Association of disruption of the right posterior arcuate fasciculus with spatial neglect

OBJECTIVE

Spatial neglect is a debilitating condition observed in patients with right-sided brain injuries in whom there is defective awareness of the contralesional space. Although classically considered a right parietal lobe deficit, there has been increasing interest in the specific white matter (WM) architecture subserving spatial neglect. Patients who have lesions associated with chronic disruptions in visuospatial networks are of significant relevance in elucidating the WM tracts associated with spatial attention. In this study, the authors used two independent analytical methods to examine the relationship between WM connectivity changes and spatial attention.

METHODS

Thirty patients with right-sided glioma underwent diffusion tensor imaging (DTI) tractography and neuropsychological testing prior to tumor resection. Spatial neglect was assessed using the Bells Test. Diffusion connectometry analysis was performed to calculate the probability of injury to 55 WM tracts. Next, quantitative DTI tractography was used to reconstruct 9 major WM tracts and obtain fractional anisotropy (FA) and streamline number values as indices of connectivity. Differences in connectivity were assessed between patients with neglect and controls.

RESULTS

Of the WM tracts analyzed by diffusion connectometry, only the right posterior segment of the arcuate fasciculus (psAF) showed a higher probability of disconnection in patients with evidence of hemispatial neglect compared to tract reconstructions of previously published healthy controls (hemineglect: 42% ± 12.5%, vs control: 6.3% ± 4.8% [mean ± SEM]; p < 0.05). Of the WM tracts reconstructed by DTI tractography, only the right psAF demonstrated consistently lower indices of connectivity based on the mean streamline number (hemineglect: 550.35 ± 183.41, vs control: 1407.01 ± 319.93; p < 0.05) and FA value (hemineglect: 0.40 ± 0.013, vs control: 0.44 ± 0.0063; p < 0.05) in patients who demonstrated neglect compared to controls. The right long segment of the arcuate fasciculus, inferior frontooccipital fasciculus, and inferior longitudinal fasciculus also demonstrated a lower streamline number, but not a lower FA value, in patients with evidence of hemineglect.

CONCLUSIONS

These findings suggest that parietotemporal networks mediated by the right psAF may play a critical role in visuospatial attention. This analysis may help to disentangle the organization of the visuospatial attention networks, predict deficits in patients with glioma, and optimize surgical planning.

White matter tracts contribute selectively to cognitive functioning in patients with glioma

Objective

The functional organization of white matter (WM) tracts is not well characterized, especially in patients with intrinsic brain tumors where complex patterns of tissue injury, compression, and neuroplasticity may be present. This study uses diffusion tensor imaging (DTI) to investigate the relationships between WM tract disruption and cognitive deficits in glioma patients.

Methods

Seventy-nine patients with glioma underwent preoperative DTI and neuropsychological testing. Thirteen WM tracts were reconstructed bilaterally. Fractional anisotropy and streamline number were obtained for each tract as indices of connectivity. Univariate regression models were used to model the association between WM tract connectivity and neuropsychological outcomes.

Results

Glioma patients exhibited variable injury to WM tracts and variable cognitive deficits on validated neuropsychological tests. We identified 16 age-adjusted associations between WM tract integrity and neuropsychological function. The left inferior frontal-occipital fasciculus (IFOF) predicted list learning and dominant-hand fine motor dexterity. The right IFOF predicted non-dominant-hand fine motor dexterity and visuospatial index scores. The left inferior longitudinal fasciculus (ILF) predicted immediate memory list learning and index scores. The right ILF predicted non-dominant-hand fine motor dexterity and backward digit span scores. The left superior longitudinal fasciculus (SLF) I predicted processing speed. The left SLF III predicted list learning, immediate memory index scores, phonemic fluency, and verbal abstract reasoning. The left cingulum predicted processing speed. The right anterior AF predicted verbal abstract reasoning.

Conclusion

WM tract disruption predicts cognitive dysfunction in glioma patients. By improving knowledge of WM tract organization, this analysis may guide maximum surgical resection and functional preservation in glioma patients.

Abstract P4-04-04: Identification and development of oral estrogen receptor PROTAC degraders for breast cancer

ER-positive breast cancers comprise approximately 70-80% of all newly diagnosed cases. Downregulation or degradation of ER is a treatment approach currently used in the clinic to target estrogen receptor signaling. Faslodex, the only clinically-approved ER-downregulator, is administered as a monthly intramuscular injection with limiting pharmaceutical properties. Reasoning that an orally-available estrogen receptor degrader would be beneficial to patients, we have leveraged our experience in targeted protein degradation to generate and characterize novel proteolysis targeting chimeras (PROTACs) against estrogen receptor alpha. PROTACs are heterobifunctional molecules that facilitate the formation of a “trimer complex” comprised of the PROTAC, a pathogenic target protein of interest and an E3 ligase, which catalyzes the ubiquitylation and subsequent degradation of the target protein via the proteasome. To identify novel ER degraders (ER PROTACs), we have used several in vitro assays to characterize the extent of target engagement and receptor degradation. Potent ER PROTACs with good oral exposure and other pharmaceutical properties in multiple pre-clinical species were further evaluated in breast cancer xenograft models. Orally-administered ER PROTACs achieved &gt;80% degradation of estrogen receptor alpha and demonstrated single agent tumor growth inhibition in these disease models. Further, combination with a CDK4/6 inhibitor resulted in the expected improvement in anti-proliferative activity.

Citation Format: Flanagan JJ, Qian Y, Gough SM, Andreoli M, Bookbinder M, Bradley J, Rousseau E, Willard R, Crews CM, Crew AP, Taylor I, Houston J. Identification and development of oral estrogen receptor PROTAC degraders for breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-04-04.

Metaphyseal debonding of the Corail collarless cementless stem: report of 18 cases and case-control study

AIMS

The Corail stem has good long-term results. After four years of using this stem, we have detected a small group of patients who have presented with symptomatic metaphyseal debonding. The aim of this study was to quantify the incidence of this complication, to delineate the characteristics of patients presenting with this complication and to compare these patients with asymptomatic controls to determine any important predisposing factors.

PATIENTS AND METHODS

Of 855 Corail collarless cementless stems implanted for osteoarthritis, 18 presented with symptomatic metaphyseal debonding. A control group of 74 randomly selected patients was assembled. Clinical and radiological parameters were measured and a logistic regression model was created to evaluate factors associated with metaphyseal debonding.

RESULTS

The prevalence of this complication was 2.1% in our series. In the multivariable model, the presence of a Dorr B-type proximal femur was associated with metaphyseal debonding (odds ratio (OR) 10.73, 95% confidence interval (CI) 2.31 to 49.97, p = 0.002), as was a body mass index > 25 kg/m² (OR 6.85, 95% CI 1.06 to 44.28, p = 0.04). Smaller stems and the use of a polyethylene acetabular liner appeared to be protective when compared with metal and ceramic setting hard-on-hard bearings.

CONCLUSION

We have described an uncommon but important mode of failure of the Corail stem. Surgeons should be aware of this phenomenon; overweight patients with Dorr B-type femurs and in whom hard bearings are used appear to be particularly at risk. Cite this article: Bone Joint J 2017;99-B:1435-41.

Frequent attenders at a primary care clinic: Occasional or regular abusers?

