RESUMEN

OBJECTIVES: The interest in the posterior aspect of the body keeps increasing, thus trigerring an increase in the number of gluteal augmentations with implants, also trigerring a proportional increase in postoperative complications and secondary gluteal surgeries. Nevertheless, there are currently few publications on this subject. The purpose of this study is to identify methods to treat and prevent gluteal augmentation complications. PATIENTS AND METHODS: In this study, the author reviews 14 cases of secondary gluteal surgeries. Some patients simply have their implants removed. For others, the solution to get rid of excess skin relies on buttock lifting or the creation of a purse with an elastic thread. A new deeper plane intramuscular pocket surgery can also be performed. Moreover, capsuloplasty is often required to treat malpositions. Finally, a "hybrid or composite augmentation" can be completed by grafting autologous fat into the subcutaneous fat layer in combination with the implants. RESULTS: Out of the 14 secondary gluteal surgery cases, the implants were removed in five cases, eight cases involved deeper insertion of implants and one case with a capsuloplasty; five cases benefited from a hybrid or composite augmentation and two cases of a butt lift. Minor postoperative complications occurred in four cases. CONCLUSION: A better knowledge of the gluteal area anatomy, a good understanding of the gluteal surgical techniques coupled with a good mastery of the composite or hybrid technique for the gluteal augmentation as well as a good management of malpositions, seromas and delayed healing can enhance secondary gluteal surgery success.

Asunto(s)

Nalgas/cirugía , Procedimientos de Cirugía Plástica/métodos , Complicaciones Posoperatorias/cirugía , Reoperación , Adolescente , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Resultado del Tratamiento , Adulto Joven

RESUMEN

UNLABELLED: Buttock enhancement using gluteal silicone implants is known as a high risk of complications procedure. However, few studies have attempted to quantify the rate of overall complications. The aim of this work is to analyze the rates and types of complications encountered by French plastic surgeons practicing this procedure, and to review their technical choices about incisional access, implant plane, implant type, postoperative instructions, and drain use. We also tried to assess patients global satisfaction rate. MATERIAL AND METHODS: A survey of 17 questions was emailed to French Plastic Surgeons (sent through the channel tamtam@plasticiens.com and emails), the criterias studied included information about number of cases performed, surgical approach used, implant placement plane and implant type, drainage, postoperative instructions, complications experienced and patients satisfaction. RESULTS: Thirteen participants provided data on 538 patients, 84.6% of surgeons used a single incision, 100% favored the intramuscular dissection plane over the subfascial plane, 38% have experienced complications (all types included). The main complications encountered were wound separation (4,4%), seroma (2.2%), infections requiring explantation (1.4%), caspular retraction (1.3%) and asymmetry (3.3%). The global patients satisfaction rate was 8/10. CONCLUSION: Our results show that this procedure remains reliable, and serious complications are rare. It also helps providing an assessment of French plastic surgeons practices with the aim of popularizing this procedure.

Asunto(s)

Nalgas/cirugía , Procedimientos de Cirugía Plástica , Pautas de la Práctica en Medicina/estadística & datos numéricos , Prótesis e Implantes , Geles de Silicona , Femenino , Francia , Humanos , Satisfacción del Paciente/estadística & datos numéricos , Prótesis e Implantes/efectos adversos , Encuestas y Cuestionarios

RESUMEN

We report the case of a 39-year-old male presenting with panhypopituitarism and diabetes insipidus. MR imaging showed focal thickening of the pituitary infundibulum and infiltration of the anterior pituitary lobe, suggesting hypophysitis. Hormonal replacement therapy induced a pronounced amelioration of general well-being. Eight months later the subject developed visual disturbances. MR imaging now showed a cystic sellar mass. Surgical drainage was performed. A second operation was necessary six weeks Later because of recurrent visual field defects. Diagnosis of papillary craniopharyngioma was finally made. This case demonstrates the remarkably rapid development of a craniopharyngioma, which initial radiological appearance was suggestive of hypophysitis. It also emphasizes the need of repeat MR examination in case of unusual presentation of hypopituitarism.

Asunto(s)

Craneofaringioma/diagnóstico , Hipopituitarismo/patología , Neoplasias Hipofisarias/diagnóstico , Adulto , Craneofaringioma/etiología , Craneofaringioma/terapia , Diagnóstico Diferencial , Humanos , Hipopituitarismo/etiología , Hipopituitarismo/terapia , Masculino , Neoplasias Hipofisarias/etiología , Neoplasias Hipofisarias/terapia

