Repeated Remissions of Cushing's Disease Due to Recurrent Infarctions of an ACTH-Producing Pituitary Macroadenoma

Infarction of prolactin-secreting or growth hormone-secreting pituitary adenomas is not unusual. However, Infarction of ACTH-secreting adenomas has rarely been reported. Cyclical course of Cushing's syndrome alternating with adrenal insufficiency due to recurrent infarction of an ACTH-secreting pituitary adenoma has not been reported. We report here a 20-year-old lady who presented with florid signs of Cushing's syndrome but was found to have adrenal insufficiency on biochemical evaluation. Magnetic resonance imaging (MRI) of the pituitary gland showed that she had infarction of an ACTH-secreting macroadenoma. Over the next 6 years, her disease ran a cyclical course characterized by periods of hypercortisolism alternating with adrenal insufficiency due to repeated episodes of infarctions of the ACTH-secreting pituitary macroadenoma with corresponding changes in the pituitary adenoma on serial MRIs. The case alerts clinicians to this possibility when a patient presents with clinical picture of Cushing's syndrome but has adrenal insufficiency on biochemical testing. It also suggests that silent or subclinical infarction of pituitary adenomas is not uncommon and is probably under diagnosed.     

Managing common endocrine disorders amid COVID-19 pandemic

Background and aimsThe novel coronavirus disease (COVID-19) pandemic and the resulting nationwide lockdowns have posed a major challenge to the management of pre-existing and newly diagnosed endocrine disorders. Herein, we have summarized the management approaches of common endocrine disorders amid the ongoing pandemic.MethodsWe have performed an extensive literature search for articles in PubMed, EMBASE and Google Scholar databases till 25 May 2020, with the following keywords: “COVID-19”, “diabetes mellitus”, “thyroid disorders”, “primary adrenal insufficiency”, “Cushing’s syndrome”, “pituitary tumors”, “vitamin D″", “osteoporosis”, “primary hyperparathyroidism”, “hypoparathyroidism”, “management”, “treatment” and “guidelines” with interposition of the Boolean operator “AND”.ResultsWe have summarized the most feasible strategies for the management of diabetes mellitus, thyroid disorders, primary adrenal insufficiency (including congenital adrenal hyperplasia), Cushing’s syndrome, pituitary tumors, osteoporosis, primary hyperparathyroidism and hypoparathyroidism amid the constraints laid down by the raging pandemic. In general, medical management should be encouraged and surgical interventions should be deferred whenever possible. Ongoing medications should be continued. Sick-day rules should be sincerely adhered to. Regular contact with physicians can be maintained through teleconsultations and virtual clinics.ConclusionsConsidering the burden of endocrine disorders in the general population, their management needs to be prioritized amid the ongoing COVID-19 pandemic.     

The impact of antiviral therapy for HCV on kidney disease: a systematic review and meta-analysis

BackgroundControversy persists about the role of hepatitis C as a risk factor for developing kidney disease in the general population. Some authors have evaluated the effect of antiviral therapy for HCV on the risk of kidney disease.Study Aims and DesignA systematic review of the published medical literature was performed to assess whether antiviral therapy for HCV has an independent impact on kidney survival in the adult general population. A random effects model was used to generate an overall estimate of the risk of kidney disease after anti-HCV therapy across the published studies. Meta-regression and stratified analysis were also carried out.ResultsFifteen studies were eligible (n = 356, 285 patients) and separate meta-analyses were conducted according to the outcome. Pooling studies based on viral responses (n = 7; 34,763 individual patients) demonstrated a relationship between sustained viral response and lower frequency of kidney disease; the overall estimate for adjusted risk of kidney disease was 2.50 (95% CI, 1.41; 4.41) (p = 0.0016) and between-study heterogeneity was found (p-value by Q test = 0.004). Aggregation of studies comparing treated vs untreated cohorts (n = 8, n = 333,312 patients) revealed an association between anti-HCV therapy and lower risk of kidney disease. The overall estimate for adjusted risk of kidney disease across the eight studies was 0.39 (95% CI, 0.25; 0.612) (p = 0.0001). Meta-regression showed that the effectiveness of antiviral therapy in reducing the frequency of kidney disease diminishes as cirrhosis (p = 0.02) and HBV infection (p = 0.0001) increase among HCV-infected individuals.ConclusionsAntiviral therapy for HCV lowers the risk of kidney disease among HCV-infected individuals. Studies to understand the mechanisms underlying this association are ongoing.     

