SPONTANEOUS CONCEPTION AND TERM DELIVERY IN A WOMAN WITH UNCONTROLLED ACROMEGALY AND HYPOGONADOTROPIC HYPOGONADISM.

BACKGROUND: Patients with acromegaly (caused by growth-hormone-secreting pituitary adenomas) are at increased risk of hypopituitarism, in particular hypogonadotropic hypogonadism, before and after multimodal therapy. In affected women of reproductive age, fertility is impaired and complex fertility treatments are needed to achieve conception. CASE PRESENTATION: We present the case of a young woman with acromegaly caused by a GH-secreting macroadenoma with suprasellar and bilateral cavernous sinus extension; hypogonadotropic hypogonadism and secondary hypothyroidism were present from the initial evaluation. Neurosurgical intervention was repeatedly recommended but the patient refused it initially; also she was non-compliant to the medical treatment of acromegaly. Transsphenoidal tumor debulking with adjuvant gamma-knife radiotherapy was eventually performed. Following treatment persistent active acromegaly and hypogonadotropic hypogonadism were diagnosed. Under chronic estroprogestative replacement therapy, the patient conceived and delivered a full-term healthy newborn without any complications. Possible mechanisms are discussed. CONCLUSIONS: Secondary hypogonadotropic hypogonadism in pituitary patients, even when considered permanent (after surgery and radiotherapy), can exceptionally allow spontaneous conception and normal course of pregnancy.

Quantifying subtle changes in cardiovascular mechanics in acromegaly: a Doppler myocardial imaging study.

AIM OF THE STUDY: To describe morphological and functional cardiovascular changes in acromegaly (ACM) patients, as well as to investigate the ability of Doppler-based myocardial deformation imaging (DMI) to characterize subtle dysfunction in ACM. METHODS: 69 patients (pts) with ACM (mean age 47 ± 10 years, 27 men) and 31 controls (mean age 43 ± 16 years, matched for age and gender) were recruited. Standard echocardiography and DMI data were obtained for all patients. Peak systolic longitudinal strain values (S) were determined for the left and right ventricles. Radial S was measured at the level of the mid inferolateral segment. Using a high-resolution echo-tracking system, the main indices of arterial stiffness were measured. RESULTS: Of the ACM subjects, 57 had active disease (group A), and 12 controlled ACM (group B). All pts with ACM presented structural changes: a higher LV indexed mass (112 ± 36, 118 ± 23 vs 74 ± 18 g/m(2), p < 0.001) and a higher relative wall thickness (0.45 ± 0.09, 0.50 ± 0.07 vs 0.40 ± 0.07, p = 0.003) compared to controls. Also, ACM pts had functional changes: reduced LV ejection fraction (57 ± 5, 55 ± 5 vs 64 ± 4%, p < 0.001) and altered diastolic function (E/A 1.0 ± 0.4, 1.1 ± 0.1 vs 1.3 ± 0.3, p = 0.005) compared to controls. Both longitudinal and radial LV S values were lower in ACM compared to controls: -16.5 ± 3.5, -16.8 ± 4.3 vs -21.5 ± 3.8%, p < 0.001 for longitudinal and 38.3 ± 12.3, 35.6 ± 11.8 vs 52.2 ± 11.7%, p = 0.002 for radial strain. CONCLUSIONS: ACM pts present LV concentric hypertrophy and LV systolic and diastolic dysfunction, even in controlled disease. Altered global LV systolic function appears to be due both to longitudinal and radial dysfunction.

Investigations of the transfructosylation reaction by fructosyltransferase from B. subtilis NCIMB 11871 for the synthesis of the sucrose analogue galactosyl-fructoside.

The exo-fructosyltransferase produced from B. subtilis NCIMB 11871 strain transfers the fructose moiety from donor alpha12 linked saccharides such as sucrose, raffinose and stachyose to the acceptor d-galactose, leading to the sucrose analogue, galactosyl-fructoside. Here, we report detailed kinetic studies. The enzyme showed a remarkably high optimal temperature at 50 degrees C and was effectively immobilised on Eupergit C 250 L and Trisopor-Amino. This is also the first report about the equilibrium of the transfructosylation reaction, its activation energy determination, the structure of the product and its preparative scale isolation.