RESUMEN

CONTEXT: Pasireotide (SOM230) is a novel multireceptor ligand somatostatin analog with affinity for somatostatin receptor subtypes sst(1-3) and sst(5). Because most GH-secreting pituitary adenomas express sst(2) and sst(5), pasireotide has the potential to be more effective than the sst(2)-preferential somatostatin analogs octreotide and lanreotide. OBJECTIVE: Our objective was to evaluate the efficacy and safety of three different doses of pasireotide in patients with acromegaly. DESIGN: We conducted a phase II, randomized, multicenter, open-label, three-way, crossover study. PATIENTS: Sixty patients with acromegaly, defined by a 2-h five-point mean GH level higher than 5 microg/liter, lack of suppression of GH to less than 1 microg/liter after oral glucose tolerance test, and elevated IGF-I for age- and sex-matched controls. Patients could have had previous surgery, radiotherapy, and/or medical therapy or no previous treatment. INTERVENTION: After treatment with octreotide 100 microg s.c. three times daily for 28 d, each patient received pasireotide 200, 400, and 600 microg s.c. twice daily in random order for 28 d. MAIN OUTCOME MEASURE: A biochemical response was defined as a reduction in GH to no more than 2.5 microg/liter and normalization of IGF-I to age- and sex-matched controls. RESULTS: After 4 wk of octreotide, 9% of patients achieved a biochemical response. After 4 wk of pasireotide 200-600 microg s.c. bid, 19% of patients achieved a biochemical response, which increased to 27% after 3 months of pasireotide; 39% of patients had a more than 20% reduction in pituitary tumor volume. Pasireotide was generally well tolerated. CONCLUSIONS: Pasireotide is a promising treatment for acromegaly. Larger studies of longer duration evaluating the efficacy and safety of pasireotide in patients with acromegaly are ongoing.

Asunto(s)

Acromegalia/tratamiento farmacológico , Somatostatina/análogos & derivados , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Glucemia/metabolismo , Estudios Cruzados , Relación Dosis-Respuesta a Droga , Método Doble Ciego , Determinación de Punto Final , Femenino , Hormona de Crecimiento Humana/sangre , Humanos , Factor I del Crecimiento Similar a la Insulina/metabolismo , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Octreótido/efectos adversos , Octreótido/uso terapéutico , Neoplasias Hipofisarias/patología , Somatostatina/efectos adversos , Somatostatina/farmacocinética , Somatostatina/uso terapéutico , Adulto Joven

RESUMEN

Adult growth hormone deficiency (AGHD) is nowadays recognized as a distinct clinical entity and replacement therapy has become a standard practice. Reflecting on the accumulated evidence, questions nevertheless arise. Should all AGHD patients be treated? What dose of GH should be given and for how long? What are the real long-term benefits, in particular regarding life expectancy? if the diagnosis of severe GHD is firmly established and if there is no contra-indication (such as an active cancer or uncontrolled diabetes), it is worthwile initiating GH replacement therapy. Treatment can indeed correct the abnormal body composition, improve various adverse cardiovascular parameters and risk factors, increase muscle strength and bone mineral density and, although to a variable degree, improve the patient's quality of life and psychological well-being. Treatment should be started with very low doses to avoid side-effects related to fluid retention and should then be gradually titrated against IGF-I values, clinical response and individual tolerance.There is unfortunately no confirmed predictive factor for the overall therapeutic response in a given individual. Thus, the decision to whether or not pursue the therapy will depend on the ratio of perceived and expected benefits over cost and risks of treatment, as well as on the persistent motivation of the patient.

Asunto(s)

Trastornos del Crecimiento/tratamiento farmacológico , Terapia de Reemplazo de Hormonas/métodos , Hormona de Crecimiento Humana/deficiencia , Hormona de Crecimiento Humana/uso terapéutico , Adulto , Presión Sanguínea/efectos de los fármacos , Composición Corporal/efectos de los fármacos , Densidad Ósea/efectos de los fármacos , Fenómenos Fisiológicos Cardiovasculares/efectos de los fármacos , Trastornos del Crecimiento/diagnóstico , Terapia de Reemplazo de Hormonas/efectos adversos , Hormona de Crecimiento Humana/efectos adversos , Humanos , Selección de Paciente , Calidad de Vida

RESUMEN

OBJECTIVE: To describe baseline clinical presentation, treatment effects and evolution of isolated GH deficiency (IGHD) to multiple pituitary hormone deficiency (MPHD) in adult-onset (AO) GHD. DESIGN: Observational prospective study. METHODS: Baseline characteristics were recorded in 4110 patients with organic AO-GHD, who were GH naïve prior to entry into the Pfizer International Metabolic Database (KIMS; 283 (7%) IGHD, 3827 MPHD). The effect of GH replacement after 2 years was assessed in those with available follow-up data (133 IGHD, 2207 MPHD), and development of new deficiencies in those with available data on concomitant medication (165 IGHD, 3006 MPHD). RESULTS: IGHD and MPHD patients had similar baseline clinical presentation, and both groups responded similarly to 2 years of GH therapy, with favourable changes in lipid profile and improved quality of life. New deficiencies were observed in 35% of IGHD patients, which was similar to MPHD patients with one additional deficit other than GH. New deficiencies most often presented within the first year but were observed up to 6 years after GH commencement. Conversion of IGHD into MPHD was not predicted by aetiology, baseline characteristics, surgery or radiotherapy, whereas in MPHD additional deficits were predicted by age (P<0.001) and pituitary disease duration (P<0.01). CONCLUSION: Both AO-IGHD and -MPHD patients have similar baseline clinical presentation and respond equally well to 2 years of GH replacement. Hypopituitarism in adults seems to be a dynamic condition where new deficiencies can appear years after the initial diagnosis, and careful endocrine follow-up of all hypopituitary patients, including those with IGHD, is warranted.

