 +/- 167.6 versus 834.6 +/- 188.1 micrograms/L/h]. The GH response to the second of two consecutive GHRH boluses was lower (p < 0.01) than that of the first one either in AN patients or in NV (67.6 +/- 27.4 and 53.1 +/- 25.7 micrograms/L/h, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

Mechanisms underlying the negative growth hormone (GH) autofeedback on the GH-releasing effect of hexarelin in man

The growth hormone (GH) response to GH-releasing hormone (GHRH) is strongly inhibited by previous administration of recombinant human GH (rhGH), likely as a consequence of a somatostatin-mediated GH negative autofeedback. Hexarelin (HEX), a synthetic hexapeptide belonging to the GH-releasing peptide (GHRP) family, possesses a GH-releasing activity greater than that of GHRH both in animals and in man. The mechanism of action of GHRPs is yet to be completely clarified, although concomitant actions at the pituitary and hypothalamic level have been hypothesized. To further clarify the mechanisms of action underlying the GH-releasing activity of HEX, in six normal young volunteers we studied the effects of rhGH (2 U intravenously [IV]) on the GH response either to GHRH (2 microg/kg IV) or to HEX (2 microg/kg IV) alone or combined with GHRH and/or pyridostigmine ([PD], 120 mg orally). The GH-releasing effect of HEX was higher than that of GHRH (area under the curve [AUC], 2,200.8 +/- 256.9 v 792.2 +/- 117.6 microg/L/h, P < .001), whereas combined administration of the two substances induced a true synergistic effect, with GH release after HEX plus GHRH (4,259.2 +/- 308.0 microg/L/h) being higher (P < .02) than the arithmetic sum of the GH increases induced by each compound separately administered. After rhGH administration, the GH-releasing effect of HEX was blunted (1,468.9 +/- 193.7 microg/L/h, P < .04; inhibition of 32.1%), whereas that of GHRH was nearly abolished (102.0 +/- 7.8 microg/L/h, P < .02; inhibition of 86.1%). The GH response to combined administration of HEX and GHRH was also blunted by the previous rhGH bolus (3,070.6 +/- 481.8 microg/L/h, P < .02; inhibition of 26.7%). PD did not modify the GH-releasing effect of HEX either alone (2,456.8 +/- 317.5 microg/L/h) or combined with GHRH (4,009.1 +/- 360.8 microg/L/h). rhGH was again able to blunt the GH response to HEX combined with PD (1,619.3 +/- 237.9 microg/L/h, P < .02), but failed to modify the GH response to HEX combined with GHRH and PD (4,548.4 +/- 698.0 microg/L/h). In conclusion, these results demonstrate that rhGH administration only blunts the GH-releasing activity of HEX, but abolishes that of GHRH. The blunting effect of rhGH on the GH response to HEX is probably mediated by a concomitant reduction in the activity of GHRH-secreting neurons and an increase of somatostatinergic tone.

Alprazolam, a benzodiazepine, does not modify the ACTH and cortisol response to hCRH and AVP, but blunts the cortisol response to ACTH in humans

Alprazolam (AL), a benzodiazepine which activates gamma-amino butyrric acid (GABA)-ergic receptors, exerts a clear inhibitory effect on the activity of the hypothalamo-pituitary-adrenal (HPA) axis and is able to markedly reduce the ACTH response to metyrapone-induced inhibition of glucocorticoid feedback. It has been suggested that its inhibitory action could be regulated by CRH or AVP mediated mechanisms. However, the effect of benzodiazepines on the HPA response to CRH or AVP is contradictory. It has been shown that benzodiazepines have specific receptors on the adrenal gland but it is unclear if they mediate biological effects in humans. In order to further clarify the mechanisms underlying the inhibitory effect of benzodiazepine on HPA axis in humans, we studied the effect of AL (0.02 mg/kg po at -90 min) or placebo in 7 healthy young volunteers (7 female, age: 26-34 yr; wt: 50-58 kg, BMI 20-22 kg/m2) on: 1) the ACTH and cortisol responses to hCRH (2.0 microg/kg iv at 0 min) or AVP (0.17 U/kg im at 0 min); 2) the cortisol, aldosterone and DHEA responses to ACTH 1-24 (0.06 and 250 microg iv at 0 and 60 min, respectively). After placebo, the ACTH and cortisol responses to hCRH (peaks, mean+/-SE: 29.8+/-4.4 pg/ml and 199.3+/-19.6 microg/l) were similar to those recorded after AVP (31.7+/-6.5 pg/ml and 164.8+/-18.0 microg/l); the cortisol response to 0.06 microg ACTH (190.4+/-11.8 microg/l) was similar to that recorded after hCRH and AVP but lower (p<0.01) than that after 250 microg ACTH (260.6+/-17.4 microg/l). AL did not modify the ACTH response to both hCRH (42.5+/-7.1 pg/ml) and AVP (33.3+/-2.7 pg/ml), which even showed a trend toward increase. AL also failed to significantly modify the cortisol response to both hCRH (156.3+/-12.7 microg/l) and AVP (119.4+/-14.5 microg/l), which, on the other hand, showed a trend toward decrease. The cortisol peaks after 0.06 microg ACTH were significantly reduced (p<0.02) by AL pre-treatment (115.0+/-7.7 microg/l) which, in turn, did not modify the cortisol response to the subsequent ACTH bolus (214.7+/-16.6 microg/l). The DHEA and aldosterone responses to all the ACTH doses were not significantly modified by AL. In conclusion, these data show that the HPA response to AVP as well as to hCRH is refractory to the inhibitory effect of AL which, in turn, blunts the cortisol response to low ACTH dose. These findings suggest that both CRH- and AVP-mediated mechanisms could underlie the CNS-mediated inhibitory effect of AL on HPA axis; in the meantime, these results suggest that benzodiazepines could also act on adrenal gland by blunting the sensitivity of the fasciculata zone to ACTH.

