Assessing men with opioid use disorder for testosterone deficiency after the development of symptoms

OBJECTIVE

Individuals with opioid use disorder (OUD) have reduced life expectancy and inferior outcomes when treated for depression, diabetes, and fractures. Their elevated risk of testosterone deficiency may contribute to all of these relationships, however few individuals prescribed opioids are evaluated with testosterone assays. The purpose of this study is to determine whether patients with opioid use disorder are evaluated for testosterone deficiency after development of a symptom that may merit investigation, such as erectile dysfunction (ED).

METHOD

We conducted a retrospective longitudinal cohort study that utilized data from a national database called TriNetX. Patients were eligible for inclusion if they were 20 to 90 years of age, male, and diagnosed with erectile dysfunction. We utilized descriptive statistics and logistic regression to address study aims.

RESULTS

Testosterone testing was uncommon for all patients with ED. Among 20,658 patients, it was assessed in 11.2% with OUD and 15.1% without OUD. Among those screened, 40% individuals with OUD and ED had testosterone deficiency. Odds of screening those with OUD were lower than matched controls (RR 0.74).

CONCLUSIONS

Individuals with OUD are at increased risk of testosterone deficiency than the general population, but nearly 90% are not evaluated for this condition even after development symptoms. That 40% of individuals assessed were classified as testosterone deficient suggests endocrine disorders may be contributing to increased fracture risk, chronic pain, and severe depression commonly encountered in patients with OUD. Addressing this care gap may reduce morbidity and mortality associated with opioid use disorder.

Decreased adrenomedullary function in infants with classical congenital adrenal hyperplasia

CONTEXT

Classical congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency can cause life-threatening adrenal crises as well as severe hypoglycemia, especially in very young children. Studies of CAH patients 4 years old or older have found abnormal morphology and function of the adrenal medulla and lower levels of epinephrine and glucose in response to stress than in controls. However, it is unknown whether such adrenomedullary abnormalities develop in utero and/or exist during the clinically high-risk period of infancy and early childhood.

OBJECTIVE

The objective of the study was to characterize adrenomedullary function in infants with CAH by comparing their catecholamine levels with controls. Design/Settings: This was a prospective cross-sectional study in a pediatric tertiary care center.

MAIN OUTCOME MEASURES

Plasma epinephrine and norepinephrine levels were measured by HPLC.

RESULTS

Infants with CAH (n = 9, aged 9.6 ± 11.4 d) had significantly lower epinephrine levels than controls [n = 12, aged 7.2 ± 3.2 d: median 84 [(25th; 75th) 51; 87] vs 114.5 (86; 175.8) pg/mL, respectively (P = .02)]. Norepinephrine to epinephrine ratios were also significantly higher in CAH patients than controls (P = .01). The control infants had primary hypothyroidism, but pre- and posttreatment analyses revealed no confounding effects on catecholamine levels.

CONCLUSIONS

This study demonstrates for the first time that infants with classical CAH due to 21-hydroxylase deficiency have significantly lower plasma epinephrine levels than controls, indicating that impaired adrenomedullary function may occur during fetal development and be present from birth. A longitudinal study of adrenomedullary function in CAH patients from infancy through early childhood is warranted.

Scleroderma-like skin changes not involving the hand in a prepubertal male with type I diabetes mellitus: A case report

To our knowledge there have been no reports of scleroderma-like skin changes, not affecting the hand in prepubertal patients with Type I Diabetes Mellitus (T1DM). We report a prepubertal caucasian male with T1DM, and early morpheatype skin changes of the trunk and extremities, not involving the hand.

