Life-threatening complications of streptococcal sepsis: a PICU contemporary series

Background

Life-threatening streptococcal sepsis nowadays represents an uncommon event in previously healthy infants and children. Critically ill patients suffering from severe streptococcal sepsis complications may present with pre-antibiotic era clinical pictures and require a timely clinical approach to achieve restitutio ad integrum.

Results

We report a series of four patient groups affected by an uncommon life-threatening streptococcal sepsis, each of them exhibiting some distinct features. Streptococcus Agalactiae sepsis was associated with cerebral thrombotic/ischaemic lesions, whereas severe cardiogenic shock was prominent in the Streptococcus Viridans group; Streptococcus Faecalis and β-hemolytic group A Streptococcus patients mostly reported lung complications.

Conclusions

Previous antibiotic treatments should not delay aggressive treatment in the intensive care setting. Early diagnostic suspicion, as well as appropriate and aggressive treatment provided within an intensive care setting are crucial for the clinical outcome.

Glucose metabolism outcomes in acromegaly patients on treatment with pasireotide-LAR or pasireotide-LAR plus Pegvisomant

INTRODUCTION

Disorders of glucose metabolism are a serious acromegaly comorbidity and may be differently impacted by medical treatments of acromegaly. In this retrospective longitudinal multicenter study, we investigated the outcome of glucose metabolism and its predictors in patients treated with Pasireotide LAR (PAS-LAR) alone or in combination with Pegvisomant (PAS-LAR + Peg-V).

SUBJECTS AND METHODS

Acromegaly patients treated continously with PAS-LAR or PAS-LAR + Peg-V for at least 6 months.

RESULTS

Forty patients (25 females, 15 males) were enrolled. At last visit, 27/40 patients (67.5%) reached biochemical control of acromegaly. Overall, glucose metabolism improved in 3 (all in PAS-LAR + Peg-V; 7.5%), worsened in 26 (65%) and remained unchanged in 11 patients (27.5%). Glucose metabolism worsened in 25 patients (73.5%) treated with PAS-LAR and in a single patient (16.7%) treated with PAS-LAR + Peg-V (p < 0.001). Among patients treated with Pas-LAR alone, GH at baseline was higher in those with worsening of glucose metabolism (p = 0.04) as compared to those with stable glucose status. A significantly higher reduction of HbA1c was observed in patients treated with PAS-LAR + Peg-V, as compared with those treated with PAS-LAR alone (p = 0.005).

CONCLUSIONS

Our data confirmed that glucose metabolism in patients treated with PAS-LAR is often worsened, and may be predicted by entity of baseline GH hypersecretion and by the dose of PAS-LAR. Moreover, our data, although limited by small numbers, may suggest that the combination treatment PAS-LAR + Peg-V can improve glucose homeostasis in selected patients.

The Role of Growth Hormone Receptor Isoforms and Their Effects in Bone Metabolism and Skeletal Fragility

Acromegaly and Growth Hormone Deficiency (GHD) are associated with skeletal fragility and with an increased prevalence of Vertebral Fractures (VFs). In the most recent years, several authors tried to investigate surrogate markers that may predict the risk of bone fragility in these endocrine disorders. The aim of this review is to evaluate the role of GH receptor polymorphisms in skeletal fragility in patients affected by GHD and acromegaly. In fact, until now, two different isoforms of the GH Receptor (GHR) were described, that differ for the presence or the absence of transcription of the exon 3 of the GHR gene. Both the isoforms produce a functioning receptor, but the exon 3-deleted isoforms (d3-GHR) has a higher sensitivity to endogenous and recombinant GH as compared to the full-length isoform (fl-GHR).

MON-311 Glucose Metabolism in Acromegaly Patients Resistant to First Generation Somatostatin Receptor Ligands Treated with Pegvisomant And/Or Pasireotide Lar

