RESUMEN
PURPOSE: Peptide receptor radionuclide therapy (PRRT) using [177Lu]Lu-DOTATATE has been shown to effectively prolong progression free survival in grade 1-2 gastroenteropancreatic neuroendocrine tumours (GEP-NET), but is less efficacious in patients with extensive liver metastases. The aim was to investigate whether tumour uptake in liver metastases can be enhanced by intra-arterial administration of [177Lu]Lu-DOTATATE into the hepatic artery, in order to improve tumour response without increasing toxicity. METHODS: Twenty-seven patients with grade 1-2 GEP-NET, and bi-lobar liver metastases were randomized to receive intra-arterial PRRT in the left or right liver lobe for four consecutive cycles. The contralateral liver lobe and extrahepatic disease were treated via a "second-pass" effect and the contralateral lobe was used as the control lobe. Up to three metastases (> 3 cm) per liver lobe were identified as target lesions at baseline on contrast-enhanced CT. The primary endpoint was the tumour-to-non-tumour (T/N) uptake ratio on the 24 h post-treatment [177Lu]Lu-SPECT/CT after the first cycle. This was calculated for each target lesion in both lobes using the mean uptake. T/N ratios in both lobes were compared using paired-samples t-test. FINDINGS: After the first cycle, a non-significant difference in T/N uptake ratio was observed: T/NIA = 17·4 vs. T/Ncontrol = 16·2 (p = 0·299). The mean increase in T/N was 17% (1·17; 95% CI [1·00; 1·37]). Of all patients, 67% (18/27) showed any increase in T/N ratio after the first cycle. CONCLUSION: Intra-arterial [177Lu]Lu-DOTATATE is safe, but does not lead to a clinically significant increase in tumour uptake.
Asunto(s)
Neoplasias Hepáticas , Tumores Neuroendocrinos , Compuestos Organometálicos , Humanos , Octreótido/efectos adversos , Compuestos Organometálicos/uso terapéutico , Neoplasias Hepáticas/radioterapia , Neoplasias Hepáticas/secundario , Tumores Neuroendocrinos/radioterapia , Tumores Neuroendocrinos/patología , RadioisótoposRESUMEN
Both somatostatin (SST) and somatostatin receptors (SSTRs) are proteins with important functions in both physiological tissue and in tumors, particularly in neuroendocrine tumors (NETs). NETs are frequently characterized by high SSTRs expression levels. SST analogues (SSAs) that bind and activate SSTR have anti-proliferative and anti-secretory activity, thereby reducing both the growth as well as the hormonal symptoms of NETs. Moreover, the high expression levels of SSTR type-2 (SSTR2) in NETs is a powerful target for therapy with radiolabeled SSAs. Due to the important role of both SST and SSTRs, it is of great importance to elucidate the mechanisms involved in regulating their expression in NETs, as well as in other types of tumors. The field of epigenetics recently gained interest in NET research, highlighting the importance of this process in regulating the expression of gene and protein expression. In this review we will discuss the role of the epigenetic machinery in controlling the expression of both SSTRs and the neuropeptide SST. Particular attention will be given to the epigenetic regulation of these proteins in NETs, whereas the involvement of the epigenetic machinery in other types of cancer will be discussed as well. In addition, we will discuss the possibility to target enzymes involved in the epigenetic machinery to modify the expression of the SST-system, thereby possibly improving therapeutic options.
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Tumores Neuroendocrinos , Receptores de Somatostatina , Epigénesis Genética , Humanos , Tumores Neuroendocrinos/genética , Receptores de Somatostatina/genética , Receptores de Somatostatina/metabolismo , SomatostatinaRESUMEN
PURPOSE OF REVIEW: Peptide receptor radionuclide therapy (PRRT) with [177Lu-DOTA0,Tyr3] octreotate is an effective and safe second- or third-line treatment option for patients with low-grade advanced gastroenteropancreatic (GEP) neuroendocrine neoplasms (NEN). In this review, we will focus on possible extensions of the current use of PRRT and on new approaches which could further improve its treatment efficacy and safety. RECENT FINDINGS: Promising results were published regarding PRRT in other NENs, including lung NENs or high-grade NENs, and applying PRRT as neoadjuvant or salvage therapy. Furthermore, a diversity of strategic approaches, including dosimetry, somatostatin receptor antagonists, somatostatin receptor upregulation, radiosensitization, different radionuclides, albumin binding, alternative renal protection, and liver-directed therapy in combination with PRRT, have the potential to improve the outcome of PRRT. Also, novel biomarkers are presented that could predict response to PRRT. Multiple preclinical and early clinical studies have shown encouraging potential to advance the clinical outcome of PRRT in NEN patients. However, at this moment, most of these strategies have not yet reached the clinical setting of randomized phase III trials.