Renal mechanisms in erythropoiesis regulation.

The kidneys, which a high content of renal erythropoietic profactor, represent an important organ in the formation of erythropoietin in hypoxia. There is, however, an extrarenal mechanism, too, for its formation. The mechanism of erythropoietin secretion could be a central nervous action of hypoxia and a direct cellular one. In the first situation, moderate hypoxia acts upon the nervous centers, whose connexions with the effector cells are made by the beta-adrenergic sympathetic nerves, determining the release in certain kidney cells and in structures outside this organ, of the proerythropoietic factor of lysosomal nature. In the second situation, long-term intense hypoxia would exert its action directly on the cells, releasing the profactor participating in the formation of erythropoietin from the kidney lysosomes or those of other organs.

Nervous control of the phagocytic system.

The complexity of the immune response, including numerous functional changes (thermoregulatory, circulatory, respiratory, metabolic etc.) led us (Benetato, Baciu & Vlad, 1945) to hypothesize nervous hypothalamic control of this important homeostatic response. This work synthesizes the experimental results obtained in the last four decades by us on the nervous control of the phagocytic system. Unfortunately at that time those findings were uninteresting, immunity being satisfactorily explained as a purely cellular process. The phagocytic response of the mobile (neutrophils and monocyte) system to i.v. administration of bacteria, may be reproduced by direct electrical stimulation of the hypothalamic tuberomammillary area, and by electroshock. It is blocked after sectioning the spinal cord, or after barbiturates. Using the original "isolated head" technique, applied to dogs, it was demonstrated that the injection of Salmonella typhi murium suspension in the head circulation, may activate phagocytosis in the body, isolated humorally, only through nervous effector ways, which are conserved. The current explanation is that the bacteria in the common circulation of head activates macrophages, producing the endogenous pirogen factor (II 1), which through area hypothalamica anterior acts on the tuberomammillary zone, triggering the phagocytic response by neural effector pathways. Phagocytosis stimulating substances appeared in blood, some as a result of activation of protease systems of the blood (coagulation, fibrinolysis, kininforming and complement). Epinephrine activates peripherally the fibrinolytic and kinin forming systems. Neuroimmunomodulatory effects were also demonstrated for the RES.

The role of nervous mechanisms in the immune response.

This review presents the results of experimental researches performed in the last decades by Cluj-Napoca physiologists, concerning the role of hypothalamic nervous centers in the triggering of the nonspecific (phagocytic reaction) and specific (primary and secondary) immune response. The following methods aiming to explore the involvement of the hypothalamic vegetative nervous centers have been applied: section of the spinal cord, somatoencephalic humoral isolation with preservation of spinal cord, stimulation or lesions under stereotaxic control of some hypothalamic areas, conditioned reflexes, electroconvulsant shocks. The results show that nervous centers from the tuberal area and from the posterior hypothalamus are involved in the regulation and integration of the immune response considered as a homeostatic function, in connexion with a preoptic, anterior and lateral hypothalamic area, with a receptive function to antigens and their endogenous products. The activation of phagocytosis (phagocytic response) can be elicited in dogs by electrical stimulation of the tuberal area and inhibited by section of the spinal cord, or by barbiturates. The specific immune response is moderately neuromodulated for antigens, as heterospecific red cells and more intensely for Salmonella and especially for the influenza virus. These results could allow an integration of other analytical data of cellular and molecular biology of immunity wider functional concept.

[Contribution to the study of stress (author's transl)]. / Beiträge zum Studium des Stresses.

The research activity of the physiological laboratories (Medical and Hygienic Institute, Cluj-Napoca, Roumania) in the area of stress studies is described from three aspects: a) Methods of stress provocation and assessment; b) The effects of hormones, especially of anterior pituitary, on the adaptation to physical load; c) Nervous and endocrine factors of stress (physical exertion, fatigue, high pressure, anoxia).

A metaanalysis of certain erythropoietin characteristics established before recombinant EPO was obtained.

