Visual inspection problem-solving strategies at different experience levels

Airport security screening is a visual inspection task comprising search and decision. Problem solving is used to support decision making. However, it is not well understood. This study investigated how airport security screeners employ problem solving during x-ray screening, and how strategies change with experience. Thirty-nine professional security screeners were observed performing x-ray screening in the field at an Australian International Airport. Video and eye-tracking data were collected and analysed to explore activity phases and problem-solving strategies. Less-experienced screeners performed more problem solving and preferred problem-solving strategies that rely on visual examination without decision support or that defer decision making, compared to more-experienced screeners, who performed efficient and independent strategies. Findings also show that screeners need more time to develop problem-solving skills than visual scanning skills. Screeners would benefit from problem-solving support tools and intensified training and mentorship within the first six months of experience to advance problem-solving competencies.

Risk mitigation at train stations: underlying causes of slips, trips, and falls for passengers with reduced mobility

Slips, trips, and falls (STFs) occur frequently at train stations and on trains, and result in passengers injuries. STFs underlying causes focussing on passengers with reduced mobility (PRM) were investigated. Mixed methods combining observation and retrospective interviews were used. Thirty-seven participants between 24 and 87 years of age completed the protocol. They navigated between three selected stations while wearing the Tobii eye tracker. In retrospective interviews, they were asked to explain their actions in selected video segments. The research identified the dominant risky locations and risk-taking behaviour in risky locations. For example: (i) risky locations were the vicinity of obstacles, (ii) risky behaviour was not looking at the gap between the platform and train. The dominant risky locations and behaviours could be considered as underlying causes of slips, trips, and falls for PRMs. They can be applied during planning and design of rail infrastructure to predict and mitigate STFs.Practitioner summary: A significant number of slips, trips, and falls (STFs) occurs at railway stations, and often result in personal injury. This research identified the dominant risky locations and behaviour as underlying causes of STFs for people with reduced mobility (PRMs). The recommendations presented could be implemented to mitigate such risk.

Pilot study to define criteria for Pituitary Tumors Centers of Excellence (PTCOE): results of an audit of leading international centers

PURPOSE

The Pituitary Society established the concept and mostly qualitative parameters for defining uniform criteria for Pituitary Tumor Centers of Excellence (PTCOEs) based on expert consensus. Aim of the study was to validate those previously proposed criteria through collection and evaluation of self-reported activity of several internationally-recognized tertiary pituitary centers, thereby transforming the qualitative 2017 definition into a validated quantitative one, which could serve as the basis for future objective PTCOE accreditation.

METHODS

An ad hoc prepared database was distributed to nine Pituitary Centers chosen by the Project Scientific Committee and comprising Centers of worldwide repute, which agreed to provide activity information derived from registries related to the years 2018-2020 and completing the database within 60 days. The database, provided by each center and composed of Excel® spreadsheets with requested specific information on leading and supporting teams, was reviewed by two blinded referees and all 9 candidate centers satisfied the overall PTCOE definition, according to referees' evaluations. To obtain objective numerical criteria, median values for each activity/parameter were considered as the preferred PTCOE definition target, whereas the low limit of the range was selected as the acceptable target for each respective parameter.

RESULTS

Three dedicated pituitary neurosurgeons are preferred, whereas one dedicated surgeon is acceptable. Moreover, 100 surgical procedures per center per year are preferred, while the results indicated that 50 surgeries per year are acceptable. Acute post-surgery complications, including mortality and readmission rates, should preferably be negligible or nonexistent, but acceptable criterion is a rate lower than 10% of patients with complications requiring readmission within 30 days after surgery. Four endocrinologists devoted to pituitary diseases are requested in a PTCOE and the total population of patients followed in a PTCOE should not be less than 850. It appears acceptable that at least one dedicated/expert in pituitary diseases is present in neuroradiology, pathology, and ophthalmology groups, whereas at least two expert radiation oncologists are needed.

CONCLUSION

This is, to our knowledge, the first study to survey and evaluate the activity of a relevant number of high-volume centers in the pituitary field. This effort, internally validated by ad hoc reviewers, allowed for transformation of previously formulated theoretical criteria for the definition of a PTCOE to precise numerical definitions based on real-life evidence. The application of a derived synopsis of criteria could be used by independent bodies for accreditation of pituitary centers as PTCOEs.

The persistence of seroprotective levels of antibodies after vaccination with PreHevbrio, a 3-antigen hepatitis B vaccine

Prevention of hepatitis B virus (HBV) infection by vaccination can potentially eliminate HBV-related diseases. PreHevbrio™/PreHevbri® is a 3-antigen (S, preS1, preS2) HBV vaccine (3A-HBV) recently licensed for adults in the US, EU and Canada. This study evaluated antibody persistence in a subset of fully vaccinated and seroprotected (anti-HBs ≥ 10 mIU/mL) Finnish participants from the phase 3 trial (PROTECT) of 3A-HBV versus single-antigen HBV vaccine (1A-HBV). 465/528 eligible subjects were enrolled (3A-HBV: 244; 1A-HBV: 221). Baseline characteristics were balanced. After 2.5 years, more 3A-HBV subjects remained seroprotected (88.1 % [95 %CI: 84.1,92.2]) versus 1A-HBV (72.4 % [95 %CI: 66.6,78.3)], p < 0.0001) and had higher mean anti-HBs [1382.9 mIU/mL (95 %CI: 1013.8,1751.9) versus 252.6 mIU/mL (95 %CI: 127.5,377.6), p < 0.0001]. In multiple variable logistic regression analysis including age, vaccine, initial vaccine response, sex and BMI, only higher post dose 3 (Day 196) antibody titers significantly reduced the odds of losing seroprotection.