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Neoplasias Intestinales/radioterapia , Tumores Neuroendocrinos/radioterapia , Neoplasias Pancreáticas/radioterapia , Radioisótopos/uso terapéutico , Neoplasias Gástricas/radioterapia , Humanos , Terapia Neoadyuvante , Octreótido/análogos & derivados , Octreótido/uso terapéutico , Compuestos Organometálicos/uso terapéutico , Receptores de Péptidos , Receptores de Somatostatina/antagonistas & inhibidores , Terapia Recuperativa , Somatostatina/análogos & derivadosRESUMEN
PURPOSE: Therapy with [177Lu-DOTA,Tyr3]octreotate is effective in patients with grade I/II metastasized and/or inoperable bronchial neuroendocrine tumour (NET) or gastroenteropancreatic NET (GEP-NET). In this study, we investigated the efficacy and safety of salvage treatment with [177Lu-DOTA,Tyr3]octreotate. METHODS: Patients with progressive bronchial NET or GEP-NET were selected for re-(re)treatment if they had benefited from initial peptide receptor radionuclide therapy (I-PRRT) with a minimal progression-free survival (PFS) of 18 months. Patients received an additional cumulative dose of 14.8 GBq of [177Lu-DOTA,Tyr3]octreotate over two cycles per retreatment with PRRT (R-PRRT) or re-retreatment with PRRT (RR-PRRT). RESULTS: The safety and efficacy analyses included 181 patients and 168 patients, respectively, with bronchial NET or GEP-NET. Overall median follow-up was 88.6 months (95% CI 79.0-98.2). Median cumulative doses were 44.7 GBq (range 26.3-46.4 GBq) during R-PRRT (168 patients) and 59.7 GBq (range 55.2-≤60.5 GBq) during RR-PRRT (13 patients). Objective response and stable disease, as best response, were observed in 26 patients (15.5%) and 100 patients (59.5%) following R-PRRT, and in 5 patients (38.5%) and 7 patients (53.8%) following RR-PRRT, respectively. Median PFS was 14.6 months (95% CI 12.4-16.9) following R-PRRT and 14.2 months (95% CI 9.8-18.5) following RR-PRRT. Combined overall survival (OS) after I-PRRT plus R-PRRT and RR-PRRT was 80.8 months (95% CI 66.0-95.6). Grade III/IV bone marrow toxicity occurred in 6.6% and 7.7% of patients after R-PRRT and RR-PRRT, respectively. Salvage therapy resulted in a significantly longer OS in patients with bronchial NET, GEP-NET and midgut NET than in a nonrandomized control group. The total incidence of acute myeloid leukaemia (AML) and myelodysplastic syndrome (MDS) was 2.2%. No PRRT-related grade III/IV nephrotoxicity was observed. CONCLUSION: A cumulative dose of up to 60.5 GBq salvage PRRT with [177Lu-DOTA,Tyr3]octreotate is safe and effective in patients with progressive disease (relapse-PD) following I-PRRT with [177Lu-DOTA,Tyr3]octreotate. Safety appears similar to that of I-PRRT as no higher incidence of AML or MDS was observed. No grade III/IV renal toxicity occurred after retreatment.
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Neoplasias de los Bronquios/metabolismo , Neoplasias de los Bronquios/terapia , Neoplasias Intestinales/metabolismo , Neoplasias Intestinales/terapia , Tumores Neuroendocrinos/metabolismo , Tumores Neuroendocrinos/terapia , Octreótido/análogos & derivados , Compuestos Organometálicos/uso terapéutico , Neoplasias Pancreáticas/metabolismo , Neoplasias Pancreáticas/terapia , Receptores de Péptidos/metabolismo , Terapia Recuperativa , Neoplasias Gástricas/metabolismo , Neoplasias Gástricas/terapia , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Octreótido/uso terapéutico , Estudios Retrospectivos , Análisis de SupervivenciaRESUMEN
Prophylactic intra-operative administration of dexamethasone may improve short-term clinical outcomes in cardiac surgical patients. The purpose of this study was to evaluate long-term clinical outcomes and cost effectiveness of dexamethasone versus placebo. Patients included in the multicentre, randomised, double-blind, placebo-controlled DExamethasone for Cardiac Surgery (DECS) trial were followed up for 12 months after their cardiac surgical procedure. In the DECS trial, patients received a single intra-operative dose of dexamethasone 1 mg.kg-1 (n = 2239) or placebo (n = 2255). The effects on the incidence of major postoperative events were evaluated. Also, overall costs for the 12-month postoperative period, and cost effectiveness, were compared between groups. Of 4494 randomised patients, 4457 patients (99%) were followed up until 12 months after surgery. There was no difference in the incidence of major postoperative events, the relative risk (95%CI) being 0.86 (0.72-1.03); p = 0.1. Treatment with dexamethasone reduced costs per patient by £921 [1084] (95%CI £-1672 to -137; p = 0.02), mainly through reduction of postoperative respiratory failure and duration of postoperative hospital stay. The probability of dexamethasone being cost effective compared with placebo was 97% at a threshold value of £17,000 [20,000] per quality-adjusted life year. We conclude that intra-operative high-dose dexamethasone did not have an effect on major adverse events at 12 months after cardiac surgery, but was associated with a reduction in costs. Routine dexamethasone administration is expected to be cost effective at commonly accepted threshold levels for cost effectiveness.