Asunto(s)

Craneofaringioma/terapia , Hormona de Crecimiento Humana/deficiencia , Hormona de Crecimiento Humana/uso terapéutico , Hipopituitarismo/tratamiento farmacológico , Hormonas Hipofisarias/deficiencia , Neoplasias Hipofisarias/terapia , Adulto , Edad de Inicio , Craneofaringioma/radioterapia , Craneofaringioma/cirugía , Bases de Datos Factuales , Femenino , Humanos , Hipopituitarismo/etiología , Hipopituitarismo/metabolismo , Masculino , Persona de Mediana Edad , Hormonas Hipofisarias/uso terapéutico , Neoplasias Hipofisarias/radioterapia , Neoplasias Hipofisarias/cirugía , Estudios Prospectivos , Factores de Riesgo , Factores de Tiempo

RESUMEN

OBJECTIVE: To test the hypothesis whether the effects of GH replacement therapy in adults could be affected by prior pituitary irradiation, the baseline characteristics and response to GH were evaluated in adults with severe GH deficiency (GHD), who had received or not irradiation for the treatment of pituitary adenoma or craniopharyngioma. DESIGN: Data from 447 patients, who had received radiotherapy (427 in addition to surgery), and 630 patients, who were operated on but not irradiated for their tumour, were retrieved from Pfizer International Metabolic Database (KIMS) and compared at baseline and 1 and 2 years following the onset of GH replacement. RESULTS: Irradiated and non-irradiated patients exhibited the expected phenotype of GHD at baseline. However, irradiated patients had a greater impairment in the quality of life (QoL), a higher fat mass, lower high-density lipoprotein cholesterol levels and a lower bone mineral content (BMC) than non-irradiated patients. Treatment with GH induced similar changes in both groups. After 1 year of GH replacement, there was an increase in serum IGF-I and fat-free mass, a reduction in fat mass and an improvement in QoL, all changes being equivalent in irradiated and non-irradiated patients. The lipid profile also improved with the irradiated patients showing a better response. These beneficial effects were maintained and the BMC also increased in both groups by the second year of treatment. CONCLUSIONS: This analysis shows that prior irradiation for pituitary adenoma or craniopharyngioma does not compromise the beneficial effects of GH replacement therapy.

Asunto(s)

Adenoma/radioterapia , Craneofaringioma/radioterapia , Hormona de Crecimiento Humana/administración & dosificación , Hipopituitarismo/tratamiento farmacológico , Neoplasias Hipofisarias/radioterapia , Radioterapia/efectos adversos , Adulto , Bases de Datos Factuales , Femenino , Estudios de Seguimiento , Hormona de Crecimiento Humana/deficiencia , Humanos , Hipopituitarismo/etiología , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del Tratamiento

RESUMEN

BACKGROUND: Patients with Cushing's disease have a high prevalence of atherosclerosis and maintain an increased cardiovascular risk even after cure of the disease. However, the impact of Cushing's disease on renal function remains to be quantified. OBJECTIVES: To evaluate glomerular filtration rate (GFR) and to identify predictors of GFR in patients with Cushing's disease. DESIGN AND METHODS: We conducted a matched case-control study: 18 patients with active or cured Cushing's disease were compared with healthy population controls matched for age and sex. The main outcome measures were GFR and micro-albuminuria. RESULTS: Patients with Cushing's disease had a lower GFR, as measured by 24-h creatinine clearance (79 versus 95 ml/min per 1.73 m2, P = 0.005) and estimated by the MDRD2 formula (75 versus 88 ml/min per 1.73 m2, P = 0.008). Multiple regression analyses indicated that disease duration was the strongest predictor for a worse GFR. The prevalence of micro-albuminuria was low (5.5% in both groups). CONCLUSIONS: Patients with Cushing's disease have a decreased GFR. Even if they are cured, close follow-up with strict control of cardiovascular risk factors and monitoring of GFR seems mandatory. Furthermore, the dosage of certain drugs should be adapted to the individual GFR.

Asunto(s)

Tasa de Filtración Glomerular , Hipersecreción de la Hormona Adrenocorticotrópica Pituitaria (HACT)/fisiopatología , Adenoma/cirugía , Anciano , Albuminuria/fisiopatología , Estudios de Casos y Controles , Femenino , Humanos , Masculino , Persona de Mediana Edad , Proyectos Piloto , Hipersecreción de la Hormona Adrenocorticotrópica Pituitaria (HACT)/cirugía , Neoplasias Hipofisarias/cirugía , Análisis de Regresión

RESUMEN

OBJECTIVE: This open label, multicentre study was designed to evaluate the efficacy and tolerability of lanreotide Autogel (L-Autogel) in acromegalic patients over a 24-week period. The outcome of treatment with this new, long-acting, aqueous formulation of lanreotide was also compared with the patients' previous treatment with octreotide long acting repeatable (LAR). DESIGN AND METHODS: Twenty-five acromegalic patients (13 males, mean age 51+/-12 years) were switched from octreotide LAR (20-40 mg/4 weeks for at least 6 months) to L-Autogel, given deep subcutaneously at a fixed dose of 90 mg/4 weeks. After 12 weeks, the dose of L-Autogel was titrated according to patients' mean GH and IGF-I levels at week 8. It was increased to 120 mg/4 weeks if GH>2.5 microg/l or if IGF-I was above the age-adjusted normal range. It was reduced to 60 mg/4 weeks if mean GH<1 microg/l and IGF-I was within the normal range. If the values did not fall within these ranges, the dose remained unchanged at 90 mg. RESULTS: After 24 weeks of treatment with L-Autogel (final doses 60 mg in 3 patients, 90 mg in 4 patients and 120 mg in 18 patients), mean serum GH (2.9+/-2.4 microg/l) and IGF-I concentrations (332+/-193 microg/l) remained statistically unchanged when compared with baseline values under octreotide LAR (GH 2.4+/-1.8 microg/l and IGF-I 337+/-201 microg/l, non significant (NS)). There was a significant improvement of the acromegalic symptom score over the study period, from 4.8+/-3.4 to 2.8+/-2.5 (P<0.001) and a small but significant reduction in the residual pituitary tumour volume (P<0.05). Local side-effects were observed less frequently and no technical problems were encountered with the L-Autogel injections, as opposed to treatment with octreotide LAR (60 difficult injections/150 (P<0.001)). CONCLUSIONS: L-Autogel appears to be as effective as octreotide LAR in lowering GH and IGF-I concentrations in acromegalic patients. This treatment was also well tolerated by the patients, giving fewer local side-effects and technical problems with injections. These advantages may improve the long-term acceptability of medical treatment in acromegaly.

