A Brazilian multicentre study evaluating pregnancies induced by cabergoline in patients harboring prolactinomas

OBJECTIVE

To evaluate the maternal-fetal outcomes of CAB-induced pregnancies in patients with prolactinoma in a large cohort.

METHODS

The prevalence of tumor growth, miscarriage, preterm, low birth weight, congenital malformations and impairment in neuropsychological development in children among women treated with CAB were assessed in a Brazilian multicentre retrospective observational study, RESULTS: We included 194 women with a mean age of 31 (17-45) years, 43.6% presenting microadenomas and 56.4% macroadenomas, at prolactinoma diagnosis. In 233 pregnancies, CAB was withdrawn in 89%, after pregnancy confirmation. Symptoms related to tumor growth occurred in 25 cases, more frequently in macroadenomas. The overall miscarriage rate was 11%, although higher in the subgroup of patients with CAB maintainance after pregnancy confirmation (38% vs. 7.5%). Amongst the live-birth deliveries, preterm occurred in 12%, low birth weight in 6% and congenital malformations in 4.3%. Neuropsychological development impairment was reported in 7% of cases.

CONCLUSIONS

Our findings confirm previous results of safety in maternal and fetal outcomes in CAB-induced pregnancies; nevertheless, CAB maintenance after pregnancy confirmation was associated with higher miscarriage rate; result that must be further confirmed.

Association of MBL2 gene exon 1 variants with autoimmune thyroid disease in Brazilian patients

We investigated the association between MBL2 gene exon 1 functional polymorphisms and autoimmune thyroid disease (AITD) in 163 Brazilian patients (87 with Hashimoto thyroiditis, HT; 76 with Graves' disease) and 214 healthy controls. Individuals carrying MBL2 O allele are at higher risk of developing AITD (OR = 1.58, 95% CI: 1.11-2.26; P-value = 0.009) and HT (OR = 1.67, 95% CI: 1.09-2.55; P-value = 0.013) as suggesting a possible role for mannose-binding lectin in influencing disease susceptibility.

Interpersonal coordination and ball dynamics in futsal (indoor football)

Here, we report an investigation of the patterned movement behavior of players for a specific sub-phase of the game of futsal, namely when the goalkeeper for the attacking team is substituted with an extra outfield player. The movement trajectories of the ball and players were recorded in both lateral and longitudinal directions and investigated using relative phase analysis. Some differences in phase relations between different playing dyads were noted, indicating specificity of phase attractions, or otherwise, for certain players. In general terms, the defenders demonstrated strong in-phase attractions with the ball and with each other, whereas weaker phase attractions, indicated by increased relative phase variability, were observed for the attackers and ball, as well as between attackers themselves. These results demonstrate different coordination dynamics for the defending and attacking dyads, from which we interpret evidence for different playing sub-systems consistent with different team objectives linked together in an overarching game structure. In keeping with dynamical systems theory for complex systems, we view this sub-phase of futsal as being characterized by coordinated behavior patterns that emerge as a result of self-organizing processes. These dynamic patterns are generated within functional constraints, with players and teams exerting mutual influence on each other.

Tactical skills are not verbal skills: a comment on Kannekens and colleagues

In 2009, Kannekens and colleagues evaluated the development of tactical skills of elite youth football players using a method based on verbal reports. Results showed no improvements in players' tactical skills over the years of their longitudinal study. These results are based on an erroneous assumption that tactical skills and verbalizations about tactical skills are equivalent. This note comprises an explanation of why verbal reports are not a valid measure of tactical skills.

The role of non-invasive dynamic tests in the diagnosis of Cushing's syndrome

OBJECTIVE

To evaluate the role of non-invasive dynamic tests in the diagnosis and differential diagnosis of Cushing's syndrome (CS).

METHODS

We studied laboratory features of 74 patients with endogenous CS, subdivided as follows: 46 (62.1%) with Cushing's disease (CD), 21 (28.3%) with an adrenal tumor, and 7 (9.5%) with ectopic ACTH syndrome (EAS).

