Convalescent or standard plasma versus standard of care in the treatment of COVID-19 patients with respiratory impairment: short and long-term effects. A three-arm randomized controlled clinical trial

BACKGROUND

The efficacy of early treatment with convalescent plasma in patients with COVID-19 is debated. Nothing is known about the potential effect of other plasma components other than anti-SARS-CoV-2 antibodies.

METHODS

To determine whether convalescent or standard plasma would improve outcomes for adults in early phase of Covid19 respiratory impairment we designed this randomized, three-arms, clinical trial (PLACO COVID) blinded on interventional arms that was conducted from June 2020 to August 2021. It was a multicentric trial at 19 Italian hospitals. We enrolled 180 hospitalized adult patients with COVID-19 pneumonia within 5 days from the onset of respiratory distress. Patients were randomly assigned in a 1:1:1 ratio to standard of care (n = 60) or standard of care + three units of standard plasma (n = 60) or standard of care + three units of high-titre convalescent plasma (n = 60) administered on days 1, 3, 5 after randomization. Primary outcome was 30-days mortality. Secondary outcomes were: incidence of mechanical ventilation or death at day 30, 6-month mortality, proportion of days with mechanical ventilation on total length of hospital stay, IgG anti-SARS-CoV-2 seroconversion, viral clearance from plasma and respiratory tract samples, and variations in Sequential Organ Failure Assessment score. The trial was analysed according to the intention-to-treat principle.

RESULTS

180 patients (133/180 [73.9%] males, mean age 66.6 years [IQR 57-73]) were enrolled a median of 8 days from onset of symptoms. At enrollment, 88.9% of patients showed moderate/severe respiratory failure. 30-days mortality was 20% in Control arm, 23% in Convalescent (risk ratio [RR] 1.13; 95% confidence interval [CI], 0.61-2.13, P = 0.694) and 25% in Standard plasma (RR 1.23; 95%CI, 0.63-2.37, P = 0.544). Time to viral clearance from respiratory tract was 21 days for Convalescent, 28 for Standard plasma and 23 in Control arm but differences were not statistically significant. No differences for other secondary endpoints were seen in the three arms. Serious adverse events were reported in 1.7%, 3.3% and 5% of patients in Control, Standard and Convalescent plasma arms respectively.

CONCLUSIONS

Neither high-titer Convalescent nor Standard plasma improve outcomes of COVID-19 patients with acute respiratory failure. Trial Registration Clinicaltrials.gov Identifier: NCT04428021. First posted: 11/06/2020.

Analysis of the 2020 Taal Volcano tephra fall deposits from crowdsourced information and field data

After 43 years of dormancy, Taal Volcano violently erupted in January 2020 forming a towering eruption plume. The fall deposits covered an area of 8605 km², which includes Metro Manila of the National Capital Region of the Philippines. The tephra fall caused damage to crops, traffic congestion, roof collapse, and changes in air quality in the affected areas. In a tropical region where heavy rains are frequent, immediate collection of data is crucial in order to preserve the tephra fall deposit record, which is readily washed away by surface water runoff and prevailing winds. Crowdsourcing, field surveys, and laboratory analysis of the tephra fall deposits were conducted to document and characterize the tephra fall deposits of the 2020 Taal Volcano eruption and their impacts. Results show that the tephra fall deposit thins downwind exponentially with a thickness half distance of about 1.40 km and 9.49 km for the proximal and distal exponential segments, respectively. The total calculated volume of erupted fallout deposit is 0.057 km³, 0.042 km³, or 0.090 km³ using the exponential, power-law, and Weibull models, respectively, and all translate to a VEI of 3. However, using a probabilistic approach (Weibull method) with 90% confidence interval, the volume estimate is as high as 0.097 km³. With the addition of the base surge deposits amounting to 0.019 km³, the volume translates to a VEI of 4, consistent with the classification for the observed height and umbrella radius of the 2020 main eruption plume. VEI 4 is also consistent with the calculated median eruption plume height of 17.8 km and sub-plinian classification based on combined analysis of isopleth and isopach data. Phreatomagmatic activity originated from a vent located in Taal Volcano's Main Crater Lake (MCL), which contained 42 million m³ of water. This eruptive style is further supported by the characteristics of the ash grain components of the distal 12 January 2020 tephra fall deposits, consisting dominantly of andesitic vitric fragments (83-90%). Other components of the fall deposits are lithic (7-11%) and crystal (less than 6%) grains. Further textural and geochemical analysis of these tephra fall deposits contributes to better understand the volcanic processes that occurred at Taal Volcano, one of the 16 Decade Volcanoes identified by the International Association of Volcanology and Chemistry of the Earth's Interior (IAVCEI) because of its destructive nature and proximity to densely populated areas. The crowdsourcing initiative provided a significant portion of the data used for this study while at the same time educating and empowering the community to build resilience.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s00445-022-01534-y.