Asunto(s)

Acromegalia/tratamiento farmacológico , Antineoplásicos/administración & dosificación , Péptidos Cíclicos/administración & dosificación , Somatostatina/administración & dosificación , Acromegalia/sangre , Acromegalia/patología , Adulto , Anciano , Anciano de 80 o más Años , Antineoplásicos/efectos adversos , Femenino , Hormona de Crecimiento Humana/sangre , Humanos , Inyecciones Subcutáneas , Factor I del Crecimiento Similar a la Insulina/metabolismo , Masculino , Persona de Mediana Edad , Octreótido/administración & dosificación , Péptidos Cíclicos/efectos adversos , Neoplasias Hipofisarias/sangre , Neoplasias Hipofisarias/tratamiento farmacológico , Neoplasias Hipofisarias/patología , Somatostatina/efectos adversos , Somatostatina/análogos & derivados

RESUMEN

The use of Surgicel, a local haemostatic absorbable gauze, is usually spread in surgery. The author reports a clinical case of face lift where the use of Surgicel 2, a more concentrated Surgicel, left under a precarious vascularized cutaneous flap led to a skin slough. He concludes that the full-thickness cutaneous necrosis is bound both to the chemical action of the soluble component (uronic acid) of Surgicel and above all to the "screen-effect" with the nourishing basement. Consequently, the Surgicel should be removed once the haemostasis obtained.

Asunto(s)

Celulosa Oxidada/efectos adversos , Dermatosis Facial/inducido químicamente , Dermatosis Facial/patología , Ritidoplastia , Piel/patología , Femenino , Humanos , Persona de Mediana Edad , Necrosis

RESUMEN

The morbidity associated with GH deficiency (GHD) in adults is now well established. Furthermore, many controlled clinical trials have demonstrated the efficacy of GH replacement therapy. The aim of the present study was to determine whether the effects of GH replacement in adults are reflected in a reduced use of healthcare resources, in addition to improving quality of life (QoL). Data concerning visits to the doctor, number of days in hospital, and amount of sick leave were obtained from patients included in KIMS (Pharmacia International Metabolic Database), a large pharmacoepidemiological survey of hypopituitary adults with GHD, for 6 months before GH treatment and for 6-12 months after the start of treatment. Assistance required with normal daily activities was recorded at baseline and after 12 months of GH therapy. QoL (assessed using a disease-specific questionnaire, QoL-Assessment of GHD in Adults) and satisfaction with physical activity during leisure time were also assessed. For the total group (n = 304), visits to the doctor, number of days in hospital, and amount of sick leave decreased significantly (P < 0.05) after 12 months of GH therapy. Patients also needed less assistance with daily activities, although this was significant (P < 0.01) only for the men. QoL improved after 12 months of GH treatment (P < 0.001), and both the amount of physical activity and the patients' satisfaction with their level of physical activity improved after 12 months (P < 0.001). In conclusion, GH replacement therapy, in previously untreated adults with GHD, produces significant decreases in the use of healthcare resources, which are correlated with improvements in QoL.

Asunto(s)

Hormona del Crecimiento/uso terapéutico , Recursos en Salud/estadística & datos numéricos , Hormona de Crecimiento Humana/deficiencia , Calidad de Vida , Métodos Epidemiológicos , Ejercicio Físico/fisiología , Femenino , Hormona del Crecimiento/efectos adversos , Terapia de Reemplazo de Hormonas , Humanos , Estilo de Vida , Masculino , Persona de Mediana Edad , Farmacoepidemiología

RESUMEN

To assess the influence of factors affecting fracture risk and bone density in adult hypopituitary patients with growth hormone deficiency (GHD), data from a large-scale pharmacoepidemiological survey (the Pharmacia & Upjohn International Metabolic Database [KIMS]) were analyzed and compared with data from a control population (the European Vertebral Osteoporosis Study [EVOS]). The KIMS group consisted of 2084 patients (1112 men and 972 women) with various types of pituitary disease and EVOS consisted of 1176 individuals (581 men and 595 women). Fracture and bone mineral density (BMD) data were available from 2024 patients from the KIMS group and 392 patients from EVOS. The prevalence of fractures in patients with hypopituitarism was 2.66 times that in the non-GH-deficient EVOS population. Adult-onset hypopituitarism with GHD was associated with a higher fracture risk than childhood-onset disease, and patients with isolated GHD had a similar prevalence of fractures to those with multiple pituitary hormone deficiencies. Hormonal replacement therapy with L-thyroxine, glucocorticoids, and sex steroids did not affect the risk of fracture in KIMS patients. In addition, fracture rates in KIMS were independent of body mass index (BMI) and the country of origin. However, smoking was associated with a higher fracture rate in this group. In summary, this is the first large-scale analysis to support the hypothesis of an increased fracture risk in adult patients with hypopituitarism and GHD. This increased risk appears to be attributable to GHD alone, rather than to other pituitary hormone deficiencies or to their replacement therapy.