A single unit of transfused allogeneic blood increases postoperative infections

The aim of this prospective study was to evaluate if there was a statistical correlation between allogeneic blood transfusion and postoperative infections, and if this could have a dose-dependent pattern. The evaluation was based on multiple logistic and receiver operating characteristics (ROC) curve analyses. On hospital admission the following parameters were determined in 267 consecutive patients with colorectal cancer: hemoglobin, serum albumin, serum cholinesterase activity, total iron binding capacity and weight loss. Duration of operation, operative blood loss, amount of transfused blood, Dukes' cancer stage and occurrence of postoperative infections were also recorded. One hundred and thirty-two patients (49.4%) were given perioperatively allogeneic blood. Postoperative infections developed in 47 (17.6%) patients. Multivariate analysis identified allogeneic blood transfusion as the only variable related to the occurrence of postoperative infections (p < 0.05). ROC curve analysis showed that the risk for the occurrence of infection was significantly higher in patients transfused one unit of blood (p < 0.01). Moreover, a significant trend between increasing number of transfused blood units and susceptibility to infection was found (p < 0.00019).

Splenectomy for idiopathic thrombocytopenic purpura: comparison of laparoscopic and conventional surgery

BACKGROUND

This study aimed to compare the safety, efficacy, and clinical benefits of laparoscopic splenectomy (LS) to open splenectomy (OS) in patients with idiopathic thrombocytopenic purpura (ITP).

METHODS

The results from 14 consecutive patients who underwent LS for ITP were reviewed and compared with the results from patients who underwent OS for the same disease. Demographics, concomitant disease on admission, and platelet counts were evaluated, as were details of the surgical procedure, postoperative physiologic status, and hospital stay.

RESULTS

Mean operative time was 88.3 min for OS and 146.4 min in LS group (p < 0.05). The conversion rate to open splenectomy was 7.1. Therapeutic response to splenectomy was 92.8% in the LS group and 86.6% in the OS group. Bowel canalization, return to liquid diet, and length of hospital stay were all significantly delayed in the OS group as compared with those who underwent LS (p = 0.01, p = 0.02, p = 0.005, respectively). In the OS group the morbidity rate was 13.3%, whereas in the LS group it was 7.1%.

CONCLUSIONS

Laparoscopic splenectomy represents a valid alternative to conventional splenectomy in the treatment of ITP.

The IGF-I response to very low rhGH doses is preserved in human ageing

OBJECTIVES

The activity of the GH/IGF-I axis varies during life and is clearly reduced in the elderly. In fact, GH, IGF-I and IGFBP-3 levels in older people are clearly reduced and similar to those observed in patients with GH deficiency. The declining activity of the GH/IGF-I axis with advancing age may contribute to changes in body composition, structure, function and metabolism. In fact, treatment with pharmacological doses of rhGH restored plasma IGF-I levels, increased lean body mass and muscle strength while decreased adipose tissue mass in healthy elderly subjects. At present it is unclear whether peripheral GH sensitivity is preserved in aging. To clarify this point, we aimed to verify the effect of both single dose and short term treatment with very low rhGH doses on the IGF-I levels in normal elderly subjects. Normal young adults were studied as controls.

DESIGN

We studied the IGF-I response to rhGH administration after single (20 micrograms/kg s.c.) or repeated administrations (5 micrograms/kg s.c. for 4 days) in two groups of young and elderly subjects.

SUBJECTS

Twenty-seven healthy elderly (ES, 14 F and 13 M, age mean +/- SEM: 69.4 +/- 1.3 years, BMI: 23.9 +/- 0.5 kg/m2) and 21 young adult subjects (YS, 12 F and 9 M, 29.8 +/- 1.2 years, 23.8 +/- 0.5 kg/m2) were studied, divided into two groups.

MEASUREMENTS

Group 1: blood samples for IGF-I and IGFBP-3 assay were drawn basally and 12 h after rhGH administration (20 micrograms/kg). Group 2: blood samples for IGF-I, IGFBP-3, glucose and insulin assays were drawn basally, 12 h after the first and the last rhGH administration (5 micrograms/kg). Free T3 (fT3), free T4 (fT4) and TSH levels were also assayed basally and after the last rhGH administration; oestradiol and testosterone levels were measured basally.