790 Pacemaker lead and atrial thrombosis, a rare event but of high clinical importance

Aims

Trans-venous lead-related thrombosis is an undervalued issue. Since the lack of guidelines or evidences regarding the best therapeutic option, treatment of endocavitary clots on pacemaker wire is left to individual decision between surgical catheter extraction, thrombolysis, or anticoagulation therapy. In some patients, the labile equilibrium between hemorrhagic and thrombotic events may further complicate management.

Methods and results

We report the case of a 86-years-old man with heart failure (HF) severely reduced ejection fraction due to chronic ischaemic cardiomyopathy and several co-morbidities. He had a reacution of HF requiring hospitalization secondary to new-onset atrial flutter. During hospital stay, in light of episodes of severe bradycardia, he underwent single-lead PM implantation. Few days after discharge he developed deep vein thrombosis in situ of PM electro catheter insertion (poor compliance to anticoagulation therapy was reported) which improved after few days of regular therapy assumption. After few months anticoagulation therapy was dismitted due to etiology unknown-anemization requiring transfusion, but 20 days later he was once again admitted, this time because of pulmonary embolism. Trans thoracic echocardiography (TTE) enlightened a severely dysfunctioning right ventricle and a mass in right atrium hanging the wire. Trans oesophageal echocardiography was then performed showing hyper-reflective and highly mobile material with numerous ‘arborizations’. Intravenous heparin was started as pulmonary embolism therapy. Once infective etiology was excluded, total body computer tomography was performed to investigate a possible paraneoplastic origin. Presence of a meningioma was enlightened. Heart-team evaluation excluded catheter extraction in light of patient’s frailty, while thrombolysis was controindicated. Vitamin K antagonists was then started. At 1 month follow up no further embolic neither haemorrhagic events were reported. TTE showed a reduction in mass dimension and an improvement in right ventricle function.

Conclusions

In a guidelines-lacking field, VKA can be an effective option in cases of lead-related thrombosis when surgery or thrombolysis is not suitable. Further studies are needed to establish their real effectiveness in management of E-C-related endocavitary thrombi.

Control of source fertility on the eruptive activity of Piton de la Fournaise volcano, La Réunion

The eruptive activity of basaltic hotspot volcanoes displays major fluctuations on times scales of years to decades. Theses fluctuations are thought to reflect changes in the rate of mantle melt supply. However, the crustal filter generally masks the mantle processes involved. Here, we show that the cyclic and generally increasing activity of the Piton de la Fournaise volcano (La Réunion) since the mid 20th century is tightly linked to the fertility of its source, as recorded by ⁸⁷Sr/⁸⁶Sr and incompatible trace elements ratios of lavas. We identify a twofold control of source fertility on eruptive activity: melt extraction from fertile, incompatible element-enriched veins initiates decadal-scale eruptive sequences, so that vein distribution in the plume source directly controls the cyclic activity. Indirectly, reactive flow of enriched melts increases mantle porosity and promotes melts extraction from the peridotite matrix. This process is thought to have caused a fourfold increase in magma supply between 1998 and 2014 at Piton de la Fournaise, and could also explain magma surges at other frequently active hotspot volcanoes, such as Kilauea, Hawaii. The short-term eruptive activity of hotspot volcanoes appears to be ultimately linked to the distribution and size of lithological heterogeneities in mantle plumes.

[Canaud central venous catheters: 4-year experience]

BACKGROUND

The use of central venous catheters for permanent vascular access has become increasingly important because of the characteristics and the clinical problems of incident patients or patients already undergoing chronic hemodialysis. In this study a short and medium term evaluation was made of a double permanent central venous catheter positioned in the right internal jugular vein. The Canaud catheter was evaluated both from the point of view of practical use and for various technical and clinical problems.

