Efavirenz-associated gynecomastia: report of five cases and review of the literature

The prognosis of HIV infection has improved dramatically since the introduction of highly active antiretroviral therapy (HAART). However, numerous adverse effects and limitations regarding tolerability remain a concern. Lipomastia (pseudogynecomastia), a breast enlargement due to central adiposity, may occur as part of a fat redistribution syndrome which has been associated with HAART regimens and several pathogenic mechanisms have been advocated in its development. Here we report an observational longitudinal study of five patients diagnosed of gynecomastia associated with efavirenz-based HAART regimens. All cases reached successful immunologic and virologic responses to HAART. The delay of appearance of gynecomastia from the beginning of HAART ranged between 4 to 15 months. In all five cases, gynecomastia regressed after efavirenz withdrawal (mean period of 5 months). In summary, we think that HAART induced gynecomastia should be suspected in HIV patients receiving efavirenz-containing regimens. Although pathogenesis is unclear, this study and a review of the English literature implicates two possible mechanisms: (a) immune restoration processes and (b) efavirenz mediated estradiol-like effects.     

Immunoglobulin therapy to control lung damage in patients with common variable immunodeficiency

BACKGROUND: Lung damage progression is the most frequent condition in patients with common variable immunodeficiency (CVID). Appropriate immunoglobulin dose adjustments and follow-up guidelines to evaluate this have not been well established. Objective: To assess the evolution of lung damage once stable residual serum levels of IgG over 600 mg/dl had been achieved. METHODS: A prospective study was conducted in 24 adult patients consecutively diagnosed with CVID, with no previous intravenous immunoglobulin (IVIG) treatment. IVIG dose, total serum IgG level, bacterial infection rate, pulmonary function tests (PFTs) and high resolution computed tomography (HRCT) of the thorax were monitored over 2 years. Moreover, outcome data were determined by measurement of chronic pulmonary disease (CPD). RESULTS: IVIG dose variability (205-372 mg/kg/21 days) to obtain the required serum IgG levels was determined. Patients with CPD needed higher doses than those without CPD (p=0.045). A significant reduction in severe and mild infections/patient-year was observed during treatment. Overall, there were no changes in PFTs and HRCT scores in patients without CPD, but both improved in patients with CPD. An increase of over 15% in overall HRCT score was detected in two patients without evidence of impairment in either clinical status or PFT values. CONCLUSIONS: Residual levels of total IgG over 600 mg/dl may help prevent progression of lung damage in patients with CVID. Levels of IgG, clinical manifestations and PFTs seem sufficient for routine follow-up. HRCT examination of the thorax, at least biennially, may help to identify patients in whom lung injury is progressing even though they may remain symptom-free and with stable PFTs.     

5-ht5B receptor mRNA in the raphe nuclei: coexpression with serotonin transporter

We used double-label in situ hybridization to examine the cellular localization of 5-ht(5B) receptor mRNA in relation to serotonin transporter mRNA in the rat dorsal raphe (DR) and central superior nucleus (CS, median raphe nucleus). 5-ht(5B) receptor mRNA hybridization signal was often found on serotonin transporter mRNA-positive neuron profiles. The degree of cellular colocalization of these mRNAs notably varied among the different regions of the raphe nuclei. In the DR, cell bodies showing 5-ht(5B) receptor mRNA expression were abundant in the medial portions of the nucleus, all of them being also labeled for serotonin transporter mRNA. In contrast, in the ventrolateral regions (lateral wings) of the DR, we observed serotonin transporter mRNA-positive cells, but they were devoid of 5-ht(5B) receptor mRNA signal. In the CS, the level of coexpression of 5-ht(5B) receptor mRNA with serotonin transporter mRNA was high in the intermediate portions of the nucleus; however, we were unable to detect specific 5-ht(5B) receptor mRNA hybridization signal in its caudal extent. Our results support the presence of 5-ht(5B) receptor in serotonergic neurons in the DR and CS, suggesting an autoreceptor role for this receptor subtype.     