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Antiinflamatorios/economía , Antiinflamatorios/uso terapéutico , Procedimientos Quirúrgicos Cardíacos/métodos , Dexametasona/economía , Dexametasona/uso terapéutico , Adulto , Anciano , Antiinflamatorios/administración & dosificación , Análisis Costo-Beneficio , Dexametasona/administración & dosificación , Método Doble Ciego , Femenino , Humanos , Incidencia , Periodo Intraoperatorio , Tiempo de Internación , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/prevención & control , Años de Vida Ajustados por Calidad de Vida , Insuficiencia Respiratoria/epidemiología , Insuficiencia Respiratoria/prevención & control , Análisis de Supervivencia , Resultado del TratamientoRESUMEN
UNLABELLED: A common effect of autologous blood withdrawal before cardiopulmonary bypass (CPB) is a decrease in haematocrit (Hct) and haemoglobin (Hb) content. A refinement of this technique is autologous blood withdrawal with the sequestration of platelet rich plasma (PRP) and red blood cells (RBCs). METHODS: One hundred and four patients were included in a randomized study stratified into three groups: the autologous blood withdrawal group (Group 1), the autologous blood withdrawal group with blood loss sequestration (Group 2) and the control group (Control group). In Group 1, the amount of withdrawn blood was transfused after CPB. In Group 2, the RBCs were transfused immediately after sequestration and the PRP was transfused after the termination of CPB. In the Control group, no autologous blood withdrawal was employed. The following variables were analysed: blood loss, blood products transfusion, fluid transfusion, diuresis, haematological and coagulation data and the duration of the operation and intensive care unit stay. RESULTS: We found no significant differences in peri-operative blood loss and transfused blood products among the three groups. There was a trend towards a lower amount of transfused fresh frozen plasma (FFP) for Group 1 (p =0.057) in the operation room (OR). The use of plasma expanders post-CPB was significantly higher in the Control group (p=0.024). RBCs coming from the auto-transfusion device were, for Group 1, significantly lower (p=0.007). The Hb and Hct values in Group 1, at start and end of CPB, were significantly lower (p=0.023-0.003 / 0.001-0.001, respectively). All other parameters were not significantly different. CONCLUSION: there were no significant differences between the study groups. This randomized trial shows that, although sequestration immediately after autologous blood withdrawal has no added value, autologous blood withdrawal in patients with a normal pre-operative Hb and Hct is simple, inexpensive and allows for autologous blood transfusion.
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Transfusión de Componentes Sanguíneos , Pérdida de Sangre Quirúrgica/prevención & control , Transfusión de Sangre Autóloga , Puente de Arteria Coronaria/efectos adversos , Hemoglobinas/análisis , Anciano , Estudios de Casos y Controles , Eritrocitos , Femenino , Hematócrito , Humanos , Masculino , Perfusión , Plasmaféresis , Cuidados Preoperatorios , Estudios ProspectivosRESUMEN
RATIONALE: When compared to other types of cancer, the prevalence of midgut neuroendocrine tumors (NET) has disproportionally increased over the past decades. To date, there has been very little progress in discovering (epi)genetic drivers and treatment options for these tumors. Recent microbiome research has revealed that enteroendocrine cells communicate with the intestinal microbiome and has provided novel treatment targets for various other cancer types. Hence, our aim was to analyze the role of the gut microbiome in midgut NET patients. METHODS: Fecal samples, prospectively collected from patients and control subjects, were analyzed with next generation 16S sequencing. Patients with neuroendocrine carcinomas and recent antibiotics use were excluded. Relevant variables were extracted from questionnaires and electronic health records. Microbial composition was compared between patients and controls as well as between groups within the patient cohort. RESULTS: 87 midgut NET patients and 95 controls were included. Midgut NET patients had a less rich and diverse gut microbiome than controls (p < 0.001). Moreover, we identified 31 differentially abundant species and a gut microbial signature consisting of 17 species that was predictive of midgut NET presence with an area under the receiver operating characteristic curve of 0.863. Gut microbial composition was not directly associated with the presence of the carcinoid syndrome, tumor grade or multifocality. Nonetheless, we did observe a potential link between microbial diversity and the presence of carcinoid syndrome symptoms within the subset of patients with elevated 5-hydroxyindolacetic acid levels. CONCLUSION: Midgut NET patients have an altered gut microbiome which suggests a role in NET development and could provide novel targets for microbiome-based diagnostics and therapeutics.