Direct inhibitory effect of glucocorticoids on corticotrophin-releasing hormone gene expression in neurones of the paraventricular nucleus in rat hypothalamic organotypic cultures

Corticotrophin-releasing hormone (CRH) in the parvocellular neurosecretory neurones of hypothalamic paraventricular nucleus governs neuroendocrine stress cascade and is the major target of the negative feedback effect of corticosteroids. To assess whether glucocorticoids exert their inhibitory effect on CRH expression directly on parvocellular neurones or indirectly through a complex neuronal circuit, we examined the effect of corticosterone (CORT) and dexamethasone (DEX) on CRH mRNA levels in slice explant cultures of the rat hypothalamus. Organotypic slice cultures were prepared from 6 days old rat pups and maintained in vitro for 14 days. CRH mRNA expression was measured by in situ hybridisation histochemistry. Under basal conditions, CRH mRNA expressing cells were exclusively revealed in the paraventricular region along the third ventricle. Inhibition of action potential spike activity by tetrodotoxin (TTX, 1 microm) reduced CRH mRNA signal in the organotypic cultures. CORT (500 nm) or DEX (50 nm) treatment for 24 h significantly inhibited CRH expression in the parvocellular neurones and this effect of corticosteroids was not affected following blockade of voltage dependent sodium channels by TTX. Forskolin-stimulated CRH mRNA levels in the paraventricular nucleus were also inhibited by CORT or DEX in the presence and in the absence of TTX. These studies identify paraventricular CRH neurones as direct target of corticosteroid feedback. Type II corticosteroid receptor agonists act directly on paraventricular neurones to inhibit basal and forskolin-induced CRH mRNA expression in explant cultures of the rat hypothalamus.

An autosomal dominant genetically heterogeneous variant of rolandic epilepsy and speech disorder

We report a three generation pedigree with 11 of 22 affected with a variant form of rolandic epilepsy, speech impairment, oromotor apraxia, and cognitive deficit. The core features comprised nocturnal rolandic seizures, interictal centrotemporal spike waves with early age of onset and late age of offset. The transmission of the phenotype was consistent with autosomal dominant inheritance, with variable expressivity but no evidence of anticipation. We found evidence that the seizure and speech traits may be dissociated. No abnormalities were found by cytogenetic analysis. Linkage analysis excluded loci at 11p, 15q, 16p12, and Xq22 for related phenotypes, suggesting genetic heterogeneity.

Is Rolandic epilepsy associated with abnormal findings on cranial MRI?

Rolandic epilepsy (RE) is designated an idiopathic epilepsy syndrome, and hence no lesional abnormalities are expected on MRI exam. Recent reports suggest that MRI abnormalities are not only common, but may be specific for temporal lobe epilepsy, and lateralized to the side of EEG discharges. However, no controlled study has been performed to test the hypothesis of association between MRI abnormalities and Rolandic epilepsy. We performed an unmatched case-control study to test the hypothesis of association between MRI abnormalities and Rolandic epilepsy, using 25 typical RE cases and 25 children with migraine. Two independent examiners rated the MRIs for abnormalities. Examiners were blinded to the study hypothesis and identity of case and control exams. Fifty-two percent of RE exams contained at least one abnormality: peri/hippocampal abnormality (one case), non-localized congenital malformation (seven cases), subcortical parenchymal hyperintensities (two cases), periventricular parenchymal hyperintensities (one case), dilated perivascular spaces (six cases). There was no difference between the number or type of abnormalities in cases and controls. No type of abnormality lateralized to the hemisphere from which the EEG spikes emanated. The odds ratio of association between MRI abnormalities and RE was 0.87, 95% CI: 0.18-4.33 after adjusting for potential demographic and technical factors. We conclude that routine cranial MRI abnormalities are common in RE, but no more common than in controls, and not specific for RE.

High risk of reading disability and speech sound disorder in rolandic epilepsy families: case-control study

PURPOSE

Associations between rolandic epilepsy (RE) with reading disability (RD) and speech sound disorder (SSD) have not been tested in a controlled study. We conducted a case-control study to determine whether (1) RD and SSD odds are higher in RE probands than controls and (2) an RE proband predicts a family member with RD or SSD, hence suggesting a shared genetic etiology for RE, RD, and SSD.

