Congenital adrenal hyperplasia in adolescence - a gynecological perspective

OBJECTIVES

Analysis of congenital adrenal hyperplasia (CAH) cases, gynaecological implications, referral reasons to gynaecologist and treatment.

MATERIAL AND METHODS

Retrospective, longitudinal, single-centre study with female CAH paediatric patients ≥ 10 years-old, followed between 1998-2018 in gynaecology and endocrinology departments at a public university tertiary hospital.

RESULTS

47 patients, 34.0% (n = 16) with classic, 66.0% (n = 31) with non-classic forms (NCAH), CYP21 deficit and 46,XX karyotype. We found a normal median menarche age (11.5 IQR 2 [6-15] years-old), but significantly earlier in NCAH (p = 0.003). Precocious puberty occurred in 48.9%, n = 23. Primary amenorrhea occurred in salt-wasting form (21.4%, n = 3). Oligomenorrhea and hirsutism were significantly more prevalent in NCAH (p = 0.018, p = 0.014 respectively) and acanthosis nigricans and virilization signs in classic forms (p = 0.05, p = 0.000 respectively). Sixteen patients (34.0%) were referred to gynaecology, mostly due to menstrual irregularities (50.0%, n = 8). Medical treatment with isolated or combined corticoids, oestrogen and progestogen were chosen in all but one case. Gonadotropin-releasing hormone analogues were used in 19.0% (n = 9). Surgery was performed in 34.0% (n = 16) patients, median age 2.0 IQR 2.5 (0.6-90) years-old.

CONCLUSIONS

This paper highlights the importance of a multidisciplinary approach. Early treatment contributes to a phenotypical feminine differentiation and normalization of the hypothalamus-pituitary-ovarian axis, which is essential given the gynaecologic and obstetric consequences of untreated cases.

Dystrophic calcinosis cutis associated with systemic lupus erythematosus: a case report

Calcinosis cutis is a rare and potentially disabling condition characterized by calcium deposition in soft tissues. When associated with autoimmune connective tissue diseases, calcinosis cutis is classified as Dystrophic Calcinosis Cutis (DCC), being its occurrence in systemic lupus erythematosus (SLE) patients fairly uncommon. We report a case of DCC in a 49 years old woman with eleven years evolution SLE that presented with a two years history of multiple painful skin lesions, some of them ulcerated and exhibiting a chalky white-yellow floor, in both hands, forearms, thighs, buttocks, abdomen and left breast. The pelvic X-ray showed soft tissue calcifications and the skin biopsy confirmed the diagnosis of DCC. The patient was treated with diltiazem 240mg/day and a significant regression of the lesions and associated pain was observed. Dystrophic calcinosis cutis is often a painful and disrupting condition in which timely diagnosis and treatment may be quite challenging.

Epithelial-mesenchymal interconversions in ovarian cancer: The levels and functions of E-cadherin in intraabdominal dissemination

The metastatic process of ovarian cancer (OC) is almost exclusively defined by direct shedding of tumor cells into the abdominal cavity, followed by clustering into multicellular aggregates and posterior peritoneal anchorage. This process relies on dynamic intercellular interactions which are modified by epithelial- mesenchymal interconversions and, therefore, E-cadherin expression variability. Although widely accepted as a tumor suppressor in many types of cancer, E-cadherin is currently known to have a dynamic expression and a much more complex role in OC. First, high E-cadherin expression is considered a sign of metaplasia in the normal ovarian epithelium, due to its association with epithelial growth factor receptor (EGFR) mediated cell proliferation. Subsequently, it is the decreased expression of E-cadherin that allows the acquisition of a more invasive phenotype, leading to the spread of primary tumor cells into the peritoneal fluid. This downregulation seems to depend on complex regulatory mechanisms, from molecular proteolysis to microenvironment interference and epigenetic regulation. E-cadherin cleavage and its resulting fragments appear to be essential to the process of dissemination and even to the formation of multicellular aggregates. Paradoxically, the maintenance of some E-cadherin expression seems to promote intercellular adhesion, resistance, and survival while decreasing cancer response to chemotherapy. Multiple studies have shown that reversing epithelial-mesenchymal transaction (EMT) and increasing E-cadherin expression prevents OC intraperitoneal dissemination, but findings that simultaneously correlate E-cadherin downregulation to higher chemotherapy sensitivity should not be ignored. Nevertheless, EMT and E-cadherin seem to have a potential interest as therapeutic targets in novel approaches to OC treatment.

