The Use of Lanreotide in the Treatment of Congenital Hyperinsulinism

CONTEXT

Congenital hyperinsulinism (HI) results in severe, persistent hypoglycemia and is associated with high risk of neurodevelopmental deficits. Sixty percent of HI cases are unresponsive to diazoxide, the only Food and Drug Administration-approved drug. Somatostatin analogs are used off-label as second-line treatment; the long-acting somatostatin analogue, lanreotide, has been used to treat HI over the past decade. Existing reports are limited to small case series.

OBJECTIVE

To assess the effectiveness and safety of lanreotide in individuals with HI.

DESIGN

Retrospective cohort study of individuals with HI treated with lanreotide between 2015 and 2020.

SETTING

The Congenital Hyperinsulinism Center at The Children's Hospital of Philadelphia.

PATIENTS

Fifty-four individuals with hyperinsulinism treated with lanreotide.

MAIN OUTCOME MEASURES

Fasting duration with plasma glucose > 70 mg/dL; frequency of lanreotide-associated side effects.

RESULTS

The median duration of lanreotide therapy was 28.7 (2.8-64.5) months. Thirty-four patients (63%) had HI due to inactivating mutations of the adenosine 5'-triphosphate (ATP) sensitive potassium channel (KATP-HI), and 39% had undergone a pancreatectomy. Of 52 patients receiving other HI therapies, 22 (42%) were able to discontinue other treatments and were managed on lanreotide alone. Fasting duration with plasma glucose > 70 mg/dL was significantly longer during therapy with lanreotide compared to prior to lanreotide initiation (8.6 ± 6.5 vs 5.1 ± 4.7 hours, P = 0.001). The most common side effects were subcutaneous nodules (26%) and gallstones (11%).

CONCLUSIONS

Lanreotide is a well-tolerated treatment for patients with HI. It results in a longer duration of fasting and a simplification of treatment regimens.

COGKNOW development and evaluation of an ICT-device for people with mild dementia

Dementia is a progressive, chronic disease affecting 5% of all persons above 65 and over 40% of people over 90. The aim of the COGKNOW project is to achieve a breakthrough with research that addresses the needs of those with dementia, particularly those with mild dementia living in the community. This entails cognitive reinforcement in four main areas: helping people to remember, helping to maintain social contact, helping with performing daily life and recreational activities and finally enhance feelings of safety. Based on a sound foundation of needs reported in dementia literature, workshops and individual interviews have been carried out with dementia sufferers and their carers in three European countries. A ranked analysis of information from workshops and interviews, and the state of the art of successful ICT solutions will be the basis for formulating the functionalities of the technical solution and for the development of a cognitive prosthetic device with associated services for people with mild dementia. The research and evaluation will be conducted from human factors, technology, and business perspectives in three phases of one year each. In this paper we discuss the design of the COGKNOW project, the first results of the user needs inquiry workshops and the ICT solutions the COGKNOW project will focus on in the first year.

Repair of transversely incised abdominal wall fascia in a rabbit model

OBJECTIVE

To compare several commonly used methods of closing transversely incised anterior abdominal wall in order to determine which technique results in the strongest incisional tensile strength.

METHODS

Thirty-six rabbits were randomized to receive either interrupted or continuous closure with 0-Vicryl. Within these groups, each animal was randomized to one of three different bite and interval techniques: 1-cm bites/0.5-cm intervals, 1-cm bites/1-cm intervals, and 2-cm bites/1-cm intervals. Each rabbit received three to four transverse abdominal wall incisions of approximately 3-8 cm in length. The incisions were excised en bloc and stored at -70C at postoperative week 1, 2, or 4 in a random fashion. Representative 1-cm strips were harvested from each incision after thawing. The Instron tensiometer was used to determine the maximum intrinsic tensile strength required to disrupt each tissue strip at the incision. Statistical analysis was performed using analysis of variance, two-sample t test, Scheffé multiple comparison, and Kruskal-Wallis test.

RESULTS

Two hundred thirty-seven strips were analyzed. The mean maximum tensile strength of all of the interrupted and continuous suture repairs was 48 and 38 lb, respectively (P < .001). The maximum tensile strength for interrupted closures was achieved at week 1 and was similar at week 4. The continuous closure was weakest at week 1 and increased to a maximum value during week 4. There was no difference in maximum tensile strength between the interrupted and continuous closure groups at week 4. There was no significant difference in the maximum tensile strength of the three repair techniques. The mean maximum tensile strength of all specimens was significantly less among those harvested during weeks 1 and 2 compared with week 4 (P = .001).

CONCLUSION

In this randomized study, the interrupted closure had a greater maximum tensile strength than the continuous closure in repair of transverse incisions during the first 2 postoperative weeks. Both repair methods were associated with a similar maximum tensile strength at 4 postoperative weeks. Repair techniques using different bite sizes and intervals resulted in similar maximum tensile strengths.

