Whole-body diffusion-weighted magnetic resonance imaging (WB-DW-MRI) vs choline-positron emission tomography-computed tomography (choline-PET/CT) for selecting treatments in recurrent prostate cancer

Objective. To determine the effectiveness of whole-body diffusion-weighted magnetic resonance imaging (WB-DW-MRI) in detecting metastases by comparing the results with those from choline-positron emission tomography-computed tomography (choline-PET/CT) in patients with biochemical relapse after primary treatment, and no metastases in bone scintigraphy, CT and/or pelvic MRI, or metastatic/oligometastatic prostate cancer (PCa). Patients with this disease profile who could benefit from treatment with stereotactic body radiation therapy (SBRT) were selected and their responses to these techniques were rated. Materials and methods. This was a prospective, controlled, unicentric study, involving 46 consecutive patients from our centre who presented biochemical relapse after adjuvant, salvage or radical treatment with external beam radiotherapy, or brachytherapy. After initial tests (bone scintigraphy, CT, pelvic MRI), 35 patients with oligometastases or without them were selected. 11 patients with multiple metastases were excluded from the study. WB-DW-MRI and choline-PET/CT was then performed on each patient within 1 week. The results were interpreted by specialists in nuclear medicine and MRI. If they were candidates for treatment with ablative SBRT (SABR), they were then evaluated every three months with both tests. Results. Choline-PET/CT detected lesions in 16 patients that were not observable using WB-DW-MRI. The results were consistent in seven patients and in three cases, a lesion was observed using WB-DW-MRI that was not detected with choline-PET/CT. The Kappa value obtained was 0.133 (p = 0.089); the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of WB-DW-MRI were estimated at 44.93, 64.29, 86.11, and 19.15%, respectively. For choline-PET/CT patients, the sensitivity, specificity, PPV, and NPV were 97.10, 58.33, 93.06, and 77.78%, respectively. Conclusions. Choline-PET/CT has a high global sensitivity while WB-DW-MRI has a high specificity, and so they are complementary techniques. Future studies with more enrolled patients and a longer follow-up period will be required to confirm these data. The initial data show that the best technique for evaluating response after SBRT is choline-PET/CT (AU)

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Whole-body diffusion-weighted magnetic resonance imaging (WB-DW-MRI) vs choline-positron emission tomography-computed tomography (choline-PET/CT) for selecting treatments in recurrent prostate cancer.

OBJECTIVE: To determine the effectiveness of whole-body diffusion-weighted magnetic resonance imaging (WB-DW-MRI) in detecting metastases by comparing the results with those from choline-positron emission tomography-computed tomography (choline-PET/CT) in patients with biochemical relapse after primary treatment, and no metastases in bone scintigraphy, CT and/or pelvic MRI, or metastatic/oligometastatic prostate cancer (PCa). Patients with this disease profile who could benefit from treatment with stereotactic body radiation therapy (SBRT) were selected and their responses to these techniques were rated. MATERIALS AND METHODS: This was a prospective, controlled, unicentric study, involving 46 consecutive patients from our centre who presented biochemical relapse after adjuvant, salvage or radical treatment with external beam radiotherapy, or brachytherapy. After initial tests (bone scintigraphy, CT, pelvic MRI), 35 patients with oligometastases or without them were selected. 11 patients with multiple metastases were excluded from the study. WB-DW-MRI and choline-PET/CT was then performed on each patient within 1 week. The results were interpreted by specialists in nuclear medicine and MRI. If they were candidates for treatment with ablative SBRT (SABR), they were then evaluated every three months with both tests. RESULTS: Choline-PET/CT detected lesions in 16 patients that were not observable using WB-DW-MRI. The results were consistent in seven patients and in three cases, a lesion was observed using WB-DW-MRI that was not detected with choline-PET/CT. The Kappa value obtained was 0.133 (p = 0.089); the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of WB-DW-MRI were estimated at 44.93, 64.29, 86.11, and 19.15%, respectively. For choline-PET/CT patients, the sensitivity, specificity, PPV, and NPV were 97.10, 58.33, 93.06, and 77.78%, respectively. CONCLUSIONS: Choline-PET/CT has a high global sensitivity while WB-DW-MRI has a high specificity, and so they are complementary techniques. Future studies with more enrolled patients and a longer follow-up period will be required to confirm these data. The initial data show that the best technique for evaluating response after SBRT is choline-PET/CT. Trial registration number NCT02858128.