Effects of rumen-undegradable protein on intake, performance, and mammary gland development in prepubertal and pubertal dairy heifers

The objective of this study was to evaluate the influence of different amounts of rumen-undegradable protein (RUP) on intake, N balance, performance, mammary gland development, carcass traits, and hormonal status of Holstein heifers at different physiological stages (PS). Sixteen prepubertal (PRE) heifers (initial BW = 106 ± 7.6 kg; age = 4.3 ± 0.46 mo) and 16 pubertal (PUB) heifers (initial BW = 224 ± 7.9 kg; age = 12.6 ± 0.45 mo) were used in an experiment over a period of 84 d. Four diets with increasing RUP contents (38, 44, 51, and 57% of dietary crude protein) and heifers at 2 PS (PRE or PUB) were used in a 4 × 2 factorial arrangement of treatments in a completely randomized design. Throughout the experiment, 2 digestibility trials were performed over 5 consecutive days (starting at d 36 and 78) involving feed and ort sampling and spot collections of feces and urine. At d 0 and 83, body ultrasound images were obtained for real-time carcass trait evaluation. The mammary gland was ultrasonically scanned at d 0 and every 3 wk during the experiment. Blood samples were taken at d 0 and 84 to determine serum concentrations of progesterone, estrogen, insulin-like growth factor I (IGF-I), and insulin. No interaction between PS and the level of RUP was found for any trait. Apparent digestibility of dry matter, organic matter, and neutral detergent fiber corrected for ash and protein was not affected by RUP level but was lower for PRE compared with PUB heifers. Sorting against neutral detergent fiber corrected for ash and protein (tendency only) and for crude protein was greater for PUB than PRE heifers. Pubertal heifers had greater average daily gain (905 vs. 505 g/d) and N retention (25.9 vs. 12.5 g/d) than PRE heifers. In addition, average daily gain and N retention were greatest at 51% RUP of dietary protein. Mammary ultrasonography indicated no effects of RUP amounts on mammary gland composition, whereas PRE heifers had greater pixel values than PUB, indicating higher contents of fat rather than protein in the mammary glands of PRE heifers. Serum progesterone and IGF-I concentration was affected only by PS, and PRE heifers had greater values of progesterone and IGF-I concentrations than PUB heifers. Serum insulin concentration was unaffected by PS but tended to be higher at 51% of RUP. In conclusion, an RUP level of 51% increases body weight, average daily gain, feed efficiency, and N retention in heifers regardless of the PS. In addition, PRE heifers have a lower sorting ability and reduced intake, total-tract digestibility, and N retention. They also have higher amounts of fat in their mammary glands, even at moderate growth rates.

[Cocaine: historical background, neurobiology of the addiction and relapse and therapeutic perspectives]

OBJECTIVE

Following more than a century of cocaine hydrochloride extraction from Erythroxylon coca, this drug remains representing a serious social and public health problema around the world. This paper intends to provide a review about the cocaine theme, focusing on historical background and on its different neurotransmission systems, as well as addresses therapeutics aspects about drug addiction.

METHOD

Electronic search in databases Medline, Pubmed and Lilacs was accomplished in order to select classics and recent studies relevant to the discussion of issue addressed.

DISCUSSION

Previous studies have shown high vulnerability to relapse to cocaine seeking following prolonged withdrawal periods. Such behavioral consequences have been cre-dited to induced changes in brain neurotransmitters provoked by repeated cocaine use. In recent years, the growing abuse of this drug has mobilized researchers worldwide in seeking for new therapies that reduce the behavioral and neurochemical changes resulting from addiction.

CONCLUSION

Numerous advances regarding the treatment of cocaine abuse and dependence have emerged in recent years. However, researche aiming at a safe and effective users' pharmacological treatment remain necessary and should be continued.

Different times of withdrawal from cocaine administration cause changes in muscarinic and dopaminergic receptors in rat premotor cortex

The present work studied neurochemical changes in rat premotor cortex 30 min, 1 and 5 days after withdrawal from cocaine repeated administration (20 and 30 mg/kg, intraperitoneally, daily for 7 days). Binding assays were performed in 10% homogenates, and ligands used were [(3)H]-N-methylscopolamine, [(3)H]-SCH 23390, and [(3)H]-spiroperidol for muscarinic, D(1)- and D(2)-like receptors, respectively. Levels of cyclic AMP (cAMP) and cyclic guanosine monophosphate (cGMP) were determined using a commercial kit. Scatchard analyses of muscarinic receptors showed an upregulation after 1 and 5 days withdrawal. While D(2)-like receptors were upregulated at all withdrawal periods, D(1)-like receptors were upregulated only at the 30 min withdrawal, and returned to normal levels after 1 day of the last injection. In relation to cAMP levels, the repeated cocaine administration, 1 day after the last injection produced a decrease (around 26%) with both doses, while a 67% increase was seen in cGMP levels with the 30 mg/kg dose. These findings indicate lasting neurochemical changes in premotor cortex caused by cocaine which remained after different withdrawal periods.