RESULTS

Basal IGF-I levels were lower in ES (whole group) than in YS (whole group) (123.1 +/- 8.9 vs. 230.4 +/- 16.1 micrograms/l, P < 0.001) while IGFBP-3 levels in the two groups were similar (2.7 +/- 0.2 vs. 3.1 +/- 0.2 mg/l). No sex-related differences in IGF-I and IGFBP-3 levels were recorded in either group. Group 1: the single administration of 20 micrograms/kg rhGH induced a significant (P < 0.001) IGF-I rise both in YS (318.0 +/- 25.3 vs. 256.0 +/- 21.6 micrograms/l) and ES (187.2 +/- 16.8 vs. 100.4 +/- 9.5 micrograms/l). IGF-I levels after rhGH in ES persisted lower than those in YS (P < 0.001), but the percentage IGF-I increase after rhGH was higher (P < 0.001) in ES (91.6 +/- 12.9%) than in YS (23.9 +/- 5.0%) subjects. Both in YS and ES IGFBP-3 levels were significantly increased to the same extent by 20 micrograms/kg rhGH (3.0 +/- 0.2 vs. 2.3 +/- 0.2 mg/l; 2.9 +/- 0.2 vs. 2.6 +/- 0.2 mg/l, P < 0.001 vs. baseline). Group 2: basal glucose, insulin, fT3, fT4 and TSH levels in YS and ES were similar; testosterone levels in aged and young men were similar while oestradiol levels in aged women were lower (P < 0.01) than in the young ones. IGF-I levels were significantly increased 12 h after the first administration of 5 micrograms/kg rhGH both in ES (166.6 +/- 15.7 vs. 138.3 +/- 12.1 micrograms/l, P < 0.03) and YS (272.2 +/- 16.1 vs. 230.4 +/- 16.1 micrograms/l, P < 0.001). Twelve hours after the last rhGH administration IGF-I levels were further increased (P < 0.001) both in ES (208.7 +/- 21.1 micrograms/l) and YS (301.7 +/- 17.6 micrograms/l). IGF-I levels in ES persisted lower than those in YS at each time point (P < 0.001); however, the percentage IGF-I increase after rhGH in ES and YS was similar (after the first administration: 22.4 +/- 5.1 vs. 21.7 +/- 5.1%; after the last administration: 52.9 +/- 9.5 vs. 39.5 +/- 9.9%). No significant variation in IGFBP-3, glucose, insulin, fT3, fT4 or TSH levels was recorded in either ES or YS.

CONCLUSIONS

Our data demonstrate that IGF-I levels in aging are reduced but the peripheral sensitivity to rhGH is preserved. In fact, in aged subjects the percentage rhGH-induced IGF-I increase is similar or even highe

Oestrogen replacement does not restore the reduced GH-releasing activity of Hexarelin, a synthetic hexapeptide, in post-menopausal women

Hexarelin (HEX), a synthetic hexapeptide, has a strong and reproducible GH-releasing activity in man after intravenous, subcutaneous, intranasal and oral administration. Its effect undergoes age-related variations, being reduced in elderly subjects. In spite of evidence in animals showing that the activity of GH-releasing peptides (GHRPs) is positively influenced by oestrogens, in young adults no sex-related difference has been found in the GH response to HEX or to other GHRPs. We aimed to clarify the influence of the menopause and oestrogens on the GH-releasing activity of HEX. We studied the GH response to the acute administration of the maximal effective dose of HEX (2 micrograms/kg i.v.) in 24 young women (YW, age: 27.3 +/- 0.5 years: body mass index (BMI): 20.7 +/- 0.3 kg/m2), 14 post-menopausal women (PW, age: 52.9 +/- 1.2 years: BMI: 23.2 +/- 0.9 kg/m2) and 14 aged women (AW, age: 68.9 +/- 1.5 years: BMI: 21.7 +/- 0.7 kg/m2). In 10 post-menopausal women the GH response to HEX was also studied after 3 months of transdermal oestradiol treatment (delivery 50 micrograms/die). Basal oestrogen and GH levels in PW were lower than those in YW (oestrogen: 4.8 +/- 3.6 vs 42.0 +/- 3.4 pg/ml (means +/- S.E.M.). P < 0.001: GH: 1.5 +/- 0.5 vs 2.9 +/- 0.6 micrograms/l, P < 0.02) and similar to those in AW (oestrogen: 1.3 +/- 0.4 pg/ml: GH: 0.9 +/- 0.2 microgram/l). IGF-l levels in PW were not different from those in YW (174.4 +/- 11.9 vs 195.5 +/- 14.9 micrograms/l) and higher than those in AW (109.8 +/- 15.8 micrograms/l, P < 0.01). The GH response to HEX in PW (areas under the curve +/- S.E.M.: 453.6 +/- 56.0 micrograms.min/l) was lower (P < 0.002) than that in YW (1630.4 +/- 259.7 micrograms.min/l) while it did not differ from that in AW (781.8 +/- 189.3 micrograms.min/l). In PW 3-month oestrogen administration increased oestradiol levels (38.3 +/- 5.9 vs 0.8 +/- 0.4 pg/ml, P < 0.001) making them similar to those recorded in YW, while it failed to modify both basal GH and IGF-l levels GH: 1.8 +/- 0.6 vs 1.5 +/- 0.7 micrograms/l: IGF-l: 164.6 +/- 14.3 vs 175.0 +/- 12.3 micrograms/l). Also the GH response to HEX was not modified by oestradiol treatment (518.4 +/- 125.6 vs 425.4 +/- 69.3 micrograms.min/l). In conclusion, present data confirm the strong GH-releasing effect of Hexarelin in humans and demonstrate that its activity is already reduced in post-menopausal women to an extent overlapping that in elderly women. Moreover, oestrogen treatment is not able to restore it. Thus, the lack of oestrogens does not seem to account for the reduced somatotraph responsiveness to GHRPs in the post-menopausal period.

The primary site of bacterial translocation

OBJECTIVE

To establish the primary anatomic site of bacterial translocation in the intestinal tract.

DESIGN

Prospective randomized experimental trials.

SETTING

Laboratory.

MATERIALS

Hartley guinea pigs.

INTERVENTIONS

In guinea pigs, 10-cm closed loops of upper jejunum, distal ileum, or proximal colon were created. The animals then received intraluminal injections of Escherichia coli labeled with radioactive carbon (14C) before a 50% full-thickness burn was inflicted. Four hours after the burn injury, the animals were killed, and the intestinal loops, mesenteric lymph nodes, spleen, liver, and lung were harvested. Intestinal loops were irrigated and then treated with ethylenedinitroilotetraacetic acid to separate the enterocytes and colonocytes from the lamina propria. Radionuclide counts were determined in the effluents, the enterocytes (or colonocytes), lamina propria, and other organs. Colony-forming units of E coli were also determined in mesenteric lymph nodes, spleen, liver, and lung.