METHODS

During the observation period, July 1995 - September 1999, these catheters were used in 39 patients (mean age 72 years), 22 females and 17 males; 31% were diabetic patients and 46% were older than 75 years. Forty-five catheters were positioned with an average dwelltime of 347 days.

RESULTS

Utilization was almost immediate and the resulting blood flow was suitable for all depurative techniques (blood flow more than 250 ml/min), with an average recirculation of 11.9% and an average resistance index of 0.54. Among the most serious complications during surgery a respiratory block was observed followed by the complete recovery of the patient. Some clinical complications were noted (5 venous thrombosis), as were some technical ones: 12% well as related to problems with the adapter, 24.3% to reversible thrombosis of the catheters occurred in 23 catheters in 22 patients. Infections.

CONCLUSIONS

Overall Canaud catheters appear to represent a valid alternative to other more recent catheters for permanent vascular access. If necessary, they can be easily substituted due to the absence of a subcutaneous cuff.

[Permanent central venous catheters for dialysis. The situation in Piedmont-Aosta Valley]

BACKGROUND

Permanent central venous catheters for hemodialysis have become increasingly important as vascular accesses for extracorporeal dialysis. The aim of this study was to evaluate the prevalence and various aspects of these catheters in the chronic dialysis population in Piedmont and Aosta Valley on 30-6-1998 using a multiple-choice questionnaire.

METHODS

A total of 2389 patients were receiving chronic hemodialysis. Permanent central venous catheters were present in 6.2% of the population (149 patients), arteriovenous fistulas in 83.1%, vascular prostheses in 9.3% and temporary catheters in 1.4%. The site chosen for permanent catheters was the internal jugular vein in 88.6% of cases, the subclavian vein in 8.7% of cases and the femoral vein in 2.7% of cases. The double catheter is the most frequently used. In 76% of centres catheters are positioned by nephrologists. Thrombosis prophylaxis is performed in 98% of cases with heparin and the most frequently used disinfectant to dress the cutaneous exit is iodopovidone.

RESULTS

This study highlights the important role played by permanent catheters. The double catheter was used in 64.4% of the entire population, confirming the greater efficiency of these catheters as reported in the literature. Operating autonomy is relative in 76.2% of centres where catheters are positioned by nephrologists who often use the collaboration of other specialists.

CONCLUSIONS

The authors stress the need to reflect on the use of iodopovidone is to dress the cutaneous exit of catheters since this disinfectant is contraindicated by one of the largest manufacturers of silicone catheters owing to its harmful medium long-term effects.

[Temporary dialysis access in patients with acute renal failure. Protocols of the dialysis centers in the Piedmont and Valled'Aosta]

BACKGROUND

A retrospective study was performed using a multiple-choice questionnaire in order to analyse the normal procedures and trends regarding the insertion and management of emergency dialysis access in patients with acute renal failure in 23 Centres in Piedment and the Aosta Valley, regions in the north of Italy with about 4.5 million inhabitants.

METHODS

The observation period ran from January 1996 to July 1997. A questionnaire with 19 main questions and 90 possible multiple answers sent to 22 Centres for adults and the only pediatric centre in both regions.

RESULTS

An analysis of the results showed that the most frequently used site in these regions is the subclavian vein (37.8%), followed by the internal jugular vein (32%), the femoral site (28.8%) and peritoneal catheter (1.4%); in pediatric patients, 5% used the femoral site, 10% the subclavian vein, 20% the internal jugular vein and 65% the peritoneal catheter. In 4 centres (18.2%), nephrologists do not position any type ofd access for acute renal failure. In 50% of centres, all doctors insert femoral catheters autonomously.

CONCLUSIONS

Some choices, such as the subclavian route, are open to criticism and may perhaps be linked to customary procedures used by anesthetists and intensive care specialists. Some centres only have relative automomy for insertion, and lastly some types of catheters and techniques are not used. The peritoneal catheter has been abandoned by adult centres as an access in acute kidney failure patients.