Background

Frequent attendance in general practice is known for being associated with certain socio-demographical characteristics (female sex and middle-old age) and with important medical-psychiatric morbidity. Moreover, it has a high impact on workload of GPs. However, we have poor literature about long-term studies on Frequent Attenders (FAs) and persistent FAs.

Objectives

To re-evaluate a group of patients of FAs after nine years since first assessment; to determine the existence of others FAs and possible differences between persistent and occasional FAs.

Methods

Consultation of computerized data on 168 patients between 2001 and 2009; interwiew to the GP and the assistant.

Setting

A primary health care center in Fiorano Modenese (Modena, Northern Italy).

Patients

56 persistent FAs, 56 occasional FAs, 56 non FAs.

Main outcome results: Twenty-eight of 40 patients (70%) evaluated in 2001 were found to be persistent FAs, most frequently older women. Medical morbidity was frequent among persistent FAs, and intermediate among occasional FAs, while psychiatric morbidity does not show important differences between the two groups; however, depression was present in 46% of persistent FAs and in 41% of occasional FAs, while somatization only in occasional FAs (10%), and not among persistent FAs. Persistent FAs received more prescriptions for all types of drugs, while among the occasional FAs the requests for a psychiatric treatment were higher.

Conclusions

The phenomenon of frequent attendance has a large amount and claims for further studies. Psychiatric morbidity between persistent and occasional FAs might have different expressions, requiring different clinical approaches to be specifically tailored.

Functional role of Calcium-stimulated adenylyl cyclase 8 in adaptations to psychological stressors in the mouse: implications for mood disorders

The Ca(2+)/calmodulin stimulated adenylyl cylcase 8 (AC8) is a pure Ca(2+) sensor, catalyzing the conversion of ATP to cAMP, with a critical role in neuronal plasticity. A role for AC8 in modulating complex behavioral outcomes has been demonstrated in AC8 knock out (KO) mouse models in which anxiety-like responses were differentially modulated following repeated stress experiences, suggesting an involvement of AC8 in stress adaptation and mood disorders. To further investigate the role of this enzyme in phenotypes relevant for psychiatric conditions, AC8 KO mice were assessed for baseline behavioral and hormonal parameters, responses to repeated restraint stress experience, and long-term effects of chronic social defeat stress. The lack of AC8 conferred a hyperactive-phenotype both in home-cage behaviors and the forced swim test response as well as lower leptin plasma levels and adrenal hypertrophy. AC8 KO mice showed baseline "anxiety" levels similar to wild type littermates in a variety of procedures, but displayed decreased anxiety-like responses following repeated restraint stress. This increased stress resilience was not seen during the chronic social defeat procedure. AC8 KO did not differ from wild type mice in response to social stress; similar alterations in body weight, food intake and increased social avoidance were found in all defeated subjects. Altogether these results support a complex role of cAMP signaling pathways confirming the involvement of AC8 in the modulation of stress responses. Furthermore, the hyperactivity and the increased risk taking behavior observed in AC8 KO mice could be related to a manic-like behavioral phenotype that warrants further investigation.

[Prevention and therapy of critical ischemia in hemodialyzed patients]

The cardiovascular disease is largely increased in chronic renal failure and the patients have a 10-20 times higher mortality respect normal population. Besides habitual risk-factors they add the mineral metabolism alterations, iperomocisteine and chronical vessel flogosis. In these patients the vascular disease is often lately diagnosed, but early diagnosis would be extremely important to establish appropriate pharmacologic or surgical treatment (PTA or by pass). The basic diagnostic methods are still digital angiography, angio-NMR or angio-CT. In our experience appears that dialysed patients present high total mortality and re-vascolarization (particularly for peripheral occlusive disease) gives less guarantee of success. During last years endovascular surgery procedures extremely improved short-term prognosis for these patients. When there is no space for the re-vascolarization and the situation is strongly compromised by the presence of extended gangrene or infected lesion, amputation is still indicated and can be considered the only possible solution.

[Peripheral arteriopathy in ESRD dialysed patients: when and how to intervene]

Critical limb ischemia secondary to chronic peripheral occlusive disease is common in chronically dialysed patients, with an incidence rate of 25-30%. Atherosclerotic lesions are more frequent in the infrainguinal arteries and long infrapopliteal occlusions often occur. Due to diabetes, hypertension and ischemic cardiopathy, the surgical prognosis is very poor in these patients; medical treatment should always be attempted associated with analgesia, without an excessive delay in surgical therapy if needed. Both spinal stimulation and lumbar simpaticectomy often fail; open and endovascular surgery are the best options before major amputation, which has a high incidence in this patient subgroup. Between 2000 and 2003, 23 chronically dialysed patients underwent surgery. Nine open and 13 endovascular procedures were performed, associated with four immediate and five late minor amputations. Despite an immediate mortality rate of 8.6%, we obtained immediate patency and limb salvage in all cases. In a medium follow-up of 25 months (range 3-36), five thromboses were found in subinguinal procedures; not one in iliac procedures. The five patients underwent major amputation. Another two patients underwent amputation despite arterious patency. Seven patients died due to cardiovascular diseases during the follow-up. Our experience confirms that the association between POAD and dialysis is a prediction factor for medium-term death and that the surgical risk is highly increased. It is important to select patients undergoing surgical treatment to check for the lowest invasivity.

60 reoperations on 890 patients after gastric restrictive surgery

BACKGROUND

Since 1988 we performed gastric restriction operations on 890 patients; 60 required subsequent re-operation.

METHODS

The Molina non-adjustable band was discontinued early because of a high percentage of re-operations. Between 1992 and 1995, we performed the Mason vertical banded gastroplasty (VBG) using a 9-cm long vertical staple-line, with a re-operation rate of 15%. Since 1996, we have been performing a 6-cm long vertical staple-line, with a re-operation rate of 0.7%. The MacLean VBG also had a low re-operation rate (0.9%), but the seriousness of its most dangerous complication, perioperative cardia fistula, limited our use of this method to specifically selected cases. With adjustable banding, we have used the Swedish band which produced a low re-operation rate (2.1%), consisting of relatively simple corrective procedures.

RESULTS

The re-operations produced results similar to those of first-time operations in terms of weight loss and nutritional status. In particular, after 3 years, re-operated patients had similar weight to those who had been operated upon with the same method initially.

CONCLUSIONS

When the surgical procedure was selected with greater astuteness and modified appropriately, the re-operation rate decreased from 17% in the period 1992 to 1995, to 1% in the period 1996 to 2000.

Adaptability and compliance of the obese patient to restrictive gastric surgery in the short term

BACKGROUND

Low compliance, as well as recurrent vomiting, are often pointed out as the main causes of both postoperative technical complications and poor weight loss.

METHODS

50 patients were examined. All underwent preoperative psychological assessment through an intensive clinical interview. Between October 1999 and January 2000, all the patients underwent vertical banded gastroplasty (VBG). Excess Weight Loss (EWL) was followed, and the number of vomiting episodes was recorded at 1, 3 and 6 months after surgery.

RESULTS

3 different groups of patients could be distinguished: 1) those with no vomiting and good weight loss; 2) those with sporadic vomiting and fairly good weight loss; and 3) those with frequent vomiting and poorer weight loss. However, this last group of patients was not homogeneous and should be divided into 2 subgroups: 1) patients who lose weight, while vomiting; 2) patients who do not lose weight, while vomiting.