RESULTS

In 100% of cases of CS we found serum cortisol levels greater than 1.8 microg/dl after low-dose dexamethasone suppression tests (LDDST), as well as elevation of midnight serum or salivary cortisol. However, urinary free cortisol was normal in 11.5% of patients. ACTH levels were suppressed in patients with adrenal tumors, normal or high in CD and invariably increased in EAS. After the 8-mg overnight dexamethasone suppression test (HDDST), serum cortisol suppression >50% was observed in 79.5% of cases of CD and in 28.6% of subjects with EAS, whereas cortisol suppression >80% was only found in CD. After stimulation with CRH or desmopressin an ACTH rise > or =35% occurred in 86.5% of individuals with CD and 14.3% of those with EAS, whereas an ACTH rise > or =50 achieved 100% specificity. Moreover, the combination of serum cortisol suppression >50% after HDDST and an ACTH increase > or =35% after the administration of CRH or desmopressin only occurred in CD.

CONCLUSION

Our findings demonstrate that LDDST had 100% sensitivity for the diagnosis of CS and that HDDST and stimulation tests with CRH or desmopressin may be very useful for confirmation of CS etiology when analyzed together or when more stringent cut-offs are used.

Diagnosis and management of hyperprolactinemia: results of a Brazilian multicenter study with 1234 patients

OBJECTIVE

The aim of the study was to evaluate clinical and laboratorial features of 1234 patients with different etiologies of hyperprolactinemia, as well as the response of 388 patients with prolactinomas to dopamine agonists.

DESIGN, SETTING, AND PATIENTS

A total of 1234 hyperprolactinemic patients from 10 Brazilian endocrine centers were enrolled in this retrospective study.

MAIN OUTCOME MEASURE

PRL measurement, thyroid function tests, and screening for macroprolactin were conducted.

RESULTS

Patients were subdivided as follows: 56.2% had prolactinomas, 14.5% drug-induced hyperprolactinemia, 9.3% macroprolactinemia, 6.6% non-functioning pituitary adenomas, 6.3% primary hypothyroidism, 3.6% idiopathic hyperprolactinemia, and 3.2% acromegaly. Clinical manifestations were similar irrespective of the etiology of the hyperprolactinemia. The highest PRL levels were observed in patients with prolactinomas but there was a great overlap in PRL values between all groups. However, PRL>500 ng/ml allowed a clear distinction between prolactinomas and the other etiologies. Cabergoline (CAB) was more effective than bromocriptine (BCR) in normalizing PRL levels (81.9% vs 67.1%, p<0.0001) and in inducing significant tumor shrinkage and complete disappearance of tumor mass. Drug resistance was observed in 10% of patients treated with CAB and in 18.4% of those that used BCR (p=0.0006). Side-effects and intolerance were also more common in BCR treated patients.

CONCLUSION

Prolactinomas, drug induced hyperprolactinemia, and macroprolactinemia were the 3 most common causes of hyperprolactinemia. Although PRL levels could not reliably define the etiology of hyperprolactinemia, PRL values >500 ng/ml were exclusively seen in patients with prolactinomas. CAB was significantly more effective than BCR in terms of prolactin normalization, tumor shrinkage, and tolerability.

Clinical and laboratory features greatly overlap in patients with macroprolactinemia or monomeric hyperprolactinemia

AIM

The aim of this study was to evaluate the clinical and laboratory features of 64 patients with macroprolactinemia and to compare them to those of individuals with monomeric hyperprolactinemia.

METHODS

The study included 64 patients (54 women and 10 men) with macroprolactinemia and 96 patients (70 women and 26 men) with monomeric hyperprolactinemia (32 with prolactinomas).

RESULTS

Symptoms related to prolactin (PRL) excess were found in about 44% of individuals from the macroprolactinemia group and in 88.5% of patients with monomeric hyperprolactinemia (P<0.0001). However, the frequency of menstrual disturbances (oligomenorrhea or amenorrhea), galactorrhea and erectile dysfunction did not differ in both groups. In contrast, the association of galactorrhea and menstrual disturbances was significantly more prevalent in women with monomeric hyperprolactinemia. Although mean PRL levels were higher in patients with monomeric hyperprolactinemia (565.9+/-2726.4 vs 113.3+/-94.5 ng/mL, P<0.001), there was a great overlap between both groups. Among macroprolactinemic patients, pituitary magnetic resonance imaging revealed an image suggestive of a microadenoma in 7 (10.9%) and a macroadenoma in 1 (1.6%). Normalization of PRL levels during therapy with dopamine agonists was significantly more frequent in patients with monomeric hyperprolactinemia than in subjects with macroprolactinemia (78.6% vs 32%, P=0.0006).

CONCLUSION

Our data show that symptoms related to PRL excess are frequently found in subjects with macroprolactinemia. Moreover, no clinical or laboratory features could reliably differentiate macroprolactinemic patients from those with monomeric hyperprolactinemia. Therefore, the screening for macroprolactin should not be restricted to asymptomatic patients.

