Testosterone deficiency independently predicts mortality in women with HFrEF: insights from the T.O.S.CA. registry

AIMS

Testosterone deficiency (TD) is associated with increased morbidity and mortality in heart failure with reduced ejection fraction (HFrEF). However, data in women are scanty. The aim of this study was to investigate the prognostic impact of TD on women with HFrEF.

METHODS

Among 480 patients prospectively enrolled in the T.O.S.CA. (Terapia Ormonale Scompenso CArdiaco) registry, a prospective, multicentre, nationwide, observational study, 94 women were included in the current analysis. The TD was defined as serum testosterone levels lower than 25 ng/dl. Data regarding clinical status, echocardiography, exercise performance, cardiovascular hospitalization, and survival after an average follow-up of 36 months were analysed.

RESULTS

Thirty patients (31.9%) displayed TD. TD was associated with lower tricuspid annular plane excursion (TAPSE) to pulmonary arterial systolic pressure PASP ratio (TAPSE/PASP) (P = 0.008), peak oxygen consumption (VO₂ peak) (P = 0.03) and estimated glomerular filtration rate (P < 0.001). TD was an independent predictor of the combined endpoint of all-cause mortality/cardiovascular hospitalization (HR: 10.45; 95% CI: 3.54-17.01; P = 0.001), all-cause mortality (HR: 8.33; 95%: 5.36-15.11; P = 0.039), and cardiovascular hospitalization (HR: 2.41; 95% CI: 1.13-4.50; P = 0.02).

CONCLUSIONS

One-third of women with HFrEF displays TD that impacts remarkably on their morbidity and mortality. TD is associated with a worse clinical profile including exercise capacity, right ventricular-pulmonary arterial coupling, and renal function. These findings lend support to an accurate profiling of women with HF, a problem often overlooked in clinical trials.

Insulin-like growth factor-1 (IGF-1) as predictor of cardiovascular mortality in heart failure patients: data from the T.O.S.CA. registry

INTRODUCTION

Data from the "Trattamento Ormonale nello Scompenso CArdiaco" (T.O.S.CA) registry showed that heart failure (HF) represents a complex clinical syndrome with different hormonal alterations. Renal failure represents a frequent complication in HF. We evaluated the relationship between renal function and insuline-like growth factor-1 (IGF-1) deficiency and its impact on cardiovascular mortality (CVM) in patients enrolled in the T.O.S.CA. registry.

METHODS

At the enrolment, all subjects underwent chemistry examinations, including circulating hormones and cardiovascular functional tests. COX regression analysis was used to evaluate factors related to CVM during the follow-up period in all populations, in high-risk patients and in the young-adult population. Also, we evaluate the effects of renal function on the CVM.

RESULTS

337 patients (41 deceased) were analyzed. CVM was related to severe renal dysfunction (HR stages IV-V = 4.86), high-risk conditions (HR 2.25), serum IGF-1 (HR 0.42), and HF etiology (HR 5.85 and HR 1.63 for valvular and ischemic etiology, respectively). In high-risk patients, CVM was related to IGF-1 levels, severe renal dysfunction and valvular etiology, whereas in young patients CMV was related to the high-risk pattern and serum IGF-1 levels.

CONCLUSIONS

Our study showed the clinical and prognostic utility of the IGF-1 assay in patients with HF.

Progressive right ventricular dysfunction and exercise impairment in patients with heart failure and diabetes mellitus: insights from the T.O.S.CA. Registry

Background

Findings from the T.O.S.CA. Registry recently reported that patients with concomitant chronic heart failure (CHF) and impairment of insulin axis (either insulin resistance—IR or diabetes mellitus—T2D) display increased morbidity and mortality. However, little information is available on the relative impact of IR and T2D on cardiac structure and function, cardiopulmonary performance, and their longitudinal changes in CHF.

Methods

Patients enrolled in the T.O.S.CA. Registry performed echocardiography and cardiopulmonary exercise test at baseline and at a patient-average follow-up of 36 months. Patients were divided into three groups based on the degree of insulin impairment: euglycemic without IR (EU), euglycemic with IR (IR), and T2D.