Serum Insulin-Like Growth Factor-1 (IGF-1) Age-Specific Reference Values for Healthy Adult Population of Serbia

CONTEXT

Insulin-like growth factor-1 (IGF-1) is main serum surrogate marker of growth hormone (GH) secretion, used in diagnostics and treatment of GH deficiency (GHD) and acromegaly. Regional, ethnic, racial or nutritional factors obscure cross-population applicability of IGF-1 reference values. Establishment of population- and assay-specific reference values requires sizable representative cohort of healthy subjects.

SUBJECTS AND METHODS

In representative sample of healthy adult population of Serbia (N=1200, 21-80 years, 1:1 male:female) serum IGF-1 was analyzed by Siemens Immulite 2000 assay under uniform laboratory conditions. Upper and lower limit of reference range (5^th - 95^th percentile) were calculated for each of the 12 quinquennial age intervals. IGF-1 distribution was normalized and standard deviation score (SDS) calculated by Logarithmic and LMS methods.

RESULTS

IGF-1 and age correlated significantly, with most prominent decline at 21-50 years, followed by a plateau up to age of 70. Gender differences were not significant overall. Plateau in age-related IGF-1 decline was less prominent in women. Correlations of IGF-1 with body mass index (BMI) or waist to hip ratio (WHR) were insignificant. Superior IGF-1 SDS transformation was achieved with LMS method, while logarithmic method was simpler to use.

CONCLUSIONS

Normative age-specific serum IGF-1 reference values were established on a representative cohort of healthy adults in Serbia. Our results support recommendations against necessity for gender-specific or BMI- and WHR-specific reference ranges. Population-based data serve to generate IGF-1 SDS, which is valuable in rational application of consensus guidelines, proper longitudinal follow-up, advancement in efficacy and safety and personalization of treatment targets.

Safe trip: Factors contributing to slip, trip and fall risk at train stations

Public transport systems are vital services in urban environments. The design of these complex socio-technical systems is continuously evolving to accommodate larger populations, and their adaptation is essential in supporting the successful and sustainable development of cities and regions. An essential part of this adaptation includes working to increase passenger safety and to minimise their risk of injury. With this focus, key objectives of the current study were to identify the causes of slip, trip and fall (STF) incidents attributable to the rail user and to train and station characteristics. An investigation of historical STF records of 1247 train and station incidents in two Australian jurisdictions was conducted. Various contributing factors to STF events were identified, including locations such as stairs, ramps, escalators, the train's entry and exit step, doorway areas, and passenger running or rushing. A mixed-method field study was then conducted at three train stations and on trains. To further investigate the contributing factors, participants (N = 40) wore an eye tracker as they navigated the stations and trains. The research illustrates that their continuous search for information, and a disconnect between the information needed and the information provided, might be a cause of passenger distraction and an increase in their risky behaviour. Therefore, we suggest that improvements in information design to reduce the high visual workload for passengers might also reduce the incidence of STFs.

Airport Security Screener Problem-Solving Knowledge and Implications

OBJECTIVE

This research investigates security screeners' knowledge and the effect that differences in knowledge have on the performance of problem-solving activities. We argue that the development of problem-solving knowledge enables security screeners to perform effective problem-solving activity, which assists search and decision-making processes.

BACKGROUND

Airport security screening research has investigated the many variables that affect security screeners' search and decision making during simulated threat-detection tasks. Although search and decision making are essential aspects of security screening, few studies have investigated the problem-solving knowledge and activities that support security screening task performance.

METHOD

Sixteen more-experienced and 24 less-experienced security screeners were observed as they performed x-ray screening in the field at an Australian international airport's departure security checkpoint. Participants wore eye-tracking glasses and delivered concurrent verbal protocol.

RESULTS

When interacting with other security screeners, more-experienced screeners demonstrated situational knowledge more than less-experienced screeners, whereas less-experienced screeners experienced more insufficient knowledge. Lag-sequential analysis using combined data from both screener groups showed that situational knowledge facilitated effective problem-solving activity to support search and decision making. Insufficient knowledge led screeners to seek assistance and defer decision making.

CONCLUSION

This study expands current understandings of airport security screening. It demonstrates that security screeners develop knowledge that is specific to problem solving. This knowledge assists effective problem-solving activity to support search and decision making, and to mitigate uncertainty during the x-ray screening task.

APPLICATION

Findings can inform future security screening processes, screener training, and technology support tools. Furthermore, findings are potentially transferable to other domains.

P4541Sarcopenia in non-cachectic males with heart failure

Background

Sarcopenia has been recently identified as a co-morbidity in patients with heart failure. Whether sarcopenia affects prognosis in non-cachectic HF patients is unknown.

Purpose

To assess the determinants of sarcopenia and its prognostic value in elderly males with HF.

Methods

A total of 73 non-diabetic, non-cachectic, male patients with HF and reduced left ventricular ejection fraction ≤40% (age: 68±7 years, left ventricular ejection fraction 29±8%) were enrolled. Sarcopenia was evaluated in accordance with revised definition of European working group on sarcopenia in older people 2 from 2018. Probable sarcopenia (or presarcopenia) was defined as low muscle strength, evaluated by lowest tertile of grip strength. A sarcopenia diagnosis was confirmed by the presence of low muscle quantity in addition to the low muscle strength, expressed as lowest tertile of appendicular skeletal muscle mass (ASM) adjusted by height square. Muscle mass was measured by dual energy X-ray absorptiometry. Patients were divided into 3 groups according to the diagnosis of the presarcopenia/sarcopenia/nonsarcopenia and were compared in respect to survival.