CONCLUSIONS

The experience of vomiting is a crucial cross-roads. The influence of psychosocial factors was noticed in all patients. The absence of psychosocial stressors, together with realistic expectations and a strong motivation to change, should be considered as reliable and replicable predictors of success. However, even those patients with accentuated psychological difficulties were able to succeed in coping with them, and achieved a good weight outcome, with good effects on the psychic side. Therefore, the evidence of psychological disorders cannot be taken as an absolute criterion of selection/exclusion of candidates for the operation. Accurate presurgical education and postoperative psychological support are likely to increase the patient's compliance and the percentage of successful cases.

Structural organization and chromosomal localization of the human type II deiodinase gene

OBJECTIVE

The selenoenzyme type 2 iodothyronine 5' deiodinase (DII) catalyzes the conversion of thyroxine into its active form tri-iodothyronine (T3), modulating thyroid hormone homeostasis in a local, tissue-specific manner. The amphibian, rodent and human cDNAs encoding this enzyme have been recently cloned and expressed. At present, little information regarding the genomic structure of mammalian DII is available.

DESIGN AND METHODS

The complete structure, including intron-exon junctions, of the human DII (hDII) gene was obtained by long PCR and rapid amplification of cDNA ends (RACE). Chromosomal assignment of the hDII gene was performed by fluorescence in situ hybridization using a highly specific probe.

RESULTS AND CONCLUSIONS

Our data demonstrated that hDII is a single copy gene located on chromosome 14, position 14q24.3. The gene spans over 15 kb, and the 7 kb transcript is encoded by three exons of 149 bp, 273 bp and 6.6 kb separated respectively by two 274 bp and 7.4 kb introns. A restriction map of the hDII gene is also reported. These data will help in further studies of the role of DII in the maintenance of peripheral thyroid hormone homeostasis.

Effect of tryptophan on the early tri-iodothyronine uptake in mouse thymocytes

OBJECTIVE

We have studied the effect of tryptophan on cellular [(125)I]tri-iodothyronine (T3) uptake by mouse thymocytes.

MATERIALS AND METHODS

Mouse thymocytes (20 x 10(6 )cells/ml) were suspended in Krebs-Ringer solution buffered by Tris-HCl and incubation (23 degrees C at pH7.45+/-0.6), in the presence or absence of 1mM tryptophan, was started by adding 25 pM [(125)I]T3. At the end of incubation, samples were cooled in ice, centrifuged over a 30% sucrose cushion and the cell-associated radioactivity was measured in the pellet.

RESULTS

Tryptophan reduced both the total and the saturable fraction of [(125)I]T3 uptake by 44% (P=0.0009) and 60% (P=0.0006) respectively, following 1 min of incubation. This effect was specific and dose-dependent, being maximal at 5mM concentration (-82%). In contrast, the pre-exposure of cells to tryptophan for up to 2h had no effect on the subsequent uptake of [(125)I]T3, in the absence of tryptophan. The effect of D-tryptophan on saturable T3 uptake was not different from that obtained using the L-stereoisomer. Tryptophan reduced the V(max) of the initial rate of saturable [(125)I]T3 uptake by two-thirds without affecting the apparent K(m) (2.2 nM) of the process, thus indicating the non-competitive nature of the inhibition. In sodium-free medium the saturable [(125)I]T3 uptake was reduced by 43%. The inhibitory effect of tryptophan on [(125)I]T3 uptake was exerted in both the presence and the absence of sodium. In fact, the inhibitory effect of tryptophan on T3 transport was greater and significantly different (P=0.0046) from that obtained by sodium depletion alone.

CONCLUSIONS

Tryptophan interferes with both the sodium-dependent and -independent components of [(125)I]T3 uptake by a dose-dependent, non-competitive mechanism which operates in cis-modality at the plasma membrane level of mouse thymocytes.

Voltammetric and functional evidence that N-methyl-D-aspartate and substance P mediate rat vascular relaxation via nitrogen monoxide release

It is known that substance P acts as a vasodilator via activation of the enzyme nitrogen monoxide synthase (NOS) in endothelial tissue and it is suggested that N-methyl-D-aspartate (NMDA) could stimulate nitrogen monoxide (NO) release within nervous tissue. However, the data reported concern NO metabolites (nitrites, nitrates), while there is no clear evidence to date of the action of the latter compound within the aortic tissue. In this study, amperometry with specifically prepared carbon fiber electrodes has been applied to examine the effect of NMDA or substance P upon NO release. In particular, the data obtained confirm that NMDA can stimulate NO release in vivo, in the striatum of anaesthetized rats, and that substance P can stimulate NO release in rat aortic rings (ex vivo experiments). In addition, they indicate that NMDA also stimulates NO release in rat aortic rings. This original data has been confirmed by the observation of a vasorelaxant action of NMDA within noradrenaline precontracted aortic rings. Thus, these experiments provide the first direct evidence that NMDA can mediate vascular relaxation via NO release.

Isolation of human type 2 deiodinase gene promoter and characterization of a functional cyclic adenosine monophosphate response element

We analyzed the structure and function of the 5' flanking region of the human type 2 deiodinase (hD2) gene. Two major transcription start sites were identified at -470/-474 from the ATG. The 5' flanking region of hD2 gene efficiently directed transcription in transient transfection studies, using luciferase as reporter gene, in HEK 293 cells. Basal transcriptional activity was significantly reduced by deleting the region containing a canonical cAMP-responsive element (CRE) located -766/-759 from ATG. Forskolin treatment significantly increased luciferase activity in cells transfected with CRE-containing constructs. This effect was abolished in constructs that did not contain CRE or contained the mutagenized CRE. Northern blot analysis in JEG-3 cells revealed that the hD2 messenger RNA was markedly increased after stimulation with cAMP agonist. The electrophoretic mobility shift assay with hD2-CRE probe and HEK 293 nuclear extract showed the occurrence of a DNA-protein complex, which was competed by specific unlabeled oligonucleotides and supershifted by the anti-CREB and anti-CRE modulator-1 antibodies. A-CREB, a dominant negative inhibitor of CREB, completely inhibited forskolin induction of the hD2 promoter. CREB protein, once cotransfected with hD2 promoter construct and pKA in F9 teratocarcinoma cells, which are unresponsive to cAMP, was able to stimulate the hD2 gene transcription. These results indicate the existence of a functional promoter within the 5' flanking region of hD2 gene which is characterized by the presence of a CRE. The specific involvement of CREB in the cAMP-mediated hD2 gene promoter induction also has been demonstrated.