MEASUREMENTS AND MAIN RESULTS

No significant differences were noted in the radionuclide counts in the lamina propria and epithelial cell fraction related to the type of loop. In addition, no significant differences were noted in the radionuclide counts in the mesenteric lymph nodes, liver, spleen, and lung related to the type of loop, but more viable bacteria were recovered when bacteria were injected into the jejunal loop.

CONCLUSIONS

Translocation of bacteria occurred with similar intensity throughout the gut, but more bacteria were killed in the process of translocation across the lower part of the intestinal tract.

The activity of GH/IGF-I axis in anorexia nervosa and in obesity: a comparison with normal subjects and patients with hypopituitarism or critical illness

GH/IGF-I axis activity changes have been reported both in anorexia nervosa (AN) and in obesity (OB). AN is characterized by GH hypersecretion and very low IGF-I levels as a result of undernutrition and acquired peripheral GH resistance. On the other hand OB is a GH hyposecretory state but IGF-I levels are generally preserved. The activity of GH/IGF-I axis in AN and OB has never been directly compared with that of other pathophysiological conditions such as hypopituitarism and critical illness in which a reduction of both GH and IGF-I secretion has been demonstrated. To this aim, we evaluated IGF-I levels and both basal and GHRH (1 microgram/kg) IV-induced GH secretion in 20 female patients with anorexia nervosa (mean age: 19.1 +/- 0.8 years) and in 15 female and 5 male patients with simple obesity (mean age: 39.0 +/- 3.0 years). We then compared the results with those of hypopituitaric patients with severe GH deficiency (GHD), including 10 female and 10 patients (mean age: 32.0 +/- 2.1 years), and with 4 female and 7 male patients with critical illness (CRI) following multiple trauma 72 hours after ICU admission (mean age: 59.2 +/- 1.2 years). Twenty-six normal subjects (NS) including 14 female and 12 male patients (mean age: 37.8 +/- 3.7 years) were studied as controls. Basal IGF-I levels in AN patients (93.5 +/- 11 micrograms/L) were lower (p < 0.001) than in the NS (201.7 +/- 13.5 micrograms/L) and OB (194.5 +/- 28.6 micrograms/L), which, in turn, were similar. IGF-I levels in AN patients were lower than in CRI patients (162.8 +/- 17.4 micrograms/L) and higher than in GHD patients (76.7 +/- 13.5 micrograms/L) but these differences did not attain statistical significance. Basal GH levels in AN patients (7.6 +/- 2.5 micrograms/L) were higher (p < 0.001) than in NS (1.8 +/- 0.3 micrograms/L), OB patients (1.1 +/- 0.5 micrograms/L), CRI patients (1.8 +/- 0.5 micrograms/L) and GHD patients (0.3 +/- 0.1 microgram/L), which were the lowest (p < 0.01). The GHRH-induced GH rise in AN patients (AUC: 2032.9 +/- 253.5 micrograms/L/h) was three fold higher (p < 0.001) than in NS (662.1 +/- 80.3 micrograms/L). On the other hand in OB (332.4 +/- 74.7 micrograms/L/h) the GH response to GHRH was similar to that in CRI (199.6 +/- 98.8 micrograms/L/h); both were clearly higher (p < 0.01) than in GHD patients (25.1 +/- 5.2 micrograms/L/h) but lower (p < 0.01) than in NS. These findings demonstrate that in AN patients, in spite of a clear increase of both basal and GHRH-induced GH secretion, IGF-I synthesis and release are as markedly impaired as in patients with panhypopituitarism and severe GHD. On the other hand in OB and in CRI, IGF-I synthesis and release are preserved despite marked impairment to GHRH-induced GH secretion. These results reinforce the major role of nutrition in conditioning the activity of GH/IGF-I axis in different patho-physiological states.

Nutrition and Infections

BACKGROUND

Patients with cancer suffer alterations of their metabolic state and nutritional depletion. This review was designed to evaluate the effect of different nutritional regimens on surgical outcomes.

METHOD

Review of the literature on parenteral and enteral nutrition and immunonutrition in patients with gastrointestinal cancer undergoing major surgery. The outcome measures were postoperative complication rate and length of hospital stay.

RESULTS

Postoperative enteral nutrition reduced significantly the rate of postoperative complications compared with parenteral feeding only in malnourished subjects. Several metaanalyses and randomized trials showed that preoperative and perioperative use of an enteral formula containing arginine and omega-3 fatty acids has a significant beneficial effect on surgical outcome in both well-nourished and malnourished patients.

CONCLUSIONS

Enteral immunonutrition should represent the first choice to nourish surgical subjects.

Single-incision versus standard multiple-incision laparoscopic cholecystectomy: a meta-analysis of experimental and observational studies

OBJECTIVE

The advantages of single-incision surgery for the treatment of gallstone disease is debated. Previous meta-analyses comparing single-incision laparoscopic cholecystectomy (SILC) and standard laparoscopic multiport cholecystectomy (SLMC) included few and underpowered trials. To overcome this limitation, we performed a meta-analysis of randomized and nonrandomized studies.

METHODS

A MEDLINE, EMBASE, and Cochrane Library literature search of studies published in and comparing SILC with SLMC was performed. The primary outcome was safety of SILC as measured by the overall rate of postoperative complications and biliary spillage. Feasibility was another primary outcome as measured by the conversion and operative time. Postoperative pain, length of hospital stay, perioperative blood loss, time to return to normal activity, and cosmetic satisfaction were secondary outcomes.

