Self-limited acute hepatotoxicity caused by pegvisomant

We present a case of acute severe hepatitis in a patient with acromegaly receiving combination therapy with somatostatin analogs and pegvisomant. Hepatitis resolved completely 18 weeks after diagnosis of hypertransaminasemia without discontinuation of therapy and with a close clinical and biochemical follow-up. In this case, despite the severity of the hepatitis, therapy could be continued as hypertransaminasemia was gradually decreasing after the maximum peak. We also review the literature on toxic hepatitis associated to pegvisomant therapy analyzing the etiology, clinical predisposing factors and natural evolution.

A single nucleotide deletion at the C1 inhibitor gene as the cause of hereditary angioedema: insights from a Brazilian family

BACKGROUND

Hereditary angioedema is an autosomal dominant disease characterized by episodes of subcutaneous and submucosal edema. It is caused by deficiency of the C1 inhibitor protein, leading to elevated levels of bradykinin. More than 200 mutations in C1 inhibitor gene have been reported. The aim of this study was to analyze clinical features of a large family with an index case of hereditary angioedema and to determine the disease-causing mutation in this family.

METHODS

Family pedigree was constructed with 275 individuals distributed in five generations. One hundred and sixty-five subjects were interviewed and investigated for mutation at the C1 inhibitor gene. Subjects reporting a history of recurrent episodes of angioedema and/or abdominal pain attacks underwent evaluation for hereditary angioedema.

RESULTS

We have identified a novel mutation at the C1 inhibitor gene, c.351delC, which is a single-nucleotide deletion of a cytosine on exon 3, resulting in frameshift with premature stop codon. Sequencing analysis of the hypothetical truncated C1 inhibitor protein allowed us to conclude that, if transcription occurs, this protein has no biological activity. Twenty-eight members of the family fulfilled diagnostic criteria for hereditary angioedema and all of them presented the c.351delC mutation. Variation in clinical presentation and severity of disease was observed among these patients. One hundred and thirty-seven subjects without hereditary angioedema did not have the c.351delC mutation.

CONCLUSION

The present study provides definitive evidence to link a novel genetic mutation to the development of hereditary angioedema in patients from a Brazilian family.

Cognitive deterioration due to GH deficiency in patients with traumatic brain injury: A preliminary report

PRIMARY OBJECTIVE

To determine whether cognitive and behavioural disorders observed in TBI patients are due to hormonal deficits or to the brain injury itself.

RESEARCH DESIGN

Transversal, between-group design.

METHODS AND PROCEDURES

Studied 22 severe TBI patients (GCS < 8): 11 had isolated GH deficiency and 11 did not. Prepared detailed clinical reports on patients and performed physical examinations, standard biochemical and full blood count analysis. Patients underwent neuropsychological assessment and hormonal evaluation 6 months after TBI diagnosis.

RESULTS

TBI patients with GH deficiency show greater deficits in attention, executive functioning, memory and emotion than those without GH deficiency.

CONCLUSIONS

Results show GH-related cognitive impairment in patients who develop GH deficiency after TBI and suggest that treatment of GH deficiency would improve cognition. The clinical importance of these findings should be established to better understand the nature, magnitude and meaning of GH-related cognitive impairment in patients who develop GH deficiency after TBI.

Primary hyperparathyroidism in pregnancy

Gestational primary hyperparathyroidism presents with features which, from a physiological and prognostic viewpoint, entail great difficulty in diagnosis and a high risk of complications. These complications occur at rates of 67% and 80% in the mother and fetus, respectively, and can be reduced by up to four times by means of prompt application of effective therapeutic measures. We report a case involving a pregnant woman in the 16th week of gestation who presented with asymptomatic hypercalcemia secondary to a solitary parathyroid adenoma. When the patient did not improve after conservative therapeutic measures, it was decided to employ surgical treatment in the second trimester of pregnancy. The surgery was successful, and the follow-up period was without complications for the mother and neonate. We therefore agree with the growing evidence that surgery in the second trimester of pregnancy constitutes a safe and effective alternative to conservative treatment.

Estrogen modulates the action of nitric oxide in the medial preoptic area on luteinizing hormone and prolactin secretion

Several substances work as neuromediators of the estrogen direct and indirect (through glial cells or interneurons) action on luteinizing hormone- releasing hormone (LH-RH) neurons in medial basal hypothalamus and medial preoptic area (MPOA). Angiotensin II (AII) in the MPOA stimulates the LH and it inhibits PRL secretion in some situations. On the other hand, the effect of excitatory amino acids on LH and PRL surges during proestrus as well LH surge induced by steroids depend on nitric oxide (NO). In the present study we investigated the participation of MPOA endogenous NO on gonadotropin and PRL secretion mediated by estrogen and AII. Plasma LH, FSH and PRL was determinated in estrogen primed and unprimed ovariectomized Wistar rats that received microinjection of AII or saline into the MPOA, associated or not with a previous microinjection of an inhibitor for NOS. Our results show the following: 1 - there was no change in plasma FSH in estrogen- primed or unprimed ovarictomized related with microinjections of AII or NO antagonist in the MPOA; 2- the increase in LH secretion after ovariectomy depends on, at least in part, NO activity in the MPOA; 3- estrogen may have an indirect negative feedback action on LH-RH neurons in the MPOA through NO; 4- the stimulatory action of AII in the MPOA on LH secretion in ovariectomized rats treated with estrogen depends on NO; 5 - NO in the MPOA stimulates or inhibits PRL secretion depending on the absence or presence of estrogen, respectively; 6- the inhibitory action of AII into the MPOA on PRL secretion does not seem to depend on NO.