Immunodulation with tacrolimus (FK506): results of a prospective, open-label, non-controlled trial in patients with inflammatory bowel disease

Tacrolimus (FK506) is widely used in the organ transplant setting, but not in the treatment of IBD.

OBJECTIVE

the aim of this study was to analyse the effectiveness of tacrolimus in specific clinical presentations of inflammatory bowel disease (IBD) in which recurrence is likely.

PATIENTS AND METHODS

inclusion criteria were: perianal Crohn's disease (PCD), CD in rectal stump, pouchitis and cuffitis with severely impaired function of the ileoanal pouch (IPAA), and proven refractoriness to other therapies. Clinical assessment: Hughes' classification (PCD); Oresland index (OI) in IPAA, endoscopy-biopsy and Quality of life (QoL) using the Spanish version of the IBDQ. Response was determined as complete (CP), partial (PR) or non-existent (NR). Tacrolimus was administered orally at a dose of 0.1 mg/kg/day (levels 5-15 .g/L).

RESULTS

nineteen patients entered the study. Mean duration of treatment was 9.6 +/- 6.3 months. In PCD, CR was reported in 66% of cases and PR in 33%, with disappearance of inflammation, stenosis and ulcers. In patients with pouchitis and cuffitis,77% presented either CR or PR. The OI scores and QoL improved significantly after treatment (p<0.006 and p<0.002, respectively). Adverse effects were minor and controlled by regulating the dose.

CONCLUSION

oral administration of tacrolimus is easy to per-form and has few adverse effects when used to treat IBD in certain clinical presentations with a high likelihood of recurrence.

Intestinal ornithine decarboxylase in short bowel syndrome patients with oral diet

The major consequence of extensive intestinal resection is loss of absorptive surface area, which results in malabsorption of nutrients; this condition is known as short-bowel syndrome (SBS). Patients with extensive small intestinal resection and colectomy leading to jejunostomy have the most severe SBS. Ornithine decarboxylase (ODC) plays a central role in cell proliferation and in the process of gut adaptation. Polyamine synthesis in crypt cells mediates the action of extracellular growth factors on DNA synthesis and mitotic activity. The aim of this study was to examine ODC expression and activity, diamine oxidase (DAO) activity and polyamine levels in the jejunal mucosa and red blood cells of SBS patients with a jejunostomy. The study group consisted of 6 patients (4 men and 2 women, mean age 55.8+/-9.8 years), who had undergone extensive small bowel resection and colectomy. All patients were maintained on cyclic parenteral nutrition and non-restricted oral nutrition. Two groups of patients operated on for unrelated reasons were included as the jejunum control group (n=6) and the ileum control group (n=13). Non statistical differences were observed in polyamine levels of red blood cells versus the control group (spermidine: 21.0+/-3.6 vs. 17.7+/-1.1 and spermine: 17.1+/-8.6 vs. 13.2+/-1.6 nmol/ml RBC, respectively). No significant decreases in putrescine and spermidine levels were observed between the groups, but spermine levels in SBS jejunum were significantly lower than the controls (P<0.05). In SBS patients a significant decrease in ODC and DAO activity were observed vs jejunum. A significant decrease in ODC-mRNA abundance was found for the SBS patients as compared to the two control groups (P<0.05). These results suggest that in SBS patients with jejunostomy intestinal adaptation may be impaired.

[Comparison of endoscopy, radiology and scintigraphy with Tc-99m-exametazine labeled leukocytes and In-111 labeled human polyclonal immunoglobulin G in the diagnosis of inflammatory bowel disease]

BACKGROUND

The 99mTc-exametazine labelled leukocytes (99mTc-WBC) scintigraphy is an established method for the inflammatory bowel disease (IBD) diagnosis, but the labelled procedure is a large and laborious process. The 111In-labelled human polyclonal immunoglobulin G (111In-IgG) can be an alternative in the non invasive IBD diagnosis.

PATIENTS AND METHODS

Thirty-four patients routinely referred for investigation of IBD were studied. The 99mTc-WBC and 111In-IgG were simultaneously injected and images were obtained at 30 min, 3 and 24 h post-injection. The diagnostic was established by histology of endoscopy and/or surgery samples. Images were blindly evaluated by two experienced observers who only knew of the clinical suspicion of IBD. IBD was confirmed in 27 patients (17 with Crohn's disease [CD] and 10 with ulcerative colitis [UC]).

