Yvonne Fulla

Assessment of adrenal function in cirrhotic patients: salivary cortisol should be preferred.

BACKGROUND & AIMS Adrenal insufficiency is a common disorder among cirrhotic patients. Adrenal function is usually assessed with serum total cortisol assays. Free cortisol (active fraction) represents only 10% of serum total cortisol, the remaining 90% being linked to cortisol-binding globulin (CBG) and albumin. In cirrhotic patients, the synthesis of these proteins is reduced, which could lead to an overestimation of the prevalence of adrenal insufficiency. Salivary cortisol assessment adequately reflects free cortisol plasma concentration. However, this method has never been validated in cirrhotic patients. The objectives of this report were to assess the following parameters by a prospective observational study: (1) correlation between salivary, serum total and free cortisol, (2) adrenal insufficiency prevalence using salivary and serum assays, (3) parameters associated with a discrepancy between both tests, and (4) adrenal insufficiency risk factors among cirrhotic patients. METHODS Salivary and serum total cortisol were assessed before and 1h following an injection of corticotropin (250 microg) in patients hospitalized for cirrhosis complications without shock. CBG was measured and free cortisol was assessed by the Coolens formula. RESULTS Eighty-eight patients were included in the study (Child-Pugh C: 68.2%). Free cortisol was more strongly correlated with salivary than with serum total cortisol (Spearman coefficient=0.91 vs. 0.76, respectively, p<0.001). Among included patients, 9.1% had adrenal insufficiency according to salivary cortisol and 33.0% had adrenal insufficiency according to serum total cortisol (p=0.001). Hypoalbuminemia was the only factor associated with a discrepancy between the results of both tests. Adrenal insufficiency risk factors were ascites and low HDL-cholesterol plasma concentration. CONCLUSION Using serum total cortisol assays overstate adrenal insufficiency prevalence among cirrhotic patients, mainly because of inaccurate concentrations related to hypoalbuminemia. Salivary cortisol assays should be preferably used in these patients.

Thoracoscopic removal of mediastinal parathyroid glands: a critical appraisal of an emerging technique.

Objective:To retrospectively evaluate the feasibility of thoracoscopic removal of mediastinal parathyroids. Summary Background Data:Mediastinal exploration to resect ectopic parathyroid(s) is needed in approximately 2% of cases in hyperparathyroidism. Recent advances in thoracoscopic surgery allow for a minimally invasive treatment. Methods:From 1999 through 2007, 13 patients affected by primary hyperparathyroidism (11 females, mean age 60 years, range: 22–88) underwent thoracoscopic removal of mediastinal parathyroids. Scintigraphy produced positive results in 11 of 13 cases, computed tomography scan in 9 of 10, parathyroid hormone venous sampling in 10 of 10 patients, and magnetic resonance imaging in 5 of 7. Right thoracoscopic access was used in 9 patients, left in 4. Postoperative outcome was analyzed. Results:Thoracoscopy enabled retrieval of mediastinal parathyroids in 10 of 13 (78%) cases. Mean operating time was 92 minutes (range: 50–240). One procedure (8%) was converted. No perioperative deaths/major complications occurred. Mild complications occurred in 2 of 13 (15%) patients (pneumothorax/pneumonia, transient recurrent nerve palsy). Mean hospital stay was 4.7 days (range: 2–15). At a mean follow-up of 73 months (range: 16–105), parathyroid hormone and calcium venous concentrations were high in 3 patients. Unsuccessful procedures were related to doubtful or non–concordant preoperative localization. Conclusions:The thoracoscopic approach for mediastinal parathyroidectomy is feasible and safe. An accurate preoperative work-up should be standardized to avoid useless procedures. In case of negative preoperative localization of the abnormal gland, thoracoscopy should not be adopted as a diagnostic tool.

Effects of aspirin and clopidogrel on plasma brain natriuretic peptide in patients with heart failure receiving ACE inhibitors

By inhibiting prostaglandins, aspirin may be deleterious in heart failure (HF) and/or may counteract angiotensin‐converting enzyme (ACE) inhibitor efficacy. Conversely, clopidogrel has no effect on prostaglandin metabolism.

L’Inhibine B sérique, marqueur sensible de la production spermatique chez l’homme

RésuméDes données acquises au cours des dernières années indiquent que le dosage de l’inhibine B sérique est un marqueur très utile de la spermatogenèse. Le propos du présent travail était l’évaluation de cette technique à l’occasion de son transfert technologique dans notre hôpital par l’étude d’hommes dans différentes situations cliniques consultant pour infécondité du couple. Nous avons ainsi pu confirmer l’intérêt majeur du dosage de l’inhibine B par le “dimeric assay” à côté du dosage de la FSH pour évaluer de manière indirecte la spermatogenèse de ces hommes. Nous avons trouvé que les valeurs d’inhibine B sérique étaient en corrélation directe avec le niveau de production spermatique et en corrélation inverse avec le taux de FSH. Cependant les taux d’inhibine B présentaient un meilleur pouvoir discriminant que les taux de FSH. Par exemple, la mesure de l’inhibine B différenciait les hommes présentant une oligozoospermie sévère des hommes azoosperme de manière beaucoup plus significative que la FSH (p=0,0002 vs p=0,007 respectivement). D’une manière générale, les résultats obtenus dans la présente étude étaient similaires à ceux rapportés dans les études déjà publiées reposant sur la même technique de dosage. En résumé et sur le plan pratique, le dosage de l’inhibine B est sensible et beaucoup plus spécifique que celui de la FSH pour refléter le niveau de fonctionnalité de la spermatogenèse et dans les cas des azoospermies, le dosage de l’inhibine B semble particulièrement intéressant pour distinguer azoospermies sécrétoires et excrétoires.AbstractSeveral recent papers indicate that the blood concentration of inhibin B measured by the dimeric assay is a marker of human spermatogenesis. The aim of the present study was to validate the dimeric assay in our hospital. For this purpose, we studied a population of 106 patients attending our infertility clinic. We found that serum inhibin B levels were positively correlated with the level of sperm production as reflected by the sperm concentration and negatively correlated with serum FSH levels. Serum inhibin B concentrations were found to be superior to FSH levels for discriminating between subgroups of patients with different levels of sperm production. For example, the differences in the inhibin B levels in severe oligozoospermia (< 5×106 sperm/ml) compared to non-obstructive azoospermia were more pronounced than the differences in FSH (p=0.0002 vs p=0.007, respectively). Overall, the results obtained in the present study were similar to those reported in other studies based on the same assay. Serum inhibin B levels in patients with non obstructive azoospermia were ten times lower than in patients with normal sperm concentrations. From a practical point of view, the measurement of serum inhibin B opens up new possibilities for the diagnosis and prognosis of many testicular disorders. Firstly, serum inhibin B determination should be performed whenever reproductive hormones are prescribed. In the particular case of azoospermia, serum inhibin B concentrations appear to be particularly useful to distinguish between obstructive and non-obstructive situations. Finally, according to a recent publication, a serum inhibin B cut-off value (> 40 pg/mL) could predict the success of testicular sperm extraction in patients with non-obstructive azoospermia. Serum inhibin B could therefore represent a unique non-invasive marker of focal hypospermatogenesis in men with non-obstructive azoospermia, who are candidates for intracytoplasmic sperm injection (ICSI) and a useful early marker to monitor possible recovery of spermatogenesis after chemotherapy or radiotherapy.