Asunto(s)

Densidad Ósea , Fracturas Óseas/etiología , Hormona del Crecimiento/deficiencia , Hormona del Crecimiento/uso terapéutico , Hipopituitarismo/complicaciones , Edad de Inicio , Humanos , Hipopituitarismo/fisiopatología , Prevalencia

RESUMEN

OBJECTIVE: Slow-release (SR) lanreotide is a long-acting somatostatin analog that has been developed in order to overcome the inconvenience of multiple daily subcutaneous injections of octreotide, required for metabolic control in acromegaly. Lanreotide SR has been found to be well tolerated and effective in reducing GH and IGF-I levels but clinical data are still limited compared with those with subcutaneous octreotide treatment. DESIGN: Sixty-six unselected patients with active acromegaly were therefore evaluated in a multi-center, prospective, open label study. Lanreotide SR was given at a dose of 30mg intramuscular every 7-14 days. METHODS: At baseline and after 2, 4, 8, 12, 24, 36 and 48 weeks patients underwent a clinical examination with assessment of acromegaly related symptoms, and blood was sampled for serum GH, IGF-I, prolactin, glycosylated hemoglobin, fasting glucose, hematology, kidney function and liver function tests. Biliary ultrasonography and pituitary magnetic resonance imaging were performed at baseline and after one year. RESULTS: Treatment resulted in a significant improvement in the symptom score from 2.69+/-0.27 to 1.06+/-0.17 (P<0.0001). Serum IGF-I levels fell from 699+/-38microg/l at baseline to 399+/-26microg/l (P<0.0001, n=60) after one month, after which levels remained stable: 480+/-37microg/l after 6 months (n=54) and 363+/-32microg/l after one year (n=46). GH levels dropped from 13.8+/-3.2microg/l to 4.3+/-0.7microg/l after one month (P<0.0001, n=60) and remained stable thereafter: 3.9+/-0.4microg/l (n=54) after 6 months and 3.5+/-1.1microg/l after one year (n=46). Twenty-nine out of 66 patients (44%) attained a normal age-corrected IGF-I level and 30 patients (45%) attained a GH level below 2.5microg/l. Pituitary adenoma shrinkage of at least 25% was found in 5 of 14 patients (36%) after one year. Side effects were mainly transient gastrointestinal symptoms and pain at the injection site, resulting in drug discontinuation in only 6 patients (9%). Two patients developed new gall stones. No difference was found between subcutaneous octreotide and lanreotide SR in efficacy and almost all patients preferred the easier dose administration of lanreotide SR. CONCLUSIONS: Long-term treatment of acromegaly with SR-lanreotide is effective in controlling GH and IGF-I levels and symptoms and is well tolerated in the majority of patients. Compared with subcutaneous octreotide, lanreotide SR considerably improves patient's acceptance of therapy while having the same overall efficacy.

Asunto(s)

Acromegalia/tratamiento farmacológico , Antagonistas de Hormonas/uso terapéutico , Péptidos Cíclicos/uso terapéutico , Somatostatina/análogos & derivados , Acromegalia/etiología , Adulto , Anciano , Anciano de 80 o más Años , Preparaciones de Acción Retardada , Femenino , Antagonistas de Hormonas/administración & dosificación , Antagonistas de Hormonas/efectos adversos , Hormona de Crecimiento Humana/sangre , Humanos , Factor I del Crecimiento Similar a la Insulina/análisis , Masculino , Persona de Mediana Edad , Octreótido/administración & dosificación , Octreótido/efectos adversos , Octreótido/uso terapéutico , Péptidos Cíclicos/administración & dosificación , Péptidos Cíclicos/efectos adversos , Neoplasias Hipofisarias/tratamiento farmacológico , Neoplasias Hipofisarias/patología , Somatostatina/administración & dosificación , Somatostatina/efectos adversos , Somatostatina/uso terapéutico

