Ventilator-associated pneumonia by methicillin-susceptible Staphylococcus aureus: do minimum inhibitory concentrations to vancomycin and daptomycin matter?

The use of vancomycin minimum inhibitory concentration (MIC) as an outcome predictor in patients with methicillin-susceptible Staphylococcus aureus (MSSA) bacteremia has become an important topic for debate in the last few years. Given these previous results, we decided to investigate whether MICs to vancomycin or daptomycin had any effect on the evolution of patients with ventilator-associated pneumonia (VAP) due to MSSA. An observational, retrospective, multicenter study was conducted among patients with MSSA VAP. We analyzed the relationship between vancomycin and daptomycin MICs and early clinical response (72 h), 30-day mortality, intensive care unit (ICU) length of stay (LOS), and duration on mechanical ventilation. Univariate and multivariate analyses were performed. Sixty-six patients from 12 centers were included. Twenty-six patients (39%) had an infection due to MSSA strains with a vancomycin MIC ≥1.5 µg/mL. Daptomycin MIC was determined in 58 patients, of whom 17 (29%) had an MIC ≥1.0 µg/mL. Ten patients (15%) did not respond to first-line treatment. Only daptomycin MIC ≥1.0 µg/mL had a significant association [odds ratio (OR): 30.00; 95% confidence interval (CI): 2.91-60.41] with early treatment failure. The 30-day mortality was 12% (n = 8). Any variable was associated with mortality in the multivariate analysis. None of the variables studied were associated with ICU LOS or duration on mechanical ventilation. In patients with MSSA VAP, vancomycin MIC does not influence the response to antibiotic treatment or the 30-day mortality. Daptomycin MIC was directly related to early treatment failure.

Assessment of food safety using a new real-time PCR assay for detection and quantification of virulence factors of enterococci in food samples.

AIMS: Development of Taqman MGB real-time PCR (q-PCR) assays for the quantitative detection of virulence factor genes in pure culture and food samples with regard to food safety assessment. METHODS AND RESULTS: New Taqman primers and probes were designed for the ace, esp and gelE genes based on the determinants of virulence profiles of enterococcal strains from GenBank. The high specificity and accuracy of the Taqman probe assay was confirmed. The limit of detection for the different virulence genes was 102  CFU ml-1 or CFU g-1 for pure culture and meat samples, and 103  CFU g-1 for cheese samples. CONCLUSION: This method provides the specific and rapid detection and quantification of ace, esp and gelE genes compared to conventional PCR assays, thus allowing the rapid and direct safety assessment of Enterococcus genus in food samples. SIGNIFICANCE AND IMPACT OF THE STUDY: This study presents efficient methods that can be used directly on food products for the rapid quantification and tracing of virulence genes, regarding food safety assessment. Moreover, this is the first study to quantify these virulence factors using a specific Taqman q-PCR assay in food samples.

Development of a real-time PCR assay for direct detection and quantification of Bacillus sporothermodurans in ultra-high temperature milk.

In our study, a new and highly sensitive real-time PCR Taqman assay was developed for the direct and specific detection of Bacillus sporothermodurans in UHT milk. The target region was selected based on the 16S rRNA gene profiles of 11 B. sporothermodurans from GenBank. A standard curve was created using a reference strain of B. sporothermodurans, DSM 10599. A low limit of detection for B. sporothermodurans in UHT milk (10 cfu/mL) was obtained. Furthermore, a total of 110 UHT milk samples from several supermarkets were directly assessed to detect and quantify B. sporothermodurans using the real-time PCR Taqman developed. The B. sporothermodurans counts obtained were highly correlated with the microbial plate counts in the UHT milk samples. This is the first time that B. sporothermodurans has been quantified directly from UHT milk. This technique could be applicable as a routine tool for preventing the growth of these bacteria by allowing for the rapid screening of raw milk samples in dairy plants. As expected, the probability of bacterial growth in UHT milk packages increased with the B. sporothermodurans counts in the raw milk.

Human gut microbiota analysis of cystic fibrosis infants using metaproteomics.

We report a metaproteomic analysis of the gut microbiota of eight infants with cystic fibrosis, during the first year of life. This is the first study in this disease that uses metaproteomics to analyze stool samples from patients at such a young age.

Clinical and microbiological features of a cystic fibrosis patient chronically colonized with Pandoraea sputorum identified by combining 16S rRNA sequencing and matrix-assisted laser desorption ionization-time of flight mass spectrometry.