Results

Compared with EU and IR, T2D was associated with increased filling pressures (E/e′ratio: 15.9 ± 8.9, 12.0 ± 6.5, and 14.5 ± 8.1 respectively, p < 0.01) and worse right ventricular(RV)-arterial uncoupling (RVAUC) (TAPSE/PASP ratio 0.52 ± 0.2, 0.6 ± 0.3, and 0.6 ± 0.3 in T2D, EU and IR, respectively, p < 0.05). Likewise, impairment in peak oxygen consumption (peak VO₂) in TD2 vs EU and IR patients was recorded (respectively, 15.8 ± 3.8 ml/Kg/min, 18.4 ± 4.3 ml/Kg/min and 16.5 ± 4.3 ml/Kg/min, p < 0.003). Longitudinal data demonstrated higher deterioration of RVAUC, RV dimension, and peak VO₂ in the T2D group (+ 13% increase in RV dimension, − 21% decline in TAPSE/PAPS ratio and − 20% decrease in peak VO₂).

Conclusion

The higher risk of death and CV hospitalizations exhibited by HF-T2D patients in the T.O.S.CA. Registry is associated with progressive RV ventricular dysfunction and exercise impairment when compared to euglycemic CHF patients, supporting the pivotal importance of hyperglycaemia and right chambers in HF prognosis.

Trial registration ClinicalTrials.gov identifier: NCT023358017

Multiple hormonal and metabolic deficiency syndrome predicts outcome in heart failure: the T.O.S.CA. Registry

AIMS

Recent evidence supports the occurrence of multiple hormonal and metabolic deficiency syndrome (MHDS) in chronic heart failure (CHF). However, no large observational study has unequivocally demonstrated its impact on CHF progression and outcome. The T.O.S.CA. (Trattamento Ormonale nello Scompenso CArdiaco; Hormone Treatment in Heart Failure) Registry has been specifically designed to test the hypothesis that MHDS affects morbidity and mortality in CHF patients.

METHODS AND RESULTS

The T.O.S.CA. Registry is a prospective, multicentre, observational study involving 19 Italian centres. Thyroid hormones, insulin-like growth factor-1, total testosterone, dehydropianoandrosterone sulfate, insulin resistance, and the presence of diabetes were evaluated. A MHDS was defined as the presence of ≥2 hormone deficiencies (HDs). Primary endpoint was a composite of all-cause mortality and cardiovascular hospitalizations. Four hundred and eighty heart failure patients with ejection fraction ≤45% were enrolled. MHDS or diabetes was diagnosed in 372 patients (77.5%). A total of 271 events (97 deaths and 174 cardiovascular hospitalizations) were recorded, 41% in NO-MHDS and 62% in MHDS (P < 0.001). Median follow-up was of 36 months. MHDS was independently associated with the occurrence of the primary endpoint [hazard ratio 95% (confidence interval), 1.93 (1.37-2.73), P < 0.001] and identified a group of patients with a higher mortality [2.2 (1.28-3.83), P = 0.01], with a graded relation between HDs and cumulative events (P < 0.01).

CONCLUSION

MHDS is common in CHF and independently associated with increased all-cause mortality and cardiovascular hospitalization, representing a promising therapeutic target.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT023358017.

Stereotactic body radiation therapy for liver metastasis from colorectal cancer: size matters

PURPOSE

We analysed our initial experience with SBRT in liver metastasis from colorectal cancer at our institution.

MATERIALS AND METHODS

Between January/2014 and December/2017, 22 patients with 31 LMCCR were treated. Local control (LC) was assessed using the Kaplan-Meier and log-rank tests. We analysed potential prognostic factors for LC: sex, PTV size, number of LM and the radiation scheme.

RESULTS

Median age: 69 years. Prior chemotherapy or local liver treatments: 81.8% and 63.6% of patients, respectively. SBRT consisted of 3 × 20 Gy (42.9%) and 3 × 15 Gy (31.4%). There were 88.5% responses (57.1% CR and 31.4% PR). Median follow-up was 30 months. LC per lesion at 12 and 24 months was 85.3% and 61.8%, respectively. Tumour volumes > 30 cc correlated with worsened 2-year-control rates (90% vs 34.5%) (p = 0.005). There was only a patient with CTC-grade 3 toxicity.

CONCLUSIONS

Liver SBRT is a safe and effective treatment that achieves high local control rates. We found a significant correlation between larger LMCRC and worse local control.

