Paola Fierabracci

Relationship between preclinical abnormalities of global and regional left ventricular function and insulin resistance in severe obesity: a Color Doppler Imaging Study

Background:The aim of this study was to evaluate the relationship between insulin resistance and preclinical abnormalities of the left ventricular structure and function detected in severe obesity by Color Doppler Myocardial Imaging (CDMI). Forty-eight consecutive severely obese patients (Group O) (11 males, 37 females, mean age 32.8±7 years) were enrolled. Forty-eight sex- and age-matched non-obese healthy subjects were also recruited as controls (Group C). All subjects underwent conventional 2D-Color Doppler echocardiography and CDMI. The homeostasis model assessment insulin resistance index (HOMA-IR) was used to assess insulin resistance results. Obese subjects had a greater left ventricular mass index (by height) (58.8±14 g/m2.7) than controls (37±8 g/m2.7) (P<0.0001), owing to compensation response to volume overload caused by a greater cardiac output (P<0.02). Preload reserve was increased in obese subjects, as demonstrated by a significant increase in left atrial dimension (P<0.0001). Obese patients had a slightly reduced LV diastolic function (transmitral E/A ratio: Group O, 1.1±0.8 vs Group C, 1.5 ±0.5; P<0.002). Cardiac deformation assessed by regional myocardial systolic strain and strain rate (SR) values was significantly lower (abnormal) in obese patients than in controls, both at the septum and lateral wall level. These strain and SR abnormalities were significantly related to body mass index. In addition, the early phase of diastolic function, evaluated using SR, was compromised in obese patients (P<0.001). The HOMA-IR values in obese patients were significantly higher (3.09±1.6) than those determined in the control group (0.92±0.5) (P<0.0001). The HOMA-IR values, in the obese group, were significantly related to systolic strain and SR values sampled at the septum level (P<0.0001).Conclusion:In conclusion, this study has demonstrated that obese patients pointed out systolic structural and functional abnormalities at a preclinical stage, in particular through strain and SR analysis; on the other hand, those altered CDMI parameters well distinguish obese subjects as compared with the control group. Furthermore, another main finding of the study was that myocardial deformation (systolic strain) could have a correlation with insulin resistance level.

Acute exogenous TSH administration stimulates leptin secretion in vivo

TSH-receptor (TSHR) has been found in a variety of cell types, including preadipocytes and adipocytes. In vitro, TSH-mediated preadipocyte and adipocyte responses include proliferation, differentiation, survival, and lipolysis. Objective To measure the response of serum leptin to exogenous administration of recombinant human TSH (rhTSH) in vivo. Patients One hundred patients with differentiated thyroid cancer already treated by total thyroidectomy and (131)I remnant ablation were enrolled. Mean (+/-s.e.m.) body mass index (BMI) was 26.9+/-0.6 kg/m(2). Methods Patients received a standard dose of rhTSH for measurement of thyroglobulin in the follow-up of their disease. Blood samples were taken for the assay of TSH and leptin before the first administration of rhTSH (time 0), and 24 h (time 1), 48 h (time 2), 72 h (time 3), and 96 h (time 4) after the first administration of rhTSH. Results Significant mean serum leptin increments, with respect to basal value, were 16, 13, 18, and 11% at times 1, 2, 3, and 4 respectively. Significant positive correlations of leptin-area under the curve with respect to basal leptin levels (r=0.43; P<0.0001) and BMI (r=0.32; P<0.005) were observed. Conclusions Acute rhTSH administration in hypothyroid subjects under l-thyroxine therapy produces a rise in serum leptin. This increase is proportional to the adipose mass suggesting that a functioning TSHR is expressed on the surface of adipocytes. The role that TSHR activation in adipocytes might play in physiological and pathological conditions remains a matter of investigation.

Effects of Bariatric Surgery on Early Myocardial Alterations in Adult Severely Obese Subjects

Objective: Aim of this study was to investigate the effect of weight loss on structural and functional myocardial alterations in severely obese subjects treated with bariatric surgery. Patients and Methods: Thirteen severely obese patients (2 males and 11 females) were enrolled in the study. All subjects underwent conventional 2D color Doppler echocardiography. The new ultrasonic techniques used were: (a) integrated backscatter for the analysis of myocardial reflectivity, referred to pericardial interface as expression of myocardial structure (increase in collagen content) and of cyclic variation index as expression of intrinsic myocardial contractility and (b) color Doppler myocardial imaging (CDMI) for the analysis of strain and strain rate (myocardial deformability). All subjects underwent bariatric surgery and were resubmitted to echocardiographic and biochemical examination 6–24 months after surgery. Results: The main finding of the present study was a quite complete normalization of myocardial functional and structural alterations after weight loss. In particular, the cyclic variation index at septum level improved from 14.6 ± 7.0 before to 25.7 ± 11.2 (means ± SD) after surgery (controls: 36.2 ± 9.1). Mean reflectivity at septum level significantly decreased from 55.8 ± 9.5 to 46.5 ± 8.8 (controls: 43.0 ± 8.0). Also, the strain at septum level significantly improved after surgery (from –11.9 ± 3.2 to –20.4 ± 5.3; controls: –23.4 ± 9). Conclusion: This study establishes: (a) the utility of new ultrasonic techniques to detect very early structural and functional myocardial alterations in severely obese patients, and (b) the regression of these subclinical abnormalities after weight loss achieved by bariatric surgery.