RESUMEN

OBJECTIVE: Although elderly hypopituitary adults demonstrate an increase in total and central fat compared with age-matched controls and are distinguishable from control subjects in terms of growth hormone (GH) responsiveness on dynamic testing, there are few data available on response to GH replacement. The objective of this study was to compare the baseline characteristics and longitudinal response to GH replacement in patients aged > 65 years with that observed in younger patients enrolled in KIMS (Pharmacia and Upjohn International Metabolic Database). KIMS is a physician-managed, open, long-term surveillance study of adult GH-deficient patients receiving GH replacement. Patients were entered and data provided by interested physicians. PATIENTS: Baseline characteristics were studied in 109 patients (66 males) aged > 65 years commencing GH replacement at time of entry into KIMS and the effects of GH replacement on blood pressure, lipids and quality of life in 64 patients who had completed at least 6 months of GH replacement. Data were compared with baseline data on 863 patients aged < 65 years with adult onset GH deficiency, who had not received GH for at least 6 months prior to entry into KIMS, 220 of whom went on to complete > 6 months GH therapy in KIMS. RESULTS: Blood pressure, cholesterol and LDL cholesterol were positively correlated with age, particularly in females, and older patients had a predictably higher prevalence of diabetes mellitus and history of hypertension. The frequency of previous fractures was increased in females but not in males aged > 65 years. Body mass index, waist/hip ratio and quality of life (AGHDA score) was similar in both groups prior to commencement of GH therapy. GH replacement doses were similar in younger and older patients and the percentage of patients with serum IGF-I of > 2SD above the age-related normal mean was not significantly different between the groups (< 65 years, 20%; > 65 years, 11%). After 6 months of GH replacement significant improvements were evident in waist circumference, waist/hip ratio, diastolic blood pressure, total and LDL cholesterol and AGHDA score in patients aged < 65 years. Similar significant reductions in total and LDL cholesterol were evident in patients > 65 years. In addition, male patients aged > 65 years demonstrated significant reductions in diastolic blood pressure and AGHDA score but no change in waist circumference whereas females aged > 65 years demonstrated a trend to reduction in waist circumference and AGHDA score. CONCLUSIONS: These data, derived from the largest series of GH-treated hypopituitary patients published to date, confirm similar baseline characteristics and positive benefit from GH replacement in older compared with younger hypopituitary patients particularly in relation to quality of life.

Asunto(s)

Hormona del Crecimiento/deficiencia , Hormona del Crecimiento/uso terapéutico , Terapia de Reemplazo de Hormonas , Hipopituitarismo/tratamiento farmacológico , Anciano , Presión Sanguínea/efectos de los fármacos , Composición Corporal/efectos de los fármacos , Colesterol/sangre , HDL-Colesterol/sangre , LDL-Colesterol/sangre , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Calidad de Vida , Factores Sexuales , Triglicéridos/sangre

RESUMEN

OBJECTIVE: Previous studies have revealed that hormonal disturbances may accompany the chronic fatigue syndrome (CFS). Changes in the secretion of the pituitary-adrenal axis have been demonstrated, as well as abnormalities in the GH-IGF-I axis. However, data have not always been well characterized and were sometimes conflicting. The small number of CFS patients investigated in earlier studies may have played a role in the interpretation of the results. SUBJECTS AND DESIGN: Hormonal testing was performed in 73 nonobese CFS patients and nonobese 21 age-and gender-matched healthy controls. We investigated GH, ACTH and cortisol responses to insulin-induced hypoglycaemia. In a subgroup of patients arginine and clonidine stimulation for GH was also performed. Nocturnal secretion of GH, ACTH and cortisol were determined. Serum levels of IGF-I, prolactin, TSH, and free thyroxine were also measured. Visceral fat mass was assessed by CT scanning. RESULTS: GH response to insulin induced hypoglycaemia assessed by peak value (17.0 +/- 13.1 microg/l vs. 22. 1 +/- 9.8 microg/l; P = 0.01) and by AUC (450.0 +/- 361.3 microg/l vs. 672.3 +/- 393.0 microg/l; P = 0.002) was significantly decreased in CFS patients vs. controls. Nocturnal GH secretion assessed by GH peak value (5.4 +/- 3.7 vs. 9.0 +/- 5.1 microg/l; P = 0.44) and by AUC (34.4 +/- 20.2 vs. 67.4 +/- 43.1; P = 0.045) was also significantly impaired in CFS patients. Arginine and clonidine administration showed no differences in GH secretion between CFS patients and controls. In the CFS group, GH peak values were significantly higher after ITT than after arginine (P = 0.017) or clonidine (P = 0.001). No differences in serum IGF-I levels were found between CFS patients and controls. Except for a significantly lower nocturnal cortisol peak value, no differences were found in ACTH and cortisol secretion between CFS patients and controls. Significantly higher serum prolactin levels (7.4 +/- 4.7 microg/l vs. 4.4 +/- 1.3 microg/l; P = 0.004) and significantly higher serum TSH levels (1.6 +/- 1.0 mU/l vs. 1.0 +/- 0.4 mU/l; P = 0.011) were found in CFS patients. Serum free thyroxine was comparable in both groups. Visceral fat mass was significantly higher in CFS patients (86.6 +/- 34.9 cm2 vs. 51.5 +/- 15.7 cm2; P < 0.001). CONCLUSIONS: We observed a significant impairment of GH response during insulin-induced hypoglycaemia and a low nocturnal GH secretion in CFS patients. These changes did, however, not lead to different concentrations in serum IGF-I. The clinical expression of this inadequate GH secretion can thus be questioned, although the alteration in body composition may be related to this relative GH deficiency. Significantly increased prolactin and TSH levels were found when compared to controls. These findings give support to the hypothesis of a decreased dopaminergic tone in CFS. Further investigations are required in order to identify specific adaptations within the neurotransmitter system in CFS and to determine the clinical importance of the impaired GH homeostasis.