[Re-irradiation with SBRT (Stereotactic Body Radiation Therapy) for locoregional unresectable relapse of head and neck cancer: a case report]

Patients with an unresectable recurrence of head and neck carcinoma (HNC) have a poor prognosis, with limited treatment options. Recent technical advances allow radiotherapy (RT) to be handled with great precision, making it possible to re-irradiate recurrent tumors by means of stereotactic body radiotherapy (SBRT) with high doses of RT while protecting healthy tissues near the tumor. Although this technique has been used to irradiate different primary tumors and their metastases, SBRT in HNC has had a much slower evolution than in the mentioned locations. This is due to the difficulties in re-irradiating the HNC, because of the expected toxicity as it is a relatively small area with dense vascularization and innervation, and where several senses are located. We present the first case of a HNC re-irradiated with SBRT in the Complejo Hospitalario de Navarra; the patient showed a complete response and continues to be disease-free sixteen months after the irradiation.

Multiple hormonal and metabolic deficiency syndrome in chronic heart failure: rationale, design, and demographic characteristics of the T.O.S.CA. Registry

Recent evidence supports the concept that progression of chronic heart failure (CHF) depends upon an imbalance of catabolic forces over the anabolic drive. In this regard, multiple hormonal deficiency syndrome (MHDS) significantly has impacts upon CHF progression, and is associated with a worse clinical status and increased mortality. The T.O.S.CA. (Trattamento Ormonale nello Scompenso CArdiaco; Hormone Therapy in Heart Failure) Registry (clinicaltrial.gov = NCT02335801) tests the hypothesis that anabolic deficiencies reduce survival in a large population of mild-to-moderate CHF patients. The T.O.S.CA. Registry is a prospective multicenter observational study coordinated by "Federico II" University of Naples, and involves 19 centers situated throughout Italy. Thyroid hormones, insulin-like growth factor-1, total testosterone, dehydroepiandrosterone , and insulin are measured at baseline and every year for a patient-average follow-up of 3 years. Subjects with CHF are divided into two groups: patients with one or no anabolic deficiency, and patients with two or more anabolic deficiencies at baseline. The primary endpoint is the composite of all-cause mortality and cardiovascular hospitalization. Secondary endpoints include the composite of all-cause mortality and hospitalization, the composite of cardiovascular mortality and cardiovascular hospitalization, and change of VO₂ peak. Patient enrollment started in April 2013, and was completed in July 2017. Demographics and main clinical characteristics of enrolled patients are provided in this article. Detailed cross-sectional results will be available in late 2018. The T.O.S.CA. Registry represents the most robust prospective observational trial on MHDS in the field of CHF. The study findings will advance our knowledge with regard to the intimate mechanisms of CHF progression and hopefully pave the way for future randomized clinical trials of single or multiple hormonal replacement therapies in CHF.

Six controversial issues on subclinical Cushing's syndrome

Subclinical Cushing's syndrome is a condition of hypercortisolism in the absence of signs specific of overt cortisol excess, and it is associated with an increased risk of diabetes, hypertension, fragility fractures, cardiovascular events and mortality. The subclinical Cushing's syndrome is not rare, being estimated to be between 0.2-2 % in the adult population. Despite the huge number of studies that have been published in the recent years, several issues remain controversial for the subclinical Cushing's syndrome screening, diagnosis and treatment. The Altogether to Beat Cushing's syndrome Group was founded in 2012 for bringing together the leading Italian experts in the hypercortisolism-related diseases. This document represents the Altogether to Beat Cushing's syndrome viewpoint regarding the following controversial issues on Subclinical Cushing's syndrome (SCS): (1) Who has to be screened for subclinical Cushing's syndrome? (2) How to screen the populations at risk? (3) How to diagnose subclinical Cushing's syndrome in patients with an adrenal incidentaloma? (4) Which consequence of subclinical Cushing's syndrome has to be searched for? (5) How to address the therapy of choice in AI patients with subclinical Cushing's syndrome? (6) How to follow-up adrenal incidentaloma patients with subclinical Cushing's syndrome surgically or conservatively treated? Notwithstanding the fact that most studies that faced these points may have several biases (e.g., retrospective design, small sample size, different criteria for the subclinical Cushing's syndrome diagnosis), we believe that the literature evidence is sufficient to affirm that the subclinical Cushing's syndrome condition is not harmless and that the currently available diagnostic tools are reliable for identifying the majority of individuals with subclinical Cushing's syndrome.