Beginning with 1975, our group has performed some studies using an erythropoietin (EPO ) extract prepared according to an original technique from sera of anemic rabbits. Our results have contributed to the understanding of the glycoproteinic nature of this extract as well as of some of its biological features. These results were confirmed only after 1985, when recombinant EPO was obtained. The aim of this study is to emphasize some of our priorities, controversial at that time. We have shown the radioprotective effect of an EPO extract, in correlation with red cell proliferation and with an increased rate of nucleic acid metabolism and bone marrow blood flow. Consequently, we proposed the investigation of the bone marrow function using EPO. Our results are correlated with recent data obtained with recombinant EPO. They refer to the ability of EPO to prevent apoptosis, its antioxidant effects, and its ability to modulate the sympathoadrenal response to hypoxia.

Integrative cybernetic model of oxygen homeostasis.

The paper presents an integrative cybernetic model of the complex physiological process generically called "oxygen homeostasis". The model has been designed in such a manner as to enable a mathematical approach, in quantitative terms, to the various functions involved in the generation and uninterrupted functioning of the mentioned process. Those functions are: pulmonary and tissular respiratory function, blood circulation, transport, erythropoiesis, as well as other functions involved in the blood pH regulation at renal and hepatic level (the resorption of Na+ ions from the glomerular filtrate and the ammonio-genetic functions of the kidneys and, respectively, the glyco-genetic, ureo-genetic and metabolization functions of the liver). All of these functions have been assumed as regulated and controlled within a unitary cybernetic system, interpreted as an open, dynamic system. That system consists of seven multicompartment subsystems which are open and interconnected by means of exchange relations, biophysical and biochemical processes involved in the performance of the respective function. Special attention was given to the mathematical modelling of the exchange processes going on in the erythrocytic membrane as part of the transport function of the circulating blood. The mathematical description of the entire homeostatic system operation was done by means of a set of differential and algebraic equations. Some of those equations (those describing the continuity of several chemical species in a compartment of the circulatory system and those characterizing the state of thermodynamic balance of the blood subsystem within the respective compartment) enable one to determine the value of the state parameters at a given moment, as a function of the external and internal conditions and as a function of the intensity of processes specific to the subsystems considered. There are other equations (equations of regulation and control devices) that enable one to determine the variations in intensity of the processes mentioned that are necessary in order to restore the system to its "normal" state, in case of possible deregulations caused by disturbing factors.

The role of hypothalamic centres in the immune specific response.

Four groups of rats were bilaterally lesioned in the anterior, lateral, tuberal and mammillary areas of hypothalamus. Seven days later these rats, as well as controls, were immunized concomitantly with three antigens: Salmonella enteritidis, sheep red blood cells and Myxovirus influenzae A (H3N2). The primary and the secondary response were tested. The bacterial and erythrocytic antigens, with marked immunogenetic capacity, produced immune responses, which were not significantly influenced by hypothalamic lesions. The immune primary and secondary response to influenza A virus is wholly suppressed in animals with lesions in tuberal and mammillary areas of the hypothalamus. It is reduced in animals with lesions in lateral and anterior regions, as compared with controls. The secondary response is greater and more rapid in controls. It is reduced in animals with lesions in anterior and lateral hypothalamus and suppressed in those with lesions at tuberal and mammillary level. It therefore seems that the modulatory intervention of the hypothalamus in the immune process depends on the antigen, on the antigen, on the intensity of its direct effects on the immuno-competent and accessory cells and on the condition of the hypothalamic centers.

Attempts to identify the active factor of reticulin-M by high voltage electrophoresis and by acetone precipitation.

The reticulin-M forte (R forte), an antianaphylactic peptide, extracted from organs rich in RES, previously stimulated with India ink, was analysed after acetone precipitation by paper high voltage electrophoresis. Finally the biological activity remains concentrated in the second, arbitrary group of basic peptides, fractions 1 and 3.

Hypothalamic mechanisms of immunity.