Results

14 (19%) and 13 (18%) patients were diagnosed with presarcopenia and sarcopenia, respectively. They were older compared to nonsarcopenia patients (72±6 and 73±6 vs. 65±7, p<0.0001), with inferior physical performance expressed by 6-minute walking distance (367±73 and 360±95 vs 430±74 m, p=0.003). Patients with sarcopenia presented with lower body mass index (25±3 vs. 29±6 kg/m2, p=0.014) along with more prominent wasting of bone compartment expressed by reduced total bone mineral content (p=0.002). Creatinine clearance was significantly reduced, while NT-proBNP (log-transformed) was higher in patients with presarcopenia/sarcopenia compared to nonsarcopenia subgroup (p=0.001 and p=0.039, respectively). In multivariate logistic regression only creatinine clearance and 6-minute walking distance were independently related with sarcopenia [OR 0.936 (95% CI 0.891–0.984), p=0.009 and OR 0.992 (95% CI 0.983–1.000), p=0.050, respectively]. A total of 41 (56%) patients died within 6 years of follow-up. Kaplan-Meier survival analysis showed impaired survival in patients with presarcopenia/sarcopenia (p=0.001, Figure 1). In univariate Cox regression analysis determinants of all-cause mortality were: age, NT-proBNP (log-transformed), left ventricular ejection fraction, creatinine clearance and presence of sarcopenia (all p<0.05). In multivariate Cox regression analysis, NT-proBNP [HR 3.000 (95% CI 1.589–5.665), p=0.001], and presence of sarcopenia [HR 0.500 (95% CI 0.241–1.038), p=0.063] were independent determinants of all-cause mortality after 6 years of follow-up.

Survival sarcopenia in heart failure

Conclusions

The rate of presarcopenia and sarcopenia was high in non-cachectic, elderly men with HF, and these patients have impaired survival compared to the patients with normal skeletal muscle status.

Acknowledgement/Funding

Grant of the Ministery of Science of Republic of Serbia 175033

DIAGNOSIS OF ENDOCRINE DISEASE: Drug-induced endocrinopathies and diabetes: a combo-endocrinology overview

In the currently overwhelming era of polypharmacy, the balance of the dynamic and delicate endocrine system can easily be disturbed by interfering pharmaceutical agents like medications. Drugs can cause endocrine abnormalities via different mechanisms, including direct alteration of hormone production, changes in the regulation of the feedback axis, on hormonal transport, binding and signaling, as well as similar changes to counter-regulatory hormone systems. Furthermore, drugs can interfere with the hormonal assays, leading to erroneous laboratory results that disorientate clinicians from the right diagnosis. The purpose of this review is to cover a contemporary topic, the drug-induced endocrinopathies, which was presented in the monothematic annual Combo Endo Course 2018. This challenging part of endocrinology is constantly expanding particularly during the last decade, with the new oncological therapeutic agents, targeting novel molecular pathways in the process of malignancies. In this new context of drug-induced endocrine disease, clinicians should be aware that drugs can cause endocrine abnormalities via different mechanisms and mimic a variety of clinical scenarios. Therefore, it is extremely important for clinicians not only to promptly recognize drug-induced hormonal and metabolic abnormalities, but also to address the therapeutic issues for timely intervention.

Age, familiarity, and intuitive use: An empirical investigation

Research has shown that older adults interact with products less intuitively than younger adults, and that familiarity is an essential element of intuitive interaction. This paper reports on the findings of two empirical studies that examined familiarity in younger and older adults. Each study comprised 32 participants over four age groups. The first study required participants to use their own contemporary products in their homes in order to investigate older adults' familiarity with them, and how this familiarity differed from that of younger adults. Older people were less familiar with their own contemporary products that younger people. The second study aimed to investigate differences in familiarity between younger and older adults while using products that they did not own and were likely to be less familiar with. When using products not already familiar to them, both middle aged and older adults showed significantly lower familiarity than younger people. The significance of this research is in its empirical findings about familiarity differences between age groups. It has been recognised that the identification and understanding of differences in familiarity will enable designers to design more intuitive interfaces and systems for both younger and older cohorts. The implications of the findings from the two studies reported here are discussed in light of this recognition.

The value of the post mortem analysis of carboxyhemoglobin concentration in the blood: A 15-year study

Introduction/Objective. The purpose of this retrospective study was to assess carboxyhemoglobin (HbCO) concentration in all autopsy cases of fire and non-fire victims ? all those who have been suspected to be under the influence of carbon monoxide (CO) in the Belgrade area during a 15-year period (1990?2005). Methods. Correlations between the concentration of HbCO, circumstances of death, vital signs, and prior health conditions, smoking and history of alcohol-abuse, have been particularly analyzed in 192 autopsy cases. Results. The investigation included 52 (27%) females and 140 (73%) males, their average age being 50.78 years. CO poisoning has been established as the cause of death in 74 cases (38%). The manner of death in 170 cases (89%) was an accident, in eight (3%) suicide, in two (1%) murder, in 11 (6%) natural death, and in one case the manner of death hasn?t been established. Such distribution of the manner of death differentiates this study from others of similar type, and it is conditioned by the specificity of life in this region. Conclusion. The predictors of a high HbCO concentration are the sex, cause of death, manner of death, soot aspiration, lower-degree burns. According to the results, we profiled a typical victim of CO poisoning.

Secondary hyperparathyroidism prevalence and prognostic role in elderly males with heart failure

AIM

Evaluation of secondary hyperparathyroidism (SHPT) and its prognostic impact on all-cause mortality in elderly males with heart failure (HF).