Estudio comparativo de la calidad de la canal y la carne de lechales de raza Churra Tensina y dos tipos ovinos comerciales amparados bajo marcas de calidad

Se estudió la calidad de la canal y la carne de lechales ovinos comerciales de raza Churra Tensina (n= 26) según la época de cría y sacrificio (primavera vs. otoño). Estos corderos se compararon con otros tipos comerciales amparados bajo marcas de calidad reconocidas en el mercado con denominación de Indicación Geográfica Protegida (IGP): Lechazo de Castilla-León (n= 13) y Ternasco de Aragón (n= 13). Todos los corderos fueron criados, seleccionados y sacrificados en condiciones comerciales. Tras el sacrificio, se valoró la calidad de la canal y de la carne en el músculo Longissimus thoracis y lumborum (LTL). Los lechales de Churra Tensina presentaron diferencias según la época de producción, fundamentalmente en las variables relacionadas con la composición tisular de la canal, presentando, los lechales de primavera, un mayor porcentaje de músculo y hueso, y menor de grasa que los de otoño (p≤0,001), así como una mayor proporción de los ácidos grasos C 12:0, CLA, C 20:2 n-3 o C 22:0 (p≤0,001) en la grasa intramuscular. Estas diferencias de composición no se reflejaron en el análisis sensorial, ya sea mediante panel entrenado o consumidores. La carne de los lechales de la raza Churra Tensina presentó una terneza superior (p≤0,001) a la de los productos IGP con los que se comparó, tanto instrumentalmente como sensorialmente (panel entrenado) y una mayor aceptabilidad tanto general, como del sabor y de la terneza (consumidores) (p≤0,001). Los resultados obtenidos reflejarían el potencial de dicha raza para la producción de lechales de calidad, en ambas estaciones del año.

[MRI findings in iliotibial band friction syndrome: a report of two cases]

We present the magnetic resonance imaging (MRI) findings in two males clinically diagnosed with iliotibial band friction syndrome (IBFS), a frequent cause of pain in the lateral compartment of the knee. Coronal T2-weighted images with fat saturation show an ill-defined area of high signal intensity in the soft tissues situated immediately below the iliotibial band lateral to the external condyle of the femur. No thickening of the iliotibial band or changes in its signal intensity were observed. Osseous edema and subchondral osseous erosion in the external condyle of the femur were observed in both cases. Pain in the lateral compartment of the knee might be due to multiple causes that should be included in the differential diagnosis and MRI can play a significant role in reaching the definitive diagnosis.

[Disk diffusion method for fluconazole susceptibility testing of Candida spp. isolates]

In order to standardize and evaluate a disk diffusion method with visual reading to detect in vitro fluconazole susceptibility of yeast, 1193 clinical isolates were tested. These included 584 Candida albicans, 196 Candida parapsilosis, 200 Candida tropicalis, 113 Candida glabrata, 50 Candida krusei and 50 Candida spp. and other opportunistic yeasts. The disks were manufactured in the INEI-ANLIS "Dr. Carlos G. Malbrán. The disk diffusion method results were compared to MIC results obtained by the reference CLSI M27-A2 broth microdilution method modified by EUCAST. The interpretative breakpoints for in vitro susceptibility testing of fluconazole were established at: zone diameter > or =16 mm for MIC < or =8 microg/ml (susceptible isolates), between 9 and 15 mm for MIC = 16-32 microg/ml (susceptible dose-dependent isolates), and < or =8 mm for MIC > or =64 microg/ml (resistant isolates). Overall agreement between the two methods was 94.7%, with 0.2% very major errors, and 0.3% major errors. Inter - and intralaboratory agreement was good. The disk diffusion method for drug susceptibility testing of Candida spp. isolates is inexpensive, reliable and reproducible. However, when the inhibition zone diameter is < or =15 mm, it is advisable to test the isolate by the reference microdilution method.

Surfactant protein D deficiency influences allergic immune responses

BACKGROUND

The collectin surfactant protein D (SP-D) confers protection against pulmonary infection and inflammation. Recent data suggest a role for SP-D in the modulation of allergic inflammation.

OBJECTIVE

The aim of this study is to characterize the immune responses of SP-D-deficient (SP-D(-/-)) mice in a kinetic model of allergic inflammation. We determined whether allergic parameters were enhanced in SP-D(-/-) mice in vivo. Further, we examined whether functional immune responses in vitro such as lymphocyte proliferation (LP) and cytokine production were modulated in the absence of SP-D.

METHODS

In vivo, wild-type (WT) and SP-D(-/-) mice were sensitized and challenged with the allergen ovalbumin (OVA) and assessed for allergic parameters (bronchoalveolar lavage (BAL) eosinophils, IL-13 production, pulmonary IFN-gamma, IL-10 expression) at early time points (1 and 3 days of challenge) in comparison with late time points (7 days of challenge). In vitro, spleen cells from WT and SP-D(-/-) mice were stimulated with the mitogen concanavalin A (ConA) and lipid A (LpA) and analysed for LP, IL-13 and IFN-gamma production. Toll-like receptor 4 (TLR4), ligand for LpA, was assessed by mRNA expression and immunohistochemistry in vivo.