[Thyroid diseases: molecular diagnosis and therapeutic perspectives]

The diagnostic algorithm of thyroid diseases, the most frequent dysendocrine condition, can be today integrated by the newly developed molecular methodologies. From the early diagnostic approaches, centered on the assessment of thyroid function, either by in vivo radioisotopic techniques, or by in vitro radioimmunological measurement of hormone plasma concentrations, it is nowadays possible to precisely define the molecular events triggered by the iodothyronine signal at the level of target tissues. In this brief review will be discussed the recent progresses on cloning and characterization of several genes involved in the regulation of thyroid differentiation, ability to trap iodine, synthesis and secretion of iodothyronines, regulation of thyroid function by TSH, transduction of the hormonal signal to subcellular structures involved in the translation of the hormone message in specific biological, effects such as those on metabolic homeostasis, cell proliferation and differentiation. It will be also discussed the most recent advancements on the genetics of thyroid diseases which have allowed to characterize the molecular basis of several thyropathies such as congenital hypothyroidism, thyroid hormone resistance syndrome, hyperthyroidism or hypothyroidism caused by TSH-receptor alterations, molecular abnormalities of oncogenes or tumor suppressor genes which are associated with benign or malignant thyroid cell transformation. The most recent developments of the diagnostic procedures of thyroid diseases, also in their pre-clinical stage, will be also reviewed together with a brief highlight on the most recent treatment options, centered on prophylactic therapeutic intervention or on the development of gene therapy strategies which will be possibly applied in a near future.

Atrophic body gastritis in patients with autoimmune thyroid disease: an underdiagnosed association

BACKGROUND

Atrophic body gastritis (ABG) has never been histologically characterized in patients with autoimmune thyroid disease (AITD), and its prevalence may be substantially different from that previously assessed based on only indirect evidence.

OBJECTIVE

To detect and characterize the presence of ABG in patients with AITD.

METHODS

Sixty-two patients with AITD (5 men and 57 women), aged between 21 and 74 years, have been screened for the presence of ABG by assaying serum gastrin levels. Patients with hypergastrinemia underwent gastroscopy followed by the histological examination of multiple biopsy specimens. The diagnosis of ABG was based on hypergastrinemia and pentagastrin-resistent achlorhydria, confirmed by histological examination.

RESULTS

Twenty-two (35%) of 62 patients had hypergastrinemia (mean +/- SEM gastrin level, 1070+/-288 pmol/L). The diagnosis of ABG has been histologically confirmed in all 22 patients, and the score of atrophy was moderate to severe. In group A (patients aged 20-40 years; n = 21), 6 patients (29%) had ABG, compared with 11 patients (37%) in group B (patients aged 41-60 years; n = 30) and 5 patients (45%) in group C (patients aged 61-80 years; n = 11). Antiparietal cell antibodies were detected in only 68% (15/22) of patients with ABG. Anemia was observed in 82% (18/ 22) of patients with AITD and ABG but only in 22% (9/40) of patients without ABG (P<.0001).

CONCLUSIONS

In the patients with AITD studied, about one third had ABG, which was diagnosed also in young patients; the measurement of gastrin levels represented the most reliable tool in the diagnosis of ABG; and the presence of anemia, even microcytic, was suggestive of undiagnosed ABG.

Laparoscopic surgery during pregnancy

STUDY OBJECTIVE

To describe the benefits, complications, and safety of laparoscopic surgery during pregnancy.

DESIGN

Retrospective case series (Canadian Task Force classification II-2).

SETTING

Community academic medical center.

PATIENTS

Nineteen pregnant women.

INTERVENTIONS

Five (26.3%) appendectomies, seven (36.8%) ovarian cystectomies, five (26.3%) cholecystectomies, one diagnostic laparoscopy (5.3%), and one (5.3%) salpingectomy. In one woman, laparoscopy was converted to exploratory laparotomy to complete a difficult ovarian cystectomy, and a second patient required a minilaparotomy incision to remove the specimen.

MEASUREMENTS AND MAIN RESULTS

No preterm labor or adverse perinatal outcome occurred, although one woman had irregular uterine contractions that promptly resolved with tocolytics. One patient delivered at 35 weeks' gestation and the rest carried their pregnancy to term, and all delivered normal infants. No malignancy was found on histopathologic examination of specimens. Hospital stay ranged from 1 to 4 days.

CONCLUSION

Laparoscopic surgery can be performed safely in pregnant women. This series adds 19 cases to the approximately 141 reported in the literature. (J Am Assoc Gynecol Laparosc 6(2):229-233, 1999)

An introduction to benign thyroid disease: pathophysiologic, epidemiologic aspects and diagnostic methodology

The role of preoperative noninvasive diagnostic procedures in the management of benign thyroid diseases is critically reviewed and on the basis of a series of more than 13,000 thyroid nodules, sequentially examined, the role of preoperative fine needle aspiration (FNA) cytology in discriminating benign from malignant lesions, is assessed. Retrospective studies were performed to determine the diagnostic accuracy of FNA adopted as routine preoperative screening procedure as compared to intraoperative frozen section (FS) analysis. US-guided FNA was shown to be more accurate allowing the preoperative identification of occult or minimal carcinoma: in fact about 3% of malignant thyroid nodules were detected. Moreover, the operation time is reduced, and unnecessary surgical treatments for benign lesions are eliminated, preventing the need of two-stage cancer surgery. FNA is a cost-effective diagnostic tool with about 20% reduction in the cost of care of patients with thyroid nodules. Most recent methods of molecular biology which seem promising in thyroid tissue sampled by FNA to detect malignant lesions missed by conventional cytology and included in the generic category of "follicular proliferation", are analyzed.

Orphan receptor hepatocyte nuclear factor-4 antagonizes estrogen receptor alpha-mediated induction of human coagulation factor XII gene

Factor XII (FXII) is a liver-specific zymogen involved in the regulation of hemostasis, particularly in the activation of fibrinolysis. Transcription of the FXII gene is stimulated by estrogens through specific interaction of the estrogen receptor alpha (ER alpha) with an estrogen response element present on FXII promoter. Interestingly, the magnitude of ER alpha induction in liver HepG2 cells is much lower than in NIH3T3 fibroblasts, suggesting that cell-specific factors may modulate ER alpha-dependent trans-activation. Comparative footprinting analysis of FXII promoter (from nucleotides -181 to +49) in liver vs. non-liver cell environments allowed identification of four deoxyribonuclease I-protected sites only in the presence of HepG2 nuclear extracts. Computerized homology search identified sites III and IV as consensus binding sequences for the liver-enriched transcription factor hepatocyte nuclear factor-4 (HNF-4), formerly an orphan receptor belonging to the superfamily of steroid/thyroid hormone nuclear receptors. In transient transfection assays in NIH3T3 cells, HNF-4 significantly inhibited (70%) estrogen induction of FXII promoter while not affecting basal promoter activity. Conversely, HNF-4 did not inhibit estrogen inducibility of FXII promoter in HepG2 cells due to the high endogenous levels of HNF-4 protein. In gel shift assays, HNF-4, either present in HepG2 nuclear extracts or generated by in vitro transcription/translation, specifically bound FXII promoter. This interaction is strictly required in eliciting the antagonistic effect because in NIH3T3 cells, selective mutations of sites III and IV abrogated HNF-4 inhibitory properties. In the liver-specific environment, the same mutant construct exhibited higher estrogen-dependent inducibility compared with native promoter. Rescue of estrogen responsiveness was also achieved using a dominant negative HNF-4, which counteracted endogenous HNF-4 activity. In conclusion, our findings address a direct role for HNF-4 in modulating estrogen-dependent transcription of the FXII gene promoter.