METHODS

Unmatched case-control study with 55 stringently defined RE cases, 150 controls in the same age range lacking a primary brain disorder diagnosis, and their siblings and parents. Odds ratios (OR) were calculated by multiple logistic regression, adjusted for sex and age, and for relatives, also adjusted for comorbidity of RD and SSD in the proband.

RESULTS

RD was strongly associated with RE after adjustment for sex and age: OR 5.78 (95% CI: 2.86-11.69). An RE proband predicts RD in family members: OR 2.84 (95% CI: 1.38-5.84), but not independently of the RE proband's RD status: OR 1.30 (95% CI: 0.55-12.79). SSD was also comorbid with RE: adjusted OR 2.47 (95%CI: 1.22-4.97). An RE proband predicts SSD in relatives, even after controlling for sex, age and proband SSD comorbidity: OR 4.44 (95% CI: 1.93-10.22).

CONCLUSIONS

RE is strongly comorbid with RD and SSD. Both RD and SSD are likely to be genetically influenced and may contribute to the complex genetic etiology of the RE syndrome. Siblings of RE patients are at high risk of RD and SSD and both RE patients and their younger siblings should be screened early.

Autosomal dominant inheritance of centrotemporal sharp waves in rolandic epilepsy families

PURPOSE

Centrotemporal sharp (CTS) waves, the electroencephalogram (EEG) hallmark of rolandic epilepsy, are found in approximately 4% of the childhood population. The inheritance of CTS is presumed autosomal dominant but this is controversial. Previous studies have varied considerably in methodology, especially in the control of bias and confounding. We aimed to test the hypothesis of autosomal dominant inheritance of CTS in a well-designed family segregation analysis study.

METHODS

Probands with rolandic epilepsy were collected through unambiguous single ascertainment. Siblings in the age range 4-16 years underwent sleep-deprived EEG; observations from those who remained awake were omitted. CTS were rated as present or absent by two independent observers blinded to the study hypothesis and subject identities. We computed the segregation ratio of CTS, corrected for ascertainment. We tested the segregation ratio estimate for consistency with dominant and recessive modes of inheritance, and compared the observed sex ratio of those affected with CTS for consistency with sex linkage.

RESULTS

Thirty siblings from 23 families underwent EEG examination. Twenty-three showed evidence of sleep in their EEG recordings. Eleven of 23 recordings demonstrated CTS, yielding a corrected segregation ratio of 0.48 (95% CI: 0.27-0.69). The male to female ratio of CTS affectedness was approximately equal.

CONCLUSIONS

The segregation ratio of CTS in rolandic epilepsy families is consistent with a highly penetrant autosomal dominant inheritance, with equal sex ratio. Autosomal recessive and X-linked inheritance are rejected. The CTS locus might act in combination with one or more loci to produce the phenotype of rolandic epilepsy.

GABAergic mechanisms constraining the activity of the hypothalamo-pituitary-adrenocortical axis

There are two major inhibitory mechanisms that constrain the activity of the hypothalamo-pituitary-adrenocortical axis: the hormonal negative feedback and the neural inhibition including that posed by the GABAergic neurons. This chapter summarizes our recent morphologic and functional findings on the role of gamma-aminobutyric acid (GABA) in the transcriptional regulation of hypophyseotropic neuropeptide genes in the parvocellular neurosecretory cells of the hypothalamic paraventricular nucleus (PVH). We used organotypic hypothalamic slice cultures and in vivo microinjection protocols in combination with in situ histologic and ultrastructural procedures to address the role of local interneurons in the regulation of hypothalamic effector neurons. Under basal conditions, an intrinsic GABAergic mechanism in the PVH microenvironment was revealed that by itself, without limbic contribution, impinged a tonic inhibitory influence on the parvocellular corticotropin-releasing hormone (CRH) neurons in vitro. In vivo, remote inputs were superimposed on the local circuit, allowing differential transcriptional regulation of CRH and arginine vasopressin (AVP) genes in the hypophyseotropic neurons. During stress, GABAergic cells that are known to project to the PVH become activated and are involved in restraining the cellular, transcriptional, and hormonal responses to stress.