RESULTS

We identified 43 studies of which 30 were observational reports and 13 experimental trials, for a total of 7489 patients (2090 SILC and 5389 SLMC). The overall rate of complications was comparable between groups (relative risk [RR] = 1.08; 95% CI = 0.87-1.35; P = .46), as were the rates of biliary spillage (RR = 1.16; 95% CI = 0.73-1.84; P = .53) and conversion rate (RR = 0.88; 95% CI = 0.53-1.46; P = .62). Operative time was in favor of SLMC (weighted mean difference = 0.73; 95% CI = 0.67-0.79; P < .0001). Secondary outcomes favored SILC, but with marginal advantages.

CONCLUSIONS

SILC is a feasible technique but without any significant advantage over SLMC for relevant end points. Although secondary outcomes favored SILC, the small magnitude of the advantage and the low quality of assessment methods question the clinical significance of these benefits.

Training period in laparoscopic colorectal surgery

BACKGROUND

Thorough training is essential to the success of colorectal laparoscopic surgery (LPS). The aim of this study was to evaluate the results of a 3-month training period in LPS.

METHODS

Before beginning the study, the surgical team attended several courses of LPS and spent a long time working at a large animal facility to perfect laparoscopic techniques. Twenty-six consecutive patients underwent LPS in a 3-month training period. Controls (n = 26) who underwent open colorectal surgery (LPT) were selected to match the LPS patients for age, gender, primary disease, type of surgery, comorbidity, and nutritional status.

RESULTS

Conversion to open surgery was necessary in one patient (3.8%). The operative time was 1 h longer for LPS than LPT (p < 0.001). The mean number of lymph nodes harvested was 17 in LPS and 18 in LPT (p = 0.76). The first flatus (p < 0.02) and bowel movement (p < 0.002) occurred earlier in the LPS group. The postoperative infection rate was 11.5% for LPS and 19.2% for LPT (p = 0.33). Two anastomotic leaks occurred in each group. The mean postoperative hospital stay was 9.6 days (standard deviation [SD], 2.6) for LPS and 11.0 days (SD, 5.2) for LPT (p = 0.68). Recovery of postoperative physical performance and social life occurred earlier in the LPS than the LPT group (p < 0.001). At 1-year follow-up, no difference was found in terms of cancer recurrence or long-term complications.

CONCLUSION

Oncologic results and postoperative morbidity were comparable for LPS and LPT. LPS allows a faster postoperative recovery.

Hormonal and metabolic responses to acute ghrelin administration in patients with bulimia nervosa

Ghrelin is generally influenced by energy balance status and is inversely associated with body mass index (BMI), being reduced in simple obesity, notable exception being Prader Willi syndrome, and elevated in several conditions of undernutrition, including anorexia nervosa (AN). Interestingly, ghrelin levels have also been found elevated in patients with bulimia nervosa (BN) in spite of normal BMI. In humans, intravenous (iv) ghrelin administration induces endocrine (increase in GH, PRL, ACTH and cortisol) and metabolic (increase in glucose and decrease in insulin) effects as well as an increase in appetite and food intake. In AN, ghrelin administration surprisingly leads to a decreased GH response and absence of glycemic variations but normal PRL, ACTH and insulin response. This pattern would reflect a decrease in sensitivity to ghrelin or, alternatively, the metabolic status of AN. To further clarify the function of ghrelin in eating disorders, the endocrine and metabolic response to acute iv ghrelin (1.0 microg/kg) was studied in seven young women with purging BN (BW, BMI, mean+/-SEM: 20.3+/-0.5 kg/m2). Circulating total ghrelin levels were also measured. The results in BW were compared to those recorded in a group of nine healthy women (HW; BMI 22.3+/-2.5 kg/m2). The GH response to ghrelin in BW overlapped with that in HW. Ghrelin administration also led to a similar increase in PRL, ACTH, cortisol and glucose levels in the two groups. Insulin levels were not significantly modified by ghrelin administration in either group. The overlapping endocrine and metabolic response to ghrelin in the two groups occurred with regard to circulating total ghrelin levels which were higher in BW than in HW. In conclusion, BN, a condition of ghrelin hypersecretion, is connoted by a normal endocrine and metabolic response to exogenous ghrelin administration.

Enhanced recovery strategies in colorectal surgery: is the compliance with the whole program required to achieve the target?

PURPOSE

The complexity of "fast track" (FT) surgery might decrease its applicability in daily practice and extensive diffusion. The aim of this study was to understand if the positive effect of FT on the outcome might be affected by the number, type, level of evidence of the components, or their possible combinations.

METHODS

We performed a Medline, Embase, Pubmed, and Cochrane Library literature search of randomized and non-randomized trials comparing FT to conventional care (CC) in elective colorectal operations. By a meta-analytic approach, the effect of FT was estimated by the risk ratio (RR) with a 95 % confidence interval (CI) for the risk of post-operative complications.

RESULTS

The analysis included 53 studies (36 non-RCTs with and 17 RCTs), with 4,100 patients in the FT group and 4,424 patients in the CC group for a total of 8,524 patients. Fifty-six different item combinations were observed. The median rate of strategy implementation was 50 %. The positive effect of FT over CC was observed regardless the number (<10 vs. ≥10) of strategies used (RR = 0.80; 95 % CI 0.66-0.98 and RR = 0.75; 95 % CI 0.65-0.87, respectively), the application of items with strong vs. low level evidence (RR = 0.78; 95 % CI 0.67-0.90 and RR = 0.76; 95 % CI 0.63-0.92, respectively), or the frequency (≥80 vs. <80 %) of items implemented (RR = 0.80; 95 % CI 0.69-0.93 and RR = 0.73; 95 % CI 0.61-0.87, respectively).