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Tumor Carcinoide , Microbioma Gastrointestinal , Neoplasias Intestinales , Tumores Neuroendocrinos , HumanosRESUMEN
Neuroendocrine ovarian metastases (NOM) predominantly derive from midgut neuroendocrine tumors (NETs) and develop in about 25% of women with advanced stage of this malignancy. Little is known of the growth rate and treatment response of NOM. We therefore evaluated the efficacy of different management options for patients with NOM, including peptide receptor radionuclide therapy (PRRT), somatostatin analogues (SSAs) and oophorectomy. Records were screened for patients with well-differentiated NOM of midgut origin that presented in our NET referral center between 1991 and 2022. Progression-free survival (PFS) and tumor growth rate (TGR) of ovarian and extra-ovarian metastases were determined using RECIST (response evaluation criteria in solid tumors) 1.1. In 12 available patients undergoing PRRT, NOM were associated with a shorter PFS than extra-ovarian metastases (P = 0.003). While PRRT induced a similar decrease in TGR for ovarian and extra-ovarian lesions in nine patients with available data (-2.3 vs -1.4, P > 0.05), only the TGR of NOM remained positive after PRRT. In 16 patients treated with SSAs, the TGR of NOM was almost three times that of extra-ovarian lesions during treatment (2.2 vs 0.8, P = 0.011). Oophorectomy was performed in 46 of the 61 included patients and was significantly associated with a prolonged OS (115 vs 38 months, P < 0.001). This association persisted after propensity score matching and correction for tumor grade and simultaneous tumor debulking. In conclusion, NOM have a higher TGR compared to extra-ovarian metastases, resulting in a shorter PFS after PRRT. Bilateral salpingo-oophorectomy should be considered for postmenopausal women with NOM undergoing surgery for metastatic midgut NETs.
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Tumores Neuroendocrinos , Quistes Ováricos , Neoplasias Ováricas , Humanos , Femenino , Octreótido , Tumores Neuroendocrinos/terapia , Quistes Ováricos/inducido químicamente , Neoplasias Ováricas/terapia , SomatostatinaRESUMEN
BACKGROUND: Serious preventable surgical events still occur despite considerable efforts to improve patient safety. In addition to learning from retrospective analyses, prospective risk-assessment methods may help to decrease preventable events further by targeting perioperative hazards. The aim of this systematic review was to assess the methods used to identify perioperative patient safety risks prospectively, and to describe the risk areas targeted, the quality characteristics and feasibility of methods. METHODS: MEDLINE, Embase, CINAHL and Cochrane databases were searched, adhering to PRISMA guidelines. All studies describing the development and results of prospective methods to identify perioperative patient safety risks were included and assessed on methodological quality. Exclusion criteria were interventional studies, studies targeting one specific issue, studies reporting on structural factors relating to fundamental hospital items, and non-original or case studies. RESULTS: The electronic search resulted in 16 708 publications, but only 20 were included for final analysis, describing five prospective risk-assessment methods. Direct observation was used in most studies, often in combination. Direct (16 studies) and indirect (4 studies) observations identified (potential) adverse events (P)AEs, process flow disruptions, poor protocol compliance and poor practice performance. (Modified) Healthcare Failure Mode and Effect Analysis (HFMEA™) (5 studies) targeted potential process flow disruption failures, and direct (P)AE surveillance (3 studies) identified (P)AEs prospectively. Questionnaires (3 studies) identified poor protocol compliance, surgical flow disturbances and patients' willingness to ask questions about their care. Overall, quality characteristics and feasibility of the methods were poorly reported. CONCLUSION: The direct (in-person) observation appears to be the primary prospective risk-assessment method that currently may best help to target perioperative hazards. This is a reliable method and covers a broad spectrum of perioperative risk areas.
