Effect of long-term growth hormone treatment on carbohydrate metabolism in children with growth hormone deficiency

OBJECTIVE

Growth hormone (GH) has well known effects on carbohydrate metabolism. We have evaluated the effects of long-term growth hormone (GH) therapy on carbohydrate metabolism in children with classical GH deficiency (GHD) or GH neurosecretory dysfunction (GHND).

STUDY DESIGN

Glucose, insulin and C-peptide concentrations at baseline and during oral glucose tolerance test (OGTT) were measured before and after 18 and 36 months of GH therapy (0.6-0.8 IU/Kg/week in 6 evening doses) in 13 GHD and 7 GHND children (15 boys and 5 girls, 15 prepubertal and 5 early pubertal; age at diagnosis 2.11-13.1 y).

RESULTS

Mean fasting insulin and C-peptide concentrations after 18 months were similar to the pretreatment values, while after 36 months they were significantly higher than before treatment. Fasting glucose concentrations were similar to pretreatment both after 18 and 36 months. The mean areas under the curve (AUC) during OGTT for glucose, insulin, and C-peptide were significantly increased after 18 and 36 months. There were no differences between GHD and GHND patients. During the treatment period 10 of the 15 prepubertal patients entered puberty. A significant increase of insulin and C-peptide concentrations occurred after 36 months of GH treatment in the patients that remained prepubertal during treatment as well as in those who were pubertal when treatment was started. In three of our patients GH treatment caused glucose intolerance, which resolved after 6-12 months of a normal calorie low-simple carbohydrate diet without requiring discontinuation of treatment.

CONCLUSION

Our data show that long-term GH treatment in GH deficient children causes hyperglycaemia and increased insulin secretion. These effects may in some patients induce glucose intolerance, which is reversible with appropriate dietary measures and does not require discontinuation of treatment.

Dataset and species aggregation method applied to food-web models in the Northern Ionian Sea (Central Mediterranean Sea)

The ecological roles of the species in the food web are studied through the Ecopath with Ecosim modelling approach. In this modelling approach, the food web is described by means of functional groups, each representing a species, a life stage of a species, or a group of species with similar trophic, ecological and physiological features. Links between the groups are formally described by a set of linear equations, informed with ecological and fishing data. Here, the data input collected to implement 3 Ecopath models in the Northern Ionian Sea (Central Mediterranean Sea) from 1995 to 2015 are reported. This dataset applied to study the ecological roles of the demersal Chondrichthyes in the study area could be useful to explore different fishing management scenarios. A large dataset of over 300 taxa is shown detailing the ecological inputs, such as Biomass (kg km-2), Production and Consumption rates (y-1), Diet information (weight in %), and fishing data represented by Landings and Discards (t km-2 y-1). In particular, the fishery data described the catches of trawls, longlines, passive nets, other gears and purse seine. In addition, a description of the aggregation method of the species is shown.

[Emergency laboratory in the pediatric module]

The emergency in the laboratory is a serious problem. The Authors, starting from management evaluations, try to analyse the problems related to the urgent examinations in the Laboratory of a Pediatric Hospital. They propose executive ways for the best working of the same laboratory.

Standalone totally thoracoscopic left appendage exclusion for stroke prevention and absolute contraindication to anticoagulation: a referral centre experience

Introduction

Left atrial appendage is the source of more than 90% of thrombi in patients with atrial fibrillation (AF). ESC guidelines state as class IIB indication left appendage exclusion in patients with contraindication to oral anticoagulation. Here we give our contribute to the issue of safety and efficacy of standalone totally thoracoscopic left appendage exclusion (TT-LAE) for stroke prevention in patients with contraindication to oral anticoagulant or at risk of life threatening hemorrhage on antiplatelet therapy: a large single Centre experience.