Clonal isolates identified as various nonfermentative Gram-negative bacilli over a 5-year period from sputum cultures of a 30-year-old cystic fibrosis patient were successfully reidentified as Pandoraea sputorum by combining 16S rRNA sequencing and matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS). Decreased lung function improved after 1 year of azithromycin and inhaled 7%-hypertonic saline treatment.

Capsaicin attenuates immunosuppression induced by chronic stress in BALB/C mice.

Although acute stress generally exerts positive effects on the immune system, chronic stress typically causes immunosuppression via the hypothalamic-pituitary-adrenal (HPA) axis. In this study, the effects of capsaicin (1.28 mg/kg intraperitoneally [i.p.] for 7 days) on immune parameters were evaluated under conditions of chronic stress. Capsaicin treatment significantly increased the immune response as evaluated by the delayed-type hypersensitivity (DTH) reaction to dinitrofluorobenzene (DNFB) and splenocyte proliferation assays- It also is able to rescue the splenocytes of the apoptosis induced by stress. The capsaicin treatment increased the production of Th1 cytokines and decreased the production of Th2 cytokines and TGF-ß1 in the plasma and culture supernatants of immunosuppressed mice, which is associated with the modulation of Th2 induced by stress cells. Moreover, the production of corticosterone significantly decreased in capsaicin-treated animals as compared to control groups. The capsaicin treatment further attenuated the immunosuppression induced by the corticosterone treatment (40 mg/kg i.p. for 7 days), albeit less potently, as exhibited in the DTH response. Intriguingly, the capsaicin treatment decreased the induction of IL-10, IL-4, and TGF-ß1 through high doses of corticosterone, indicating direct cellular immunomodulation. These results show, that capsaicin is able to modulate chronic stress-induced immunosuppression, mediating corticosterone released inhibition, but also, that capsaicin significantly modulates the pharmacological action of corticosterone in vivo.

The functional neuroanatomy of blood-injection-injury phobia: a comparison with spider phobics and healthy controls.

BACKGROUND: Most neuroimaging studies of specific phobia have investigated the animal subtype. The blood-injection-injury (BII) subtype is characterized by a unique biphasic psychophysiological response, which could suggest a distinct neural substrate, but direct comparisons between phobia types are lacking. METHOD: This study compared the neural responses during the presentation of phobia-specific stimuli in 12 BII phobics, 14 spider (SP) phobics and 14 healthy controls using functional magnetic resonance imaging (fMRI). RESULTS: Subjective ratings showed that the experimental paradigm produced the desired symptom-specific effects. As in many previous studies, when viewing spider-related stimuli, SP phobics showed increased activation in dorsal anterior cingulate and anterior insula, compared to BII phobics and healthy controls. However, when viewing images of blood-injection-injuries, participants with BII phobia mainly showed increased activation in the thalamus and visual/attention areas (occipito-temporo-parietal cortex), compared with the other two groups. The degree of provoked anxiety and disgust by phobia-relevant images was strongly associated with activation in several common regions across the two phobia groups (thalamus, cerebellum, occipito-temporal regions) but only correlated with activation in the dorsal anterior cingulate gyrus and the anterior insula in the SP phobics. CONCLUSIONS: These results suggest partially distinct neurobiological substrates of animal and BII phobias and support their current classification as two distinct subtypes in the DSM-IV-TR. Further research is needed to better understand the precise neurobiological mechanisms in BII phobia and particularly the fainting response.

Analysis of pharmacodynamic interaction of sevoflurane and propofol on Bispectral Index during general anaesthesia using a response surface model.

BACKGROUND: Propofol and sevoflurane act on the GABA(A) receptor, modulating the function of this receptor in an additive manner. The pharmacodynamic interaction of both drugs considering their effect on EEG activity analysed by the bispectral index (BIS) was identified as additive, but this has not been studied in a clinical setting. The objective of this study was to analyse the pharmacodynamic interaction of propofol and sevoflurane on BIS using a surface response model in patients undergoing general anaesthesia with i.v. induction and inhalation maintenance. METHODS: We performed a prospective study in 24 patients undergoing general anaesthesia with propofol induction and sevoflurane maintenance. Anaesthetic depth was measured with a BIS VISTA Bilateral monitor. Propofol biophase concentration was determined using a three-compartment pharmacokinetic model, and sevoflurane end-tidal concentration was measured continuously. The response surface model described by Minto and colleagues was used to analyse the interaction. Statistical analysis was performed with Excel 2002 and SPSS v11.0. RESULTS: The mean value of U(50)(theta) was 0.956 (sd 0.029) in the overall estimated data, and remained within the predefined range for all ratios of the drugs, fulfilling the criterion of additivity. The median of the weighted residuals between the actual BIS value and the BIS value predicted by the model was -5.926%. CONCLUSIONS: Under the study conditions, it was confirmed that sevoflurane and propofol have an additive effect on BIS, with no evidence suggesting the existence of a synergistic effect for the concentrations of both drugs typically used in clinical practice.