Increased prevalence of primary hyperparathyroidism in treated breast cancer.

Hypercalcemia occurring in patients with advanced breast cancer (BC) is generally due to osteolytic metastases or to the activity of circulating tumor-derived products. In these conditions, the production of endogenous PTH is reduced. The frequency of hypercalcemia due to primary hyperparathyroidism in breast cancer is unknown. We examined the occurrence of primary hyperparathyroidism in a large group of women with treated BC. A total of 100 consecutive women aged 28–80 years with treated breast cancer were enrolled. One hundred and two healthy age-matched women and 60 age-matched female patients with differentiated thyroid carcinoma examined before thyroidectomy were used as controls. Intact serum PTH and serum calcium were measured in all patients and controls. Hypercalcemia associated with elevated serum PTH concentration indicating primary hyperparathyroidism was found in 7 BC patients (7%) and in none of healthy women or patients with thyroid cancer. The pre-operative staging of BC patients with primary hyperparathyroidism was I in six and II in one of them, and no patient had evidence of distant metastases. A parathyroid adenoma was found in all 6 BC patients submitted to neck exploration, one patient refused surgery. Serum calcium and PTH concentrations returned to normal levels after surgery. Two BC patients had increased serum PTH and normal calcium concentrations. One of them had low serum 25-hydroxyvitamin D [25(OH)D]. One patient with spread bone metastases had neoplastic hypercalcemia with undetectable serum PTH concentration. All remaining 90 BC patients had serum calcium and PTH concentrations within normal limits, but their mean (±SD) values (9.6±0.5 mg/dl for serum calcium, 38.0±16.4 mg/dl for serum PTH ) were slightly but significantly greater than in normal controls (9.3±0.5 mg/dl, p=0.003 and 27.9±10.6 pg/ml, p=0.0001, respectively) and in patients with thyroid cancer (9.2±0.6 mg/dl, p=0.001 and 26.2±11.0 pg/ml, p=0.001), with no relationship with clinical staging or anti-tumor therapy. In conclusion: 1) an increased frequency of parathyroid adenoma was found in BC patients with mildly aggressive neoplastic disease; 2) in BC patients with no evidence of primary hyperparathyroidism mean serum PTH and calcium concentrations were significantly greater than in healthy controls and in patients with thyroid carcinoma; and 3) this finding was unrelated to clinical staging or anti-tumor therapy. Thus, primary hyperparathyroidism should be considered as a possible cause of hypercalcemia in patients with non-aggressive breast cancer. We suggest that serum PTH should be determined in all BC patients with increased serum calcium concentration, especially in those with no evidence of metastatic disease.

Artificial Neural Networks in the Outcome Prediction of Adjustable Gastric Banding in Obese Women

Background Obesity is unanimously regarded as a global epidemic and a major contributing factor to the development of many common illnesses. Laparoscopic Adjustable Gastric Banding (LAGB) is one of the most popular surgical approaches worldwide. Yet, substantial variability in the results and significant rate of failure can be expected, and it is still debated which categories of patients are better suited to this type of bariatric procedure. The aim of this study was to build a statistical model based on both psychological and physical data to predict weight loss in obese patients treated by LAGB, and to provide a valuable instrument for the selection of patients that may benefit from this procedure. Methodology/Principal Findings The study population consisted of 172 obese women, with a mean±SD presurgical and postsurgical Body Mass Index (BMI) of 42.5±5.1 and 32.4±4.8 kg/m2, respectively. Subjects were administered the comprehensive test of psychopathology Minnesota Multiphasic Personality Inventory-2 (MMPI-2). Main goal of the study was to use presurgical data to predict individual therapeutical outcome in terms of Excess Weight Loss (EWL) after 2 years. Multiple linear regression analysis using the MMPI-2 scores, BMI and age was performed to determine the variables that best predicted the EWL. Based on the selected variables including age, and 3 psychometric scales, Artificial Neural Networks (ANNs) were employed to improve the goodness of prediction. Linear and non linear models were compared in their classification and prediction tasks: non linear model resulted to be better at data fitting (36% vs. 10% variance explained, respectively) and provided more reliable parameters for accuracy and mis-classification rates (70% and 30% vs. 66% and 34%, respectively). Conclusions/Significance ANN models can be successfully applied for prediction of weight loss in obese women treated by LAGB. This approach may constitute a valuable tool for selection of the best candidates for surgery, taking advantage of an integrated multidisciplinary approach.