Appearance of severe jaundice after radiometabolical treatment of thyrotoxicosis

The appearance of moderate jaundice with mildly raised levels of plasma bilirubin is an uncommon complication of thyrotoxicosis and is usually accompanied by signs of right heart failure. Some described cases were actually related, at least in part, to autoimmune chronic hepatitis. In this paper we describe a case of thyrotoxicosis accompanied by deep jaundice with very high levels of bilirubin occuring in the absence of cardiac failure and with no signs of hepatitis. Jaundice disappeared shortly after the start of thyrostatic drug treatment, supporting a possible detrimental effect of hyperthyroidism on the hepatic bilirubin metabolism.

[Hyperthyroidism and cholestasis: a case report]

Intrahepatic cholestasis has rarely been observed in patients with thyrotoxicosis and generally occurs in association with coexistent congestive heart failure. We report the case of a 63-year-old man who was referred to our Institution because of jaundice and hyperthyroidism. During his hospital stay, his plasma bilirubin level reached 27.41 mg/dL. Clinical, biohumoral, and instrumental examinations excluded heart failure and autoimmune or viral hepatitis. After the start of therapy with methimazole, thyroid hormone and plasma bilirubin levels decreased progressively and simultaneously, eventually returning to normal. Plasma bilirubin values as high as the ones we recorded, in the absence of congestive heart failure or autoimmune chronic hepatitis, have not, to our knowledge, been previously reported.

Correlations between bone histopathology and serum biochemistry in uremic patients on chronic hemodialysis

To define which noninvasive investigations are of value in predicting bone histology, we analyzed transiliac bone specimens (66 biopsies, 14 autopsies) from 80 uremic patients on chronic dialysis. Results were compared with values of different measurements of parathyroid hormone (PTH), alkaline phosphatase (APH), osteocalcin, calcitonin, baseline and post-deferroxamine (DFO) aluminium (Al),--beta 2 microglobulin, ferritin and bone mineral density. Among histomorphometric parameters, woven osteoid, active osteoblastic surface and resorption surface showed the best correlations with dynamic and biochemical marks of active bone metabolism. Among biochemical parameters, intact PTH and APH were better related to histomorphometric and dynamic bone parameters than other PTH measurements as well as osteocalcin, while calcitonin was related to no parameters. Stainable Al alone, and not total bone Al content was related to bone histology. Baseline Al was related to lamellar osteoid, while post-DFO Al was related to stainable Al. beta 2 microglobulin was positively related to active osteoid surface and ferritin was inversely related to the mineral apposition rate, while bone mineral density was related only to total bone volume. We conclude that, though definite diagnosis requires the use of histological methods, few simple biochemical parameters may offer insight to the bone metabolic status, useful to the physician in day to day clinical practice.

[Permanent vascular catheters for extracorporeal dialysis. Preliminary study: Canaud and Tesio catheters]

The use of alternative permanent vascular accesses has recently become increasingly common. The possibility of using the catheterization of central venous vessels has therefore been taken into consideration, in particular the internal jugular vein. During an observation period of 32 months the catheterization of the internal jugular vein (IJV) was used as a definitive access in 34 patients (12 M, 22 F; mean age 67.5, mean dialytic age 56 months in 18 patients, in 16 patients the insertion was by primary intention). A total of 44 IJV catheters were used, of which 18 Tesio and 26 Canaud. The authors examined the immediate complications following insertion and the episodes occurring during the observation period, including the problem of infection. The insertion of catheters was possible in all cases. In terms of catheter function, blood flow was adequate for the various purifying techniques. No severe complications were reported: gaseous embolism, pneumothorax, hemothorax, hemomediastinum. Infection was observed in 11 patients and 13 catheters, of which 70% were mainly provoked by Staphylococcus aureus and epidermidis. During the observation period there was a drop-out of 14 patients, 11 of whom died (3 following sepsis that failed to respond to antibiotic therapy). This preliminary experiment shows that permanent jugular catheters may be regarded as a valid access for hemodialytic treatment both in patients with severe problems of vascular access and for patients who present a short-term prognosis of dialysis and life expectancy at the time of starting hemodialysis.