CONCLUSION

The positive effects of FT seem to be achieved regardless the multiplicity and variance of item grouping.

Prognostic Impact of Preoperative Nutritional Risk in Patients Who Undergo Surgery for Pancreatic Adenocarcinoma

BACKGROUND

Nutritional derangements are common hallmarks of pancreatic cancer (PC). Their early detection and management are usually overlooked in routine practice. This study aimed to explore preoperative nutritional status and its prognostic value in patients undergoing surgery for PC.

METHODS

Data from 73 patients who underwent surgery for PC from November 2015 to January 2018 at the General and Pancreatic Surgery Unit, The Pancreas Institute, University Hospital of Verona Hospital, Verona, Italy, were retrospectively evaluated. The Nutritional Risk Screening (NRS)-2002 was used to evaluate the preoperative nutritional risk. Body composition was assessed using bioimpedance vectorial analysis (BIVA) on the day prior to surgery. The effect of clinical, pathological, and nutritional characteristics on overall survival (OS) was investigated using a Cox and logistic regression model. Kaplan-Meier curves were compared using the log-rank test.

RESULTS

Most patients (80.8%) were at preoperative risk of malnutrition (NRS-2002 ≥ 3) despite a mean BMI of 24.1 kg/m²(± 4.3). Twenty-four patients (32.9%) received neoadjuvant therapy prior to surgery. Preoperative NRS-2002 was significantly higher in this subset of patients (p = 0.026), with a significant difference by chemotherapy regimens (in favor of FOLFIRINOX, p = 0.035). In a multivariate analysis, the only independent prognostic factor for OS was the NRS-2002 score (HR 5.24, p = 0.013). Particularly, the likelihood of 2-year survival was higher in NRS < 3 (p = 0.009).

CONCLUSIONS

Our analysis confirms that preoperative malnutrition has a detrimental impact on OS in PC patients undergoing radical surgery for PC. Careful preoperative nutritional evaluation of PC patients should be mandatory, especially in those who are candidates for neoadjuvant therapy.

Further evidence of cholinergic impairment of the neuroendocrine control of the GH secretion in Down's syndrome

There are data indicating that cholinergic activity is precociously impaired in Down's syndrome (DS). On the other hand, acetylcholine as well as arginine (ARG) play a major stimulatory role in the neural control of growth hormone (GH) secretion in humans, likely acting via the inhibition of hypothalamic somatostatin release. The aim of the present study was to verify the effects of pyridostigmine (PD, 120 mg p.o.), a cholinesterase inhibitor, and ARG (0.5 g/kg i.v.) on the growth hormone-releasing hormone (GHRH) (1 microgram/kg i.v.)-induced GH rise in 15 adult patients with DS (M/F: 8/7; age 26.5 +/- 2.2 years; body mass index, BMI: 25.7 +/- 1.0 kg/m2) in which the potentiating effect of PD on GH secretion has been reported to be reduced. The results in DS were compared to those in 15 normal subjects (NS) (M/F: 8/7; age: 30.0 +/- 1.3 years; BMI: 21.4 +/- 0.4 kg/m2). Basal GH and insulin growth factor I (IGF-1) levels in DS (1.8 +/- 0.7 and 206.5 +/- 21.0 micrograms/l) were similar to those in NS (1.4 +/- 0.3 and 179.4 +/- 11.0 micrograms/l). The GH response to GHRH alone in DS (526.5 +/- 120.1 micrograms/l/h) was lower (p < 0.05) than that recorded in NS (895.4 +/- 153.7 micrograms/l/h). The GHRH-induced GH rise was potentiated by PD both in DS (1,138 +/- 184.2 micrograms/l/h; p < 0.02 vs. GHRH alone) and in NS (2,213.8 +/- 212.8 micrograms/l/h; p < 0.005 vs. GHRH alone); however, as the percent potentiating effect of PD was similar in both groups (215 and 247%, respectively) the GH response to GHRH + PD in DS was lower (p < 0.005) than that in NS. The GHRH-induced GH rise was also potentiated by ARG in both DS (2,243 +/- 362.4 micrograms/h; p < 0.001 vs. GHRH alone) and NS (2,764.3 +/- 325.7 micrograms/l/h; p < 0.005 vs. GHRH alone). As the percent potentiating effect of ARG in DS was more marked than in NS (425 vs. 308%, respectively), the GH response to GHRH + ARG became similar in both groups. No sex-related difference was found in the GH response to various stimuli both in DS and NS. In conclusion, these data demonstrate that the potentiating effect of PD but not that of ARG is impaired in adults with DS in whom a reduced somatotrope responsiveness to GHRH is present. These findings indicate that in DS the pituitary GH releasable pool is fully preserved while an impairment of the tuberoinfundibular cholinergic pathways could lead to somatostatinergic hyperactivity and low somatotrope responsiveness to GHRH.