Retroperitoneal fibrosis: unusual localization

Six cases of retroperitoneal fibrosis, each with a different pathogenesis and unusual localization were observed from 1980 to 1996. Four patients had had previous surgery for a neoplasm, one patient had idiopathic retroperitoneal fibrosis, and the last patient was hardly classifiable due to the complexity of the clinical pattern. The mean survival in 3 patients with malignant retroperitoneal fibrosis was 7 months. Two patients treated with medical therapy are still alive and in good clinical condition. The aspecificity of the symptoms makes early diagnosis difficult. CT and NMR are essential procedures for differential diagnosis of abdominal masses. Histology differentiates benign from malignant retroperitoneal fibrosis. The choice between medical or surgical therapy depends on the general condition of each patient.

Genomic characterization of the coding region of the human type II 5'-deiodinase gene

Type II 5'-Deiodinase (5'DII) is a key element in the maintenance of peripheral thyroid hormone homeostasis through the regulation of local T4 to T3 conversion in pituitary, brain, brown adipose tissue and placenta. The cDNA containing the coding region of the human 5'DII (HDII) has been recently cloned from infant brain. In the present paper we report the genomic structure, chromosomal localization and restriction map of the coding region of HDII. The presence of a single intron located at codon 75 was demonstrated using a PCR-based strategy; the exon-intron junctions were then cloned and partially sequenced. Chromosomal localization was performed by radiation hybrid mapping. This study demonstrated that the entire coding region of the HDII gene is contained in two exons spliced at codon 75 by a 7.4 Kb intron and that the HDII chromosomal location is 14q24.3. These data will allow further studies of the role of HDII in the pathophysiology of thyroid homeostasis.

Combined impairment of nutritional parameters and thyroid homeostasis in mildly iodine-deficient children

The relation between thyroid homeostasis and the biochemical parameters of subclinical protein malnutrition has been analyzed in schoolchildren in a rural area in the south of Italy, known to be moderately iodine-deficient. The sera of 32 children (15 males and 17 females aged 6 to 11 years) have been analyzed. These children were divided into two groups, according to thyroid function: (1) 16 euthyroid children (mean thyrotropin [TSH] 2.38 +/- .35 mU/L; 6 with goiter) and (2) 16 subclinical hypothyroid children (mean TSH 7.32 +/- 1.68 mU/L; 6 with goiter). Retinol circulating complex (RCC) components were determined in serum by high-performance liquid chromatography (HPLC) and radial immunodiffusion and the essential and nonessential amino acid levels by ion exchange chromatography. Reduced retinol binding protein (RBP) and transthyretin (TTR) levels were recorded in the sera of 11 of 32 (34%) and in 5 of 32 (16%) patients, respectively. The linear regression analysis revealed that RBP and TSH levels were inversely correlated (r = -0.514; p < 0.0026). The RBP levels were subnormal in 2 of 16 euthyroid and in 9 of 16 hypothyroid patients (Fisher test p < 0.023), and the mean RBP levels were significantly reduced in the hypothyroid patients when compared with those of the euthyroid group (p < 0.0026). The retinol/RBP ratio was also significantly different between euthyroid and hypothyroid children (0.75 vs. 0.95; p < 0.0002). The mean essential amino acid levels, with the exception of methionine, were all in the normal range. The selected amino acid ratios confirmed that the patients were exposed to mild protein malnutrition. These results provide evidence that even mild protein-energy malnutrition may have detrimental effects on thyroid homeostasis in iodine-deficient areas.

Diagnostic accuracy of conventional versus sonography-guided fine-needle aspiration biopsy of thyroid nodules

Fine-needle aspiration biopsy (FNAB) is an accurate, slightly invasive, and safe method for the preoperative diagnosis of thyroid nodules. Recently, ultrasound guidance has been suggested as a valuable aid to enhance FNAB diagnostic performance. In this study, we have compared diagnostic accuracy of conventional FNAB (C-FNAB) versus sonography-guided FNAB (SG-FNAB) on a large sample population of 9683 patients with thyroid nodules. Over a 15-year period, 4986 patients were investigated by C-FNAB and 4697 underwent SG-FNAB. A valid cytological diagnosis was obtained in 85.9% of C-FNAB and in 91.5% of SG-FNAB cases, allowing detection of thyroid cancer in 1.6% and 2.1% of patients, respectively. The indeterminate pattern of follicular neoplasia was observed in 238 C-FNAB (5%) and in 272 (5.4%) SG-FNAB nodules. Specimens were cytologically inadequate in 433 C-FNAB (8.7%), but only in 167 SG-FNAB cases (3.5%). A total of 535 C-FNAB and 540 SG-FNAB nodules underwent surgery. False-negative results occurred in 7 C-FNAB nodules (2.3%), but only in 3 SG-FNAB cases (1%). Sensitivity, specificity, and global diagnostic accuracy of C-FNAB compared with SG-FNAB were 91.8% versus 97.1%, 68.8% versus 70.9%, and 72.6% versus 75.9%, respectively. Our results, based on a large population of thyroid nodules, demonstrate that SG-FNAB allows a more precise and adequate sampling of thyroid nodular lesions and is associated with a lower rate of false-negatives, thus improving global diagnostic accuracy in the preoperative selection of thyroid cancer.

Osteocalcin production in primary osteoblast cultures derived from normal and Hyp mice

Rickets and osteomalacia are characteristic features of the Hyp mouse model of human X-linked hypophosphatemia. Hyp mice demonstrate elevated circulating osteocalcin levels, as well as altered regulation of osteocalcin by 1,25(OH)2D3. Whether this osteocalcin abnormality is intrinsic to the osteoblast, or mediated by the in vivo milieu, has not been established. We therefore characterized osteocalcin production and its regulation by 1,25(OH)2D3 in primary cultures of murine osteoblasts and examined osteocalcin and its messenger RNA in response to 1,25(OH)2D3 in cultures of Hyp mouse-derived osteoblasts. Cell viability and osteocalcin production are optimal when murine cells are harvested within 36 h of age. Murine primary osteoblast cultures mineralize and produce osteocalcin in a maturation-dependent fashion (as demonstrated in other species), and continuous exposure to 1,25(OH)2D3, beginning at day 9 of culture, inhibits osteoblast differentiation and osteocalcin production and prevents mineralization of the culture. However, in contrast to other species, exposure to 1,25(OH)2D3, added later (days 17-25) in culture, does not stimulate osteocalcin but arrests osteocalcin production at current levels. Ambient media levels of osteocalcin were no different in cultures from Hyp mice and their normal litter mates, and the down-regulatory response to 1,25(OH)2D3 was comparable in cultures from normal and Hyp mice. Furthermore, expression of osteocalcin messenger RNA in murine cultures is reduced with exposure to 1,25(OH)2D3, and there is no difference between normal and Hyp cultures in this response. Thus, primary murine osteoblasts manifest a species-specific effect of 1,25(OH)2D3 on osteocalcin production. Furthermore, the increased serum osteocalcin production seen in intact Hyp mice, and the altered response to 1,25(OH)2D3 in Hyp mice, are not observed in osteoblast cultures derived from the mutant strain. These data indicate that abnormalities of osteocalcin described in intact Hyp mice require factors other than those present in cultured cells.