Hipoglucemia por hiperinsulinemia endógena en el adulto / Hypoglycemia due to endogenous hyperinsulinism in an adult

Introducción: La nesidioblastosis es una causa conocida de hipoglucemia en recién nacidos. Sin embargo, en adultos permanece poco entendida, creando un dilema tanto diagnóstico como terapéutico. Exponemos el caso de un paciente varón de 63 años que presenta hipoglucemia hiperinsulinémica en el que no se identificó la existencia de insulinoma antes ni durante la cirugía, practicándosele una pancreatectomía subtotal. La histología mostró la existencia de una nesidioblastosis. Conclusión: Identificamos un paciente con hipoglucemia hiperinsulinémica grave ocasionada por una proliferación difusa de los islotes pancreáticos, por lo que pensamos que esta entidad debe ser tenida en consideración ante un paciente que se intervenga con el diagnóstico de insulinoma no identificado previamente. En estos casos debe considerarse la realización de una pancreatectomía subtotal, a pesar de que el tratamiento óptimo está por determinar

Introduction: Nesidioblastosis is a well-known cause of hypoglycemia in neonates. However, it is poorly understood in adults, creating both diagnostic and therapeutic dilemmas. Case report: A 63-year-old man presented with hyperinsulinemic hypoglycemia. An insulinoma was not identified prior to or during surgery, and subtotal pancreatectomy was performed. Histological examination revealed the presence of nesidioblastosis. Conclusion: We identified a patient with severe hyperinsulinemic hypoglycemia due to diffuse islet cell disease. This etiology should always be considered in patients with a preoperative presumptive diagnosis of insulinoma. In these cases, partial pancreatectomy is indicated, although the optimal treatment remains to be determined

Incidentalomas hipofisarios: revisión de 21 casosNo disponible / Pituitary incidentalomas: review of 21 patients

Objetivo La utilización habitual de la tomografía computarizada y la resonancia magnética está incrementando el descubrimiento casual de masas selares. Por este motivo, hemos analizado a los pacientes enviados a nuestra consulta por incidentalomas hipofisarios, para determinar sus características e intentar definir el tratamiento y el seguimiento más adecuado. Pacientes y método Estudio retrospectivo de 21 pacientes con incidentaloma hipofisario. A los pacientes con masas menores de 10 mm se les realizó un estudio hormonal hipofisario basal y ninguno fue tratado quirúrgicamente. A los pacientes con lesiones mayores de 10 mm se les evaluó con una prueba de estimulación múltiple y un estudio campimétrico; posteriormente se trataron quirúrgicamente. El seguimiento medio de los enfermos fue de 3,6 años. Resultados El 85,7 por ciento de los pacientes presentaba un adenoma hipofisario (el 52,38 por ciento macroadenomas y el 33,34 por ciento microadenomas). El 36,36 por ciento de las masas selares de más de 10 mm condicionaba inicialmente alteraciones campimétricas. Se detectaron deficiencias hormonales en el 63,63 por ciento de las masas mayores de 10 mm. Sólo 1 paciente tuvo hipersecreción hormonal. Se realizó cirugía transesfenoidal en 8 casos, y en 1, cirugía transfrontal. Los incidentalomas no tratados quirúrgicamente no han aumentado de tamaño durante el seguimiento ni han desarrollado deficiencias hormonales. Discusión: El incidentaloma hipofisario es un motivo de consulta cada vez más frecuente. Los incidentalomas menores de 10 mm deberían evaluarse clínica y analíticamente para descartar hipersecreción hormonal. En las masas mayores de 10 mm se debe descartar tanto la hipersecreción como la hiposecreción hormonal y estudiar si existe afección campimétrica, ya que éstas pueden estar presentes ya en el momento del diagnóstico. El tratamiento quirúrgico, si fuera necesario, sólo debería realizarlo un cirujano con amplia experiencia (AU)

Plasma lipids and blood fluidity in patients with polygenic hypercholesterolaemia treated with fluvastatin.