RESULTS

Sensitivity, specificity and accuracy were 88.5, 100 and 90.3% respectively for endoscopy, 73.7, 75 and 73.9% for radiology, 59.3, 85.7 and 64.7% for 111In-IgG scan and 96.3, 85.7 and 94.1% for 99mTc-WBC scan. In the diagnosis of CD involvement of small bowel, the 99mTc-WBC scan identified 9/11 patients with confirmed disease, whereas the 111In-IgG scan diagnosed only four of them. In the evaluation of colonic disease, the 99mTc-WBC scan correctly diagnosed 21/22 confirmed patients, being the 111In-IgG scan positive in 13 of them. As far as disease extension concerned, the 99mTc-WBC demonstrated a statistically significance rather number of disease segments than endoscopy, radiology and 111In-IgG scan.

CONCLUSIONS

The 99mTc-WBC was an effective method in the diagnosis of suspected IBD patients, both in the evaluation of small bowel disease and colonic disease, with slightly best results for colonic disease, whereas the 111In-IgG scan seems to have no utility neither in diagnosis nor in extension evaluation of IBD.

[An analysis of the impact of the COMBELL project on clinical medical competence. Competencia clínica Bellvitge]

OBJECTIVE

The most frequent tests for evaluate medical education in our country, do not analyze clinical competence. The aims of this project was to introduce a method for the assessment of clinical skills in two different groups of students using the simulation methodology with standardized patients and to compare with classical methods of assessment.

METHODS

Seventy three last year medical students were evaluated using 10 standardized patients encounters in April 1995 (COMBELL III project) and the other group of last year medical students was assessed in March 1996 using the same group of standardized patients (COMBELL IV project).

RESULTS

The global score for the COMBELL III, was 50.6% +/- 4.8 lower to COMBELL IV, 55.6% +/- 6 (p = 0.0001), remarking the improving of the item of physical examination (39.6% +/- 7.7 versus 48.1 +/- 9.6 p < 0.0001). Personal intercommunication also improved, 63.1% +/- 11.4 versus 70.4% +/- 12.2 (p = 0.0008). We did not find differences between academic grades and did not find correlations between clinical competence assessment and academic grades in COMBELL III but we found correlations in COMBELL IV.

CONCLUSIONS

Our results show that when this new assessment method was introduces in our medical school the clinical competence levels improved.

Clinical skills assessment with standardized patients

Previous projects (Combell I & II) to assess clinical skills were conducted in medical schools in Catalonia, in order to introduce a model of such an assessment using standardized patients (SP). The aim of this study (Combell III) was to measure selected characteristics of our model. Seventy-three medical students in the final year at the Bellvitge teaching unit of the University of Barcelona participated in a clinical skills assessment (CSA) project that used 10 SP cases. The mean group scores for the four components of clinical skills for each day of testing were studied, and ratings for each student in the 10 sequential encounters were checked. The study also compared the clinical skills scores with their academic grades. The total case mean score (mean score of history-taking, physical examination and patient notes scores) was 51.9%, and the mean score for communication skills was 63.6%. The clinical skills scores over the 8 testing days showed no day-to-day differences. The study did not find differences among the sequential encounters for each student (training effect). There was a lack of correlation between clinical skills scores and academic grades. The project demonstrated the feasibility of the method for assessing clinical skills, confirmed its reliability, and showed that there is no correlation between scores with this method and academic examinations that mainly reflect knowledge.

Quinagolide efficacy and tolerability in hyperprolactinaemic patients who are resistant to or intolerant of bromocriptine

OBJECTIVE

To audit the efficacy of quinagolide (CV205-502, Norprolac, Sandoz) in lowering prolactin, and its tolerability, in patients with bromocriptine resistance (BCR) or bromocriptine intolerance (BCI), in view of the paucity of results published in patients specifically with BCR or BCI, by collating results in our own patients with the reports in the literature.

DESIGN

Open prospective, uncontrolled administration of quinagolide in patients with BCR (defined for this report as failure to attain normal prolactin levels after 4 months of bromocriptine at maximum tolerated doses), or BCI (defined as a patient request to cease bromocriptine treatment because of side-effects at doses that were required, or failed, to normalize PRL levels).

MEASUREMENTS

Prolactin levels, menses or pregnancy, and side-effects.

PATIENTS

Six with BCR, and six with BCI (microprolactinoma in 7, macroprolactinoma in 5), treated with quinagolide 75 micrograms nightly increasing incrementally to a maximum of 450 micrograms. One patient who had taken part in a multicentre study of quinagolide in macroprolactinomas had BCI, and 11 further patients in the endocrine clinic who had BCR or BCI were offered quinagolide therapy under named-patient compassionate arrangements.