Monitoring sedation in the critically ill child.

Sedation is an essential part of the management of the critically ill child, and its monitoring must be individualised and continuous in order to adjust drug doses according to the clinical state. There is no ideal method for evaluating sedation in the critically ill child. Haemodynamic variables have not been found to be useful. Clinical scales are useful when sedation is moderate, but are limited by their subjective nature, the use of stimuli, and the impossibility of evaluating profoundly sedated patients or those receiving neuromuscular blocking drugs; in addition, many of these scales have not been evaluated in children. The COMFORT scale is the most appropriate, as it was designed and validated for critically ill children requiring mechanical ventilation. Electroencephalography-derived methods permit continuous monitoring, provide an early indication of changes in the level of sedation, and facilitate a rapid adjustment of medication. However, these methods were designed and validated for patients under anaesthesia and their results cannot be fully extrapolated to the critically ill patient; in addition, some of them have not been validated in small children and there is still little experience in critically ill children. The main indications for the use of these methods are in patients with deep sedation and/or neuromuscular blockade. The bispectral index is the most widely used method at the present time. Analysis and comparison of the efficacy of the different methods for evaluating sedation in the critically ill child is required.

Angiographic and clinical outcomes of drug-eluting versus bare metal stent deployment in the Occluded Artery Trial.

BACKGROUND: The majority of patients randomized to percutaneous coronary intervention (PCI) in the Occluded Artery Trial (OAT) and its angiographic substudy, the Total Occlusion Study of Canada 2 (TOSCA-2) were treated with bare metal stents (BMS). We aimed to determine if stenting of the target occlusion in OAT with drug-eluting stents (DES) was associated with more favorable angiographic results and clinical outcome when compared with treatment with BMS. METHODS: TOSCA-2 DES was a prospective nonrandomized substudy that provided 1-year angiographic comparison of late loss and reocclusion in 25 patients treated with DES and in 128 treated with BMS. In addition, all PCI-assigned patients enrolled from the time when DES were first utilized were similarly categorized (DES n = 77, and BMS n = 386) and compared using the 3-year cumulative OAT primary combined endpoint of death, myocardial infarction, or Class-IV heart failure, as well as angina. RESULTS: In-segment late loss was 0.14 +/- 0.45 mm for DES and 0.75 +/- 0.86 mm for BMS (P < 0.001). Corresponding binary restenosis rates were 13.0% and 44.3% (P = 0.005). Occlusion at 1 year was observed in 4.0 and 12.1%, respectively (P = 0.23). The 3-year cumulative primary event rate was 13.8% with DES and 12.5% with BMS (hazard ratio 1.08, 99% confidence intervals 0.44, 2.64; P = 0.83). Angina over time occurred less frequently in the DES group (P = 0.01). CONCLUSIONS: Although the reduction of late loss and trend to reduction in reocclusion with the use of DES for PCI of persistently occluded IRA 3-28 days post myocardial infarction did not translate into a signal for reduction in death, reinfarction, or Class IV heart failure, DES use was associated with less angina over time. Further follow-up is warranted.

Responsiveness to stimuli of bispectral index, middle latency auditory evoked potentials and clinical scales in critically ill children.

SUMMARY: We performed simultaneous recordings of Bispectral Index (BIS) and middle latency auditory evoked potentials. We also recorded two clinical scales, the Modified Ramsay scale and the COMFORT scale. Heart rate and blood pressure were measured once a day, for a maximum of 5 days, in 81 critically ill children. Changes with tactile, auditory, and painful stimuli were analysed. All the stimuli significantly increased the BIS value, the painful stimulus having the greatest effect. The painful stimulus was the only one that altered the middle latency auditory evoked potentials. Although the responses of the clinical scales to stimuli were statistically significant, they were of little clinical relevance. None of the stimuli used significantly altered the heart rate or blood pressure. We conclude that tactile, auditory and painful stimuli produced changes of little relevance in the clinical scales, BIS or middle latency auditory evoked potentials. We found the BIS was the most sensitive method and the painful stimulus had the greatest effect.