Effects of dopaminergic and cholinergic interactions on rat behavior

The present work studied the effects of dopaminergic and muscarinic receptor agonists and antagonists on rat locomotor activity and catalepsy. Results showed that carbachol at the highest dose used (10 mg/kg, p.o.) decreased and pimozide at the dose used abolished locomotor activity. Atropine at a low dose (1 mg/kg, p.o.) increased and at a high dose decreased this parameter. Mazindol at a high dose also increased locomotor activity. A significant and dose-dependent increase in the time on the bar was observed in animals treated with carbachol or pimozide as compared to controls. The increase observed with pimozide was greater than 60 s. Effects of carbachol on locomotor activity were observed already after the first drug exposure, but the increased time on bar produced by this drug in the test of catalepsy was observed only after repeated exposure (7th day). The effect of the highest dose (10 mg/kg, p.o.) of atropine (decreased activity) as related to the lowest one was evident at the 7th day, but the increased locomotor activity seen at the low dose was detected already at the first day. There was a predominance of the effect of pimozide on the open field as well as on catalepsy after its association with each one of the three doses of carbachol. The association of atropine and mazindol did not seem to alter locomotor activity and catalepsy as related to each drug alone. Our results indicate that interactions between dopaminergic and cholinergic systems play an important role on behavior and motor functions.

Gastric pseudotumor

The authors present a case report of a pseudotumor of the stomach and a brief discussion about this very unusual entity. A 75-year-old female patient was admitted with melena and a large epigastric tumor; she underwent upper gastrointestinal endoscopy, abdominal ultrasound, magnetic resonance imaging, guided needle aspiration and angiography. Preoperative diagnostic hypothesis included a partially thrombosed aneurysm of the splenic artery, pancreatic cystic neoplasm with gastric invasion and pancreatic pseudocyst complicated with hemorrhage. Laparotomy revealed a gastric tumor and the patient was submitted to a radical subtotal Billroth II gastrectomy. Only the pathologic examination revealed the unexpected definitive diagnosis of an organized intramural gastric hematoma. There were no postoperative complications and she remains asymptomatic 10 months after surgery.

Early withdrawal from repeated cocaine administration upregulates muscarinic and dopaminergic D2-like receptors in rat neostriatum

The present results show an increase in locomotor activity 24 h following repeated cocaine administration only with the higher dose (10 mg/kg, i.p., daily for 1 week) compared to controls (administered with saline). Binding assays were done and the ligands used were [3H]N-methylscopolamine ([3H]-NMS), [3H]-SCH 23390, and [3H]-spiroperidol to determine muscarinic (M1- and M2-like), D1 and D2 receptors, respectively. Scatchard analyses revealed alterations in Bmax not only for muscarinic, but also for D2-like receptors that were significantly increased. On the other hand, no alterations were detected on D1-like receptors densities and dissociation constant values. However, the Kd value was significantly increased for D2 receptors. The changes in muscarinic receptors were observed predominantly on M2-like, which presented an increase of 84% with the 10 mg/kg, i.p., dose only. On D2-like receptors, increases of 63 and 54% were demonstrated with the doses of 5 and 10 mg/kg, i.p.. The preferential effects of cocaine on muscarinic and D2-like receptors were also demonstrated in vitro where decreases in [3H]-NMS and [3H]-spiroperidol binding were observed. The results indicate that the effects of cocaine on muscarinic and dopaminergic postsynaptic receptors are functions of dose, duration of treatment, and time of drug withdrawal.