The clinical benefit brought about by HMG-CoA reductase inhibitors (statins) may not entirely be due to their lipid-lowering effect. Further investigation is necessary in order to determine the significance of ancillary effects to the clinical benefit of statin treatment. We studied 27 polygenic hypercholesterolaemia (PHC) patients before and 3 and 6 months after fluvastatin treatment. A control group of 38 normal, sex and age matched, subjects were also studied. The following parameters were measured: haematimetry, serum lipids and general biochemistry, apo-A/B and lipoproteins, fibrinogen, blood filterability, red blood cell aggregation, blood and plasma viscosity. PHC patients showed lower blood filterability (16.00+/-0.99 vs 19.90+/-2.90 microl/s), higher plasma fibrinogen (274.8+/-41.5 vs 241.6+/-43.2 mg/dl), increased erythrocyte aggregation at low shear stress (8.10+/-1.15 vs 7.19+/-1.29) and increased plasma viscosity (1.26+/-0.06 vs 1.23+/-0.05 mPa.s). Notable lipid changes after 6 months fluvastatin treatment were not accompanied by measurable changes in the haemorheological alterations of the PHC patients.

Influence of age on clinical and immunological characteristics of newly diagnosed type 1 diabetic patients.

The aim of this study was to analyse the immunological and clinical characteristics of a group of patients at the onset of type 1 diabetes and to determine if these findings are age related. For this purpose, 68 newly diagnosed type 1 diabetes mellitus patients referred to our hospital between 1997 and 1999 were studied; 42 were adults (mean age 24+/-3.5 years) and 26 children (mean age 6.1+/-4 years). Autoantibody markers islet cell antibodies, glutamic acid decarboxylase antibodies (GADA) and tyrosine phosphatase antibodies (IA-2A), pancreatic reserve (glucagon test) and HbA1c were determined. Some clinical characteristics, such as mode of presentation and insulin requirements, were also analysed. Type 1 diabetes mellitus was found to be autoimmune in 83.8% of the patients and idiopathic in 16.2%, without significant differences between adults and children. In the whole autoimmune group, GADA was more prevalent in adults and IA-2A more frequent in children. On the other hand, adults showing autoimmune markers developed ketosis more frequently and needed higher insulin doses at diagnosis, while children did not exhibit clinically significant differences associated with the presence or absence of antibodies. In conclusion, in children the presence of autoimmune markers is not related to the mode of presentation or characteristics of type 1 diabetes. In adults, however, the autoimmune group presents with more-severe clinical disease than antibody negative patients. Age at onset seems to be an important parameter in the natural history of type 1 diabetes and must be taken into account in epidemiological or intervention studies.

[Value of RHD fetal genotyping in the prevention of anti-D immunization]. / Intérêt du génotypage foetal RHD dans la prévention de l'immunisation anti-D.

Anti-D prophylaxis is currently applied in France after birth of an RhD positive infant, after interruption of pregnancy and after some antenatal immunizing events (amniocentesis...). However this program does not cover all the prenatal exposures to fetal RhD antigen, and maternal Rh immunization continues to occur. DNA RhD genotyping of the fetus is now reliably performed on amniotic fluid, and pre diagnostic studies on fetal DNA extracted from maternal plasma are promising. The widespread use of fetal RhD genotyping on maternal blood would allow the antenatal administration of Rh immunoglobuline in all Rh negative patients bearing an Rh positive fetus, insofar as it would preclude exposing the other Rh negative patients to the above plasma derived and rather expensive blood product.

How to stabilize the level of ionized calcium and citrate during plateletpheresis.

BACKGROUND AND OBJECTIVES: Citrate reactions are uncomfortable and potentially dangerous to apheresis donors. Reduction of citrate increases comfort, but may lead to platelet clumping. MATERIALS AND METHODS: We describe a protocol for stepwise reduction of the volume of ACD-A injected during plateletpheresis. This protocol has been carried out in 45 healthy donors with the Cobe 2997 (Cobe) cell separator, and in 35 with the Fenwal-CS 3000 (CS). RESULTS: Using this protocol, during the first hour of platelet collection, ionised calcium decreased on average by 18% for CS and by 18.4% for Cobe. During the second hour, Ca2+ and citrate ion concentration did not change with either Cobe or CS (about 65% of citrate ion load is eliminated). We observed mild signs of neuromuscular hyperexcitability in only 22% and 28% of donors with Cobe and CS, respectively. We also found a significant reduction of phosphate ions (p < 0.0001) at the end of the procedures. CONCLUSIONS: With this stepdown citrate reduction protocol, we obtained a significant reduction of injected citrate without the complication of platelet clumps.