[Instantaneous clearances: standard heparin versus low molecular weight heparin]

Standard heparin is still considered as a reference point for anticoagulation in CEC, although its use is not totally devoid of long-term and short term side effects, considering the risk of hemorrhage that patients undergo during dialysis. Numerous attempts have been made in the search for an alternative anticoagulating method. The recent discovery that low molecular weight fractions (LMWH) of standard heparin (UFH) assure the same antithrombotic effect but with a minor anticoagulating action, points to such a drug as an interesting alternative to the traditional use of heparin during dialysis. Our present task is to evaluate the purifying efficiency of different cuprophan and synthetic membranes with two LMWH and UFH, measuring the instantaneous ureic clearance of different dialysers at the start and end of each dialysis. N. 43 chronic patients were examined whilst undergoing different methods of treatment; using 12 different kinds of membrane, for a total of 22 filters. Every patient underwent a dialysis using each kind of heparin at least once, for a total of 189 dialysis. Neither the initial nor the final ureic clearances, nor the percentage of decreasing had changed by using different types of heparin and membranes with diverse thrombogenicity and ultrafiltration capacities. We may conclude from the results of the tests that the purifying efficiency of small molecules, judging from the istantaneous clearances, do not significant results compared to UFH.

Plasma endothelin in NIDDM patients with and without complications

OBJECTIVE

To measure plasma endothelin 1 (ET-1) levels in uncomplicated non-insulin-dependent diabetes mellitus (NIDDM) and investigate whether ET levels may be related to angiopathy, blood pressure, metabolic control, or duration of illness.

RESEARCH DESIGN AND METHODS

Plasma levels of ET-1 were measured in 44 NIDDM patients, of whom 24 had uncomplicated diabetes, 20 had angiopathy, and 10 had hypertension. In 21 patients, the duration of illness was > 10 years, and in 23 the duration of illness was < 10 years. Serum creatinine levels, microalbuminuria, and HbA1c were determined simultaneously. Thirty normotensive healthy (nondiabetic) individuals (20 men and 10 women) served as control subjects.

RESULTS

No significant statistical differences in plasma ET-1 levels were found among all diabetic patients, diabetic patients with and without angiopathy, diabetic patients with different durations of diabetes, and normal subjects. No significant correlation of plasma ET-1 with blood pressure, age, serum creatinine level, duration of diabetes, HbA1c, or diabetic complications was found.

CONCLUSIONS

Plasma ET-1 levels are similar in patients with NIDDM and healthy subjects and do not seem to act as a marker of diabetic complications.

[Renal insufficiency due to cholesterol embolism. 4 cases]

Atheroembolic disease is a complication of atheromatous disease and is quite often misunderstood. A precise diagnosis can be made difficult, by the lack of specific tests. The first case, in which we identified this disease, resulted from a bladder biopsy, in the instance of a patient with a suspected carcinoma. The experience, with this initial patient, led us to identification of a further 3 cases, within our previous 2 years case histories. One must consider the possibility of atheroembolic disease during the differential diagnosis of acute renal failure in geriatric patients, given the serious prognosis.

Plasma endothelin in essential hypertension and diabetes mellitus

This study was designed to determine plasma endothelin-1 levels in patients with essential hypertension and diabetes mellitus. Endothelin immunoreactivity was measured in normal controls (n = 30), mild-moderate essential hypertensives (n = 25), Type II diabetic normotensives (n = 25) and hypertensive patients (n = 20). In addition, in ten patients of each group we investigated the relationships of endothelin with other vasoactive hormones. Plasma endothelin concentrations were similar in healthy controls, in essential hypertensives and in diabetic patients with or without hypertension, averaging 8.23 +/- 1.68 pg/ml, 7.7 +/- 1.1 pg/ml, 5.05 +/- 0.94 pg/ml, 7.88 +/- 1.41 pg/ml, respectively. No correlations were observed between endothelin and concentrations of plasma renin activity, aldosterone, catecholamines, atrial natriuretic peptide and arginine-vasopressin. The present study suggests that Type II diabetic patients with or without essential hypertension do not have demonstrably higher values of plasma endothelin than essential hypertensives or healthy subjects.