The present article considers a synthetical analysis of the results reported by our laboratory in the last twenty years in the field of neuroimmunomodulation. The studies we discuss here continue a previous research activity, a synthesis of which has also been published in this journal (Baciu, 1988). In that paper, we reported data concerning the role of the hypothalamic tubero-mammillary area in triggering of the phagocytic and of the secondary immune specific response. Here, we present an analysis of experimental facts gathered after 1988, and also of some prior to that date, which were not included in the above-mentioned review. They regard localizations, attained with stereotactical methods, of hypothalamic areas involved in maintenance of basal phagocytosis and of its circadian rhythm, of the phagocytic and of the primary and secondary specific response. We attempted to re-analyze these data in an integrative view, and accomplish a coherent image of the hypothalamic mechanisms of the nonspecific and specific immune response. The conclusion we draw is that the nervous system may exert its modulatory action upon the immune response in several ways: i) subsequent to a direct hypothalamic stimulation (electrical or through bacteria or bacterial products) or to a cortico-hypothalamic stimulation; ii) depending on the nature, intensity, duration, and frequency of the appropriate stimulus, it may either enhance the immune response, via neural and humoral pathways, or depress it; iii) via the hypothalamus-pituitary-adrenal axis. Nervous triggering and enhancement of the immune response are essential, their occurrence in the initial stages ensuring its favorable course. The finding that repeated electroconvulsant shocks, employed for hypothalamus stimulation in dogs of different breed, age, weight, and individual history, are followed by extremely variable changes of the phagocytic activity raises the question on the individuality of the immune response.

Effects of electrolytic bilateral symmetric lesions of the arcuate nucleus on the phagocytic activity and on the phagocytic response in rats.

Previous researches of Cluj-Napoca laboratories of Physiology (Benetato, Baciu et al., 1945, 1946, 1947) demonstrated that direct electrical stimulation of the tubero-mammillary area in dogs increases, in the following hours, the blood polymorphonuclears phagocytic activity. By contrast, electrical damage of the same region produces a depression of the basal phagocytic activity and a blocking of the phagocytic response (Baciu et al., 1958, 1988). In the present research we assumed there is a stimulating effect of the arcuate nucleus, located in this area, on the phagocytic activity of blood neutrophils. We used an anodal current to stereotaxically induce lesion of the arcuate nucleus in six rats. A control group of six animals was used. Five days later, phagocytic response was induced with a Gram negative bacterial extract given i.v. The results demonstrated a decrease of the phagocytic activity from 164.31 +/- 17 bacteria engulfed by 100 neutrophils in controls, to 138 +/- 12.8 in the lesioned group p < 0.05. Phagocytic response after five hours appears depressed in the lesioned group (138 +/- 12.8 to 156.25 +/- 13.3, p < 0.05). Similar results were obtained after 24 hours. In control animals the response is very significant after 5 and 24 hrs., respectively, (p < 0.001). In conclusion, the arcuate nucleus is moderately involved in sustaining the basal phagocytic activity of blood neutrophils. It has an important role in phagocytic response.

The sympatho-adrenal response and erythropoietin production in adaptation to hypoxia.

The research activity upon erythropoiesis regulation carried out by the team in the Physiology Department and in the Institute of Medical Research of the Romanian Academy in Cluj-Napoca developed continuously after 1950. Our studies contributed to the isolation, identification and characterization of erythropoietin (Epo) and also to a better understanding of the nervous adaptation mechanisms to hypoxia. At present, it is well known that hypoxia acts upon erythropoiesis through Epo production. Direct central nervous stimulation through hypoxia induces, via a neuro-humoral mechanism, a sympatho-adrenal response and release of Epo. Adaptive polyglobulia as a response to hypoxia increases the capacity of oxygen binding and transport. In this paper we attempted to identify the role of the sympathetic nervous system in adaptation to hypoxia correlated with Epo secretion. Experiments were carried out in three groups of rats, respectively, with cervical, thoracic, and lumbar (without celiac) sympathectomy. The sympathectomized animals were submitted to hypobaric or to hemorrhagic hypoxia, in parallel with control groups. Erythrocytic parameters (red blood cells, reticulocytes, hematocrit, and haemoglobin) were repeatedly assayed during the following 2-4 weeks. The results showed that animals with cervical sympathectomy adapt in a deficient manner to hypoxia; lacking the adaptive sino-carotid reflexes, adaptation occurs through increased Epo secretion, animals with cervical sympathectomy having higher counts of reticulocytes and of red blood cells at the end of experiment than intact animals. Thoracic sympathectomy has little influence upon the erythrocytic response, as the largest part of the respiratory and circulatory sympathetic reactions occur via the cervical sympathetic nerve. Lumbar sympathectomy without removal of the celiac ganglion does not decrease the erythrocytic response as expected; on the contrary, the erythrocytic response is increased as compared to controls.