METHODS

Seventy three males (67 ± 7 years old) with systolic HF were included. Baseline PTH was measured. Patients were grouped according to PTH cut-off levels of 65 pg/ml (>65 pg/ml = SHPT vs. normal PTH). All-cause mortality was evaluated at 6-year follow-up.

RESULTS

SHPT was diagnosed in 43 (59 %) patients. They were more severe compared to the patients with normal PTH regarding NYHA functional class (2.4 ± 0.5 vs. 2.1 ± 0.2, p = 0.001), quality of life score (34 ± 14 vs. 24 ± 12, p = 0.005), 6-min walking distance (378 ± 79 vs. 446 ± 73 m, p < 0.0001), left ventricular ejection fraction (27 ± 8 vs. 31 ± 7 %, p = 0.019), and NT-proBNP [2452 (3399) vs. 918 (1372) pg/ml, p < 0.0001]. No differences in age, vitamin D status, and renal function were noted between studied groups. A total of 41 (56 %) patients died within 6 years of follow-up. Kaplan-Meier survival analysis showed impaired long-term survival in patients with SHPT versus patients with normal PTH (p = 0.009). The rate of death was highest (75 %) in the group of patients with SHPT and NT-proBNP levels above median value (p = 0.003). Cox regression analysis demonstrated that NT-proBNP was the single independent predictor of all-cause mortality at 6-year follow-up [HR 3.698 (1.927-7.095), p < 0.0001].

CONCLUSION

SHPT was highly prevalent in elderly males with HF and was associated with impaired survival. HF patients with SHPT had more severe disease compared to the patients with normal serum PTH. Determination of serum PTH levels provided additional value to NT-proBNP for risk stratification in these patients.

Cancerous leptomeningitis and familial congenital hypopituitarism

People are at higher risk of cancer as they get older or have a strong family history of cancer. The potential influence of environmental and behavioral factors remains poorly understood. Earlier population and case control studies reported that upper quartile of circulating IGF-I is associated with a higher risk of developing cancer suggesting possible involvement of the growth hormone (GH)/IGF system in initiation or progression of cancer. Since GH therapy increases IGF-1 levels, there have been concerns that GH therapy in hypopituitarism might increase the risk of cancer. We report a 42-year-old female patient who presented with subacute onset of symptoms of meningitis and with the absence of fever which resulted in death 70 days after the onset of symptoms. The patient together with her younger brother was diagnosed at the age of 5 years with familial congenital hypopituitarism, due to homozygous mutation c.150delA in PROP1 gene. Due to evolving hypopituitarism, she was replaced with thyroxine (from age 5), hydrocortisone (from age 13), GH (from age 13 until 17), and sex steroids in adolescence and adulthood. Her consanguineous family has a prominent history of malignant diseases. Six close relatives had malignant disease including her late maternal aunt with breast cancer. BRCA 1 and BRCA 2 mutational analysis in the patient's mother was negative. Histology after autopsy disclosed advanced ovarian cancer with multiple metastases to the brain, leptomeninges, lungs, heart, and adrenals. Low circulating IGF-1 did not seem to protect this patient from cancer initiation and progression in the context of strong family history of malignancies.

Contemporary issues in the evaluation and management of pituitary adenomas

Pituitary adenomas are common benign monoclonal neoplasms accounting for about 15% of intracranial neoplasms. Data from postmortem studies and imaging studies suggest that 1 of 5 individuals in the general population may have pituitary adenoma. Some pituitary adenomas (mainly microadenomas which have a diameter of less than 1 cm) are exceedingly common and are incidentally diagnosed on magnetic resonance imaging (MRI) performed for an unrelated reason (headache, vertigo, head trauma). Most microadenomas remain clinically occult and stable in size, without an increase in tumor cells and without local mass effects. However, some pituitary adenomas grow slowly, enlarge by expansion and become demarcated from normal pituitary (macroadenomas have a diameter greater than 1 cm). They may be clinically silent or secrete anterior pituitary hormones in excess such as prolactin, growth hormone (GH), or adrenocorticotropic hormone (ACTH) causing diseases like prolactinoma, acromegaly, Cushing's disease or rarely thyroid-stimulating hormone (TSH) or gonadotropins (LH, FSH). The incidence of the various subtypes of pituitary adenoma varies but the most common is prolactinoma. Clinically non-functioning pituitary adenomas (NFPAs), which do not secrete hormones often cause local mass symptoms and represent one-third of pituitary adenomas. Given the high prevalence of pituitary adenomas and their heterogeneity (different tumor subtypes), it is critical that clinicians have a thorough understanding of the potential abnormalities in pituitary function and prognostic factors for behavior of pituitary adenomas in order to timely implement specific treatment modalities. Regarding pathogenesis of these tumors genetics, epigenetics and signaling pathways are the focus of current research yet our understanding of pituitary tumorigenesis remains incomplete. Although several genes and signaling pathways have been identified as important factors in the development of pituitary tumors, current treatment modalities fail to completely control the disease and prevent the associated morbidity and mortality. This article reviews the advances in our understanding of pituitary adenoma, the guidance in evaluation and management of different subtypes of pituitary adenomas and the possibility of new therapeutic approaches.