Perfil de consulta ambulatoria otorrinolaringológica en pandemia por COVID-19 / Profile of patients in otorhinolaryngological consultation in a COVID-19 pandemic

Introducción: La patología otorrinolaringológica (ORL) presenta alta incidencia en atención primaria, alcanzando hasta 49% de las consultas, sin embargo, la pandemia por SARS-CoV-2 repercutió de manera transversal en los servicios sanitarios, pudiendo haber influido en el perfil de consulta, por lo que se requiere un análisis para la elaboración de estrategias que permitan asegurar la atención sanitaria ante eventos de esta magnitud. Objetivo: Analizar el perfil de consulta libre por patología ORL ambulatoria en un centro médico privado en La Serena durante los años 2019 y 2020. Material y Método: Estudio analítico de corte transversal sobre consultas ambulatorias durante los años 2019 y 2020 realizadas en un centro privado de atención abierta en La Serena. Se estimaron frecuencias en números absolutos y proporciones, estimación de promedios y medianas. Resultados: Durante 2019 hubo un total de 11.932 consultas y en 2020 hubo 9.576. Se observó un predominio de sexo femenino en las consultas de 51% en ambos años. La mediana en 2019 fue de 35 años y en 2020 de 39 años. En 2020 las patologías con mayor consulta fueron nariz (44%), oído (37%) y faringolaringe (14%). Existió un aumento significativo en la consulta por patología cocleovestibular durante 2020. Conclusión: En 2020 hubo una disminución del 19,7% de las consultas dado, probablemente, a las restricciones de movilidad y aforos. Existió un aumento significativo en la proporción de consultas por patologías cocleovestibulares, como vértigo periférico, hipoacusia súbita y tinnitus, atribuido probablemente al estrés emocional generado por la pandemia.

Introduction: Otolaryngological (ENT) pathology presents high incidence in primary care reaching up to 49% of morbidity consultations, however, the pandemic by SARS-CoV-2 had a transversal impact on health services, and may have influenced the consultation profile, so an analysis is required for the development of strategies to ensure health care in the face of events of this magnitude. Aim: To analyze the profile of spontaneous consultation for outpatient ENT pathology in a medical center in La Serena city during 2019 and 2020. Material and Methods: Cross-sectional analytical study of outpatient consultations during the years 2019 and 2020 performed in a private open care center in the commune of La Serena. Frequencies were estimated in absolute numbers and proportions; averages and medians were estimated. Results: During 2019 there were a total of 11,932 consultations and in 2020 there were 9,576. There was a predominance of female sex in the consultations of 51%. The median in 2019 was 35 years and in 2020 it was 39 years. In 2020, the pathologies with the highest number of consultations were nose (44%), ear (37%) and laryngopharynx (14%). There was an increase in consultation for cochleovestibular pathology during 2020. Conclusion: In 2020 there was a 19.7% of consultation decrease probably due to mobility and capacity restrictions. There was a significant increase in the proportion of consultations for cochleovestibular pathologies such as peripheral vertigo, hearing loss and tinnitus, probably attributed to the emotional stress generated by the pandemic.

Phytanic acid consumption and human health, risks, benefits and future trends: A review.

Phytanic acid is a methyl-branched fatty acid present in the human diet, derived from the enzymatic degradation of phytol and subsequently oxidized by the rumenal microbiota and certain marine organisms. Consequently, phytanic acid is carried into the human body by means of food ingestion, mostly via red meat, dairy products and fatty marine foods. This fatty acid accumulates in people with some peroxisomal disorders and is traditionally related to neurological damage. However, some benefits derived from phytanic acid intake have also been described, such as the prevention of metabolic syndrome or type 2 diabetes. The aim of this work was to conduct an overview of the literature on the phytanic acid content of foods, management of the phytanic content during food production and biochemical mechanisms of phytanic acid metabolism, as well as to assess the evidence for the health benefits and risks of phytanic acid consumption in human health.

Biofilm formation, phenotypic production of cellulose and gene expression in Salmonella enterica decrease under anaerobic conditions.