ANTECEDENTES: A pesar de los esfuerzos considerables para mejorar la seguridad del paciente, aún se producen complicaciones quirúrgicas graves prevenibles. Además de adquirir conocimientos a través de los análisis retrospectivos, los métodos de evaluación de riesgos prospectivos por su enfoque en los riesgos perioperatorios, pueden ayudar a disminuir aún más los efectos adversos prevenibles. Esta revisión sistemática tiene como objetivo evaluar los métodos utilizados para identificar de forma prospectiva los riesgos perioperatorios de seguridad del paciente, describiendo las áreas de riesgo y las características de calidad y viabilidad de los métodos. MÉTODOS: Se realizaron búsquedas en las bases de datos MEDLINE, EMBASE, CINAHL y Cochrane siguiendo las recomendaciones PRISMA. Se incluyeron todos los estudios que describían el desarrollo y los resultados de métodos prospectivos para identificar los riesgos perioperatorios de seguridad del paciente y se evaluó su calidad metodológica. Se excluyeron los estudios de intervención, aquellos estudios dirigidos a un tema específico, los estudios enfocados a factores estructurales relacionados con elementos hospitalarios clave, y los estudios no originales o series de casos. RESULTADOS: La búsqueda electrónica identificó 16.708 publicaciones, pero solamente se incluyeron 20 publicaciones en las que se describían 5 métodos prospectivos de evaluación de riesgos. La observación directa fue el método utilizado en la mayoría de los estudios, a menudo en combinación con métodos indirectos. Las observaciones directas (80%) e indirectas (20%) identificaron efectos adversos potenciales (potential adverse events, (P)AEs), disrupciones en el flujo de los procesos, baja adherencia a los protocolos y prácticas deficientes. El análisis (modificado) de fallo de la atención sanitaria por modo y efecto (Healthcare-Failure-Mode-and-Effect Analysis) (25%) enfocado a fallos potenciales de disrupción de los procesos y la vigilancia directa de los (P)AEs (16%) identificaron (P)AEs de forma prospectiva. Los cuestionarios (15%) identificaron una baja adherencia a los protocolos, alteraciones en el flujo del proceso quirúrgico y la disposición de los pacientes para hacer preguntas sobre su atención. En general, las características de calidad y la viabilidad de los métodos se describían de manera deficiente. CONCLUSIÓN: La observación directa (en persona) es el principal método prospectivo de evaluación de riesgos que actualmente podría ser el mejor método para el enfoque en los riesgos perioperatorios. Es un método confiable y cubre un amplio espectro de áreas de riesgo perioperatorio.
Asunto(s)
Seguridad del Paciente , Estudios Prospectivos , Medición de Riesgo/métodos , Procedimientos Quirúrgicos Operativos/efectos adversos , Humanos , Periodo Perioperatorio , Factores de RiesgoRESUMEN
Adrenocortical carcinoma is a rare and highly malignant disease which can cause hypercortisolism leading to dysregulation of blood pressure and glucose levels. Most patients present with advanced disease. We describe the classic presentation of a functional adrenocortical carcinoma in a patient with metabolic syndrome.
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Neoplasias de la Corteza Suprarrenal/metabolismo , Carcinoma Corticosuprarrenal/metabolismo , Síndrome de Cushing/etiología , Síndrome Metabólico/etiología , Neoplasias de la Corteza Suprarrenal/sangre , Neoplasias de la Corteza Suprarrenal/complicaciones , Carcinoma Corticosuprarrenal/sangre , Carcinoma Corticosuprarrenal/complicaciones , Anciano , Síndrome de Cushing/sangre , Femenino , Humanos , Hidrocortisona/biosíntesis , Hidrocortisona/sangre , Síndrome Metabólico/sangreRESUMEN
Well-differentiated neuroendocrine tumours (NETs) of the digestive tract are being increasingly detected, which is partly explained by the increased use of endoscopic and cross-sectional imaging as well as improved recognition at histopathological evaluation. After the discovery of this relatively indolent type of epithelial malignancy over 100 years ago, their sporadic occurrence and divergent biological behaviour at multiple primary sites have hampered dedicated studies into NET pathogenesis and testing of drug efficacy in well-designed clinical trials. The last decade, however, has seen significant improvements in the NET field regarding our understanding of their pathophysiology. This has been substantiated by novel and exciting diagnostic and therapeutic options, including superior positron emission tomography imaging, treatment with unlabelled and radiolabelled somatostatin analogues and inhibitors of the mammalian target of rapamycin and vascular endothelial growth factor pathways. This review summarises contemporary studies within NET patients, which have enriched our clinical repertoire for this disease and have been instrumental in securing a remarkable improvement of overall survival within recent years.