First Report of Soybean Cyst Nematode (Heterodera glycines Ichinohe) on Soybean in the Province of Quebec, Canada

In eastern Canada, soybean, Glycine max (L.) Merr., is the most important legume, and its cultivation is expanding to new regions as cultivars for the short growing season are developed. The soybean cyst nematode (SCN), Heterodera glycines Ichinohe, is among the most destructive pests of soybean in the world. This nematode is also under quarantine regulations in many countries, including Canada. Until now, in Canada, SCN was only reported in the province of Ontario. Since its first detection in 1988 in the southwestern part of the province (1), SCN has been found in 12 other counties. It appears that SCN has been spreading in a north and northeast direction along the St. Lawrence River. We report here the first detection of SCN in the province of Quebec. Second stage juveniles (J2) and cysts were found in St. Anicet, Quebec, Canada, in a 10-ha soybean field. Light textured soil is a characteristic of the field, the same site where Pratylenchus alleni was recently discovered (2) and where irregular patches of stunted soybean plants were observed. Morphological and molecular studies of J2 and cysts confirmed the identification of this nematode population as SCN. The J2 were typical for SCN with a body length of 393 to 428 μm, lateral fields harboring four straight lines, a well-developed stylet 23 to 25 μm long, sub-ventral base knobs with posterior slops, a tail length of 43 to 50 μm, and a hyaline part of 23 to 29 μm. Cysts were brown and lemon-shaped with a posterior protuberance, ambifenestrated, underbridged, and had a strongly developed bullae. Key morphometrics were: a cyst fenestra 40 to 57 μm long and 28 to 44 μm wide, and a vulval slit 39 to 53 μm long. All of these are coincident with those of SCN (3). Ribosomal DNA of the ITS, 18S, and D2/D3 regions, and mitochondrial COX1 gene were PCR amplified from cysts and J2s gDNA using primers ITS-F (5'-TTGATTACGTCCCTGCCCTTT-3') and ITS-R (5'-ACGAGCCGAGTGATCCACCG-3'); 18S-F (5'-TTGGATAACTGTGGTTTAACTAG-3') and 18S-R (5'-ATTTCACCTCTCACGCAACA-3'); D2A (5'-ACAAGTACCGTGAGGGAAAGT-3') and D3B (5'-GACCCGTCTTGAAACACGGA-3'); and COXI-F (5'-CCTACTATGATTGGTGGTTTTGGTAATTG-3') and COX1-R (5'-GTAGCAGCAGTAAAATAAGCACG-3'), respectively, and sequenced. The nucleotide sequences were 98 to 100% similar to those of SCN found in NCBI nr database (July 2013). All the sequences have been submitted to GenBank with the following accession numbers: ITS (KF453621); 18S (KF453622); D2/D3 (KF453623); and COX1 (KF453624). Using species specific sequence characterized amplified region (SCAR) primers (4) also confirmed this was H. glycines. This is the first reported case of SCN in Quebec, Canada. The proximity of St. Anicet to the Ontario border is in accordance with the North/Northeastern dispersal hypothesis. The HG type of the SCN population will have to be determined before any resistant cultivars are deployed for the management of this pathogen in the province. References: (1) T. R. Anderson et al. Plant Dis. 72:453, 1988. (2) G. Bélair et al. Plant Dis. 97:292, 2013. (3) R. H. Mulvey. Can. J. Zool. 50:1277, 1972. (4) S. Ou et al. Nematology 10:397, 2008.

Growth hormone replacement normalizes impaired fibrinolysis: new insights into endothelial dysfunction in patients with hypopituitarism and growth hormone deficiency

BACKGROUND

Cardiovascular morbidity in adult patients with growth hormone deficiency (GHD) and hypopituitarism is increased. Clustering of cardiovascular risk factors leading to endothelial dysfunction and impaired fibrinolysis has also been reported and may account for progression to overt vascular changes in these patients. However, effect of long lasting GH replacement therapy on fibrinolytic capacity in GH deficient patients has not been investigated so far.

OBJECTIVE

To investigate fibrinolysis before and after challenge with venous occlusion in GHD patients with hypopituitarism before and during one year of growth hormone replacement.

DESIGN

Hospital based, interventional, prospective study.

INVESTIGATED SUBJECTS

Twenty one patient with GHD and fourteen healthy control subjects matched for age, sex and body mass index (BMI).

METHODS

Anthropometric, metabolic and fibrinolytic parameters were measured at the start and after three, six and twelve months of treatment with human recombinant GH.

RESULTS

At baseline GHD patients had significantly impaired fibrinolysis compared to healthy persons. During treatment with GH, significant changes were observed in insulin like growth factor 1(IGF-1) [from baseline 6.9(2.4-13.5) to 22.0(9.0-33.0) nmol/l after one month of treatment; p<0.01] and fibrinolysis. Improvement in fibrinolysis was mostly attributed to improvement of stimulated endothelial tissue plasminogen activator (t-PA) release in response to venous occlusion [from baseline 1.1(0.4-2.6) to 1.9(0.5-8.8) after one year of treatment; p<0.01].

CONCLUSION

Growth hormone replacement therapy has favorable effects on t-PA release from endothelium and net fibrinolytic capacity in GHD adults, which may contribute to decrease their risk of vascular complications.

The importance of timing in surgical treatment of unruptured symptomatic aneurysm of abdominal aorta

AIM OF STUDY

Aim of this study is to define an entity of unruptured symptomatic AAA, to examine the influence of timing of the surgical treatment and to analyze the results of the treatment of unruptured symptomatic AAA in acute expansion.

MATERIALS AND METHOD

The study is designed as retrospective analysis of 390 operatively treated patients in the last five years at the Clinics of Vascular Surgery in Novi Sad. All patients were grouped into four categories: elective operative surgical treatment, surgical treatment 24 hours after the admission through the Department of Urgent Surgery with an urgent CT diagnosis (in first 2 hours), surgical treatment within 24 hours since the admission through the Department of Urgent Surgery with an urgent CT diagnosis (in first 2 hours) and immediate surgical treatment of ruptured AAA.