[Clinical assessment of free serum prostate specific antigen (PSA)]

The prostate specific antigen (PSA) level represents all of the immunoreactive serum PSA, either free or bound to alpha-1-anti-chymotrypsin. Isolated assay of free PSA has demonstrated a higher free PSA/total PSA ratio in cases of benign prostatic hyperplasia (BPH) than in cases of cancer, suggesting the possible use of this ratio in the detection of prostatic cancer when the PSA level is between 4 and 10 ng/mL. We retrospectively assayed free PSA in 64 cases of localized prostate cancer, 90 cases of BPH before transurethral resection and 59 healthy controls. By comparing the mean values of the 3 populations and the ROC curves, we confirmed the superiority of the free PSA/total PSA ratio over total PSA in the detection of prostatic cancer, but these results, established in a retrospectively constituted population, need to be confirmed by prospective epidemiological studies. Nevertheless, in routine urological practice, we propose that free PSA assay be performed in all men with a PSA level between 4 and 10 ng/mL and a normal prostate on digital rectal examination.

[Bilateral splanchnicectomy by transhiatal approach in pain of pancreatic origin. 37 cases]

OBJECTIVES

Surgical splanchnicectomy remains a useful means to relieve pain induced by malignant tumours of the pancreas and chronic pancreatitis. We report our experience in 37 patients.

METHODS

Between 1983 and 1993, 37 patients underwent transhiatal bilateral splanchnicectomy; 32 had a non-resectable adenocarcinoma and 5 chronic pancreatitis. In all cases, morphine had been required for pain relief.

RESULTS

Symptomatic pain relief was immediately achieved, with complete sedation in 84.3% of the cases. Prolonged antalgic effect continued for the survival period in 84.3%. Mean post-operative follow-up was 12.7 weeks corresponding to mean survival in 32 patients with pancreatic tumour. Post-operative mortality was 21.6% with no direct relationship with neurectomy. Specific morbidity related to pleural drainage was 10.8%.

CONCLUSION

Compared with other surgical procedures, trans-hiatal bilateral splanchnicectomy is a simple technique which can be performed whatever the stage of the locoregional tumour extension. In patients without an indication for exploratory laparoscopy, percutaneous chemical neurolysis is still indicated, even if the long-term result is less effective. In case of failure or technical impossibilities, thoracoscopic splanchnicectomy should be performed.

[Preliminary study of the feasibility of intraoperative ultrasonography of the biliary tract during cholecystectomy under celioscopy]

Peroperative echography and cholangiography provide similar information during the exploration of the biliary tree for conventional surgery for gall stones. Peroperative cholangiography is more difficult to perform via the coeolioscope with a failure rate of 10% in the most skillful teams. We investigated the technical feasibility of peroperative echography during coeliosurgery for gall stones. The technique was performed in 13 patients using a pulsed Doppler 7.5 MHz scan laparoscope. The entire biliary tree was successfully imaged in 12 patients and the three structures of the hepatic pedicle were identified in all cases. The exploration took less than 10 minutes and there was no morbidity. One gall stone was discovered and endoscopic sphincterotomy was performed immediately. None of the patients presented signs suggesting residual lithiasis with a mean follow-up of 2 months. This preliminary study suggests that the technique is very favourably feasible and may play an important role in the exploration of the bile tract during coelioscopic cholecystectomy.

[Pelvic lipomatosis. A case with ureteral and venous obstruction]

The authors report a case of pelvic lipomatosis in a 62 year old man associated with venous obstruction (third case reported in the literature), diagnosed after bilateral ureteric obstruction, and review of the literature on this subject. The diagnosis was suggested by the radiological triad of hyperlucency of the pelvis on plain abdominal X-ray, "hot air balloon" appearance of the bladder on IVU and a rigid and ascended rectosigmoid on barium enema, and was confirmed by CT and MRI. Treatment combining corticosteroids and urinary tract disinfection was partially effective. A double J ureteric stent resolved the problem of persistent right ureteric obstruction.