Introduction: Acromegaly (Acro) is a systemic disease characterized by high growth hormone (GH) and insulin like growth factor-I (IGF-I), insulin resistance, glucose intolerance (IGT) and higher diabetes mellitus (DM) risk in 15% - 38% of patients (pts). Moreover, different medical therapies of Acro are reported to have variable effects on glucose metabolism. An association between blood glucose (BG) and serum IGF-I levels in patients with DM and Acro has been suggested, while IGF-I levels and hemoglobin A1c (HbA1c) correlation is still controversial because of the multifactorial influence.Study aim: to investigate glucose metabolism in pts with Acro resistant to 1st gen somatostatin receptor ligands (SRLs) treated with Pegvisomant (Peg) or Pasireotide LAR (Pasi). Patients and Methods: Retrospective, international, multicenter study; consecutive pts enrolled according to following inclusion criteria for at least 6 consecutive months: (1) resistant to 1st gen SRLs, (2) treated with Pasi or Peg for active Acro. Patients with concomitant treatments with known action on glucose metabolism were excluded, with the exception of glucocorticoid replacement for central hypoadrenalism. Results: 72 pts with active Acro, mean age at study entry 37 ±15 yrs, 47 females (65.3%). 28 (38.9%) pts were treated with Pasi and 44 pts with Peg (61.1%). Peg was monotherapy in 18 pts (40.9%) and in combo with first generation SRLs for 26 pts (59.1%). The number of pts with IGT and DM2 was superimposable between the 2 groups (Pasi and Peg). In Pasi group, 19 pts had Acro control (67.9%); glucose metabolism worsened in 16 pts (57.1%). Worsening of glucose metabolism occurred most frequently in pts with persistently active Acro (62.5%) and in pts with higher BG and HbA1c values at study start. Similarly, HbA1c was higher in pts with active Acro, although HbA1c worsened during Pasi treatment both in euglycemic and IGT at study entry, regardless of Acro control. In Peg group, 31 pts reached Acro control (73%); glucose metabolism worsened in 12 (27.3%) but improved in 5 pts (11.4%). All pts who experienced glucose metabolism improvement had controlled Acro, regardless of the use of a combo with first generation SRL. Among the 13 pts with active Acro after Peg, BG worsened in 5 cases (38.4%). Moreover, we found that pts with worsening BG control had higher HbA1c (p=0.03) and required higher Peg doses (mean ±SD 25 ±10 mg/day; p=0.04). Patients with higher HbA1c had higher IGF-I, both at study entry and at study end and were treated with higher Peg dose (mean 25 mg/day). Conclusion: Impaired glucose metabolism was more frequent after Pasireotide treatment and in patients of both Pasireotide and Pegvisomant groups with altered pre-treatment glucose and persistently active disease. Therefore, in such acromegaly patients close monitoring of glucose status is recommended during treatment.

Environmental pollution effects on reproductive health - clinical-epidemiological study in southern Italy

This study aims to address the clinical, statistical and Epidemiological Relationship Between Birth Defects and Environmental Pollution, in the Campania Region and in Salerno.

OBJECTIVES

WE EXAMINED FOUR GROUPS OF SUBJECTS AS FOLLOWS: a sample of pregnant women living in Salerno, a sample of pregnant women living in highly polluted areas, a sample of controls, pregnant women and residents out of the Campania Region, considered in unpolluted areas (Foggia) and in the Salerno area.

METHODOLOGIES

a toxicological and genetic analysis was conducted on patients examined.

CONCLUSIONS

there is an epidemiological link between environmental pollution and reproductive health in the Salerno area. Experimentally there are the first evidences of endocrine disruptors by the PCB. It has been inferred an overexpression of the mir-191 as a marker of pollution by dioxin-like compounds. Socially, correct information of populations at risk is necessary and a possible preventive and ongoing medical care must be ensured.

A new long-term reversible contraception method: sexual and metabolic impact

BACKGROUND

Data relating to the influence of hormonal contraception on sexual life are conflicting and mostly they refer to oral contraceptives. In this study we evaluated the effect of a long-acting contraceptive on sexual function, metabolism and bleeding pattern variations.

METHODS

23 women with a permanent partner and an active sexual life completed a specific questionnaire at the start of the study and after cycles 3 and 6 of contraceptive use; a blood sample was performed or metabolic evaluation and a "bleeding calendar" was compiled by the patients.

CONCLUSION

There is an increase of quality and frequency of sexual function after 6 month of contraception; there aren't significant change in metabolic parameters and is detectable a modification of bleeding patterns.

Estrogens and neuropeptides in postmenopausal women: un update

Menopause is characterized by depletion of ovarian follicles, a reduction of ovarian hormones to castrate levels and elevated levels of serum gonadotropins from the anterior pituitary gland. Although this process has significant repercussions throughout the body and affects a large proportion of our society, the neuroendocrine control mechanisms that accompany menopause are poorly understood. This review aims to examine rigorously the most accredited literature to provide an update about our current understanding of the role of the hypothalamic-pituitary axis in the onset of and transition into female reproductive senescence, focusing on the role of some specific neuropeptides in regulating the HPG axis and on their effects on several menopausal symptoms, especially referring to the cardiovascular risk, to open up new horizons for new therapeutic strategies.