Kinetics of aluminoxamine and feroxamine chelates in dialysis patients

To achieve a rational basis for the use of deferoxamine (DFO) in aluminum (AL) -and iron (Fe)-overloaded uremic patients, important insights may be provided by the recently available micromethods to determine DFO and its metallochelates aluminoxamine (AlA) and feroxamine (FeA). With this procedure, AlA and FeA plasma kinetics were evaluated in a pilot study in 10 uremic patients during a whole week after a single DFO infusion performed during the first hour of the first standard bicarbonate hemodialysis (HD) of the week. Patients were divided into normal (n = 6) and high (n = 4) ferritin groups (1 and 2 respectively). Baseline Al concentrations were greater than 2 less than 6 in group 1 and less than 1.5 mumol/l in group 2. DFO was given at doses of 40, 20 and 10 mg/kg. AlA and FeA showed substantially different kinetics. AlA kinetics were similar in group 1 and 2: they reached their peak at the beginning of the 2nd HD, decreased during the 2nd and 3rd HD, and with the highest DFO dose still increased between the 2nd and 3rd HD. At similar pre-DFO Al values (greater than 2 less than 3.3 mumol/l), increased DFO doses produced increased AlA concentrations ranging from 95 to 40% of total plasma Al for all the week. At higher pre-DFO Al values (greater than 3.5 less than 6 mumol/l), even a DFO dose as low as 10 mg/kg was sufficient to form consistent AlA amounts (from 80 to 15% of total Al).(ABSTRACT TRUNCATED AT 250 WORDS)

Repeated albumin infusions do not lower blood pressure in preeclampsia

Since intravascular volume contraction is regarded as an important pathological feature in preeclampsia, it has been proposed that plasma volume expansion could be a therapeutic manoeuver that interrupts the pathogenetic chain of hypovolemia inducing increased vascular resistance. Furthermore, tissue perfusion should be improved and, if albumin is used as plasma expander agent, interstitial edema should also be reduced. We report the results observed in an open pilot study in ten preeclamptic patients treated with daily albumin infusions (0.4 to 1 g/kg) from 7 to 36 days. No acute effects were shown on blood pressure, and the need for antihypertensive therapies did not decrease in the following days. Serial evaluation after at least five or ten days of repeated albumin infusions did not show stable changes in electrolytes excretion, renal clearances, serum protein concentration and hematocrit value, nor in aldosterone, renin and atrial natriuretic peptide basal levels, while proteinuria tended to increase. Uteroplacental and fetoplacental blood flow acutely ameliorated in 3 cases only after albumin 1 g/Kg, but reached basal values again on the next day. The clinical implications are that daily albumin infusions with this schedule dosage do not lower blood pressure and that they are unable to induce stable changes in renal function, uteroplacental and fetoplacental resistance. No maternal complications were observed during the conservative management, but fetal mortality was high (6/10). Given the uncontrolled study, we cannot know whether similar results had been achieved by conventional therapy only.

[Weekly dialysis integrated with low-protein diet and essential amino acids. Preliminary data]

The possibility of applying a once-a-week dialysis programme supplemented with hypoproteic diet as an adequate technique for starting the uraemic patient on dialysis is examined. Thirteen patients have been so treated, 7 of them currently under treatment for a global period of observation of 46 months. At the moment dialysis began, mean glomerular filtrate was 5.14 ml/min. Once-a-week dialytic treatment with bicarbonate dialysis was associated with a hypoproteic diet of 0.5 g/kg/die of proteins, supplemented with essential amino acids. This treatment showed excellent dialytic tolerance, the values of dialysis start blood nitrogen were lower than 200 mg/dl and dialytic efficiency was compatible with a Kt/v greater than 1.1. There was no observation of any subjective or objective symptomatology that could be related to dialytic inadequacy. Taken as a whole these results make it possible to state that this type of approach permits a gradual start to dialysis and deserves further study.