Impact of enteral nutrition on intestinal bacterial translocation and mortality in burned mice

The aim of these experiments was to study the effect of early enteral nutrition with either standard or enriched (arginine, n-3 fatty acids, RNA) enteral formulas on translocation of bacteria from the gut and acute mortality rate following thermal injury. In the first experiment 60 Balb c mice were gavaged with 10(10)Escherichia coli and received a 20% burn injury. In 40 mice enteral nutrition (20 standard, 20 enriched) was started immediately after injury and stopped 36 h later. In the control group (n = 20) aliquotes of Ringer's solution was administered intragastrically. Mortality rate was observed for 10 days post-injury. In the second experiment 60 Balb c mice were gavaged with 10(10)E. coli labelled with biotin(111) Indium and then burned. In 40 mice enteral nutrition (20 standard, 20 enriched) was started immediately after burn. The control group (n = 20) received aliquotes of Ringer's solution. 4 h after injury all animals were sacrificed and liver, lungs, kidneys, spleen and systemic blood were harvested, and radionuclide counts were measured. No animal died after day 3 post-burn. The mortality rate was significantly lower at day 1 in the groups infused with both enteral solutions (15%) compared to controls (30%; p = 0.05). At day 3 the animals fed with the enriched diets showed a lower mortality (5%) versus the standard and control groups (10%). Bacterial translocation to the liver and lungs was significantly higher in Ringer's group than in both enterally fed groups. Early post-burn enteral nutrition reduces both translocation and acute mortality. Supplementation of the diets with specific nutrients appears to exert additional advantages on outcome.

Management and Outcomes of Pancreatic Resections Performed in High-Volume Referral and Low-Volume Community Hospitals Lead by Surgeons Who Shared the Same Mentor: The Importance of Training

BACKGROUND

High hospital volume improves outcomes after pancreatic resection. The aim of this study was to assess if practice and outcomes differed between high- and low-volume centers across which chief surgeons shared a similar training and mentoring.

METHODS

Data on patients undergoing standard pancreatic resections (2010-2013) at 7 Italian hospitals were collected. Chiefs of pancreatic surgery at each hospital had received the same training, with the same mentor. Two centers were high-volume referral hospitals for pancreatic disease, while 5 were low-volume hospitals.

RESULTS

A total of 856 patients were included, with median annual volume of resections 82 at high-volume referral hospitals and 11 at low-volume hospitals. Patients at low-volume hospitals were older, had more comorbidities, and were more often referred from the emergency room. Intraoperative techniques and reconstruction methods were similar. Comparable rates of major postoperative complications (18 vs. 22%; p = 0.236) and pancreatic fistula (29 vs. 32%; p = 0.287) were achieved in both groups, with no significant increases in failure to rescue from grade B-C fistula (6.2 vs. 15.0%; p = 0.108) and mortality (2.4 vs. 4.1%; p = 0.233) in low-volume hospitals. Postoperative length of stay was shorter in high-volume referral hospitals (10 vs. 15 days; p < 0.001).

CONCLUSION

Similar postoperative outcomes can be achieved across high- and low-volume centers where chief surgeons shared a similar training and mentoring. However, multidisciplinary postoperative provision more often associated with high-volume centers may also affect outcomes.

Reduction of bacterial translocation with oral fibroblast growth factor and sucralfate

The aim of this study was to evaluate the ability of basic fibroblast growth factor (bFGF) and sucralfate to prevent bacterial translocation after burn injury. Four groups of Balb/c mice (n = 10/group) were treated by gavage with bFGF (10 micrograms/kg/d), sucralfate (15 mg/kg/d), bFGF plus sucralfate, or saline for 4 days prior to receiving a gavage with 1 x 10(10) 14C-radiolabeled Escherichia coli and a 20% full-thickness burn. Four hours after burn, the mesenteric lymph nodes, liver, spleen, and blood were harvested aseptically. For each tissue, the number of viable bacteria and radionuclide counts of the translocated 14C-labeled E. coli were measured, and the percentage of translocated organisms that remained alive was calculated. The results indicated that treatment with either bFGF or sucralfate alone had a partial effect on translocation, whereas the combined treatment with bFGF plus sucralfate significantly decreased the magnitude of translocation in all tested tissues (p < 0.05, ANOVA), which was associated with complete preservation of gut mucosal integrity. None of the treatments affected the ability of the host to kill translocated bacteria when the results were compared with those of the controls. The additive effect of the combined therapy may be due to the high affinity of sucralfate for bFGF, decreasing the degradation of bFGF by gastric acid.

Vasodilators and primary pulmonary hypertension. Variability of long-term response

Long-term response to vasodilator therapy was assessed in six patients with PPH. Following an acute trial, each patient was restudied after (1) two months of drug administration, (2) one month of abstinence from therapy, and (3) an additional two months of therapy. Three of six patients had no long-term reduction of PVR after treatment; one showed a progressive increase. Of the three patients whose PVR was still reduced at the end of the second therapy period none showed a return of PVR to baseline during the abstinence phase, which may suggest that long-term reduction of pulmonary vascular tone may modify the vasoconstrictive component of this disease. The heterogeneous response of this small number of patients to sequential drug administration and withdrawal demonstrates the difficulty of interpreting previously reported clinical trials and underscores the need for a well-designed controlled study of vasodilator administration in these patients.

Effects of beta-adrenergic agonists and antagonists on the growth hormone response to growth hormone-releasing hormone in anorexia nervosa

BACKGROUND

In anorexia nervosa (AN), growth hormone (GH) hypersecretion and low insulin-like growth factor I (IGF-I) levels are present. It is unclear whether this is due to a peripheral GH resistance and a reduced IGF-I negative feedback on GH secretion or to a primary hypothalamic dysfunction. In AN, in contrast to normal subjects, cholinergic antagonists and agonists, whose action is somatostatin (SS)-mediated, have reduced and absent effects on the GH response to growth hormone-releasing hormone (GHRH). Since arginine, another substance acting via inhibition of SS, maintains its potentiating effect on GH secretion in AN, it has been hypothesized that somewhat specific alteration of the SS-mediated cholinergic influence may be present in this condition. To further clarify the neural control of AH secretion in AN, we evaluated the effects of beta-adrenergic agonists and antagonists, which are known to inhibit and increase, respectively, the GHRH-induced GH secretion in normal subjects.