[Patients in treatment for malnutrition in primary care, study of 500 real patients]

OBJECTIVE

The worsening of the nutritional status of certain segments of the population has led to frequent situations of chronic undernourishment even in the healthy population. There are very few data available on the prevalence and causes of malnutrition in Primary Health Care. The present study attempts to provide measurable information, obtained at random from the doctors involved in the country's Primary Health Care, on the characteristics of the undernourished patients, the cause of the undernourishment, the diagnostic means used, the treatment applied and the progress of the patients regularly treated in Primary Health Care facilities.

MATERIALS AND METHOD

A sample of 1,819 doctors in Primary Health Care were surveyed to know their opinions on the nutritional status of their patients. They were asked to complete a "Patient Record" for the first patient to enter their office suffering from undernourishment. A total of 505 Patient Records were received from the different Primary Health Care doctors taking part in the study throughout Spain.

RESULTS

Of the patients included, 10% were aged less than 10, while 46.7% were between 16 and 65 years of age and 44.2% were over 65. The main diagnosis in these patients was varied, with cancer patients (22.6%) and anorexics, including anorexia nerviosa and other non-oncological causes, (16.4%) the most common. As for the tests used for diagnosing undernourishment, those most frequently applied were physical examination (61%) and biochemical tests (56.4%). The risk factor most commonly found in these patients was old age/senility (21%). Nutritional support (55.8%) and dietary recommendations (45.3%) were the therapies most often applied. Only 47% of patients correctly implemented their treatment according to the doctors in Primary Health Care and the prognosis was as follows: 31% were expected to improve, 20% to worsen and 44% of cases would remain stable.

CONCLUSIONS

From this study, it is concluded that most undernourished patients in Primary Health Care are there due to a severe pathology or because of age; that anthropometric and biochemical methods are used for diagnosis purposes although the clinical interview is of basic importance; that a large proportion of patients require some type of nutritional supplements; and finally that, according to the doctors, the expectations of improvement in the nutritional status of these patients are not good.

Pheochromocytoma in a pregnant woman with multiple endocrine neoplasia type 2a

Pheochromocytoma is a rare cause of hypertension. Its coexistence with pregnancy is exceptional and laparoscopic removal has rarely been reported. We describe the case of a 34-year-old woman with multiple endocrine neoplasia type 2a (MEN 2a) with adrenal pheochromocytoma diagnosed in the 6th week of pregnancy. After pretreatment with phenoxybenzamine, a successful transperitoneal laparoscopic adrenalectomy was performed in the twentieth week of gestation. The management of pheochromocytoma in pregnancy and the indications for laparoscopic surgery in pregnant patients are discussed.

Iodine-131 treatment of thyroid papillary carcinoma in patients undergoing dialysis for chronic renal failure: a dosimetric method

Until recently, the therapeutic protocol widely accepted for ablation of the thyroid remnant and for metastases of thyroid papillary carcinoma was the administration of 131I after surgery. However, at present, some data question the usefulness of such treatment in patients considered low risk. The treatment with radioiodine in patients suffering from end-stage renal disease (ESRD) undergoing hemodialysis requires controlled dosages and individualized administration guidelines. The need to include these patients on the waiting list for a renal transplantation, once they have overcome the disease, and the higher prevalence of thyroid carcinoma in ESRD patients makes this an increasingly significant problem. The cases reported in the literature are few and the therapeutic models followed are very difficult. In this paper we propose a therapeutic model that provides the highest thyroid ablative dosage, minimizing radiation exposure to the rest of the organs. The main difference between our protocol and that already described is the performance of daily hemodialysis during the first 5 days of treatment, as well as the administration of a dose of 131I equivalent to that administered to patients who show normal renal function.

[Patients at risk for malnutrition in primary care. Social and health study]

GOALS

The worsening nutritional condition of certain population segments is an ever more frequent situation. Malnutrition also has considerable consequences, both in healthy individuals and in patients, leading to an increase in morbidity/mortality among the general population. The purpose of the present study is to learn the opinion of doctors in primary health care about the frequency of patients at risk of malnutrition attending their clinics; the most common forms of diagnostic technique used, the groups of population and situations that show the greatest risk of malnutrition as well as the therapeutic actions undertaken.

MATERIALS AND METHODS

The present study effected 1819 opinion polls of primary health care doctors, distributed in proportion to the provincial distribution of doctors throughout Spain. With a margin of error of +/- 2.3% and a confidence interval of 95.5% (K-2).

RESULTS

Of the patients seen in primary health care centres, 11% are at risk of malnutrition and approximately 61% of the total are detected at the medical clinic. The situations with the greatest risk are advanced age (71%), marginalized population (drug abusers, alcoholics) (56%), anorexia (50%), patients with mental disorders (42%), oncological pathologies (41%) and prolonged confinement in bed (39%). The therapeutic attitudes considered most appropriate by primary health care practitioners are a greater attention to diets and the use of nutritional supports in cases of established malnutrition.

CONCLUSIONS

The present study reflects a high incidence of malnutrition risk among patients attending primary health care clinics (11%); and highlights the importance, from the point of view of preventive medicine, of improving nutritional education among professionals, as well as the availability of simple therapeutic actions and support measures that might help to avoid larger-scale problems with a large social and financial cost.