Diagnosis of thyroid carcinoma

Despite being one of the most frequent neoplasms occurring in the endocrine system, thyroid carcinoma is, nevertheless, a relatively rare event (0.5-1.5% of all malignant tumours in man); the differentiated forms are the most prevalent and are characterized by a high mean survival rate, whereas the very aggressive forms are rare and prognosis is unfavourable. Diagnostic evaluation of carcinomatous lesions, particularly in the early stages, may give rise to considerable difficulties at a clinical level due to the differentiation of the benign lesions, which are a frequent finding. The traditional clinico-semeiological and instrumental parameters, which, in the past, were used in the assessment of suspected malignancy, should not be considered as markers of malignancy; however, exposure to ionizing radiations during childhood may have a well defined role of risk. Following the recent progress in genetic and molecular studies, it is now possible to exploit genetic-molecular tumor markers and, at present, thyroid medullary carcinoma may be identified also in the absence of clinical evidence, particularly the familial form, thus allowing suitable prophylaxis in those subjects with specific genetic impairment (e.g. preventive thyroidectomy in infancy). Since no discriminating clinico-semeiological parameters are available, considering the aspecificity of scintigraphic findings and the lack of reliability of echographic imaging in providing data which enable us to distinguish a rare neoplastic pattern from the more frequent finding of a benign thyroid mass, fine-needle aspiration (FNA) cytology may today be considered the technique of choice in the screening of the thyroid nodule. Our experience in over 12,000 nodular lesions since 1982, has confirmed that the cytological examination is the most discriminating investigation, diagnostic reliability being far greater than that of traditional techniques. Considering the high frequency of thyroid nodule disease which rarely harbours a carcinomatous lesion, a very scrupulous diagnostic algorithm is mandatory. The FNA cytology, together with morphofunctional and immunological examinations, as well as dynamic exploration of the thyroid hypothalamo-pituitary axis, which allows a nosographic picture of the thyroid nodule disease, provides a more discriminating appraisal for the surgical approach to a single, solitary or prominent nodule.

Reversible increase of intraocular pressure in subclinical hypothyroid patients

OBJECTIVE

The aim of the study was to analyse the relationship between the ocular parameters, namely intraocular pressure (IOP), and the early forms of subclinical hypothyroidism.

DESIGN

Fifty-three subjects (9 male and 44 female) aged from 18 to 45 years (mean 32 +/- 7 years) were selected for this study. Twenty-nine met the criteria of subclinical hypothyroidism and 24 euthyroid subjects, age- and sex-matched, were used as controls.

METHODS

All individuals underwent a complete ocular examination, including visual field examination and serial measurement of IOP by means of a Goldmann tonometer. A tonographic examination was also performed.

RESULTS

The hypothyroid patients showed a substantially higher pressure in both eyes compared with control subjects (right eye = 17.52 +/- 4.74 vs 13.42 +/- 1.95 mmHg, P < 0.0001; left eye = 17.55 +/- 3.99 vs 13.71 +/- 1.55 mmHg, P < 0.0001). Indeed, the tonometric pressure exceeded 18 mmHg in 11 out of the 29 (38%) patients in the right eye and in 8 out of 29 (27%) patients in the left eye. The outflow index was normal in all subjects except in two hypothyroid patients. After two months of L-thyroxine (L-T4) replacement therapy, only one patient continued to show tonometric values above 18 mmHg and the hypothyroid patients showed a significant reduction in mean IOP in both eyes compared with pre-treatment values (right eye = 14.96 +/- 1.32 mmHg, P < 0.0097; left eye = 15.03 +/- 1.38 mmHg, P < 0.0018). Treatment did not lead to any change in the outflow indices; however, the C value (outflow coefficient at the sclerocorneal corner) returned to normal in the two patients with increased pre-treatment tonographic values.

CONCLUSIONS

These findings indicate that the intraocular pressure is increased even in subclinical hypothyroid patients and that, at this early stage, the impairment is fully reversible with L-T4 therapy.

[Clinical significance of Hürthle cell in the cytology of thyroid disease]

The natural history of Hürthle cell (HC) lesions has been the focus of a considerable debate. The difficulties in defining the malignant potential of HC has led to the current designation of HC tumor, with the implication that it may behave as either a benign or a malignant lesion. The objective of our study was to verify the clinical and prognostic relevance of the cytological diagnosis of HC in the thyroid lesion, 10,950 consecutive patients (F/M = 5.6/1) with thyroid nodules were evaluated by means of fine needle aspiration biopsy (FNAB). Cytological diagnosis showed the presence of HC in 285 cases (2.6%), with a F/M ratio of 8.2/1. In 123 cases (43.2%) cytologic diagnosis resulted benign. A suspicious pattern of follicular neoplasm was observed in 159 cases (55.8%). Only in 3 cases (1%) thyroid carcinomas were preoperatively identified. No false positive or negative cases were observed. Among the HC lesions, 85 patients (29.8%) underwent thyroid surgery because of a malignant or suspicious cytologic diagnosis, continuous nodular growth despite LT4 therapy, mechanical compression or clinical judgement. The other two hundred patients were clinically evaluated and, one year later, repeated FNAB confirmed the cytologic diagnosis of benignity. Among the follicular neoplasm nodules, 80 cases (55.3%) were surgically explored, and thyroid carcinoma diagnosed in 30 of them (37.5%), this percentage being greater than that observed in the group of non-HC follicular neoplasm (17%). Pathologic criteria for malignancy (vascular invasion, transcapsular penetration, destructive capsular invasion) were described in 25 out of all carcinomas.

Thyroid carcinoma in children and adolescents

A clinical and pathological study was undertaken to define the prevalence, clinical presentation and outcome of thyroid carcinoma in children and adolescents. Clinical records from 48 patients under 20 years of age at diagnosis, out of 372 patients with thyroid cancer examined between 1980 and 1994, were retrospectively reviewed. Female/male ratio was 3.8/1. None had a previous positive history of head and neck irradiation. Patients underwent near-total (44 patients) or partial (4 patients) thyroidectomy followed by 131I ablation of residual thyroid tissue. The mean follow up period was 58.4 months, ranging between 2 and 190 months. Clinically a thyroid mass was present in 41 patients, 28 of whom also showed neck lymph node involvement. Node metastases were present in 50% of the patients and lung metastases in 4.2%. Histological type was papillary in 41, follicular in 6, and medullary in 1 case. Surgical complications were observed in 19 patients (40%). In 3 patients papillary thyroid cancer was associated with chronic lymphocytic thyroiditis. All patients were treated with 1-thyroxine suppressive therapy. Recurrences of cancer after surgical and radio-iodine treatment was observed only in one patient 8 months after surgery.

CONCLUSION

Our experience demonstrates that thyroid carcinoma in childhood cannot be considered a rare occurrence, since it represents about 13% of all thyroid cancers, and is frequently associated with lymph node but rarely with distant metastases. Nevertheless, the prognosis of thyroid carcinoma in childhood is fairly good.

p53 re-expression inhibits proliferation and restores differentiation of human thyroid anaplastic carcinoma cells

Alterations of the tumor suppressor gene p53 are uncommon in differentiated thyroid neoplasia but are detected at high frequency in anaplastic thyroid carcinoma suggesting that impaired p53 function may contribute to the undifferentiated and highly aggressive phenotype of these tumors. Effects of wild type p53 (wt-p53) re-expression were investigated in a human anaplastic thyroid carcinoma cell line (ARO) expressing a mutated p53. ARO cells were stably transfected with the temperature-sensitive p53 Val135 gene (ts-p53) which exhibits wild type-like activity at 32 degrees C. Exogenous wt-p53 function in ARO-tsp53 clones was assessed by evaluating its transcriptional activity on a CAT reporter vector containing p53 binding sites. At 32 degrees C, a significant reduction in the proliferation rate (approximately or equal to 50%) was observed, with accumulation of cells in the G0/G1 phase of the cell cycle. This effect was accompanied by induction of the expression of the growth inhibitor p21/Waf1 gene. At 32 degrees C, ARO-tsp53 clones also showed a marked impairment of their tumorigenic potential. Furthermore, transfected clones re-acquired the ability to respond to thyrotropin (TSH) stimulation showing an increased expression of thyroid-specific genes (thyroglobulin, thyroperoxidase and TSH receptor). In conclusion, re-expression of wt-p53 activity in ARO cells, inhibits cell proliferation and restores responsiveness to physiological stimuli.