Asunto(s)

Síndrome de Fatiga Crónica/fisiopatología , Hormona de Crecimiento Humana/metabolismo , Hipoglucemia/fisiopatología , Hormona Adrenocorticotrópica/sangre , Adulto , Estudios de Casos y Controles , Ritmo Circadiano/fisiología , Síndrome de Fatiga Crónica/sangre , Femenino , Hormona de Crecimiento Humana/sangre , Humanos , Hidrocortisona/sangre , Hipoglucemia/inducido químicamente , Hipoglucemia/metabolismo , Insulina , Factor I del Crecimiento Similar a la Insulina/metabolismo , Masculino , Persona de Mediana Edad , Prolactina/sangre , Tirotropina/sangre

Asunto(s)

Diabetes Mellitus Tipo 2/inducido químicamente , Hormona del Crecimiento/efectos adversos , Hormona de Crecimiento Humana/deficiencia , Adulto , Hormona del Crecimiento/administración & dosificación , Humanos , Resistencia a la Insulina , Factor I del Crecimiento Similar a la Insulina/metabolismo , Factores de Riesgo , Resultado del Tratamiento

RESUMEN

We report the case of a 45-year-old male presenting with unilateral exophthalmos due to a large tumoral mass invading the skull base. Ophthalmologic examination did not show any visual field defects. Imaging techniques demonstrated extension of a huge tumor (approx. 8x8x8 cm) into the right orbit and nasopharynx. Endocrine work-up revealed grossly elevated serum prolactin (PRL) levels (26,466 microg/l, nl. < 12), pointing to a large, invasive macroprolactinoma. Stimulation tests indicated associated partial adrenal and growth hormone deficiencies. Planned surgery was abandoned, and the patient was instead treated with the long-acting dopamine agonist, cabergoline. Over a period of one year, serum PRL dropped to 131 microg/l, while the tumor mass shrank to less than 50% of its original volume (with 3.5 mg/week of cabergoline). The exophthalmos disappeared, and the patient did not develop rhinorrhea or any other side effects from treatment with cabergoline. The efficacy was maintained throughout the second year (ultimate serum PRL 74 microg/l, and final size less than 10% of the original). With reference to this case, we review other macroprolactinomas reported in the recent literature for associated exophthalmos, grossly elevated serum PRL levels (> or = 15,000 microg/l), and/or "giant" size (> or = 4 cm in maximum diameter). We highlight the use of dopamine agonists in the treatment of prolactinomas with such unusual characteristics.

Asunto(s)

Agonistas de Dopamina/uso terapéutico , Ergolinas/uso terapéutico , Exoftalmia/etiología , Neoplasias Hipofisarias/complicaciones , Neoplasias Hipofisarias/tratamiento farmacológico , Prolactinoma/complicaciones , Prolactinoma/tratamiento farmacológico , Cabergolina , Humanos , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Neoplasias Hipofisarias/sangre , Neoplasias Hipofisarias/diagnóstico , Prolactina/sangre , Prolactinoma/sangre , Prolactinoma/diagnóstico

RESUMEN

Intrathecal administration of opioids is a very efficient tool in the long-term control of intractable nonmalignant pain. However, despite the well known role of opioids in endocrine regulation, few data are available about possible effects on hypothalamic-pituitary function during this treatment. Seventy-three patients (29 men and 44 women; mean age, 49.2 +/- 11.7 yr) receiving opioids intrathecally for nonmalignant pain were enrolled for extensive endocrine investigation. At the time of hormonal determination, the mean duration of opioid treatment was 26.6 +/- 16.3 months; the mean daily dose of morphine was 4.8 +/- 3.2 mg. The control group consisted of 20 patients (11 men and 9 women; mean age, 54.2 +/- 14.0 yr) with a comparable pain syndrome but not treated with opioids. Decreased libido or impotency was present in 23 of 24 men receiving opioids. The serum testosterone level was below 9 nmol/L in 25 of 29 men and was significantly lower than that in the control group (P < 0.001). The free androgen index was below normal in 18 of 29 men and was significantly lower than that in the control group (P < 0.001). The serum LH level was less than 2 U/L in 20 of 29 men and was significantly lower than that in the control group (P < 0.001). Serum FSH was comparable in both groups. Decreased libido was present in 22 of 32 women receiving opioids. All 21 premenopausal females developed either amenorrhea or an irregular menstrual cycle, with ovulation in only 1. Serum LH, estradiol, and progesterone levels were lower in the opioid group. In all 18 postmenopausal females significantly decreased serum LH (P < 0.001) and FSH (P = 0.012) levels were found. The 24-h urinary free cortisol excretion was below 20 microg/day in 14 of 71 opioid patients and was significantly lower than that in the control group (P = 0.003). The peak cortisol response to insulin-induced hypoglycemia was below 180 microg/L in 9 of 61 opioid patients and was significantly lower than that in the nonopioid group (P = 0.002). The insulin-like growth factor I SD score was below -2 SD in 12 of 73 opioid patients and was significantly lower than that in the control group (P = 0.002). The peak GH response to hypoglycemia was below 3 microg/L in 9 of 62 subjects and was significantly lower than that in the control group (P = 0.010). Thyroid function tests and PRL levels were considered normal. No metabolic disturbances were recorded, apart from significantly decreased high density lipoprotein cholesterol levels (P = 0.041) and elevated total/high density lipoprotein cholesterol ratio (P = 0.008) in the opioid group compared to the control group. Supplementation with gonadal steroids improved sexual function in most patients. In conclusion, of all patients receiving intrathecal opioids, the large majority of men and all women developed hypogonadotropic hypogonadism, about 15% developed central hypocorticism, and about 15% developed GH deficiency. These findings suggest that further investigations are required to determine the need for systematic endocrine work-up in these patients and the necessity for substitutive therapy.