Relevance of estrogen and progesterone receptors enzyme immunoassay in malignant, benign and surrounding normal thyroid tissue

Several authors have demonstrated the presence of estrogen receptors (ER) and progesterone receptors (PR) in thyroid tissue, generally using dextran coated charcoal method (DCCA). The aim of this study was to measure ER and PR in thyroid specimens using an immunoenzymatic method, and to evaluate the meaning of different prevalence of ER and PR in malignant and benign thyroid disease, as compared with normal thyroid tissue. We have measured ER and PR in thyroid tissue from 28 benign and 20 malignant thyroid lesions, and in 38 samples of surrounding normal thyroid tissues. The sensitivity of ER-EIA and PR-EIA was 1.0 and 1.5 fmol/mg protein, respectively. In thyroid carcinoma the frequency of ER positivity (ER+) was 7/20 (35%); it was significantly higher in the surrounding normal tissue (15/20;71%) (p=0.03). In benign thyroid disease, the prevalence of ER+ was 11/28 (39%) and in the surrounding normal tissue it was 11/18 (61%) (p=not significant). PR+ was detected in 7/20 (35%) thyroid cancers and in 15/28 (53%) benign lesions without significant difference with the frequency detected in the surrounding normal tissues. ER and PR concentrations (mean±SD) in thyroid cancer was 2.2±2.2 and 2.2±2.9 respectively, similarly to that detected in benign thyroid disease and in normal tissue. The simultaneous presence of ER and PR (ER+PR+) was also evaluated. We have found that the frequency of ER+ PR+ was significantly higher in benign lesions (8/28; 28.6%) as compared with malignant samples (1/20; 5%) (p<0.05); the frequency of ER+PR+ was significantly higher in normal tissue surrounding the malignant lesions (9/20;45) (p=0.003). Our data indicate i) EIA method is appropriate to detect ER and PR in thyroid tissue. ii) The frequency of ER+ and ER+PR+ specimens is significantly higher in normal thyroid tissue than in pathologic tissues. This indicates that ER and PR immunoassays may be useful tools to evaluate the normal biological activity of thyroid cells.

Stromal IGF-II messenger RNA in breast cancer: Relationship with progesterone receptor expressed by malignant epithelial cells

In breast cancer, insulin-like growth factor II (IGF-II) is stromal in origin and is considered an important regulator of tumour epithelium growth. The presence of progesterone receptor (PR) is expression of an intact oestrogen regulatory pathway of breast malignant epithelial cells and represents a parameter of cell differentiation in breast cancer. In this study we have examined the relationship between IGF-II mRNA expression and ER, PR content in 75 breast cancer. Formalin-fixed paraffin-embedded tissue sections were used to preserve histological details. IGF-II mRNA was evaluated by in situ hybridisation method and ER, PR by immunohistochemistry. IGF-II mRNA was scored semi-quantitatively: 2.6% breast tumour specimen expressed no IGF-II mRNA, 46.7% had low levels of expression (IGF-II -) and 50.7% had moderate or high IGF-II mRNA content (IGF-II +). IGF-II mRNA was found in the stroma fibroblasts surrounding malignant lesions and no signal was detected in malignant epithelial cells. In contrast, ER and PR were expressed only by neoplastic epithelial cells and no immunoreactivity was found in the stroma: 50/75 (66.6%) breast cancer specimens were positive for ER (ER+) and 35 (46.6%) for PR (PR+). Both, IGF-II mRNA and PR were directly correlated with the stromal proliferation (p<0.05 and p<0.001, respectively). No relationship was found between IGF-II RNA and ER. In contrast 24/35 (73.5%) PR breast cancer tissues were IGF-II+(p<0.01) and a strong correlation was found between epithelial PR immunostaining and stromal IGF-II mRNA content (p<0.003). Our data indicate that in breast cancer IGF-II mRNA is generally expressed by stromal cells and ER and PR by ephitelial cancer cells, and that IGF-II mRNA expression is strongly related with both percentage and staining intensity of PR+ epithelial cancer cells. These data support the hypothesis that IGF-II produced by the fibroblasts may exert a paracrin effect on malignant epithelium regulating its differentiation.