Laparoscopic cholecystectomy for recurrent gallstone pancreatitis during pregnancy

A pregnant patient with gallstone-induced pancreatitis initially responded to medical treatment, but the pancreatitis recurred. Endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy were done at 28 weeks' gestation. The remainder of the pregnancy was unremarkable. Although 20 cases of laparoscopic cholecystectomy have been reported for cholecystitis during pregnancy, this is the first report of laparoscopic management of recurrent gallstone pancreatitis in a pregnant patient.

[Post-operative hypothyroidism]

Hypothyroidism is not a rare condition, since it represents about 10% of thyroid diseases. It is more frequent in women (F/M = 5/1), and in patients older than 60 years of age. Postoperative hypothyroidism is secondary to thyroidectomy, and the incidence varies, with a reported range between 14% and 75%. This may be related to the amount of thyroid removed, the experience of the surgeon, age of patient, the function of remaining thyroid, and duration of postoperative observation. The analysis of our cohort of more than 23,000 thyroid patients showed a prevalence of hypothyroidism of 11.1%. Postoperative hypothyroidism represents about 39.7% of all hypothyroid cases, and 44% of patients underwent surgery. The prevalence is six fold higher in patients over the age of 60. Factors favoring development are the presence of lymphocytic infiltration of the thyroid and a positive serological test for thyroid antibodies. Overt hypothyroidism represented the largest proportion, prevailing in 60% of postoperative hypothyroid patients. In view of the insidious development of postoperative hypothyroidism in some patients, an accurate follow-up should be required, allowing an opportune treatment with LT4.

Molecular basis of estrogen regulation of Hageman factor XII gene expression

Estrogen therapy has been reported to cause multiple alterations in hemostasis and to increase blood levels of several procoagulants, including Hageman factor [factor XII (FXII)]. Liver FXII gene expression has been investigated in ovariectomized rats, treated or not with 17 beta-estradiol. A 6-fold stimulation of FXII gene transcription was observed in treated compared to untreated animals, indicating that 17 beta-estradiol is able to induce FXII gene expression in vivo. We have recently shown that human FXII promoter contains an imperfect palindrome, 5'-GGGCAnnnTGACC-3', at position -43/-31 resembling the consensus estrogen-responsive element (ERE). Portions of different length of the FXII promoter were fused to the chloramphenicol acetyltransferase (CAT) coding sequence and transiently cotransfected with human estrogen receptor (ER) into NIH3T3 and HepG2 cells in the presence or absence of 17 beta-estradiol. A 230-base pair fragment of FXII promoter, spanning nucleotides - 181/49, conferred a strong estrogen responsiveness to the CAT reporter gene, suggesting that a functional ERE resides in this region. Cognate receptors, such as those for thyroid hormone or retinoic acid, did not stimulate CAT activity. Gel mobility assays demonstrated a specific interaction between ER and the 230-bp FXII promoter fragment containing the putative ERE palindrome. Similar results were obtained when an oligonucleotide spanning the consensus ERE was used; the complex between ER and FXII promoter sequences was supershifted after the addition of an anti-ER monoclonal antibody. Insertion of FXII-ERE into the heterologous thymidine kinase promoter conferred a strong estrogen responsiveness that was abolished by mutations of the 5'-half of the palindrome. These results represent the first demonstration at the molecular level of the regulation of a blood coagulation factor gene by 17 beta-estradiol as well as the first identification of a functional ERE within this class of genes.

Lag in endometrial morphology in artificially reproduced cycles (ARC)

To observe if endometrial artificially reproduced cycles were identical to the natural spontaneous ones, we have matched for the endometria of 22 assessed spontaneous ovulating women and 16 postmenopausal ones sequentially treated with exogenous ovarian steroid hormones. The endometrial samples were drawn in the middle luteal phase (20th-22nd of an ideal cycle, 6-8 days from ultrasound assessed ovulation or progesterone exposure), because this is the "implantation window" period. These results can be particularly interesting in the FIV-OD technique that implyes the implantation of the zygote in a fully matured endometrium. Adversely to previous reports there was always an endometrial hystologic lag (2 min.-4 max. days) in all the artificially reproduced cycles observed, while no other endometrial anomalies were found in these last ones. Probably the contrasting results of the previous studies agree with the later timing of endometrial biopsy, because in the late luteal artificially reproduced or spontaneous endometrium there is no hystological difference.

PCR amplification and analysis of ras oncogenes from thyroid cytologic smears

Fine needle aspiration (FNA) cytology represents a reliable diagnostic procedure for preoperative identification of thyroid carcinoma. For improving its diagnostic accuracy, a technique that allows the analysis of cancer-related gene abnormalities on thyroid FNA smears has been developed. Cells were collected by scraping from thyroid smears, DNA-extracted and ras proto-oncogene sequences amplified by the polymerase chain reaction (PCR). Preliminary destaining of cytologic smears was essential for efficient PCR amplification. Twelve thyroid FNA cytologic smears, characterized by the indeterminate pattern of follicular neoplasia, were analysed for the presence of ras mutations known to confer an oncogenic potential. The same nucleotide substitution at codon 12 of the H-ras proto-oncogene was detected in two different thyroid nodules among six cases that, at final histology, were identified as follicular carcinomas. No ras mutations were observed in the remaining six cases that were diagnosed as follicular adenoma at histologic examination. Molecular analysis of FNA smears may provide additional information on the nature of the lesion underlying thyroid neoplasia, thus improving diagnostic accuracy of conventional FNA cytology.

[The autonomous nodule. Clinical aspects]

Autonomously functioning thyroid nodule (AFTN) includes a wide spectrum of unique or multifocal diseases, either hyper or euthyroid, which share the same independence from thyroid stimulating hormone (TSH) regulation in terms of growth and function. The pathological basis and the recent molecular implications of the disease are briefly discussed. Clinical and epidemiologic data of 1572 patients with AFTN, out of a population of 14107 patients with thyroid diseases, sequentially evaluated from 1974 to 1992, have been retrospectively examined. The mean age of AFTN occurrence is 41 years and it appears more frequently in women (F/M = 5.3/1). Clinical hyperthyroidism occurs only in 17% of patients and is more frequently observed in men over 40 years of age. The presence of sonolucent area inside the nodule is detectable in 8.6% of cases and may be associated with spontaneous arrest of growth. When AFTN is submitted to cytologic evaluation, patterns similar to those observed in nodular goiter are shown (colloid lesion, cyst and nodular hyperplasia). Signs of hyperactivity are also shown by follicular cells. In the presence of a cyst, a fine needle aspiration was performed and a complete resolution was observed in 40% of cases. When cyst recurred after aspiration, a solution of tetracycline was inserted into the cavity. Sclerosing therapy was efficient in evacuating the volume of the nodule in 50% of the cases. Patients with AFTN were followed for a mean period of 61 months and 84.7% of them did not show any morphological or functional change, while the remaining 15.3% of cases became hyperthyroid.(ABSTRACT TRUNCATED AT 250 WORDS)

[A Morgagni-Larrey hernia. A case report]

The paper reports a case of Morgagni-Larrey hernia observed by the authors. The etiopathogenesis is described and the importance of surgery is underlined even in asymptomatic cases in order to ensure a benign postoperative outcome.