[Clinical effectiveness and tolerance of acarbose in the treatment of insulin-dependent diabetic patients (type I)]. / Eficacia clínica y tolerancia de la acarbosa en el tratamiento de pacientes diabéticos dependientes de la insulina (tipo I).

BACKGROUND: Acarbose is a reversible inhibitor of the intestinal alpha-glucosidases, the oral administration of which delays or diminishes the postprandial increase of glucose and insulin. METHODS: A multicentric double-blind clinical trial (11 centers), controlled versus placebo, crossed and randomized, was carried out with 137 insulin-dependent diabetic type I patients treated with diet and insulin. During the first 3 months of the trial the patients received placebo or acarbose randomly. Following one month of wash out with placebo the patients received the inverse medication for 3 more months. During the first month of each phase the patients were given 50 mg three times per day of acarbose or placebo and the two following moths received 100 mg x 3/day. RESULTS: Upon comparison of the two treatments significant statistical differences were found in HbA1 (p = 0.0005) and in postprandial glycemia (p = 0.007). There were differences, although not statistically significant, in the amounts of triglycerides, cholesterol and fasting glycemia. One hundred and two patients referred adverse events, most being gastrointestinal (flatulence, meteorism). CONCLUSIONS: Acarbose may be useful in the treatment of insulin-dependent diabetic type I patients treated with insulin and diet since it reduces the levels significantly of HbA1 and postprandial glucose.

[Clinical efficacy and tolerance to acarbose in the treatment of non-insulin-dependent diabetic patients]. / Eficacia clínica y tolerancia de la acarbosa en el tratamiento de pacientes diabéticos no dependientes de la insulina (tipo II).

BACKGROUND: Acarbose is a pseudotetrasacaride which reversibly and competitively inhibits the intestinal alpha-glycosidases leading to a decrease in the increase of postprandial glycemia. METHODS: A multicentric double-blind clinical trial (8 centers), controlled versus placebo, crossover and randomized was carried out in 90 non insulin dependent diabetic patients under treatment with diet or with diet and sulphonilureas. During the first three months of the trial the patients received placebo or acarbose randomly. Following one months of wash-out with placebo the patients received the inverse medication for 3 more months. During the first month of each phase the patients received 3 x 50 mg/day of acarbose or placebo and the following 2 months 3 x 100 mg/day. RESULTS: Upon comparison of the two treatments significant statistical differences were observed in HbA1 (p = 0.0115) and in postprandial glycemia (p = 0.0001). There were differences, although not significant, in the levels of triglycerides, cholesterol, fasting glycemia, and postprandial insulinemia. Episodes of hypoglycemia appeared in 12 patients and 57 patients referred undesirable gastrointestinal effects. CONCLUSIONS: The results of this trial indicate that acarbose may be useful in the treatment of non insulindependent diabetic patients since it significantly reduces the amount of postprandial glycemia and HbA1.

Transmission of HIV by transfusion of HIV-screened blood: the value of a national register. The 'Recipients' Study Group of the French Society of Blood Transfusion.

A National Register of transfusion-transmitted infections was opened by the French Society of Blood Transfusion on 1 October, 1986. Out of 54 initially reported cases of HIV-infection, allegedly transmitted by blood components, further investigation could be completed in 33 cases. The transfusional origin of contamination was considered as established or probable in 28/33 cases, either because a potentially infectious unit was identified among those transfused to the recipient (23/28), or because the recipient was known to be seronegative before transfusion (5/28), or both (10/28). In 5/33 cases transfusion was considered as presumably responsible for contamination because no other risk factor was found in the recipient. Among the 33 documented cases of HIV-transmission by screened blood, 29 (88%) occurred between 1985 and 1987, and four (12%) during 1988. Out of 19 implicated donors later found seropositive, 16 belonged to a high-risk group for HIV-infection. The majority of HIV-infections occurred as a consequence of blood donation in the window period between contamination and the appearance of detectable antibodies in the donor's serum (11/19). In three instances, however, human and operational errors led to the release of seropositive units. We conclude that the main value of this Register is to provide a potential trend-indicator of transfusion-related infectious risks, to allow objective documentation of reported cases and to contribute to the improvement of blood transfusion practice.