RESULTS

Normal prolactin in 4/5 with BCR (3/6 with side-effects, none of them quinagolide intolerant), and normal prolactin in 2/6 with BCI (4/6 with side-effects, two of them quinagolide intolerant).

CONCLUSIONS

Results in our 12 patients are broadly in line with those in 51 patients with bromocriptine resistance and 39 with bromocriptine intolerance extracted from various published reports, which together suggest that prolactin can be normalized in 16% of patients with bromocriptine resistance by quinagolide in doses of 225 micrograms or less, and in a further 20% by higher doses up to 600 micrograms. In bromocriptine intolerance, prolactin was normalized by quinagolide in doses of 225 micrograms or less in 58% of published cases and in 3 more patients by higher doses up to 1050 micrograms. About half the patients with bromocriptine resistance or bromocriptine intolerance who are treated with quinagolide experience side-effects, and around 7% are quinagolide intolerant. Doses need not exceed 225 micrograms, until failure to respond at this dose level is demonstrated.

Granulocyte-specific monoclonal antibody technetium-99m-BW 250/183 and indium-111 oxine-labelled leucocyte scintigraphy in inflammatory bowel disease

Thirty-three patients suspected of suffering from inflammatory bowel disease were studied. Autologous leucocytes were labelled with indium 111 oxine and re-injected simultaneously with 0.3-0.5 mg of technetium 99m granulocyte-specific monoclonal antibody BW 250/183. Two scans were obtained, the early scan 3-4 h postinjection (p.i.) and the late scan 18-24 h p.i. Using the endoscopy study as standard, the diagnostic accuracy of both agents was determined. Sensitivity, specificity and accuracy of 111In scans was 88.8%, 100.0% and 93.7% at 4 h and 94.7%, 100.0% and 96.9% at 24 h, respectively. Concerning the results using antibodies, the values were 61.1%, 100.0% and 78.1% at 4 h and 78.9%, 92.8% and 84.8% at 24 h, respectively. Segmental analysis showed concordance in 89.3% and 93.3% of the cases at 4 and 24 h, respectively. Though less sensitive and less accurate than scanning employing indium 111 leucocytes, BW 250/183 granulocyte-specific scintigraphy can be used for inflammatory bowel disease diagnosis and localization.

Protein-energy malnutrition: an integral approach and a simple new classification

A new approach to the classification of protein-energy malnutrition (PEM) in adults is proposed. Three widely accepted measurements, triceps skinfold (TSF), mid-arm muscle circumference (MAMC) and serum albumin (SA) were evaluated simultaneously as representative of the three main body nutritional compartments, that is, fat, muscle protein and visceral protein, respectively. These measurements were carried out in a group of 1709 healthy controls (1038 men and 671 women) living a normal life in the geographical area served by our hospital, in order to define the standard values (50th percentile) of the chosen variables for different age and sex groups. The lower limits of normal values were obtained by calculating the 5th percentile for each age and sex group and were expressed as the percentage of the 50th percentile. Once the standards and lower limits of normality were established, the chosen variables were incorporated into a tridimensional Cartesian system, the origin of the three axes (point 0) being the lower limits of normality (5th percentile). Each axis was then divided into positive (optimal) and negative (suboptimal) zones. This provided eight theoretical possibilities of protein-energy nutritional status. In order to define completely the nutritional status in a particular individual, the degree of severity for each variable should be added (mild, moderate and severe). This quantification can be represented with a point in the corresponding nutritional space. This classification was used to assess the nutritional status in 135 consecutive GI hospital in-patients (82 men and 53 women, mean age 48.23 years) at the time of admission, and in a group of 50 consecutive GI out-patients (28 men and 22 women, mean age 47.98 years) when seen for the first time at a NHS Gastroenterology Clinic. Only 32 per cent of the GI in-patients fulfilled the criteria of being well-nourished. The prevalence of PEM in this group was 68 per cent, the predominant types being mixed and kwashiokor-like (35 and 24 per cent, respectively). The prevalence of PEM in the GI out-patient group was 18 per cent, with a total absence of mixed types. Statistical analysis was performed between nutritional measurements among the three groups studied, as well as for the prevalence of PEM in different diseases among in-patients. This series was compared with other reported series, using the same nutritional variables but a different approach.(ABSTRACT TRUNCATED AT 400 WORDS)