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Neoplasias del Sistema Digestivo/diagnóstico , Neoplasias del Sistema Digestivo/terapia , Neoplasias Pulmonares/diagnóstico , Neoplasias Pulmonares/terapia , Tumores Neuroendocrinos/diagnóstico , Tumores Neuroendocrinos/terapia , Algoritmos , Neoplasias del Sistema Digestivo/epidemiología , Neoplasias del Sistema Digestivo/fisiopatología , Humanos , Neoplasias Pulmonares/epidemiología , Neoplasias Pulmonares/fisiopatología , Clasificación del Tumor , Tumores Neuroendocrinos/epidemiología , Tumores Neuroendocrinos/fisiopatología , PronósticoRESUMEN
Non-functional pancreatic neuroendocrine tumours (NETs) can present with advanced local or distant (metastatic) disease limiting the possibility of surgical cure. Several treatment options have been used in experimental neoadjuvant settings to improve the outcomes in such cases. Peptide receptor radionuclide therapy (PPRT) using beta emitting radiolabelled somatostatin analogues has been used in progressive pancreatic NETs. We report a 55-year-old female patient with a 12.8 cm pancreatic NET with significant local stomach and superior mesenteric vein compression and liver metastases. The patient underwent treatment with [177Lutetium-DOTA0,Tyr3]octreotate (177Lu-octreotate) for the treatment of local and metastatic symptomatic disease. Six months after 4 cycles of 177lutetium-octreotate, resolution of the abdominal complaints was associated with a significant reduction in tumour size and the tumour was rendered operable. Histology of the tumour showed a 90% necrotic tumour with abundant hyalinized fibrosis and haemorrhage compatible with PPRT-induced radiation effects on tumour cells. This report supports that PPRT has a role in unresectable and metastatic pancreatic NET. LEARNING POINTS: PRRT with 177Lu-octreotate can be considered a useful therapy for symptomatic somatostatin receptor-positive pancreatic NET.The clinical benefits of PRRT with 177Lu-octreotate can be seen in the first months while tumour reduction can be seen up to a year after treatment.PRRT with 177Lu-octreotate was clinically well tolerated and did not interfere with the subsequent surgical procedure.PRRT with 177Lu-octreotate can result in significant tumour reduction and may improve surgical outcomes. As such, this therapy can be considered as a neoadjuvant therapy.
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BACKGROUND: A Surgical Patient safety Observation Tool (SPOT) was developed and tested in a multicentre observational pilot study. The tool enables monitoring and benchmarking perioperative safety performance across departments and hospitals, covering international patient safety goals. METHODS: Nineteen perioperative patient safety observation topics were selected from Dutch perioperative patient safety guidelines, which also cover international patient safety goals. All items that measured these selected topics were then extracted from available local observation checklists of the participating hospitals. Experts individually prioritized the best measurement items per topic in an initial written Delphi round. The second (face to face) Delphi round resulted in consensus on the content of SPOT, after which the measurable elements (MEs) per topic were defined. Finally, the tool was piloted in eight hospitals for measurability, applicability, improvement potential, discriminatory capacity and feasibility. RESULTS: The pilot test showed good measurability for all 19 patient safety topics (range of 8-291 MEs among topics), with good applicability (median 97 (range 11·8-100) per cent). The overall improvement potential appeared to be good (median 89 (range 72·5-100) per cent), and at topic level the tool showed good discriminatory capacity (variation 27·5 per cent, range in compliance 72·5-100 per cent). Overall scores showed relatively little variation between the participating hospitals (variation 13 per cent, range in compliance 83-96 per cent). All eight auditors considered SPOT a straightforward and easy-to-use tracer tool. CONCLUSION: A comprehensive tool to measure safety of care was developed and validated using a systematic, stepwise method, enabling hospitals to monitor, benchmark and improve perioperative safety performance.
RESUMEN
Cushing syndrome (CS) during pregnancy is a rare condition with only a few cases reported in the literature. Misdiagnosis of CS is common because of overlapping features like fatigue, weight gain, striae and emotional changes that can occur during normal pregnancy. Changes in maternal hormones and their binding proteins complicate assessment of glucocorticoid hormone levels during gestation. CS during pregnancy is most frequently due to an adrenal adenoma and to a lesser degree to adrenocorticotropic hormone (ACTH) hypersecretion by a pituitary adenoma. Furthermore, aberrant expression of luteinizing hormone (LH) receptors in the adrenal cortex has been suggested to be involved in the pathogenesis of adrenal CS during pregnancy. We report three pregnant women with ACTH-independent Cushing's syndrome and an adrenal tumor. After uncomplicated delivery, patient 1 underwent in vivo testing for aberrant hormone receptor expression by the adenoma. Cortisol responses were found after administration of luteinizing hormone-releasing hormone (LHRH), human chorionic gonadotropin (hCG), glucagon, vasopressin and a standard mixed meal. All patients were treated with laparoscopic adrenalectomy. Adrenal tumor tissue of two patients showed positive immunohistochemical staining of LH receptors. Considering the cortisol responses to LHRH and hCG, and the development of CS during pregnancy in these patients, it is likely that ACTH-independent hypercortisolism was induced by the pregnancy-associated rise in hCG levels that activated aberrantly expressed LH receptors in the adrenal adenoma. Remarkably, adrenal adenomas may simultaneously express multiple aberrant receptors and individual ligands may play a role in the regulation of cortisol production in CS during pregnancy.