Metabolic responses to cholecystectomy: open vs. laparoscopic approach

Laparoscopic cholecystectomy is considered a minor surgical procedure. In a prospective, randomized study, we compared the metabolic responses to surgery in two groups of patients submitted to open or laparoscopic cholecystectomy. The aim of the study was to verify if the latter caused less metabolic changes. Blood samples were drawn before the operation (basal), 1 h and 2 h after skin incision, and on the first and second postoperative days. The following parameters were studied: cortisol, renin, and leukocytes, including subpopulations. The mean values for age, weight, height, basal neutrophil and lymphocyte counts, basal values of cortisol and renin of patients, and sex distribution of group 1 patients (open, n = 20) matched with those for group 2 (laparoscopic, n = 20), with the exception of age (p < 0.05). No differences were detected between the two groups in terms of cortisol and renin values. However, the neutrophil count 1 h after skin incision was statistically significantly higher with the laparoscopic approach (p < 0.05). The lymphocyte count on the second postoperative day was also statistically significantly higher in group 2 (p < 0.05). We conclude that when a cholecystectomy is performed, the laparoscopic approach has no advantage over the open approach from the standpoint of the metabolic responses we studied. It appears that leukocytes have a more rapid return to normal values after laparoscopic cholecystectomy. Although pneumoperitoneum is known to be responsible for important cardiorespiratory changes, no worse response was found in the laparoscopic group than in the open group.

[Ileoanal pouch for the treatment of adenomatous polyposis and ulcerative colitis--clinical and functional results]

The results of the first 9 patients with proctocolectomy and ileal pouch operated on between 1983 and 1990 were analysed. This procedure was carried out in 8 patients with adenomatous polyposis. Three of these patients had an associated rectal cancer and one a degenerated sigmoid polyp. One patient had ulcerative colitis and was previously submitted to a colectomy related with perforated fulminant colitis. Three types of pouches were constructed: 3 S, 3 J and 3W, all with a temporary ileostomy. A circular stapler was used in 2 cases for ileoanal anastomosis. Three postoperative complications were observed: two patients with pouchitis during the presence of a diverting ileostomy and an ileal fistula following ileostomy closure, all medically treated. Clinical and functional results were evaluated 1 to 7 years after the procedure. The average daytime stool frequency was 4 with 1 nocturnal. All patients indicated normal continence. One patient had her professional life affected due to the increased number of defecations. Differences in the clinical results of the patients with S, J and W pouches were not statistically different. The functional results expressed as median and range were as follows: resting and pressure 45 cm H2O (20-60), voluntary anal pressure 70 cm H2O (34-120), compliance 3.70 ml/cm H2O (1.14-11.40), maximal tolerated volume (MTV) 320 ml (110-48) and threshold volume 95 ml (40-170). The MTV values of the groups with J and W pouches were 190 ml (180-200) and 370 ml (340-480), respectively (p = 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of piracetam administration on 3H-N-methylscopolamine binding in cerebral cortex of young and old rats

Piracetam, a nootropic drug, has been used for some time in Alzheimer's disease for its facilitatory effect on learning and memory. Rats treated with piracetam (500 mg/kg, p.o.) daily, during 1 and 2 weeks, showed a significant increase in muscarinic receptor number (Bmax) and in the dissociation constant values (Kd) in the cerebral motor cortex, in binding studies using 3H-NMS as ligand. The effect was observed not only in young rats (control- Bmax = 663.4 fmol/mg protein, Kd = 0.45 nM; treated- Bmax = 961.9 fmol/mg protein, Kd = 0.82 nM) but also in aged animals (control- Bmax = 628.0 fmol/mg protein, Kd = 0.47 nM; treated-Bmax = 747.6 fmol/mg protein, Kd = 0.84 nM). Since piracetam does not interact with muscarinic receptors, the reason for its effect expressed as the enhanced number of brain muscarinic receptors is not clear but could be the result of stimulation of phospholipid synthesis and thus would represent an indirect action of the drug.

Effect of mazindol administration on (3H)-N-methylscopolamine binding to rat cerebral cortex

Mazindol has been shown to produce anorexia in several animal species including humans, and its pharmacological effects may be elicited by blockade of neuronal reuptake of dopamine and norepinephrine. Chronic treatment of rats with mazindol (10 mg/kg daily, p.o.) caused an increase in muscarinic receptor density (Bmax = 874.7 femtomoles/mg protein) as compared to controls (Bmax = 629.1 femtomoles/mg protein) in the cerebral motor cortex. An increase in dissociation constant (Kd) values was also observed which changes from 0.57 nM (control) to 1.17 nM after mazindol treatment. The mechanism underlying the observed effect of mazindol on receptors could be related to processes involving other neurotransmitters which also regulate cholinergic activity in the CNS. However, the implications of the eventual dopaminergic control on muscarinic receptors in the cortex is still an open question.