Interference of thyroperoxidase on immuno-cytochemical determination of steroid receptors in thyroid tissue

The presence of sexual steroid receptor proteins in thyroid tissue has been previously demonstrated by biochemical means. The aim of this study was to determine the estrogen (ER) and progesterone (PR) receptors in malignant (12 papillary and 1 follicular carcinoma) and nonmalignant (19 multinodular goiters, 1 Graves’ disease, 1 Hashimoto’s thyroiditis) thyroid diseases using immunocy-tochemical assay employing monoclonal anti-ER and anti-PR antibodies and the peroxidase-antiperoxi-dase technique. Positive results were obtained in 24/34 (70%) for ER (ER-ICA+) and 22/34 (64%) for PR (PR-ICA+). To evaluate the possible interference of thyroperoxidase in the immunostaining, in consecutive sections of a positive specimen, primary antibody or primary antibody plus bridging antibody or PAP complex was omitted. Using these modified procedures, staining distribution was similar to that obtained by the standard procedure: in contrast, no staining was found in the positive control, i.e. a breast cancer specimen. The inhibition of the endogenous peroxidase caused a loss of staining in both the standard and modified procedures on thyroid specimens; no staining modification was obtained in the positive control. These results suggest that the staining observed in thyroid tissue is not specific and related to the activity of thyroperoxidase on chromogen solution. The complete loss of staining after peroxidase inhibition appears to be in contrast with the results obtained by biochemical method, and different antigenicity of thyroid receptors in comparison with breast receptors may explain this discrepancy.

Identification of a novel mutation in the polymerase delta 1 (POLD1) gene in a lipodystrophic patient affected by mandibular hypoplasia, deafness, progeroid features (MDPL) syndrome ☆

OBJECTIVE Progressive lipodystrophy is one of the major features of the rare MDPL syndrome. Until now, 9 patients affected by this syndrome have been described and a recent study identified in 4 of them an in-frame deletion (Ser605del) of a single codon in the POLD1 gene. Sequence alterations of the POLD1 gene at different sites have been previously reported in human colorectal and endometrial carcinomas. MATERIALS/METHODS A 48-year-old woman was admitted to our department for the assessment of a previously diagnosed lipodystrophy. She did not report a family history of diabetes or other metabolic disorders. Hypertriglyceridemia was diagnosed incidentally when she was 25years old. At that time she was also diagnosed with sensorineural bilateral hearing loss. At physical examination she presented lipoatrophy affecting nearly the entire body, mandibular hypoplasia, bird-like face, beaked nose, progeroid facial features, with crowded teeth, small mouth and uvula. Abdominal ultrasound showed hepatomegaly and hepatosteatosis. Fat mass index measured with DXA was 4.59kg/m(2), indicating a fat deficit; the oral glucose tolerance test showed an impaired glucose tolerance. RESULTS Sequence analysis of the entire coding region of the POLD1 gene, disclosed a novel heterozygous mutation in exon 13 (R507C). CONCLUSION The MDPL patient herein described harbors a novel mutation in the exonuclease domain of POLD1. This new variant provides further evidence for a role of POLD1 in the pathogenesis of MDPL. The mechanisms that link changes at various sites of the protein with different diseases remain to be clarified.

Insulin-like growth factor II (IGF-II) immunohistochemistry in breast cancer: relationship with the most important morphological and biochemical prognostic parameters.

Recent in situ hybridization experiments have shown a high content of IGF-II mRNA in breast cancer stroma. The aim of this study was to examine the relationship between IGF-II protein expression and several prognostic parameters in 75 infiltrating ductal carcinomas (IDC) of the breast. Tissue sections were evaluated for proliferative activity, IGF-II protein, ER, PgR, p53, and p21 expression using immunohistochemical procedures. The degree of stromal proliferation was assessed. Menopausal status, axillary lymph node involvement and nuclear grade were known. Thirty-five patients (44.3%) were premenopausal and 47 (62.6%) had lymph node metastases. Marked stromal proliferation was found in 34 (45.3%) specimens and high nuclear grade in 20 (26.5%). Eighteen tumors (24%) showed no IGF-II immunostaining. In the positive cases, IGF-II was detected both in the tumor stroma and in the cytoplasm of epithelial cancer cells: a high IGF-II content was found in 12 specimens (16.0%), a low content in 14 (18.7%) and a moderate content in 31 (41.3%). Twenty-four tumors (32.0%) showed high proliferative activity. Both ER and PgR were expressed in the nucleus of cancer cells: 49 tumors (65.3%) were ER positive (ER+) and 34 (45.3%) PgR positive (PgR+). p21 protein was detected in 37 tumors (49.6%) and p53 in 12 (16%). IGF-II protein was not correlated with menopausal status, lymph node metastases, nuclear grade, proliferative activity, ER or p53. In contrast, IGF-II correlated strongly with stromal proliferation (p=0.008), PgR (p=0.03) and p21 (p=0.01). This study demonstrates that in IDC of the breast IGF-II protein is expressed in the epithelium and stroma of the majority of tumors and is correlated with stromal amount, PgR and p21 expression. These preliminary results indicate that IGF-II expression in breast cancer is connected with two important regulators of breast cancer growth and differentiation.