Salmonella enterica subsp. enterica is one of the main food-borne pathogens. This microorganism combines an aerobic life outside the host with an anaerobic life within the host. One of the main concerns related to S. enterica is biofilm formation and cellulose production. In this study, biofilm formation, morphotype, cellulose production and transcription of biofilm and quorum sensing-related genes of 11 S. enterica strains were tested under three different conditions: aerobiosis, microaerobiosis, and anaerobiosis. The results showed an influence of oxygen levels on biofilm production. Biofilm formation was significantly higher (P<0.05) in aerobiosis than in microaerobiosis and anaerobiosis. Cellulose production and RDAR (red, dry, and rough) were expressed only in aerobiosis. In microaerobiosis, the strains expressed the SAW (smooth and white) morphotype, while in anaerobiosis the colonies appeared small and red. The expression of genes involved in cellulose synthesis (csgD and adrA) and quorum sensing (sdiA and luxS) was reduced in microaerobiosis and anaerobiosis in all S. enterica strains tested. This gene expression levels were less reduced in S. Typhimurium and S. Enteritidis compared to the tested serotypes. There was a relationship between the expression of biofilm and quorum sensing-related genes. Thus, the results from this study indicate that biofilm formation and cellulose production are highly influenced by atmospheric conditions. This must be taken into account as contamination with these bacteria can occur during food processing under vacuum or modified atmospheres.

Prevalence, molecular characterization and antimicrobial resistance of Salmonella serovars isolated from northwestern Spanish broiler flocks (2011-2015).

The present study investigated the prevalence, antimicrobial resistance to twenty antibiotics, and class 1 integron and virulence genes of Salmonella isolated from poultry houses of broilers in northwestern Spain between 2011 and 2015. Strains were classified to the serotype level using the Kauffman-White typing scheme and subtyping with enterobacterial repetitive intergenic consensus PCR. The prevalence of Salmonella spp. was 1.02%. Sixteen different serotypes were found, with S. typhimurium and S. arizonae 48:z4, z23:- being the most prevalent. A total of 59.70% of strains were resistant to at least one, and 19.70% were resistant to multiple drugs. All Salmonella spp. were susceptible to cefotaxime, ciprofloxacin, gentamicin, kanamycin, levofloxacin, neomycin, and trimethoprim. The highest level of resistance was to sulfamethoxazole (40.29%), doxycycline (17.91%), and nalidixic acid (17.91%). None of the isolates carried class 1 integron and only isolates of S. enterica subspecies enterica were positive for all virulence factors tested, whereas S. arizonae lacked genes related to replication and invasion in nonphagocytic cells. This study demonstrates that the prevalence and antimicrobial resistance of Salmonella spp. in poultry houses of broilers of northwestern Spain is low compared with those found in other studies and in other steps of the food chain.

Biofilm Formation and Morphotypes of Salmonella enterica subsp.arizonae Differs from Those of Other Salmonella enterica Subspecies in Isolates from Poultry Houses.

Salmonella serovars are responsible for foodborne diseases around the world. The ability to form biofilms allows microorganisms to survive in the environment. In this study, 73 Salmonella strains, belonging to four different subspecies, were isolated from poultry houses and foodstuffs and tested. Biofilm formation was measured at four different temperatures and two nutrient concentrations. Morphotypes and cellulose production were evaluated at three different temperatures. The presence of several genes related to biofilm production was also examined. All strains and subspecies of Salmonella had the ability to form biofilms, and 46.57% of strains produced biofilms under all conditions tested. Biofilm formation was strain dependent and varied according to the conditions. This is the first study to analyze biofilm formation in a wide number of Salmonella enterica subsp. arizonae strains, and no direct relationship between the high prevalence of Salmonella enterica subsp. arizonae strains and their ability to form biofilm was established. Morphotypes and cellulose production varied as the temperature changed, with 20°C being the optimum temperature for expression of the red, dry, and rough morphotype and cellulose. Salmonella enterica subsp. arizonae, whose morphotype is poorly studied, only showed a smooth and white morphotype and lacked the csgD and gcpA genes that are implicated in biofilm production. Thus, Salmonella biofilm formation under different environmental conditions is a public health problem because it can survive and advance through the food chain to reach the consumer.

Sex Hormones Promote Opposite Effects on ACE and ACE2 Activity, Hypertrophy and Cardiac Contractility in Spontaneously Hypertensive Rats.