METHODS

We studied the effect of atenolol (ATE), a beta 1-adrenergic antagonist, and salbutamol (SALB), a beta 2-adrenergic agonist, on the GHRH-induced GH release in 10 patients with AN and in 10 normal age-matched women (NW).

RESULTS

Basal GH levels were higher, whereas IGF-I were lower in AN than in NW. The GHRH-induced GH rise in AN was higher than that in NW. ATE significantly enhanced the GH response to GHRH in NW, but not in AN. The GH responses to GHRH after ATE pretreatment were similar in NW and in AN. The GH response to GHRH was inhibited by SALB in both NW and AN. The GH responses to GHRH after SALB pretreatment were similar in NW and AN.

CONCLUSIONS

These data reveal an exaggerated somatotrope responsiveness to GHRH in AN that is not further increased by beta-adrenergic blockade, while is abolished by beta-adrenergic activation. This suggests that an impairment of beta-adrenergic influence on GH secretion is present in anorexia nervosa.

Adrenocorticotropin- and cortisol-releasing effect of hexarelin, a synthetic growth hormone-releasing peptide, in normal subjects and patients with Cushing's syndrome

GH-releasing peptides (GHRPs) are synthetic, nonnatural molecules that strongly stimulate GH secretion, but also slightly increase PRL, ACTH, and cortisol levels in man. To investigate the mechanism underlying the ACTH- and cortisol-releasing activity of GHRPs in man, we compared the ACTH- and cortisol-releasing activity of Hexarelin (HEX; 2.0 micrograms/kg, iv), a hexapeptide belonging to the GHRP family, with that of human CRH (hCRH; 2.0 micrograms/kg, iv) in normal subjects (6 men and 6 women, 24-68 yr old) and patients with Cushing's syndrome (2 men and 15 women, 16-68 yr old). The GH response to HEX administration was also studied. In normal subjects, HEX administration significantly increased ACTH (peak us. baseline, mean +/- SD, 32.4 +/- 17.7 vs. 16.3 +/- 7.2 pg/mL; P < 0.005) and cortisol levels (135.9 +/- 51.0 vs. 110.0 +/- 31.6 micrograms/L; P < 0.01). The ACTH and cortisol responses to hCRH [35.7 +/- 13.2 vs. 17.1 +/- 7.7 pg/mL (P < 0.01) and 162.8 +/- 50.1 vs. 102.8 +/- 28.1 micrograms/L (P < 0.01), respectively] were similar to the responses to HEX. The stimulatory effect of HEX, but not that of hCRH, on both ACTH and cortisol secretion in Cushing's disease was clearly higher (P < 0.01) than that observed in normal subjects. In fact, in Cushing's disease both HEX and hCRH elicited a clear increase in ACTH levels [381.1 +/- 350.0 vs. 52.4 +/- 25.0 (P < 0.005) and 100.0 +/- 86.2 vs. 53.3 +/- 29.7 pg/mL (P < 0.01), respectively but the ACTH increase induced by HEX was about 7-fold greater (P < 0.02) than that induced by hCRH. Similarly, both HEX and hCRH elicited a significant increase in cortisol levels [366.9 +/- 189.5 vs. 189.7 +/- 86.3 micrograms/L (P < 0.005) and 209.9 +/- 125.4 vs. 167.2 +/- 96.3 micrograms/L (P < 0.02), respectively], but the cortisol increase induced by HEX was about 4-fold greater (P < 0.05) than that induced by hCRH. In patients with Cushing's syndrome due to adrenal adenoma or ectopic ACTH, no change in ACTH and cortisol levels was observed after either HEX or hCRH administration. The peak GH response to HEX in normal subjects was clearly higher (P < 0.03) than that in hypercortisolemic patients (45.8 +/- 20.5 vs. 22.4 +/- 21.1 micrograms/L). In conclusion, the ACTH- and cortisol-releasing activity of HEX is similar to that of hCRH in normal subjects, whereas it is dramatically enhanced in patients with Cushing's disease. This evidence indicates the importance of the ACTH-releasing activity of GHRPs and suggests that it could be at least partially independent of CRH-mediated mechanisms. As the stimulatory effect of HEX on ACTH and cortisol secretion is lost in patients with Cushing's syndrome due to adrenal adenoma or ectopic ACTH, these findings suggest the usefulness of GHRPs to investigate the activity of the hypothalamo-pituitary-adrenal axis in pathophysiological conditions and possibly to differentiate pituitary from ectopic ACTH-dependent Cushing's syndrome.

Functional hypothalamic and drug-induced amenorrhea: an overview

BACKGROUND

Functional hypothalamic amenorrhea (FHA) is a form of chronic anovulation not due to identifiable organic causes and with adverse health consequences. The identification of women with this disorder or the precocious identification of women at risk is based on the knowledge of lifestyle risk factors or behaviors such as stress, weight loss, and excessive physical exercise that are known to negatively impact gonadal axis activity.

METHODS

In this overview, we described the most common forms of FHA, in particular stress-induced amenorrhea and overtraining-induced amenorrhea. In addition, although its mechanisms can differ from those involved in FHA, we reviewed the available literature on drug-induced amenorrhea, highlighting the clear connection between this condition and psychoactive drugs such as antipsychotics, antidepressants and anti-epilectics thus raising concern about the role that the abuse of substances such as opioids or alcohol can possibly have on the growing unexplained infertility of the female population.