RESULTS

In the period from Jan 1, 2005 to Dec 31, 2009, 390 patients with AAA were operatively treated. 89 patients had ruptured AAA, 52 were operated 24 hours after the urgent admission, 18 patients were operated in the first 24 hours after the urgent admission and 231 patients were planned for elective surgery. Mortality rates between the groups were as follows: elective surgery-5.1 %, patients operated 24 hours after the urgent admission 7.2 %, patients operated in the first 24 hours after the urgent admission 23 %, and patients who had ruptured AAA 34 %.

CONCLUSION

Considering the obtained data, it can be concluded that the treatment of unruptured symptomatic AAA is related to a higher risk of postoperative mortality in relation to an elective surgery. Moreover, surgical treatment in the first 24 hours after the urgent admission of unruptured symptomatic AAA has higher rate of mortality and morbidity compared to surgical treatment 24 hours after the urgent admission of the patients, so we can conclude that the early (semi) elective surgery is a method of choice for the treatment of unruptured symptomatic AAA in acute expansion (Tab. 2, Fig. 2, Ref. 21).

Pulmonary thromboembolism after air travel: two case reports, the review of literature and forensic implications

Air travel as a risk factor for pulmonary thromboembolism (PTE) is rarely described in forensic literature. Two cases of PTE after air travel are presented in this report. Each flight was intercontinental and lasted for more than 10 h, resulting in typical "traveler's thrombosis" within 2 weeks. In both cases, the risk factors were age, duration of flight and also peripheral circulation problems caused by heart (hypertension, arrhythmia), and varicose veins failures. Possible pathophysiological mechanisms of thrombus formation in these cases were blood flow stasis from prolonged recumbence, reduced function of the lower leg muscle pump, dehydration, and hypobaric hypoxia. Legal aspects of death due to PTE after air travel and possible responsibility of air companies are discussed.

Parathyroid hormone response to vitamin D insufficiency in elderly males with chronic heart failure

Secondary hyperparathyroidism (SHPT) may contribute to the systemic illness that accompanies chronic heart failure (CHF). Healthy elderly with vitamin D deficiency who did not develop hyperparathyroidism (functional hypoparathyroidism, FHPT) had lower mortality than those who did. This study was designed to examine determinants of the PTH response in the vitamin D insufficient CHF patients. Sixty five vitamin D insufficient males with NYHA class II and III and 20 control subjects age >/=55 years were recruited. Echocardiography, physical performance, NT-pro-BNP, PTH, 25-hydroxyvitamin D (25(OH)D), adiponectin and bone activity surrogate markers (OPG, RANKL, OC, beta-CTx) were assessed. Increased NYHA class was associated with SHPT, while physical performance was inferior compared to FHPT. SHPT was associated with lower left ventricular ejection fraction (LVEF) and flow mediated dilatation, but with higher left heart dimensions, left ventricular mass index and right ventricular systolic pressure. CHF patients with SHPT had increased NT-pro-BNP, adiponectin and bone markers, but decreased 25(OH)D compared to those with FHPT. Independent determinants for SHPT in CHF patients with vitamin D insufficiency were LVEF, adiponectin and beta-CTx, irrespective of renal function and serum vitamin D levels. In conclusion, increased PTH levels, but not low vitamin D, demonstrated close relation to CHF severity.

Manifesto for the current understanding and management of traumatic brain injury-induced hypopituitarism

Traumatic brain injury (TBI)-induced hypopituitarism remains a relevant medical problem, because it may affect a significant proportion of the population. In the last decade important studies have been published investigating pituitary dysfunction after TBI. Recently, a group of experts gathered and revisited the topic of TBI-induced hypopituitarism. During the 2-day meeting, the main issues of this topic were presented and discussed, and current understanding and management of TBI-induced hypopituitarism are summarized here.

Could lactates in vitreous humour be used to estimate the time since death?

Vitreous humour (VH) is a useful medium for postmortem analysis. During the supravital period, anaerobic glycolysis that occurs results in the increased lactate concentration (L) in cytosol. We analysed the concentration of lactic acid in 567 samples of VH from 63 autopsy cases by a repetitive withdrawal of VH from the same corpse, while the outside temperature remained constant. The samples were taken from the same eye in intervals of three hours for the period of 24 hours. The subjects were divided into two groups: group 1 included individuals who died during winter and were kept for analysis at 40C, while group 2 consisted of those who died during spring and autumn (continental climate) and were stored at 200C. Only the cases of a sudden traumatic death of previously healthy individuals were included in the study. Statistically significant correlation of L against postmortem interval (PMI) was observed in the group 1 experiment (r = 0.675; P < 0.01), but the effect of hypothermia made the estimation of PMI practically impossible. A much stronger correlation of L against PMI was observed in group 2 (r = 0.866, P < 0.01); a functional relationship between PMI and L were demonstrated using the formula PMI = 1.696 x L - 10.562, which enabled more accurate prediction of the PMI.

Association of increased parathyroid hormone with neuroendocrine activation and endothelial dysfunction in elderly men with heart failure