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Síndrome de Cushing/sangre , Síndrome de Cushing/diagnóstico por imagen , Complicaciones del Embarazo/sangre , Complicaciones del Embarazo/diagnóstico por imagen , Adulto , Síndrome de Cushing/complicaciones , Femenino , Humanos , Recién Nacido , Embarazo , Ultrasonografía Prenatal/métodosRESUMEN
Somatostatin, a neuropeptide with multiple activities, exerts its function via G-coupled membrane receptors. Five somatostatin receptor subtypes, sst1-5, have been identified. We have recently established that somatostatin acts as a chemoattractant on normal hematopoietic progenitor cells. Here, we studied the expression of somatostatin receptors (sst) on leukemic cells from 16 AML patients. Using fluorescent somatostatin (Fluo-SS) in flow cytometry, we found that sst are expressed in variable amounts on primary AML cells. Reverse transcriptase polymerase chain reaction (RT-PCR) analysis and immunochemistry revealed that only sst subtype 2 is expressed by AML cells. Using a two-chamber in vitro migration assay, we show that AML cells migrated towards a gradient of octreotide, a stable synthetic analogue of somatostatin. The degree of migration correlated with the cell surface density of sst2 as measured by Fluo-SS binding. These findings indicate that somatostatin influences trafficking of AML cells, which may have implications for the distribution of AML cells in the body and for clinical applications of somatostatin and analogues thereof in the context of AML.
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Leucemia Mieloide Aguda/patología , Receptores de Somatostatina/fisiología , Somatostatina/fisiología , Células de la Médula Ósea/fisiología , Movimiento Celular , Humanos , Inmunofenotipificación , Octreótido/farmacología , Receptores de Somatostatina/análisis , Reacción en Cadena de la Polimerasa de Transcriptasa Inversa , Somatostatina/análisisRESUMEN
BACKGROUND: Laparoscopic procedures are increasing in number and extensiveness. Many patients undergoing laparoscopic surgery have coexisting disease. Especially in patients with cardiopulmonary comorbidity, pneumoperitoneum and positioning can be deleterious. This article reviews possible pitfalls related to the combination of anesthesia, positioning of the patient, and the influence of pneumoperitoneum in the course of laparoscopic interventions. METHODS: A literature search using Medline's MESH terms was used to identify recent key articles. Cross-references from these articles were used as well. RESULTS: Patient positioning and pneumoperitoneum can induce hemodynamic, pulmonary, renal, splanchnic, and endocrine pathophysiological changes, which will affect the entire perioperative period of patients undergoing laparoscopic procedures. CONCLUSION: Perioperative management for the estimation and reduction of risk of morbidity and mortality due to surgery and anesthesia in laparoscopic procedures must be based on knowledge of the pathophysiological disturbances induced by the combination of general anesthesia, pneumoperitoneum, and positioning of the patient.
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Anestesia , Laparoscopía/métodos , Neumoperitoneo Artificial , Humanos , Complicaciones Intraoperatorias/etiología , Laparoscopía/efectos adversos , PosturaRESUMEN
We describe a young woman with complications of a primary varicella-zoster infection. She was admitted with varicella pneumonitis and developed the syndrome of Guillain-Barré. At admission she also had a myocardial infarction. We stress the lack of symptoms of pulmonary disease and the various neurological complications in varicella infection at older ages. We discuss the possible relationship between varicella infection and myocardial infection.