RESULTS

Following allergen exposure in vivo, SP-D(-/-) mice expressed higher BAL eosinophils and IL-13 concentrations and lower IFN-gamma expression at early time points compared with WT mice. IL-10 expression was increased at early time points in SP-D(-/-) compared with WT mice. Allergen-induced TLR4 expression was increased in WT, but not in SP-D(-/-) mice. After stimulation with LpA and ConA in vitro LP was increased and IFN-gamma concentration was decreased in SP-D(-/-) mice.

CONCLUSION

SP-D may be critical for the modulation of early stages of allergic inflammation in vivo.

A six month mitotane course induced sustained correction of hypercortisolism in a young woman with PPNAD and Carney complex

A low-dose mitotane (MT) regimen was evaluated as a pharmacological approach for correcting the severe hypercortisolism in a young woman affected by Carney complex (CNC) and primary pigmented nodular adrenocortical disease (PPNAD). In the first 12 week period, the MT daily dose was progressively increased from 0.5 to 4.0 g/day. This dosage was maintained for an additional 16 weeks (cumulative dose 602 g, plasma MT maximum level 12 microg/ml), and then stopped because of sustained signs of hypoadrenalism requiring prednisone replacement. Complete regression of seborrhea, acne, and plethora was observed after 8 weeks of treatment (cumulative dose 95 g). Regular menses returned after 13 weeks (cumulative dose 197 g, plasma MT 8 microg/ml). Profound decrease of both serum cortisol (from 615 to 220 nmol/l) and urinary free cortisol (UFC) values (from 1498 to 477 nmol/day) was noted after 16 weeks of treatment (cumulative dose 314 g, plasma MT 8 microg/ml). MT treatment was associated with mild gastric discomfort and reversible increase of cholesterol plasma levels. Low serum cortisol and UFC were still observed 41 weeks after MT was discontinued (plasma MT 0.2 microg/ml). Our report demonstrates that low dose MT treatment may be a safe and effective modality for a sustained correction of hypercortisolism by PPNAD in subjects with CNC waiting for surgery.

Diagnostic utility of thyroglobulin detection in fine-needle aspiration of cervical cystic metastatic lymph nodes from papillary thyroid cancer with negative cytology

Cystic changes in metastatic cervical lymph nodes (CLN) from papillary thyroid cancer (PTC) may be a diagnostic pitfall in fine-needle aspiration biopsy (FNAB) cytology. We investigated in a series of CLN metastases from thyroid cancers (TC), including cystic PTC, and from a wide spectrum of extrathyroidal malignancies, the diagnostic role for metastatic TC of the rapid detection of thyroglobulin in eluates from FNAB (FNAB-Tg) of CLN. The study was carried out in a group of 79 subjects (22/57 M/F; median age, 56 years; range, 20-86 years) with enlarged CLN and thyroid nodules (TN), examined for potential metastatic TC, and harboring a large spectrum of incidentally diagnosed extrathyroidal malignancies (n = 24, mostly represented by lymphomas, lung, and breast cancers), CLN metastases from thyroid cancers (n = 28, including 6 cystic metastatic PTC), 6 specific lymphadenitis and 21 reactive lymphadenitis mostly detected (n = 16) during follow-up of patients with previously ablated TC. Markedly high FNAB thyroglobulin (Tg) values were found in all metastatic CLN TC. Two of the six cases with cystic metastatic CLN PTC were diagnosed by FNAB-Tg but not by cytology. In conclusion, FNAB-Tg has been confirmed as an easy modality and fast procedure to diagnose CLN metastasis from TC and high FNAB-Tg values with nondiagnostic cystic cytology strongly suggest cystic metastatic PTC.

Liver transplantation for hepatocellular carcinoma in cirrhotic patients

A consecutive series of 88 patients underwent transplantation for hepatocellular carcinoma with cirrhosis over a 7-year period. Liver transplantation was indicated because of the tumor in 75 cases (85.2%); tumor was an incidental finding in 13 cases (14.8%). One patient was retransplanted due to primary nonfunction. The perioperative mortality was 4.5%. Tumor recurrence was observed in seven patients (7.95%) with incidental tumor recurrence in one case. As in patients with known primary liver tumors pretransplant, a thorough follow-up is advisable to establish an early diagnosis of recurrence. The actuarial survival for nonincidental hepatocellular carcinoma at 1, 3, and 5 year was 92%, 77%, and 75%, respectively. The differences in actuarial survival between hepatitis C negative and positive hepatocellular carcinoma were not significant (log-rank test P=.27), though there was a clear improvement in results (94%, 85%, and 78% vs 90%, 71%, and 71%), at 1, 3, and 5 years meaning that HCV infection is an important prognostic factor. Although transplantation for HCC has the advantages of removing the tumor and the cirrhotic liver, it remains a controversial topic. In our experience patients showing lesions less than 5 cm or three or fewer lesions experience an equivalent survival to transplanted patients who do not have cancer.