[The perinatal transmission of the hepatitis B virus in the Paris area]. / Transmission périnatale du virus de l'hépatite B dans la région de Paris.

HBsAg was detected in 152 pregnant women among 6,605 (2.3%) screened in the prenatal clinics of four hospitals representative of the Paris metropolitan area. In 98% of cases, HBsAg positivity indicated chronic HBV carrier status. Among patients born out of continental France (47% of screened women, 79% of positive women) relative risk of chronic infection was 6 in Asians, 5.5 in Africans, and 4 in French women born in non-continental France. No significant difference in medical history was seen between HBsAg-positive and HBsAg-negative patients, in any of the birthplace groups. In women born out of continental France, number of children and crowding in the home were correlated with HBsAg-positivity; these correlations were not found in French women born in continental France. In non-African, non-Asian women, screening on the basis of medical, social and familial criteria (simulated in this study) would not be effective. Routine screening for HBsAg in pregnancy is advocated. The cost of the prevention of each case of perinatally acquired chronic HBV infection by routine screening followed by prophylactic treatment of a risk neonates was estimated at 180,000 French Francs (35,000 dollars). This approach is the only means of preventing the long-term life-threatening complications of chronic HBV infection in the 600 neonates born each year in France to HBsAg-positive mothers.

[Prevention of perinatal hepatitis B virus transmission. Epidemiology and cost/efficacy ratio in the Paris region]. / Prévention de la transmission périnatale du virus de l'hépatite B. Epidémiologie et rapport coût/efficacité dans la région de Paris.

The HBs antigen (AgHBs) was detected in 152 out of 6605 (2.3 percent) pregnant women who attended four representative maternity clinics in the Paris region. In 98 percent of the cases this finding reflected chronic hepatitis B virus infection. Among women born outside France (47 percent of the women tested, 79 percent of the AgHBs positive women), the relative risk was 6 for Asiatics, 5.5 for Africans and 4 for French women born in overseas departments or territories. Whatever the women's geographical origin, studies of their medical history revealed no significant difference between AgHBs positivity and AgHBs negativity. Overcrowding and multiparity correlated globally with the presence of AgHBs, but this correlation was absent in French women born in France. In non-African and non-Asiatic women detection guided by medical and socio-familial criteria would not be efficacious. The authors recommend systematic detection of AgHBs in pregnant women and estimate at about 180,000 french francs the cost of prevention for each case evolving toward the vital complications of chronic hepatitis B virus infection, an outcome which in the long term may affect 600 individuals born each year and who had contracted the infection during the perinatal period.

[Perinatal transmission of the hepatitis B virus in Paris region]. / Transmission périnatale du virus de l'hépatite B dans la région de Paris.

HBsAg was detected in 152 pregnant women among 6,605 (2.3%) screened in the prenatal clinics of four hospitals representative of the Paris metropolitan area. In 98% of cases, HBsAg positivity indicated chronic HBV carrier status. Among patients born out of continental France (47% of screened women, 79% of positive women) relative risk of chronic infection was 6 in Asians, 5.5 in Africans, and 4 in French women born in non-continental France. No significant difference in medical history was seen between HBsAg-positive and HBsAg-negative patients, in any of the birthplace groups. In women born out of continental France, number of children and crowding of the home were correlated with HBsAg-positivity; these correlations were not found in French women born in continental France. In non-African, non-Asian women, screening on the basis of medical, social and familial criteria (simulated in this study) would not be effective. Routine screening for HBsAg in pregnancy is advocated. The cost of the prevention of each case of perinatally acquired chronic HBV infection by routine screening followed by prophylactic treatment of at risk neonates was estimated at 180,000 French Francs (35,000 dollars). This approach is the only means of preventing the long-term life-threatening complications of chronic HBV infection in the 600 neonates born each year in France to HBsAg-positive mothers.