Neutrophil adherence in rats submitted to light-dark alternance and to constant light.

A good amount of experimental data suggests the existence of a circadian control of the inflammatory process. It was shown that migration of neutrophils in chemotactic gradient, ingestion of particles, vascular permeability etc. are rhythmical circadian functions. Melatonin, the pineal hormone secreted during the darkness phase, has been shown to be involved in the control of inflammation. The present study aims to assess whether neutrophil adherence to nylon fibers exhibits circadian rhythmicity and also if its amplitude and/or chronostructure are altered in a constant light regimen. Wistar rats were submitted to either an artificial light-darkness 12/12 regimen (LD) or to constant light (LL), for 15 days. Adherence of the neutrophils in whole blood was assessed at 10:00, 16:00, 22:00, and 04:00 hrs. In LD. neutrophil adherence appears to be a rhythmic, biphasic function, with the acrophase at 10:00, a secondary peak at 22:00 and trough values in the late dark hours. Constant light induces a depression of the adherence ability by about 10%, except for the 04:00 hrs point, where the value in LL is higher than in LD. The fact that adherence and phagocytic activity do not oscillate in phase suggests that the physiological relevance of neutrophil adherence goes beyond that of a first stage of the phagocytic process.

Circadian phagocytic activity in rats under light-dark and constant light regimens.

The phagocytic function was proved to be a periodic, circadian process. Its acrophase appears to be differently timed in species with different activity type, occurring in the evening in diurnal species and at night in nocturnal ones. The main pineal hormone melatonin, whose secretion occurs strictly at dark, has been shown to play a role in the control of inflammation and to exert a certain stimulatory effect upon phagocytosis in vitro. The aim of the present study was to assess whether the phagocytic activity of neutrophils in the blood of rats exhibits a circadian rhythmicity similar to that of other nocturnal rodents (mice) and also if a constant light regimen alters its amplitude and/or chronostructure. Wistar rats were submitted to either an artificial light-dark 12/12 regimen (LD) or to constant light (LL), for 15 days. In vitro phagocytosis of the neutrophils in whole blood against E.coli was assessed at 10:00, 16:00, 22:00, and 04:00 hours. In LD, phagocytosis appears to be a rhythmical function, with statistically significant differences between the highest value at 04:00 hrs and the lowest at 10:00 hrs. Constant light induces a 30% depression of the phagocytic ability throughout the whole 24 hours cycle, without altering its oscillations. The darkness period appears to play the role of a synchronizer; in its absence the rhythm tends to free-run. It may be stated that rhythmical melatonin secretion is responsible only for maintenance of the phagocytic level, probably via the anterior hypothalamic area and thymus, while it cannot account directly for the nocturnal increase of phagocytosis.

The effects of electroconvulsant shocks on phagocytic activity and on phagocytic response.

The influence of a single or several subsequent convulsant electroshocks at different time laps (2-4 day), over a month, on the phagocytic activity was studied on seven dogs. The electroconvulsant shock was performed with bitemporal electrodes, at a liminal electric power. Phagocytosis was studied in vitro with amidon particles in whole blood, incubated 1h at 37 degrees C. After 4 hours the phagocytosis increases in all animals and remains higher for 12 days. Later on the repeated shocks produce very different changes of the phagocytic activity, depending, not only on the stressor agent, but also on the animal particular reactivity, conditioned genetically and by its individual history.