Emergency contraception: an updated review

Emergency contraception is a common practice now. Many categories of drugs are marketed with modifications in dosage, in combination and even in the timing of administration. Recent re-analysis suggests that there is still no uniformity of opinion on the actual mechanism of action and this has often fueled the ethical controversy. This review analyzes the most common emergency contraception drugs: levonorgestrel, mifepristone and ulipristal acetate about their action underlining that the hormonal products, when used in emergency contraception, play different roles depending on the phase of the menstrual cycle during which they are administered.This review aims to examine rigorously the most accredited literature to verify if a evidence-based uniformity of opinions has been achieved about the biological effects of hormones administered after the sexual intercourse.

Mixing and reaction efficiency in closed domains

We present a numerical study of mixing and reaction efficiency in closed domains. In particular, we focus our attention on laminar flows. In the case of inert transport the mixing properties of the flows strongly depend on the details of the Lagrangian transport. We also study the reaction efficiency. Starting with a little spot of product, we compute the time needed to complete the reaction in the container. We find that the reaction efficiency is not strictly related to the mixing properties of the flow. In particular, reaction acts as a "dynamical regulator".

[Revascularized jejunum loop in hypopharyngeal reconstruction: oncological and functional results]

The aggressiveness of hypopharyngeal cancer makes broad resectioning of the circular pharyngolaryngoesophageal segments necessary, followed by reconstruction to restore the anatomical gap created as fully as possibly creating a neoesophagus with thin walls that can easily be released. Over the years several procedures have been fine tuned for reconstruction of the upper digestive tract employing transposed viscera, miocutaneous pedunculated flaps, revascularized fascio-cutaneous or visceral free flaps. Currently the revascularized jejunum loop is one of the most commonly used methods in the reconstruction of the hypopharynx. Its popularity is due to some anatomical and physiological advantages: it requires transposition of a brief intestinal tract anatomically well adapted to the reconstruction site, ensuring rapid functional recovery. The authors report the oncological and functional results obtained in 25 patients who underwent circular pharyngolaryngectomy followed by reconstruction with a revascularized jejunum loop. The percentage of transplant survival was 90% and local and general complications were reduced to a minimum. The functional results--both in terms of deglutition and phonation--were satisfactory while patient survival (6-37 months follow-up) was in line with that reported by other authors for the same tumor (47%). Although prognosis for hypopharyngeal-esophageal neoplasms is still quite poor, this experience shows that circular pharyngolaryngectomy followed by reconstruction with autotransplant of the jejunum is an excellent choice since it offers the patient a prompt, acceptable functional recovery and a fair quality for his remaining life.

[Treatment of the nephrotoxicity of immunosuppressive drugs with insulin-like growth factor-I]

BACKGROUND

Delayed graft function is a common and severe complication after cadaveric kidney transplantation. Besides a more complicated postoperative course, DGF can worsen the overall graft survival. In particular, DGF enhances the nephrotoxicity of mainstream immunosuppressants cyclosporine and FK506. This study evaluates a new therapeutical approach to the treatment of DGF related nephrotoxicity, based on the administration of IGF-I.

METHODS

Sixty inbred Lewis rats underwent a bilateral clamping of the renal pedicles (20') as standard damage. The animals were stratified in six groups, according to the postoperative treatment. Group 1 served as control and received only the standard ischemic injury. Cyclosporine and FK506 were added in groups 3 and 5. Groups 2, 4 and 6 had the same treatment of groups 1, 3, 5 respectively, plus the administration of IGF-I. Blood samples were drawn daily to evaluate creatinine and BUN for 7 days.

RESULTS

The rats treated with IGF-I had significantly better values compared to the respective controls (2-way ANOVA, p < 0.05).

CONCLUSIONS

In conclusion, IGF-I improves the nephrotoxicity of mainstream immunosuppressants in this model. Its use is potentially beneficial for transplantation.

[Duodenal schwannoma. Clinical considerations]

The recent observation of a case of schwannoma in the second part of the duodenum lead the authors to a literature survey in order to state the present knowledge of this subject. Schwannoma is an ectodermal neoplasm arising from the nerve sheath that envelop axons. In the gastrointestinal tract these tumours can concern cells of the myentericus and submucosus plexus of the intestinal wall. A duodenal location is extremely rare. Gastroduodenal endoscopy, abdominal ultrasonography and CT scan were found as important investigatory tools, but only histological examination of the excised tissue suggests the definitive diagnosis. Therapy consists in the radical excision of the tumour; this is rarely obtained by endoscopic way because of the submucosal neoplastic growth. Then a surgical laparotomic approach is more often required and it allows to perform local excisions through a duodenotomy, partial duodenectomy or ampullectomy and more complex operations, like a cephalic duodenopancreatectomy, in front of extended papillar involvement. The latter was the suitable treatment for radical removing of the juxtapapillar schwannoma reported by the authors; the uneventful postoperative course, the patient's excellent general conditions and nutriture at 12 months confirm the validity of the therapeutic policy.