Materials and methods

60 patients with non valvular AF and contraindication to oral anticoagulation (25 cerebral hemorrhages,8 GI bleeding, 18 non cerebral/Gi bleeding requiring multiple transfusions, 2 myelodysplastic syndrome, 7 anatomy unsuitable for percutaneous closure, 75%male, patients age ranged 53–87 years,mean CHAD-VASC 6.4,mean HASBLED range 4.7, type of AF permanent 76.6%, 23.4% longstanding persistent), underwent stand alone totally thoracoscopic appendage exclusion. All patinets enrolled after Heart Team evaluation, were screened preoperatively with 3D CT scan, transesophageal echocardiography, spirometry and cerebrovascuar doppler ultrasound. Intraoperative appendage exclusion were guided and confirmed by transesophageal echo. All patients were not on anticoagulation nor antiplatelet therapy at the time of surgery, at discharge and at control visit. Follow up (range 35–1 months) included outpatient visit and CT scan or TEE at 3–6-12 month in all patients to document LAA exclusion. Perioperative mortality and early and late morbidity in addition to freedom from neurological events at follow up were analyzed by chart evaluation and full outpatient neurological examination including including the Questionnaire for Verifying Stroke Free Status (QVSFS) as validated screening tool.

Results

Mean duration of surgery “skin to skin” was 52.4 minutes; all patients were extubated shortly after the procedure. There were no deaths nor need for blood transfusion or pulmonary procedure related morbidities, only three casea of pericarditis treated with colchicine till complete resolution was documented. On CT or TEE follow up 100% of patients had complete exclusion of the left appendage with minimal residual stumps and no dislodgement of the clip detected. Freedom from neurological events in all patients was documented in absence of anticoagulation or antiplatelet regime from the time of surgery to the time of the follow up visit and questionnaire filling.

Conclusion

Standalone totally thoracoscopic left appendage clipping is a safe and effective procedure for stroke prevention in patients with permanent and longstanding persistent atrial fibrillation with contraindication to oral anticoagulation. Longer follow up and an European registry are needed to, possibly, confirm this preliminary results.

Funding Acknowledgement

Type of funding source: None

3050Non valvular atrial fibrillation, contraindication to anticoagulation or antiplatelet therapy and heart team approach: a single centre experience

Introduction

Left atrial appendage is the source of more than 90% of thrombi in patients with atrial fibrillation (AF). Protect-AF and Prevail trials have tested the non inferiority of left appendage percutaneous closure to warfarin for stroke prevention but contraindication to anticoagulation was an exclusion criteria for enrollment. On the surgical side recent studies have shown the efficacy of left appendage exclusion concomitant to open chest cardiac surgery or totally thoracoscopic Maze. In these studies all patients were on anticoagulation or antiplatelet regime at discharge and follow up. Here we give our contribute to the issue of safety and efficacy of stand alone totally thoracoscopic left appendage clipping for non valvular AF related stroke prevention in patients with contraindication to oral anticoagulant or antiplatelet therapy.

Materials and methods

20 patients with non valvular AF and cerebral hemorrhages (16 males, patients age range 53–87, CHAD-VASC range 4–8, HASBLED range 4–7), underwent stand alone totally thoracoscopic appendage exclusion with a clipping device. All patients, after Heart Team evaluation, were screened preoperatively with 3D CT scan, transesophageal echocardiography and cerebrovascular doppler ultrasound. Intraoperative device positioning and atrial appendage exclusion were guided and confirmed by transesophageal echo. All patients were not on anticoagulation nor antiplatelet therapy from the time of surgery to the control visit. Follow up (range 6–21 months) included outpatient visit, CT scan or TEE. Perioperative mortality and early and late morbidity were analyzed by chart evaluation and full outpatient neurological examination including the Questionnaire for Verifying Stroke Free Status.

Results

Mean duration of surgery “skin to skin” was 62 minutes; all patients were extubated shortly after the procedure. There were no deaths or pulmonary procedure related morbidities, only one case of pericarditis treated with colchicine was documented. On CT or TEE follow up 100% of patients had complete exclusion of the left appendage with residual stumps less than 1 cm and no dislodgement of the clip detected. Freedom from neurological events in all patients was documented in absence of anticoagulation or antiplatelet regime from the time of surgery to the time of the follow up visit.

Conclusion

Totally thoracoscopic left appendage exclusion is a safe, expeditous and effective procedure in preventing non valvular AF related strokes in patients with contraindication to oral anticoagulation or antiplatelet therapy. The efficacy of the procedure is comparable to open chest surgery and this procedure may be considered as valid therapeutic option in patients at high risk of hemorrhage if on anticoagulant or antiplatelet therapy. Clearly further data, longer follow up and possibly an European registry are needed to confirm this preliminary results.