Hemorrhagic dilation of the fourth ventricle: an ominous predictor

Very little is known about the effect of computerized tomography (CT)-documented fourth intraventricular hemorrhage (IVH). An analysis of 50 patients with CT-documented fourth IVH treated between 1987 and 1992 is presented. The various etiologies included intraparenchymal hemorrhage with secondary fourth IVH (19 cases), spontaneous subarachnoid hemorrhage (18 cases), spontaneous IVH (seven cases), and trauma (six cases). Overall, 28 patients (56%) had hemorrhagic dilation of the fourth ventricle and all 28 suffered brain death, despite aggressive therapy in 79% of cases. Twenty-two patients (44%) had fourth IVH without dilation; of these, nine (41%) died and 13 (59%) experienced functional survival, despite aggressive care in 90% of cases. The survival rate was significantly worse for patients with dilation of the fourth ventricle (p < 0.01, chi-squared test). Of the 28 patients with fourth IVH associated with dilation, 25 (89%) had diffuse clot, involving the lateral and third ventricles as well, and three (11%) had isolated fourth IVH. Of the 22 patients with fourth IVH and no dilation, 13 (59%) had diffuse IVH (eight of these died and five had functional recovery) and nine (41%) had isolated fourth IVH (one died and eight had functional recovery). Diffuse ventricular clot was associated with an increased mortality rate for patients with fourth IVH and no dilation (p < 0.05). Of the 28 patients with fourth IVH associated with dilation, 24 (86%) presented with a Glasgow Coma Scale (GCS) score of 3 or 4, one with a GCS score of 6, and three with a GCS score of 13 to 15; all 28 died. For the 22 patients with fourth IVH and no dilation, nine presented with a GCS score of 3 to 5 (eight died and one had functional recovery), three had a GCS score of 6 to 8 (all three had functional survival), two had a GCS score of 9 to 12 (both had functional survival), and eight had a GCS score of 13 to 15 (one died and seven had functional survival). There was a greater chance of higher GCS scores in patients with fourth IVH and no hemorrhagic dilation (p < 0.01). Logistic regression multivariate analysis showed hemorrhagic fourth ventricular dilation to be the most significant outcome predictor (p = 0.0001), followed by GCS score (p = 0.007) and the presence of diffuse IVH (p = 0.0279).

Closed continuous drainage of cerebrospinal fluid via a lumbar subarachnoid catheter for treatment or prevention of cranial/spinal cerebrospinal fluid fistula

One hundred and seven patients who had a lumbar subarachnoid catheter (teflon or silicone) placed for closed continuous cerebrospinal fluid (CSF) drainage between 1983-1991 are presented. Overall, the drain was successful in achieving the desired goal in 101 of 107 (94%) cases. There were no deaths. Five of 107 (5%) patients developed infections including two cases (2%) of meningitis. There were three cases (3%) of overdrainage with temporary neurologic decline, but all recovered. Five of fifteen (33%) teflon catheters required replacement because of occlusion, but only 5 of 92 (5%) silicone catheters required replacement. Transient lumbar nerve root irritation was seen in 15 of 107 (14%) patients treated for a CSF fistula, and all symptoms resolved after drain removal. CSF fistula/pseudomeningocele after spine surgery was cured by CSF drainage in 36 of 39 (92%) cases; there was a 10% incidence of infection (1 wound, 2 discitis, 1 meningitis). CSF fistula after cranial surgery was cured in 22 of 25 (87%) cases; there was 1 case of (4%) infection and 1 case (4%) of overdrainage. A drain was used to augment a tenuous dural closure in 38 patients with 100% success; no infection occurred and there were 2 cases (5%) of overdrainage. Five patients were successfully treated for traumatic CSF rhinorrhea/otorrhea without complications. The silicone catheter appears superior to the teflon catheter; however, both are simple, safe, and efficacious for the treatment or prevention of CSF fistulas.

Cell kinetics by bromodeoxyuridine labeling and deoxyribonucleic acid ploidy in prostatic carcinoma needle biopsies

We studied 63 prostate carcinomas in needle biopsies after labeling in vitro by incubating the entire biopsy specimen with tritiated thymidine or bromodeoxyuridine before fixation. Biopsies from 176 patients were labeled, of which 98 were benign and 78 were carcinomas (15 carcinomas were excluded because of scant tissue). The procedure did not interfere with histological diagnosis. Median labeling index was 0.87% (range 0.1 to 29.3%). A labeling index exceeding 3% was unusual but it may indicate the potential for rapid clinical progression. Deoxyribonucleic acid (DNA) flow cytometry was performed on the last 44 carcinomas using cells shed by the prostatic needle biopsy tissue samples during transportation to the pathology laboratory. A sufficient number of cells were obtained for analysis in 37 cases, of which 6 were DNA aneuploid. Labeling index correlated with Gleason histological grade and score, and data from the 6 DNA aneuploid carcinomas suggest association between DNA aneuploidy and a high labeling index. Estimates of percentage of S-phase cells by flow cytometry did not correlate with variables other than DNA index, and appear to have been affected by a high noise-to-signal ratio (few proliferative cells relative to cellular debris) and inability to discriminate between benign and carcinomatous cells.