Molecular identification of streptomycin monoresistant Mycobacterium tuberculosis related to multidrug-resistant W strain

A distinct branch of the Mycobacterium tuberculosis W phylogenetic lineage (W14 group) has been identified and characterized by various genotyping techniques. The W14 group comprises three strain variants: W14, W23, and W26, which accounted for 26 clinical isolates from the New York City metropolitan area. The W14 group shares a unique IS6110 hybridizing banding motif as well as distinct polymorphic GC-rich repetitive sequence and variable number tandem repeat patterns. All W14 group members have high levels of streptomycin resistance. When the streptomycin resistance rpsL target gene was sequenced, all members of this strain family had an identical mutation in codon 43. Patients infected with the W14 group were primarily of non- Hispanic black origin (77%); all were US-born. Including HIV positivity, 84% of the patients had at least one known risk factor for tuberculosis.

[Stability of theophylline in mono- and multi-layer parenteral nutrition bags]

The addition of drugs to parenteral nutrition (PN) presents a high risk of physical and chemical incompatibilities. In certain patients with water restriction or limited vein access, however, it may be necessary to add medicines to PN. Although there are numerous studies into the stability of aminophylline in PN, all of them refer to periods of less than 2 days. The purpose of the present study is to determine the stability of anhydrous theophylline over 24 hours at room temperature in 24 hours parenteral nutrition and over five days (four days stored in refrigerator and 24 hours at room temperature). In addition, to assess whether its degradation is affected by the use of single-layer or multi-layer bags. The composition of PN corresponds to a standard 1,800 Kcal diet at our hospital with a concentration of 0.164 mg/ml of anhydrous theophylline. No statistically significant differences were obtained in any of the cases studied, thus demonstrating the stability of theophylline under our study conditions both after 24 hours at room temperature and after four days of storage in the refrigerator followed by 24 hours at room temperature. Nor were differences found between storing the drug in single-layer and multi-layer bags.

Pregnancy in a patient with chronic intestinal pseudo-obstruction on long-term parenteral nutrition

Parenteral nutrition support is provided in most instances for short intervals during pregnancy in conditions where oral/enteral intake is severely compromised. Few reports describe the use of parenteral nutrition from conception to delivery. We report the case of a 30-year-old woman suffering from a severe form of chronic intestinal pseudo-obstruction on long-term parenteral nutrition because of malabsorption and malnutrition. Pregnancy and delivery developed uneventfully. The fetus grew normally throughout pregnancy. Our patient needed only slight modifications in her parenteral nutrition regimen during lactation. There were no metabolic complications during pregnancy. We conclude that female patients even with severe forms of gastrointestinal diseases, such as chronic intestinal pseudo-obstruction requiring long-term home parenteral nutrition, can conceive and carry successfully a pregnancy to term.

[Infection after orthotopic liver transplantation: analysis of the first 120 consecutive cases]

OBJECTIVE

To report the infectious complications and presentation time of the first 120 consecutive liver transplants performed at our institution.

METHODS

Prospective study of infectious complications among 120 consecutive adult patients who received orthotopic liver transplantation at Hospital de Cruces, from February 1996 to November 1998. Two patients received a renal transplant concomitantly. The same surveillance protocols were used for all patients and the criteria used to define infections were those reported by other authors.

RESULTS

The group consisted of 120 patients, 95 males and 25 females. The age ranged from 20 and 66 years (mean: 54 +/- 9 years). The indications for transplantation included alcoholic cirrhosis (47%), HCV cirrhosis (20%), hepatocellular carcinoma (17.5%), fulminant hepatitis (6%), primary biliary cirrhosis (2.5%) and miscellaneous conditions (7%). Three patients required retransplantation. Acute rejection was histologically diagnosed in 38 patients (31%). None of the patients had corticosteroid-resistant rejection. Fifty-one patients (42.5%) developed 76 episodes of severe infection, which included: 48 episodes of bacterial infection among 33 patients (27.5%), tuberculosis in 7 patients (6%), 9 episodes of fungal infection among 8 patients (7%) and cytomegalovirus (CMV) infection among 8.5% of patients. No patient developed Pneumocystis carinii pneumonia. Fifteen (12.5%) patients died: six (12.5%) with active infection, and in four of them the infection was considered the cause of death.