Pattern of thyroid hormones in mildly protein-deficient women in area endemic for goiter

This study refers to 23 nonpregnant and 5 pregnant Ethiopian women living in a severely iodine-deficient area exposed to marginal chronic protein malnutrition. About half the study group exhibited goiter. The components of retinol circulating complex have been measured: transthyretin, retinol, and retinol-binding protein were 31 +/- 8 mg/dl, 36 +/- 6 micrograms/dl, and 3.1 +/- 0.6 mg/dl, respectively. No differences in circulating thyroid hormone pattern were found among goitrous and nongoitrous subjects. In nonpregnant women, the circulating thyroid hormone pattern was characterized by a low total T4 (TT4, 53 ng/ml), whereas free T4 (FT4, 0.5 ng/dl) was below the lower level of the range. Thyroid-stimulating hormone and FT3 were in the normal range, and TT3 was at the upper level of the range. The pregnant women exhibited the expected increase in total thyroid hormones (TT3 3.0 ng/ml, TT4 96 ng/ml), whereas the free fractions were equal to those of the nonpregnant subjects (FT3 2.5 pg/ml, FT4 0.6 ng/dl). In the whole group, the T3-T4 ratio was 3.4 x 10(-2), i.e., twice the normal ratio. No antibodies against thyroid structures were detected. These results indicate that the circulating thyroid hormone pattern of these marginally malnourished women differs from that reported for subjects with pure protein-calorie malnutrition or exposed to chronic iodine deficiency only. The main difference is that, even in the presence of low TT4 and FT4, the hypophysis-thyroid axis has apparently remained unchanged. The normal levels of TT3 and FT3, may account for the normal thyroid-hypophysis feedback.

Effect of extracellular sodium on thyroid hormone uptake by mouse thymocytes

In mouse thymocytes, a stereospecific saturable energy-dependent and ouabain-inhibitable system facilitates T3, but not T4, entry. We studied here the effect of sodium depletion on cellular uptake of thyroid hormones by mouse thymocytes. Time-course experiments indicated that extracellular sodium depletion reduced [125I]T3 uptake at each time studied. At equilibrium, the removal of extracellular sodium and its substitution with isoosmotic choline decreased saturable [125I]T3 uptake by 60 +/- 10%; this effect was dose dependent. The substitution of sodium with lithium, instead of choline, had no effect on the uptake process. [125I]T4 uptake was lower than that of [125I]T3 and not affected by sodium depletion. The half-maximal effect of sodium deprivation on [125I]T3 uptake was reached at an extracellular sodium concentration of about 40 mM. The variation of external pH influenced T3 accumulation by thymocytes. [125I]T3 progressively decreased from acid to alkaline pH under normal and sodium-depleted conditions; however, the sodium-dependent fraction was more than doubled at physiological pH compared to that at more acidic and more alkaline pH. The sodium ionophore monensin decreased T3 uptake by 51% at a concentration of 20 microM. These results indicated the existence of a sodium-related mechanism of T3 uptake into mouse thymocytes that does not operate for T4 uptake.

[Hypothyroidism: current clinical, physiopathological and therapeutic aspects]

The correct diagnosis and an appropriate classification of hypothyroidism must be considered on the light of the most recent physiopathological and molecular information. Hypothyroidism is no longer regarded as the rare disease characterized by a myxedematous condition as described since one century ago. With the present improvement of the diagnostic tools the thyroid hypofunction now includes all those blunted forms that are classified as subclinical or latent hypothyroidism. Thus, the hypothyroid syndrome, previously considered a rare event in its overt form, reaches a prevalence of 14% in female aged over fifty years. Following a coherent, concise historical review, the influence of age, surgery, drugs and autoimmunity on the etiology of the disease are critically discussed. The early detection and treatment of congenital hypothyroidism, to avoid an irreversible damage of the central nervous system, by means of the screening on the paper spot is also stressed. Replacement therapy with synthetic levothyroxine has to be personalized, according to the age and other clinical conditions, and should be prescribed also in the treatment of subclinical hypothyroidism.

Cytofluorometric analysis of lymphocyte subsets in thyroid aspirates from patients with autonomously functioning nodules

A microscale method, based on two-colour dye immunolabelling and flow sorting cytofluorometry, was used to characterize lymphocyte subsets in thyroid tissue specimens obtained by fine-needle aspiration (FNA) in 21 patients with autonomously functioning thyroid nodule (AFTN) and five patients with cold thyroid nodule (CTN). Inversion of the ratio between CD4+ and CD8+ lymphocytes, due to a relative increase of CD8+ cells, was found among intrathyroidal lymphocytes in AFTN patients. The abnormal lymphocyte subset distribution was not observed in the peripheral blood of the same group of patients. In patients with CTN the lymphocyte subset distribution was normal, both in the thyroid and in the peripheral blood. In AFTN patients, a significant correlation was observed between the decrease of intrathyroidal CD4+/CD8+ ratio and the increase of plasma thyroid hormone levels. Whether the immunological abnormalities found in AFTN could play a pathogenetic role in the clinical presentation and outcome of the disease remains to be established. The FNA-applied micromethod used in this study could be extended as a routine investigation to characterize the immunogenic substrate of thyroid disorders.

Carrier-mediated [125I]-T3 uptake by mouse thymocytes

Thyroid hormone entry into the thymocyte, a thyroid hormone target, was investigated by incubating the cells with tracer amounts of [125I]L-T3. At 37 C T3 uptake was linear with time up to 2 min, and then approached a plateau. The specific T3 uptake, obtained by subtracting the uptake in the presence of excess unlabeled T3, represented 48 +/- 6% of the total at equilibrium. Unlabeled L-T4, D-T3, and triiodothyroacetic acid were less effective than L-T3 in reducing [125I]T3 uptake. Kinetic studies on the initial rate of T3 uptake indicated, for the saturable process, a maximum velocity of approximately 1 pmol/10(6) cells.min and a Km of approximately 0.8 nM. Lowering incubation temperature to 4 C resulted in a two thirds reduction of the total T3 uptake. Washout experiments indicated a different hormone release, being more rapid for cells incubated at 4 C than at 37 C; at 30 min 70% of labeled T3 was released when incubation was carried out at 4 C compared to only 35% after incubation at 37 C, indicating the major intracellular location of the hormone at the latter temperature. An energy requirement of T3 uptake in thymocytes was shown by sensitivity to oligomycin; the effect was dose dependent, showing a maximal decrease in specific uptake of 85%. The involvement of cation movement in the entry process of T3 was indicated by the sensitivity to ouabain. These results indicate the existence of a stereospecific, energy-dependent, saturable process for T3 entry in thymocytes.