Ratio between aldosterone and atrial natriuretic peptide in pregnancy

The possibility of evaluating the ratio between aldosterone and atrial natriuretic peptide (ANP) instead of the two hormones by themselves in studying sodium handling in normal pregnancy and in preeclampsia in the steady state and following albumin infusion was examined in this study. In 32 normal pregnancies monitored monthly, the highest aldosterone/ANP ratio was observed in the last weeks (28.7 +/- 12), and dropped in the first postpartum week (3.6 +/- 2.8), without changes in fractional excretion of sodium. In 18 preeclamptic patients, the ratio was significantly lower than in normal pregnancy at the same gestational ages, and it was coupled with absolute reduction in the sodium excretion. Among preeclamptic patients, a significant inverse correlation (P less than 0.025) was revealed between the ratio and sodium excretion. Natriuresis in response to acute volume expansion with albumin infusion occurred only in 50% of preeclamptic patients, and was associated with an ANP increase, an aldosterone decrease, and a further decrease in the ratio. A blunted natriuresis was observed in cases with a particularly low prealbumin value of this ratio. Furthermore, in preeclampsia, a particularly low ratio seemed to be typical of the patients who showed poorer placental flows and fetal outcomes. These results suggest that the balance between aldosterone and ANP may be a useful index in understanding sodium homeostasis in these settings.

Prevention and treatment of aluminum overload in uremic patients: long-term results

The authors evaluate the efficacy of a protocol of prevention and treatment of aluminum (Al) overload in RDT patients during a 7-year period (from 1981, 164 patients, to 1987, 161 patients). Al in dialysate solutions was always less than 25 micrograms/l. Baseline Al levels greater than 100 micrograms/l were found in 22% of patients in 1981 but in none in 1987, while the percentage of values less than 60 micrograms/l increased from 55 to 91%. DFO tests were positive in 54% and 7% of cases in 1981 and 1987, respectively. A clinical diagnosis of Al intoxication was performed in 6 patients in 1981, and no further cases were diagnosed later. DFO treatment (50 mg/kg once a week) was employed preventively in 31 patients owing to positive DFO-tests, and in the 6 Al-intoxicated patients therapeutically. In the former patients none developed clinical intoxication. In the latter group clinical improvement was only temporary in the three parathyroidectomized patients. Al hydroxide [Al(OH)3] as a phosphate binder was tapered off in 1981 and substituted by Al-free chelants. In 1987, 66% of patients were given CaCO3 or Mg (OH)2 alone or in association, while 34% still needed Al(OH)3, although at low dosages (less than 2 g/day). The conclusion is that such a protocol is able to prevent and to treat cases of Al intoxication, albeit only partially.

Short term ethanol ingestion can affect the testicular response to single-dose human chorionic gonadotropin in normal subjects

Ten sober adult male subjects, with normal sexual development and function, were examined under basal conditions and after a short-term period (7 days) of alcohol ingestion (200 g/daily). Plasma concentrations of testosterone (T), 17 beta estradiol (E2), progesterone (P) and 17-hydroxyprogesterone (17-OH P) were measured on blood samples drawn before and then every 24 h until the 96th h following a single dose of human chorionic gonadotropin (hCG, 2,000 IU im). Basal plasma T was significantly decreased after short-term ethanol ingestion (p less than 0.01) whereas E2, P and 17-OH P were comparable in both conditions. The magnitude of the T response to hCG injection was significantly lower after ethanol ingestion but still significantly higher than the corresponding one obtainable in chronic alcoholics. At the 7th day of ethanol ingestion plasma LH levels were higher than controls (p less than 0.05). These results demonstrate that short-term ingestion of 200 g ethanol daily can lead to altered testicular response to hCG in normal adult males and corroborate the view that ethanol is a gonadal toxin.

[Obesity and non-insulin-dependent diabetes mellitus. Considerations on an epidemiological study]

We have investigated the age of onset of diabetes mellitus and the body weight in an ethnically homogeneous population of type II diabetics (737 subjects, of whom 248 newly diagnosed). In newly diagnosed diabetics the mean age of onset of diabetes was significantly (p less than 0.001) lower in males than in females. The mean percentage of overweight was significantly (p less than 0.001) higher in female than in male diabetics. In percent, newly diagnosed female diabetics were more obese than newly diagnosed male diabetics. In males, no correlation was found between age and weight, at the moment of diagnosis, while in females a poorly significant (p less than 0.05) negative correlation was found. Our results seem to indicate that in an ethnic group, besides overweight, other (genetic?, dietetic?, environmental?) factors can be prevalent causes of diabetes mellitus.