[Urine analysis in a pediatric laboratory using reagent strips read visually (visual dip sticks)]

The Authors studied the possibility of using some dip sticks visual for urinalysis. One hundred of urine samples have been analyzed at the beginning with the instrumental laboratory analytical system and then with the dip sticks visual; the results put in evidence that there is a real discrepancy as far as glucose is concerned. Glucose is overestimated in dip sticks visual method. Bilirubin, blood and proteins are in a decreasing order the most different items. Concerning to pH the results have been comparable. Specific weight cannot be compared to the laboratory method, on the other hand it can be used for screening. On the whole the Authors are quite satisfied about dip sticks visual method; it can be used in order to accelerate diagnosis and avoid pre-analytical mistakes.

An heart team stroke prevention decision-making process comparing percutaneous endocardial and thoracoscopic epicardial left atrial appendage occlusion

Introduction

Left atrial appendage occlusion (LAAO) is a validated therapeutic option in patients with atrial fibrillation (AF) at high thrombo-embolic risk and contraindication to oral anticoagulation. Large clinical trials have demonstrated excellent efficacy of percutaneous LAAO, but also stand-alone thoracoscopic LAAO has shown promising results with the advantage of absence of antiplatelet therapy. No direct comparison of both strategies has been published yet.

Purpose

To evaluate an Atrial Fibrillation Heart Team guided approach to percutaneous or thoracoscopic left appendage exclusion in patients with non valvular atrial fibrillation (NVAF).

Methods

Forty patients with a contraindication to oral anticoagulation (OAC) were evaluated in the AF Heart Team for LAA exclusion. Contraindication for OAC was based upon a history of cerebral hemorrhages (n=17), non-cerebral life-threatening hemorrhages (n=9), repetitive bleeding (n=8) and having underlying diseases associated to high bleeding risk (n=6). The 20 patients included in the LAAO-Percutaneous group (LAAO-P) were on low molecular weight heparin pre-procedure, whereas in the LAAO-thoracoscopic group (LAAO-TT) none were on low molecular weight heparin nor antiplatelet therapy since the bleeding risk was estimated too high. The LAAO-P group were 70% male, with a mean age of 72.3±7.5 (range 57–82), mean CHA2DS2VASc 4.2 (range 1–6) and a mean HASBLED 3.5 (range 1–5) with an expected risk of bleeding between 3.7–8.7% per year. The LAAO-TT were 72.5% male, with a mean age of 74.9±8 (range 53–87 years), mean CHA2DS2-VASc 6.05 (range 4–8), HASBLED mean 5.4 (range3–8) expected risk of bleeding >12.5% per year. Variables considered were CHA2DS2VASc, HASBLED, documented blood transfusions, comorbidities related risk of bleeding, anatomy of the LAA, lung function, patient quality of life. LAAO-P patients were on dual antiplatelet therapy (DAT) at discharge for the first three months and aspirine 100mg/day thereafter, whereas the LAAO-TT patients were not. Follow up included TEE at 1 months and CT scan at 3 months.

Results

Mean duration of procedures for LAAO-P was 54.4 minutes, for LAAO-TT 52.01 minutes, mean post procedural ventilation time was respectively 11.2±6.4 and 15.8±16.4 minutes. No major complications occurred in both groups. One patient in the LAAO-P crossed over because of an unsuitable anatomy which became apparent intra-operatively. Mean hospital stay were comparable in both groups, 3.4±0.7 and 3.8±0.9 days respectively. At mean follow up of 24.3±10.1 months (range 5–36) all patients had complete exclusion of the appendage, no neurological events were reported.

Conclusions

The Heart Team can improve decision making in complex stroke prevention where LAAO is a therapeutic option, percutaneous and thoracoscopic occlusion seem to be comparably safe and effective. An epicardial LAAO could be advised in patients were the bleeding risk is estimated too high for AP therapy.

Funding Acknowledgement

Type of funding sources: None. Appendage closure: CT scan viewAppendage closure: surgical view