A novel exon 5 mutation (N139H) in the SOD1 gene in a Spanish family associated with incomplete penetrance

BACKGROUND: Allelic heterogeneity and phenotype variability-especially in age at onset, penetrance and progression-are reported in ALS1 families. For this reason, SOD1 gene mutation data in ALS1 patients are currently being gathered to better understand the genotype-phenotype relationship in this disorder. Here, we report the clinical and molecular characteristics of a Spanish ALS1 family with incomplete penetrance. PATIENTS AND METHODS: Clinical data including age at onset, initial topography, progression and survival were available in three affected members. Erythrocyte SOD1 activity was measured in four individuals. Analysis of the SOD1 gene was performed by PCR and direct sequencing. RESULTS: A novel missense mutation in the exon 5 of the SOD1 gene, an A-to-C transversion at nucleotide position 1485 leading to N139H residue change, was identified in three family members. The phenotype was similar in all cases, with initial symptoms in the distal limb muscles and a mean survival time of around 4 years. Incomplete penetrance was observed in our family, as two obligate carriers did not develop any symptoms of amyotrophic lateral sclerosis (ALS). CONCLUSIONS: N139H is the fifth SOD1 gene mutation reported in Spain, and the first one presenting with incomplete penetrance. Genetic counseling for at-risk relatives in these low-penetrance families could be difficult as some individuals harbouring the mutation remain asymptomatic throughout their lives. Further genetic characterisation of ALS1 families should provide information regarding the distribution of SOD1 mutants in different ethnic groups.     

Complications with femoral access in cardiac cathetization. Impact of previous systematic femoral angiography and hemostasis with VasoSeal-ES collagen plug

INTRODUCTION AND OBJECTIVES: Most cardiac catheterizations are performed via femoral artery access, and hemostatic devices are commonly used. We evaluate the relationship between the strategy used for femoral arteriography and the use of VasoSeal-ES, and local vascular complications. PATIENTS AND METHOD: Prospective study of 540 consecutive catheterizations with systematic femoral artery and sheath angiography. VasoSeal-ES was used in 427 patients. Predictors of local vascular complications such as patient-related factors, anatomy and hemostasis were analyzed. Variables related to failure of the collagen plug were also studied. RESULTS: Punctures of the common femoral artery occurred in 35.9% of all patients (16% in the deep femoral artery and its ostium). Spasm was evident in 18% (ranging from 58.1% in the deep femoral artery to 5.2% in the common femoral artery). Puncture at the site of ramification was seen in 11.3%. Angiographically significant atheroma was seen in 17.8%. The femoral head was a valid landmark for the common femoral artery in only 63.9% of the pateints. Risk factors for local vascular complications were punctures of the common femoral artery, female sex and failure of VasoSeal-ES to achieve hemostasis (15.8% in the first two months of use, 5.2% in the last months of the study). Complications involving superficial and deep femoral arteries occurred in 6.7% and 1.2% of the patients, respectively, in contrast to 0.6% involving the common femoral artery. Variables related to collagen plug failure were patient-related factors, weight less than 55 kg, operator-related factors and the learning curve. CONCLUSIONS: Systematic femoral angiography provides data that aids the choice of the best hemostasis procedure to reduce local vascular complications. Punctures of the common femoral artery were more frequent than expected, and were associated with a higher complication rate. VasoSeal-ES is a safe and useful method of hemostasis, and its infrequent failures were associated with high complication rates that were substantially reduced with experience.     

Gastric leptin: a putative role in the short-term regulation of food intake

The discovery of the production of leptin by the stomach, in addition to its production by adipose tissue, has initiated new investigation into the possible role of this protein in the digestive physiology, in particular in the short-term control of energy balance. Leptin has been identified in the lower half of the stomach glands both in the pepsinogen granules of chief cells and in the granules of a specific endocrine cell type, suggesting that leptin action is exerted by both exocrine and endocrine pathways. Gastric leptin is sensitive to the nutritional state, being rapidly mobilized in response to food intake following fasting, or after the administration of satiety factors; this suggests a role for this protein in the short-term regulation of feeding, acting in collaboration with satiety peptides such as cholecystokinin. Leptin, produced by gastric cells and by adipocytes, could act on both acute and chronic regulation of feeding behaviour respectively, giving information to the brain on the availability of external (food) and internal (fat depots) energy resources, thus participating in short- and long-term satiation.