Neonatal hyperglycaemia and abnormal development of the pancreas

Transient and permanent neonatal diabetes mellitus (TNDM and PNDM) are rare conditions occurring in around 1 per 300,000 live births. In TNDM, growth-retarded infants develop diabetes in the first few weeks of life, only to go into remission after a few months with possible relapse to permanent diabetes usually around adolescence or in adulthood. In PNDM, insulin secretory failure occurs in the late fetal or early postnatal period. The very recently elucidated mutations in KCNJ11 and ABCC8 genes, encoding the Kir6.2 and SUR1 subunits of the pancreatic K(ATP) channel involved in regulation of insulin secretion, account for a third to a half of the PNDM cases. Molecular analysis of chromosome 6 anomalies and the KCNJ11 and ABCC8 genes encoding Kir6.2 and SUR1 provides a tool for distinguishing transient from permanent neonatal diabetes mellitus in the neonatal period. Some patients (those with mutations in KCNJ11 and ABCC8) may be transferred from insulin therapy to sulphonylureas.     

老年人慢性心力衰竭早期肾功能损害的临床观察

目的探讨老年人慢性心力衰竭(CHF)患者早期肾功能损害及其与心功能的关系。方法测定40例60～80岁的CHF患者、40例同年龄的心功能代偿的心脏病患者及40例同年龄的健康对照者的常规尿蛋白(UP)、血清/尿肌酐(S/UCr)、尿素氮(BUN)、尿微量白蛋白(UMA)、尿β_2-微球蛋白(Uβ_2-MG)水平。并与左心室射血分数(LVEF)进行相关分折。结果老年CHF患者UMA水平较健康对照组和心功能代偿的心脏病组明显升高[分别为(8．69±10．23)、(1．72±1．25)和(2．30+2．08)mg/mmol UCr],差异有统计学意义(均为P＜0．01);与LVEF呈显著负相关(r= -0．36,P＜0．01);Uβ_2-MG 3组分别为(0．143±0．223)mg/mmol UCr、(0．135±0．215)mg/mmol UCr和(0．146±0．249)mg/mmol UCr,差异无统计学意义(均为P＞0．05)。结论老年CHF患者存在以肾小球滤过功能受损为特征的早期肾功能异常;CHF程度越重,肾小球滤过功能损害越明显。     

肺心病慢性呼吸衰竭患者脑诱发电位的研究

目的用诱发电位方法检测肺心病慢性呼吸衰竭患者在发生临床肺性脑病前脑功能的改变。方法对２８例老年肺心病慢性呼吸衰竭无肺性脑病临床表现的患者、２０例老年肺炎患者及３０例老年健康人同时进行脑干听觉、体感诱发电位（ＢＡＥＰ、ＳＥＰ）检查。结果ＢＡＥＰ异常：肺心病组２３例（８２％），肺炎组７例（３５％）；ＳＥＰ异常：肺心病组２４例（８６％），肺炎组８例（４０％）。经统计学检验，肺心病组ＢＡＥＰ、ＳＥＰ与健康组、肺炎组差异有显著性，肺炎组与健康组差异无显著性。结论肺心病慢性呼吸衰竭患者有脑干功能受损和弥漫性脑功能障碍。     

Echocardiographic Assessment of Melody Versus Sapien Valves Following Transcatheter Pulmonary Valve Replacement

ObjectivesThe aim of this study was to compare the immediate and midterm echocardiographic performance of the Melody (Medtronic Inc) and Sapien (Edwards Lifesciences Inc) valves after transcatheter pulmonary valve replacement (TPVR) in native and conduit right ventricular outflow tracts (RVOTs).BackgroundTPVR is now a common procedure, but limited data exist comparing postimplantation echocardiographic findings between Melody and Sapien valves.MethodsThis was a single-institution retrospective cohort study of all patients who underwent successful TPVR from 2011 to 2020. Patient demographics, procedural details, and immediate and midterm echocardiographic findings were collected and compared between valve types using the Wilcoxon rank sum, chi-square, or Fisher exact test as appropriate. Subgroups were analyzed individually and were adjusted for multiple comparisons using the Bonferroni method.ResultsA total of 328 patients underwent successful TPVR (Melody: n = 202, Sapien: n = 126). The groups had a similar baseline age, weight, and diagnosis. The most common indications for TPVR were pulmonary stenosis (32.2%) or mixed disease (46%) in the Melody group and pulmonary insufficiency in the Sapien group (52.4%) (P < 0.001). Sapien valves were more often placed in native RVOTs (43.7% vs 18.8%; P < 0.001). The discharge and follow-up mean and peak Doppler gradients were similar between the Melody and Sapien groups. Valves implanted in native RVOTs had significantly lower postimplantation gradients at each follow-up period.ConclusionsEchocardiographic performance after TPVR was generally acceptable and similar when comparing Melody and Sapien valves despite differences in the indication and anatomy in each group. The peak and mean gradients were lower in transcatheter valves implanted in native RVOTs compared with those implanted in conduits or bioprosthetic valves.     