CONCLUSIONS

Infection rates due to bacteria and fungi were similar to those reported in the literature. A high rate of tuberculosis was found, which possible correlated with the high incidence of this disease in the general population. The low incidence of CMV infection was probably due to the preemptive therapy with gancyclovir. Trimethoprim-sulfamethoxazol prophylaxis against Pneumocystis carinii was highly effective.

Thyroid follicular carcinoma: a case report

We present an 8-year-old boy with thyroid follicular carcinoma. Differentiated thyroid follicular carcinoma is very uncommon in childhood and is not usually suspected as the explanation of a thyroid nodule during infancy. The purpose of our paper is to demonstrate the imaging findings in a child and to emphasise the importance of including this tumour in the differential diagnosis of thyroid nodules in children.

Unexpected activation of pituitary-adrenal axis in healthy young and elderly subjects during somatostatin infusion

In this study we explored, in man, the effect of acute attenuation of growth hormone (GH) release induced by somatostatin (SRIH) on ACTH and cortisol plasma levels. Sixteen young (8 women, aged 23-32 years, and 8 men, aged 18-27 years) and 14 elderly (8 women, aged 65-82 years, and 6 men, aged 65-70 years) healthy subjects volunteered to participate in this investigation. Each subject was tested on two separate occasions by: (1) a 90-min i.v. infusion of SRIH given in 50 ml 0.9% saline delivered at a rate of 9 microg/kg/h, and (2) a 90-min i.v. infusion of isovolumetric amounts of 0.9% saline. Plasma GH, ACTH, cortisol and glucose concentrations were determined prior and up to 180 min after SRIH or saline infusion. SRIH induced a significant (p < 0.05) decrease in plasma GH levels from basal values of 0.6 +/- 0.15 and 0.5 +/- 0.15 microg/l to nadir values 0.25 +/- 0.1 and 0.2 +/- 0.1 microg/l in young and elderly subjects, respectively. The administration of SRIH was associated with a clear-cut increase in plasma ACTH levels both in young (peak, 10.6 +/- 1.6 pmol/l; AUC, 558.6 +/- 147.5 pmol/l/h) and in elderly (peak, 21.3 +/- 5.6 pmol/l; AUC, 841.9 +/- 153.8 pmol/l/h) subjects with a significant (p < 0.01) difference as compared to saline infusion. Consistent with these results, SRIH infusion resulted in an unequivocal rise in plasma cortisol levels both in young (peak, 394.8 +/- 36.4 nmol/l; AUC, 18,591.62 +/- 1,372.45 nmol/l/h) and in elderly (peak, 585.6 +/- 51.5 nmol/l; AUC, 24,871.05 +/- 1,837.03 nmol/l/h) subjects. The ACTH and cortisol responses to SRIH were significantly (p < 0.05 and p < 0.01) higher in elderly than in young subjects. No sex-related differences occurred in the SRIH-induced activation of hypothalamic-pituitary-adrenocortical (HPA) axis. We conclude that (1) infusion of SRIH, at a dose that inhibited basal GH secretion, was associated with an activation of HPA axis, and (2) this response was higher in elderly individuals compared with younger adults. The reason for this novel and unexpected SRIH effect is presently unclear; however, the latter may be mediated, at least in part, by some central nervous system ACTH-releasing mechanisms activated by SRIH-induced decrease in GH secretion.

Evaluation of hormonal function in a series of incidentally discovered adrenal masses