High PTH levels have been reported in patients with chronic heart failure (CHF). Similarly, its levels increase with aging and are related to impaired survival in elderly adults. However, its relationship with neuroendocrine activation and endothelial dysfunction in CHF has not been previously studied. Seventy-three CHF males with New York Heart Association (NYHA) classes II and III and 20 control subjects aged ≥ 55 yr were recruited. PTH, 25-hydroxyvitamin D [25(OH)D], N-terminal pro-brain natriuretic peptide (NT-pro-BNP), adiponectin, and osteoprotegerin were measured. Endothelial function (brachial flow mediated dilation), echocardiography, physical performance, and quality of life were assessed, as well. CHF patients had markedly increased serum PTH (77 ± 33 vs 40 ± 11 pg/ml, p<0.0001), NT-pro-BNP [1809 (2742) vs 67 (74) pg/ml, p<0.0001], adiponectin (17 ± 9 vs 10 ± 2 μg/ml, p<0.0001), osteoprotegerin, whereas 25(OH)D levels were decreased compared to controls. Increased PTH is positively correlated with NTpro- BNP (r=0.399, p<0.0001), adiponectin (r=0.398, p<0.0001), and osteoprotegerin, whereas negatively with 25(OH)D in CHF patients. Additionally, increased serum PTH was associated with endothelial dysfunction, echocardiographic variables of heart failure progression, impaired physical performance, and deteriorated quality of life. In a multivariate linear regression analysis, increased serum PTH was independently associated with neuroendocrine activation (NT-pro-BNP, adiponectin) and endothelial dysfunction in elderly CHF men (R2=0.455). Additionally, demonstrated relations with other well-established variables of heart failure severity suggest the potential role of serum PTH in the pathogenesis and non-invasive monitoring of heart failure progression. Future studies are needed to evaluate the predictive value of serum PTH for clinical outcomes as well as beneficial potential of PTH suppression in CHF patients.

Psychiatric and neuropsychological changes in growth hormone-deficient patients after traumatic brain injury in response to growth hormone therapy

OBJECTIVE

Traumatic brain injury (TBI) has been recently recognized as a risk factor for cognitive impairment and hypopituitarism, presented most frequently with GH deficiency (GHD). GHD is associated not only with changes in body composition, but also with impaired quality of life, cognitive dysfunctions and some psychiatric sequelae, usually classified as "depression" or "atypical depression". The impact of GH therapy on mental status in TBI patients is still unknown.

DESIGN

Psychiatric and cognitive functions were tested in 6 GHD patients at baseline (minimum 3 yr after TBI), reassessed after 6 months of GH therapy as well as 12 months after discontinuation of GH therapy. Psychiatric and cognitive examinations included semi-structured interviews and 3 instruments: Symptom-checklist (SCL-90-R), Zung Depression Inventory, and standard composite neuropsychological battery.

RESULTS

Six months of GH therapy in GHD TBI patients improved cognitive abilities (particularly verbal and non-verbal memory) and significantly improved psychiatric functioning. Severity of depression decreased, as well as intensity of interpersonal sensitivity, hostility, paranoid ideation, anxiety, and psychoticism. Somatization, obsessive-compulsive symptoms and phobic anxiety decreased in all except in one patient. In 3 GHD patients who stopped GH therapy for 12 months we registered worsening of the verbal and non-verbal memory, as well symptoms in 3 SCL dimensions: inter-personal sensitivity, anxiety, and paranoid ideation.

CONCLUSION

GH-deficient TBI patients are depressed and have cognitive impairment. GH therapy induced reduction of depression, social dysfunction, and certain cognitive domains. Our preliminary data support the necessity of conducting randomized placebo-controlled trials on the effects of GH therapy on neuropsychological and psychiatric status in GHD TBI patients.

ACTH and cortisol responses to ghrelin and desmopressin in patients with Cushing's disease and adrenal enlargement

BACKGROUND

Overexpression of ghrelin and vasopressin (V3) receptors demonstrated on corticotrophe adenomas accounts for exaggerated ACTH and cortisol responses to ghrelin and desmopressin (DDAVP) in patients with Cushing's disease (CD).

AIM

In this study we have compared ACTH and cortisol responsiveness to DDAVP and ghrelin in CD patients with and without adrenal enlargement.

SUBJECTS AND METHODS

Ghrelin and DDAVP tests were performed in 15 patients with CD (7 with and 8 without signs of adrenal enlargement) with CRH test in 8 patients. In 7 age and sex-matched healthy subjects, ghrelin test was performed. Plasma ACTH and serum cortisol concentrations were measured after ghrelin, DDAVP and CRH. Growth hormone was measured after stimulation with ghrelin.

RESULTS

Significantly higher baseline and peak ACTH and cortisol concentrations after ghrelin were observed in all patients with CD compared to healthy control subjects. Patients with CD and adrenal enlargement had significantly lower baseline and peak ACTH concentrations after stimulation with ghrelin compared to CD patients without adrenal enlargement, while cortisol levels at baseline and after ghrelin administration were similar. Three out of seven patients with CD and adrenal enlargement did not respond to DDAVP while they responded well to CRH and ghrelin.

CONCLUSION

Patients with CD and adrenal enlargement pose special diagnostic problems. They may have lower baseline ACTH levels and may not respond to DDAVP while they respond to ghrelin and CRH. Despite increased endogenous cortisol levels in CD, cortisol responses to ghrelin and CRH are preserved in patients with CD and adrenal enlargement.

Investigating users' intuitive interaction with complex artefacts

This paper examines the role of intuition in the way that people operate unfamiliar devices. Intuition is a type of cognitive processing that is often non-conscious and utilises stored experiential knowledge. Intuitive interaction involves the use of knowledge gained from other products and/or experiences. Two initial experimental studies revealed that prior exposure to products employing similar features helped participants to complete set tasks more quickly and intuitively, and that familiar features were intuitively used more often than unfamiliar ones. A third experiment confirmed that performance is affected by a person's level of familiarity with similar technologies, and also revealed that appearance (shape, size and labelling of features) seems to be the variable that most affects time spent on a task and intuitive uses during that time. Age also seems to have an effect. These results and their implications are discussed.

From isolated GH deficiency to multiple pituitary hormone deficiency: an evolving continuum - a KIMS analysis

OBJECTIVE

To describe baseline clinical presentation, treatment effects and evolution of isolated GH deficiency (IGHD) to multiple pituitary hormone deficiency (MPHD) in adult-onset (AO) GHD.