BACKGROUND: There is growing interest in sex differences and RAS components. However, whether gender influences cardiac angiotensin I-converting enzyme (ACE) and angiotensin-converting enzyme 2 (ACE2) activity is still unknown. In the present work, we determined the relationship between ACE and ACE2 activity, left ventricular function and gender in spontaneously hypertensive rats (SHRs). METHODOLOGY/PRINCIPAL FINDINGS: Twelve-week-old female (F) and male (M) SHRs were divided into 2 experimental groups (n = 7 in each group): sham (S) and gonadectomized (G). Fifty days after gonadectomy, we measured positive and negative first derivatives (dP/dt maximum left ventricle (LV) and dP/dt minimum LV, respectively), hypertrophy (morphometric analysis) and ACE and ACE2 catalytic activity (fluorimetrically). Expression of calcium handling proteins was measured by western blot. Male rats exhibited higher cardiac ACE and ACE2 activity as well as hypertrophy compared to female rats. Orchiectomy decreased the activity of these enzymes and hypertrophy, while ovariectomy increased hypertrophy and ACE2, but did not change ACE activity. For cardiac function, the male sham group had a lower +dP/dt than the female sham group. After gonadectomy, the +dP/dt increased in males and reduced in females. The male sham group had a lower -dP/dt than the female group. After gonadectomy, the -dP/dt increased in the male and decreased in the female groups when compared to the sham group. No difference was observed among the groups in SERCA2a protein expression. Gonadectomy increased protein expression of PLB (phospholamban) and the PLB to SERCA2a ratio in female rats, but did not change in male rats. CONCLUSION: Ovariectomy leads to increased cardiac hypertrophy, ACE2 activity, PLB expression and PLB to SERCA2a ratio, and worsening of hemodynamic variables, whereas in males the removal of testosterone has the opposite effects on RAS components.

Mammographic parenchymal patterns and risk of breast cancer in postmenopausal women.

A case-control study was conducted to assess whether certain "high-risk" mammographic parenchymal patterns are associated with the increased occurrence of breast cancer in postmenopausal women. Patients in the case group included 105 women with histologically confirmed breast cancer; subjects in the control group included 104 women with fibrocystic breast disease and 103 women with clinically normal breasts. All mammographic results were evaluated "blindly" by a radiologist who classified the breast parenchyma into "high-risk" and "low-risk" categories according to the criteria proposed by Wolfe. These data showed a similar proportion of allegedly "high-risk" breast parenchymal patterns among patients in all three groups. The finding that breast parenchymal patterns are not associated with an increased risk of breast cancer in women 50 years of age or older is consistent with the results of earlier studies in which the association is present only in younger, premenopausal women, and is absent in older, predominantly postmenopausal women. Consequently, it is concluded that these parenchymal patterns should not be used to select postmenopausal women for breast cancer screening programs, or to guide the evaluation of postmenopausal women with breast lumps or symptoms.

Induction of puberty with human chorionic gonadotropin and follicle-stimulating hormone in adolescent males with hypogonadotropic hypogonadism.

OBJECTIVE: To evaluate the clinical and hormonal responses of adolescent males with hypogonadotropic hypogonadism (HH) in response to gonadotropin replacement with the use of long-term combined hCG and FSH therapy. DESIGN: Prospective clinical study. SETTING: Clinical pediatric department providing tertiary care. PATIENT(S): Seven prepubertal males with isolated HH with a mean (+/-SD) age of 15.44+/-1.97 years and seven prepubertal males with panhypopituitarism-associated HH with a mean (+/-SD) age of 18.1+/-3.24 years were studied. INTERVENTION(S): Human chorionic gonadotropin (1,000-1,500 IU IM) and FSH (75-100 IU SC) were administered every alternate day of the week until the total induction of puberty and spermatogenesis was achieved. MAIN OUTCOME MEASURE(S): Serum testosterone levels, testicular volume, penis length, and sperm count were evaluated after the administration of hCG and FSH. RESULT(S): All patients achieved normal sexual maturation and normal or nearly normal adult male levels of testosterone. The increase in testicular size was significant in both groups. Positive sperm production was assessed in four of five patients with isolated HH and in three of three patients with panhypopituitarism-associated HH. CONCLUSION(S): Long-term combined hCG and FSH therapy is effective in inducing puberty, increasing testicular volume, and stimulating spermatogenesis in adolescent males with isolated HH and panhypopituitarism-associated HH.