Asunto(s)

Analgésicos Opioides/uso terapéutico , Hormonas/sangre , Dolor Intratable/tratamiento farmacológico , Dolor Intratable/fisiopatología , Adulto , Anciano , Anciano de 80 o más Años , Amenorrea/inducido químicamente , Analgésicos Opioides/administración & dosificación , Andrógenos/sangre , Presión Sanguínea , Disfunción Eréctil/inducido químicamente , Estradiol/sangre , Femenino , Hormona Folículo Estimulante/sangre , Humanos , Hidrocortisona/sangre , Hidrocortisona/orina , Hidromorfona/administración & dosificación , Hidromorfona/uso terapéutico , Inyecciones Espinales , Libido/efectos de los fármacos , Hormona Luteinizante/sangre , Masculino , Persona de Mediana Edad , Morfina/administración & dosificación , Morfina/uso terapéutico , Dolor Intratable/sangre , Posmenopausia , Premenopausia , Progesterona/sangre , Valores de Referencia , Estudios Retrospectivos , Globulina de Unión a Hormona Sexual/análisis

RESUMEN

Cortisol resistance (CR) is a rare disease characterized by a generalized reduced sensitivity of end-organs to the actions of glucocorticoids (GCs). GC effects are mediated by the GC receptor (GR). The molecular alterations in CR described thus far were located in the hormone-binding domain of the GR gene. Recent reports of a considerable prevalence of abnormalities in the GR in patients attending the endocrine clinic prompted us to carry out further investigations with respect to GR protein and GR gene in patients attending the endocrine clinic for a broad spectrum of complaints and biochemical evidence suggesting a CR. In the present study, we describe five patients with biochemical and clinical CR. All patients showed a diurnal rhythm of serum cortisol concentrations (albeit at a high level), an insufficient suppression of serum cortisol concentration in reaction to 1 mg dexamethasone (DEX), and variable degrees of androgen overproduction, in the absence of clinical signs and symptoms of Cushing's syndrome. Three of the four female patients presented with complaints of androgen overproduction, two of them in combination with fatigue. The other female patient had severe steroid-resistant asthma. The only male patient and his son were asymptomatic. In four patients, we investigated receptor protein characteristics on mononuclear leukocytes in a whole cell DEX binding assay and studied the ability of DEX to inhibit mitogen-induced cell proliferation in mononuclear leukocytes in vitro. In all patients investigated, we found alterations in receptor number or ligand affinity and/or the ability of DEX to inhibit mitogen-induced cell proliferation. To investigate the molecular defects leading to the clinical and biochemical pictures in these patients, we screened the GR gene using PCR/single-strand conformational polymorphism/sequence analysis. No GR gene alterations were found in these patients. In conclusion, the five patients described had clinical and biochemical evidence of CR, but no abnormalities were demonstrated in the GR gene. Probably, as yet undefined alterations somewhere in the cascade of events starting with ligand binding to the GR protein, and finally resulting in the regulation of the expression of GC responsive genes, or postreceptor defects or interactions with other nuclear factors form the pathophysiologic basis of CR in these patients.

Asunto(s)

Resistencia a Medicamentos , Glucocorticoides/fisiología , Hidrocortisona/fisiología , Receptores de Glucocorticoides/genética , Adolescente , Adulto , Anciano , Andrógenos/biosíntesis , Dexametasona/farmacocinética , Dexametasona/farmacología , Femenino , Glucocorticoides/farmacología , Hirsutismo , Humanos , Hidrocortisona/farmacología , Linfocitos/efectos de los fármacos , Linfocitos/fisiología , Masculino , Trastornos de la Menstruación , Reacción en Cadena de la Polimerasa , Polimorfismo Conformacional Retorcido-Simple

RESUMEN

There is still less incidence of venous thromboembolic accidents in plastic surgery (% of unknown deep vein thrombosis and pulmonary embolism unknown) than in general surgery (6 to 12% of deep vein thrombosis and 0.3 to 1.1% of pulmonary embolism). However, these accidents present a dangerous and dreaded complication. Based on the recommendations of the Assistance Publique--Hôpitaux de Paris and on a recently published medical study, an algorithm of preventive measures is proposed. The combination of the type of surgical procedure (liposuction, dermolipectomy and abdominoplasty) and the predisposing individual patient risk factors (age, obesity, varicose veins, estrogens, venous thromboembolism history, inherited disorders of coagulation) defines the level of thromboembolic risk which can be mild, moderate or high. Prevention is based on general guidelines (early mobilization, leg elevation, etc.); in addition, at every level of potential risk, the use of low molecular weight heparin (LMWH) and/or wearing anti-thrombosis stockings, as well as surveillance of detection of venous thromboembolism, notably the duplex venous scanning of lower limbs, will be adapted to each patient. This algorithm is a means to elaborate a rational, but unfixed strategy or protocol of prevention to reduce the risk of venous thromboembolic complications, and if they occur, to detect them at an early stage and to treat them in order to avoid evolution towards pulmonary embolism, notably mortal pulmonary embolism.

Asunto(s)

Algoritmos , Procedimientos de Cirugía Plástica/efectos adversos , Tromboembolia/etiología , Tromboembolia/prevención & control , Humanos