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Varicela/complicaciones , Infarto del Miocardio/etiología , Neumonía Viral/etiología , Polirradiculoneuropatía/etiología , Adulto , Femenino , HumanosAsunto(s)
Dolor Postoperatorio/tratamiento farmacológico , Dolor Postoperatorio/etiología , Neumonectomía/métodos , Toracotomía/métodos , Analgésicos/administración & dosificación , Analgésicos/uso terapéutico , Humanos , Dimensión del Dolor , Neumonectomía/efectos adversos , Toracotomía/efectos adversosRESUMEN
The antifungal agent ketoconazole is often used to suppress cortisol production in patients with Cushing's syndrome (CS). However, ketoconazole has serious side effects and is hepatotoxic. Here, the in vitro effects of ketoconazole and fluconazole, which might be less toxic, on human adrenocortical steroidogenesis were compared. The effects on steroidogenesis were examined in primary cultures of nine human adrenocortical tissues and two human adrenocortical carcinoma cell lines. Moreover, the effects on mRNA expression levels of steroidogenic enzymes and cell growth were assessed. Ketoconazole significantly inhibited 11-deoxycortisol (H295R cells; maximum inhibition 99%; EC(50) 0.73âµM) and cortisol production (HAC15 cells; 81%; EC(50) 0.26âµM and primary cultures (mean EC(50) 0.75âµM)). In cultures of normal adrenal cells, ketoconazole increased pregnenolone, progesterone, and deoxycorticosterone levels, while concentrations of 17-hydroxypregnenolone, 17-hydroxyprogesterone, 11-deoxycortisol, DHEA, and androstenedione decreased. Fluconazole also inhibited 11-deoxycortisol production in H295R cells (47%; only at 1âmM) and cortisol production in HAC15 cells (maximum inhibition 55%; EC(50) 35âµM) and primary cultures (mean EC(50) 67.7âµM). In the cultures of normal adrenals, fluconazole suppressed corticosterone, 17-hydroxypregnenolone, and androstenedione levels, whereas concentrations of progesterone, deoxycorticosterone, and 11-deoxycortisol increased. Fluconazole (1âmM) slightly increased STAR mRNA expression in both cell lines. Neither compound affected mRNA levels of other steroidogenic enzymes or cell number. In conclusion, by inhibiting 11ß-hydroxylase and 17-hydroxylase activity, pharmacological concentrations of fluconazole dose dependently inhibit cortisol production in human adrenocortical cells in vitro. Although fluconazole seems less potent than ketoconazole, it might become an alternative for ketoconazole to control hypercortisolism in CS. Furthermore, patients receiving fluconazole because of mycosis might be at risk for developing adrenocortical insufficiency.
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Corteza Suprarrenal/efectos de los fármacos , Corteza Suprarrenal/metabolismo , Fluconazol/farmacología , 17-alfa-Hidroxiprogesterona/metabolismo , Apoptosis/efectos de los fármacos , Línea Celular Tumoral , Proliferación Celular/efectos de los fármacos , Células Cultivadas , Cortodoxona/metabolismo , Desoxicorticosterona/metabolismo , Humanos , Hidrocortisona/metabolismo , Cetoconazol/efectos adversos , Cetoconazol/farmacología , Pregnenolona/metabolismo , Progesterona/metabolismoRESUMEN
OBJECTIVE: Aberrant adrenal expression of various hormone receptors has been identified in ACTH-independent macronodular adrenal hyperplasia (AIMAH) causing cortisol hypersecretion regulated by hormones other than ACTH. We aimed to determine aberrant expression of multiple hormone receptors in vivo and in vitro in adrenal tissue of a patient with AIMAH. DESIGN: The design of the study includes clinical case description, and biochemical and immunohistochemical analysis to demonstrate aberrant expression of multiple hormone receptors in AIMAH. METHODS: The subject of the study is a male diagnosed with Cushing's syndrome because of AIMAH. Directly after laparoscopic removal of the adrenals, adrenal tissue was incubated with and without test substances (ACTH, forskolin, arginine vasopressin (AVP), desmopressin, epinephrine, norepinephrine, purified human chorionic gonadotropin (hCG), metoclopramide and the combinations of AVP with ACTH, epinephrine and metoclopramide). LH/hCG-receptor (hCG-R) immunohistochemistry and RT-PCR analyses were performed to demonstrate aberrant expression of LH/hCG-R and V(1-3)-AVPR. RESULTS: AIMAH was characterized by in vivo cortisol responsiveness to AVP and in vitro cortisol responses to AVP, hCG, epinephrine, and norepinephrine suggesting aberrant adrenal expression of the receptors for AVP (the V(1-3)-AVPRs), catecholamines (the beta-AR), and LH (the LH/hCG-R). Incubation with combinations of AVP and ACTH and of AVP with epinephrine induced a stronger cortisol response compared with incubation with the individual agents. Moreover, we demonstrated adrenal V(1-3)-AVPR and LH/hCG-R expression. CONCLUSIONS: AIMAH tissue may simultaneously express multiple aberrant hormone receptors, and individual ligands may potentiate each other regarding cell proliferation and cortisol production.