高敏C反应蛋白对老年女性急性心肌梗死患者肾功能不全的独立预测作用

目的探讨高敏C反应蛋白(hs-CRP)对于老年女性急性心肌梗死(AMI)患者肾功能不全的预测作用。方法选择天津医科大学第二医院就诊的老年女性AMI患者317例,根据估算的肾小球滤过率(eGFR)水平分为肾功能正常组209例[eGFR≥60 ml/(min·1.73 m^2)],肾功能不全组108例[eGFR<60ml/(min·1.73 m^2)]。采用Spearman相关性分析eGFR与临床生化指标的关系,二元logistic回归分析老年女性AMI患者肾功能不全的危险因素。结果与肾功能正常组比较,肾功能不全组年龄、饮酒、KillipsⅡ级、尿酸、尿素、肌酐、hs-CRP、N末端钠尿肽前体、肌酸激酶水平明显升高,TC、LDL-C和白蛋白/球蛋白比值明显降低(P<0.05,P<0.01)。Spearman相关性分析显示,hs-CRP与eGFR呈负相关(r=-0.317,P=0.000)。单因素logistic回归分析显示,hs-CRP是老年女性AMI患者肾功能不全的重要预测指标(OR=1.010,95%CI:1.005~1.015,P=0.000)。多因素logistic回归分析显示,年龄、hs-CRP和N末端钠尿肽前体是老年女性AMI患者肾功能不全的危险因素(P=0.011,P=0.024,P=0.000)。结论 hs-CRP与老年女性AMI患者肾功能密切相关。     

术前、术中肺通气功能与术后呼吸衰竭的关系

目的探讨机械通气时呼吸力学与术前肺功能的关系．确定术前通气功能参数能否预测术后呼吸衰竭。方法择期行肺切除术的原发性肺癌病人100例．ASAⅠ级或Ⅱ级，术前测定肺功能：一秒用力呼气容量（FEV1）、用力肺活量（FVC）、一秒用力呼气量与用力肺活量之比（FEV1／FVC％）、最大肺活量（VC）、最大通气量（MVV）、75％肺活量位用力呼气流速（FEh）、最大中期呼气流速（MMEFm）、功能残气量（FRC）、残气量与肺总量之比（RV/TLC％）；测定脉冲震荡肺功能：共振频率（Fres）、呼吸总阻抗（Zres）、中心阻力（Rc）、5Hz和20Hz时粘性阻力（R5、R30）。分别记录插管后机械通气初始和开胸单肺通气后双肺气道峰压（Tpeak）、双肺胸肺顺应性（TCT）和单肺气道峰压（Opeak）、单肺胸肺顺应性（OCT），取其平均值。Opeak和OCT与身高、体重及肺功能的关系采用多元逐步回归。一般情况和肺功能与术后呼吸衰竭的关系采用非条件Logistic回归分析。根据术后是否发生呼吸衰竭分为2组：呼吸衰竭组（RF）和非呼吸衰竭组（NRF）。结果Opeak与Zres、身高、体重和FEF。呈线性关系（R2=0．504），OCT与Zres、身高、VC和RVfrLC％呈线性关系（R^2=0.602）。与NRF组比较，RF组FEV1、FVC、FEV1／FVC％、MVV、MMEFw均降低（P〈0．01）。年龄≥60岁的老年患者FEV1≤60％、FEV1／FVC≤60％、MVV≤50％、MMEn％≤35％时，RF组术后呼吸衰竭发生率高于NRF组（P〈0．05）。Logistic回归表明．年龄和MVV是术后呼吸衰竭的两个主要影响因素。结论术中单肺通气时的气道峰压和胸肺顺应性分别与身高、体重和术前肺功能呈线性相关。中度肺功能减退的老年患者行胸科手术后发生呼吸衰竭的风险性大：年龄和MVV是术后呼吸衰竭的两个主要影响因素。