The discovery of an asymptomatic adrenal mass (incidentaloma) during the investigation of an unrelated condition is relatively common. In this study, we report the clinical, radiologic, and endocrine evaluation of 38 patients (22 women and 16 men aged 24 to 84 years) with adrenal incidentaloma (size, 1 to 12 cm). The patients underwent basal and dynamic evaluation of the hypothalamic-pituitary-adrenal (HPA) axis, renin-angiotensin-aldosterone system, and adrenomedullary function. Moreover, computed tomograpy (CT) scan and 131I-6beta-iodomethyl-19-norcholest-5(10)-en-3beta-ol(NP-59) and/or 131I-metaiodobenzylguanidine (MIBG) scintigraphy were performed. The endocrine evaluation indicated two cases of pheochromocytoma and four cases of preclinical Cushing's syndrome, three of which underwent surgery with histologic diagnosis of two adrenocortical adenomas and one carcinoma. Low levels of serum dehydroepiandrosterone sulfate (DHEA-S), associated with a markedly increased 17-hydroxyprogesterone (17-OHP) response to a corticotropin (ACTH) test, were found in patients with incidentaloma. On the basis of endocrine and morphologic data, 13 patients underwent surgical treatment: five adrenocortical adenomas (two functioning), two pheochromocytomas, two ganglioneuromas, one cortisol-secreting adrenal carcinoma, one lymphangiomatous cyst, one myelolipoma, and one hemorrhage were found. Careful diagnostic assessment of incidentally discovered adrenal masses must be performed to exclude the presence of malignant and/or functioning lesions and to verify the possibility that patients with incidentaloma have a genetic or acquired deficit of adrenal steroidogenic activity.

Bovine papillomavirus type 4

Papillomavirus induce benign tumours (papillomas) in a variety of animals. The papillomas generally regress but occassionally persist and may eventually progress to squamous cell carcinoma. One of the most extensively studies papillomaviruses is bovine papillomavirus type 4 (BPV4). BPV-4 induces papillomas of the upper alimentary canal which are at high risk of progressing to cancer in cattle eating bracken fern. In this review, several aspects of the biology of the virus are described and compared with other papillomavirus systems, including regulation of transcription of the viral oncogenes, function of the viral oncoproteins, cooperation between virus and chemical cofactors, and prophylactic and therapeutic vaccination programmes.

Acute administration of human galanin in normal subjects reduces the potentiating effect of pyridostigmine-induced cholinergic enhancement on release of norepinephrine and pancreatic polypeptide

The neuropeptide galanin (GAL) is widely distributed in the central and peripheral nervous systems where it often coexists with catecholamines and acetylcholine. Recently we have reported that human GAL (hGAL) in man depresses the release of norepinephrine (NE) and the responses to both assumption of upright posture and insulin-induced hypoglycemia. To gain an insight into the action of hGAL on sympathetic nervous system activity in man, we investigated the effects of a 60-min infusion (80 pmol/kg/min) of hGAL or saline on the release of NE, epinephrine (E) and pancreatic polypeptide (PP) induced by an acetylcholinesterase inhibitor, pyridostigmine bromide (PD), in nine healthy volunteers. PD (120 mg orally) induced a significant rise in plasma concentrations of NE (1.6 +/- 0.04 vs. 1.08 +/- 0.06 nmol/l), E (0.34 +/ 0.05 vs. 0.12 +/- 0.04 nmol/l) and PP (178.06 +/- 33 vs. 37.57 +/- 7.35 pmol/l), whilst it significantly reduced heart rate (HR; 61 +/- 2 vs. 71 +/- 4 beats/min). Changes in plasma levels of PP were determined as an indirect measure of amplification of endogenous cholinergic activity produced by PD. Administration of hGAL blunted the release of NE and PP evoked by PD. The mean (+/- SEM) area under the curve produced by PD of NE (50.05 +/- 3.97 nmol/l.90 min) and PP (8,692.87 +/- 1,724 pmol/l.90 min) was significantly (p < 0.001) reduced by hGAL infusion (2.65 +/- 1.57 nmol/l.90 min and 248.1 +/- 148 pmol/l.90 min, for NE and PP, respectively). hGAL failed to affect significantly the E release evoked by PD. hGAL was able to enhance HR significantly (104 +/- 5 vs. 69 +/- 3 beats/min), and completely prevented the PD-induced slowing of HR. Both PD and hGAL did not alter supine systolic and diastolic blood pressure. We conclude that hGAL significantly reduces the release of NE and PP stimulated by PD-induced enhancement of cholinergic activity. These findings are consistent with a functional interrelationship between GAL and the cholinergic system in man, and may suggest the participation of a cholinergic pathway in the galaninergic modulation of the autonomic nervous system.

Metastatic tumours of the hand. Report of six additional cases

Six metastatic tumours of the hand are reported. Five were located in long bones of the hand and one in the soft tissues without bone involvement. The primary tumours arose in the lung, kidney, hard palate, larynx and pharynx. Treatment was palliative and consisted of amputation for distal lesions and local excision and/or radiation for proximal lesions when symptomatic. Short-term prognosis was poor with a median survival of 7 months. In two patients, hand metastases were the first sign of malignant disease.