Plasma testosterone, estradiol, progesterone and 17-hydroxy-progesterone responses to single-dose stimulation with human chorionic gonadotropin in chronic male alcoholics

Ten chronic male alcoholics presenting with hypogonadism but without overt liver failure were examined under basal conditions and after stimulation of the testicular steroidogenesis with a single dose of human chorionic gonadotropin (hCG, 2,000 IU im). Plasma concentrations of testosterone (T), 17 beta-estradiol (E2), progesterone (P) and 17-OH progesterone (17-OHP) were measured between 08:00-09:00 prior to injection and then every 24 h at the same time in the morning until the 96th hour following the injection. Controls were 10 male adult volunteers, examined under the same conditions. Four alcoholics underwent a second hCG stimulation after 10 day controlled abstinence from alcohol. Basal plasma T and P were significantly decreased and increased respectively in the alcoholics (p less than 0.001) whereas E2 and 17-OHP were much the same in both groups. The magnitude of the T response to hCG injection was significantly lower in the alcoholics at any considered time (p less than 0.001). The E2 response, too, was lower, whereas the ratio E2 change/T change after hCG was higher. The response peak occurred earlier for E2 than for T both in controls and alcoholics. The mean percent change at 24 h and the mean maximum increase of 17-OHP were higher in the alcoholics (p less than 0.01 and p less than 0.05 respectively). An increase in P after hCG was observed in only 5 alcoholics (responders), while some subjects displayed paradoxical decreases. Abstinence was always followed by an increased T response and a decreased 17-OHP response. The E2 response was unchanged and two P responders displayed an increased response.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of ethanol infusion on the pituitary-testicular responsiveness to gonadotropin releasing hormone and thyrotropin releasing hormone in normal males and in chronic alcoholics presenting with hypogonadism

Nine chronic male alcoholics presenting with hypogonadism but without overt liver failure were examined under baseline conditions and after acute injection of gonadotropin releasing hormone (GnRH, 100 micrograms iv) and thyrotropin releasing hormone (TRH, 200 micrograms iv), performed at 60 min of a 3-h infusion of saline and 0.4 g/kg ethanol, respectively. Controls were 10 male adult volunteers examined under the same conditions. Six alcoholics and six controls underwent a third test with the infusion of 0.8 g/kg ethanol. Subjects were hospitalized and the infusion was started after a 48-h period of abstinence from alcohol. Tests were performed in random order at intervals of at least three weeks, always at 15:00 following a standard meal in the morning. Plasma levels of FSH, LH, prolactin (PRL) and testosterone (T) were measured by radioimmunoassay. Significantly higher levels of FSH, LH and PRL, and significantly lower levels of T were recorded in alcoholics vs. controls on plasma samples drawn at about 08:00 for three consecutive days. Ethanol infusion at the dose of 0.4 g/kg did not change the pattern of response to GnRH and TRH of controls and alcoholics. Doubling the alcohol dosage yielded a significant reduction of LH response in normal subjects whereas did not result in a similar effect in alcoholics. The mean LH increment of alcoholics was significantly less than that of normals at all times during saline and infusion of 0.4 g/kg ethanol; significance was not attained when the dose of ethanol was 0.8 g/kg.(ABSTRACT TRUNCATED AT 250 WORDS)

Circadian patterns of plasma cortisol and testosterone in chronic male alcoholics

Twelve alcoholic men (28-55 yr) presenting hypogonadal features but without overt liver failure were hospitalized and examined still consuming alcohol regularly. Sleep was approximately from 2200 to 0600; three equicaloric meals were served at 0700, 1200, and 1800. Blood samples were drawn at 4-hr intervals throughout a 24-hr span starting from 0800. Measured levels of cortisol and testosterone were then analyzed by rhythmometric procedures in order to estimate parameters of the circadian oscillation such as mesor, amplitude, and acrophase, and the relevant confidence limits. Data were compared to those obtained in a matched group of 20 healthy controls. With regard to cortisol, the rhythmometric analyses allowed the demonstration of a normally synchronized circadian rhythm substantially superimposable in alcoholics and controls. With regard to testosterone, the results were compatible with a significant circadian oscillation only in the control group. Alcoholics did show ample interindividual variability of plasma testosterone levels, but the apparent lack of the circadian rhythm was independent of the steroid concentration. These data extend previous observations and are consistent with the occurrence of important abnormalities in the circadian pattern of plasma testosterone in chronic male alcoholics prior to liver failure.