DESIGN

Observational prospective study.

METHODS

Baseline characteristics were recorded in 4110 patients with organic AO-GHD, who were GH naïve prior to entry into the Pfizer International Metabolic Database (KIMS; 283 (7%) IGHD, 3827 MPHD). The effect of GH replacement after 2 years was assessed in those with available follow-up data (133 IGHD, 2207 MPHD), and development of new deficiencies in those with available data on concomitant medication (165 IGHD, 3006 MPHD).

RESULTS

IGHD and MPHD patients had similar baseline clinical presentation, and both groups responded similarly to 2 years of GH therapy, with favourable changes in lipid profile and improved quality of life. New deficiencies were observed in 35% of IGHD patients, which was similar to MPHD patients with one additional deficit other than GH. New deficiencies most often presented within the first year but were observed up to 6 years after GH commencement. Conversion of IGHD into MPHD was not predicted by aetiology, baseline characteristics, surgery or radiotherapy, whereas in MPHD additional deficits were predicted by age (P<0.001) and pituitary disease duration (P<0.01).

CONCLUSION

Both AO-IGHD and -MPHD patients have similar baseline clinical presentation and respond equally well to 2 years of GH replacement. Hypopituitarism in adults seems to be a dynamic condition where new deficiencies can appear years after the initial diagnosis, and careful endocrine follow-up of all hypopituitary patients, including those with IGHD, is warranted.

Human experience and product usability: principles to assist the design of user-product interactions

This paper introduces research that investigates how human experience influences people's understandings of product usability. It describes an experiment that employs visual representation of concepts to elicit participants' ideas of a product's use. Results from the experiment lead to the identification of relationships between human experience, knowledge, and context-of-use--relationships that influence designers' and users' concepts of product usability. These relationships are translated into design principles that inform the design activity with respect to the aspects of experience that trigger people's understanding of a product's use. A design tool (ECEDT) is devised to aid designers in the application of these principles. This tool is then trialled in the context of a design task in order to verify applicability of the findings.

Glucose metabolism during ghrelin infusion in patients with anorexia nervosa

Anorexia nervosa (AN) is an eating disorder characterized by self-induced starvation due to fear of adiposity. Ghrelin, gastric peptide with potent orexigenic, adipogenic, GH-releasing and metabolic properties, is elevated in AN. We have previously shown that intervention with exogenous ghrelin is not effective in terms of inducing neuroendocrine and appetite responses in AN. In this arm of the same study protocol we investigated glucose metabolism responses to 5 h i.v. infusion of active ghrelin in a) 9 severely malnourished AN patients, b) 6 AN patients who partially recovered body weight (PRAN), c) 10 constitutionally thin female subjects with regular menstrual cycles. At baseline, no significant differences were observed in blood glucose, insulin, c-peptide, adiponectin, and homeostasis model assessment index values, between the studied groups. During ghrelin infusions, blood glucose levels significantly increased in all groups although significantly less in low-weight AN; insulin levels were not significantly affected, while c-peptide levels were significantly suppressed only in the constitutionally thin and PRAN subjects. In addition to our previous findings of impaired neuroendocrine and appetite responses in patients with AN, we conclude that metabolic responses to ghrelin are attenuated in these patients, which tend to recover with weight gain.

Late Relapse of Pediatric Medulloblastoma

Medulloblastoma ( MB), the most common malignant brain tumor of childhood, is classified according to pathomorphologic characteristics in the group of central nervous system embryonal tumors, but both its pathogenesis and biologic behavior remain unknown. In addition, the relationship of MB to other embryonal brain tumors is debated and response to therapy is difficult to predict. The authors report an uncommon case of unfavorable late relapse, local as well as distant, in a 26-year old male patient, who was free of disease and without treatment-related morbidity for fifteen years after combined therapy for pediatric MB.

Plasma ghrelin levels of gastrectomized and vagotomized patients are not affected by glucose administration

BACKGROUND

Ghrelin is a brain-gut peptide with GH-releasing and appetite-inducing activities, secreted mainly by the stomach. Circulating ghrelin concentrations fall rapidly after nutrient ingestion as well as after oral and intravenous glucose challenge. A number of gut hormones including ghrelin require an intact vagal system, which has been hypothesized to have a major role in initiating the postprandial fall in ghrelin levels.

AIM

We aimed to investigate the effect of oral glucose challenge on ghrelin secretion in gastrectomized (GASTRX) and vagotomized patients.

DESIGN

Interventional study.

PATIENTS

Six GASTRX-vagotomized patients and 11 healthy sex- and body mass index (BMI)-matched subjects.

METHODS

An oral glucose tolerance test (OGTT) was performed in all subjects. At baseline, circulating plasma total ghrelin, serum glucose, insulin and GH levels were measured. Serum glucose, insulin, GH and plasma ghrelin levels were determined every 30 min for 2 h.

RESULTS

Plasma ghrelin levels at baseline were reduced by 55% in GASTRX-vagotomized patients compared to the control group (P < 0.01). In control subjects, plasma ghrelin levels decreased significantly during the OGTT whereas in GASTRX-vagotomized patients no reduction was registered (26.4 +/- 2.8% vs. 5.5 +/- 3.4%). The OGTT revealed a significantly greater increase in circulating glucose levels and serum insulin levels while GH response was not different in GASTRX-vagotomized patients compared to control subjects.

CONCLUSIONS

Our data show that circulating ghrelin levels in GASTRX and vagotomized patients were not suppressed after oral glucose administration, unlike control subjects, suggesting that this effect could be due, at least in part, to the lack of contribution of the vagal nervous system to the regulation of ghrelin.

Ghrelin test for the assessment of GH status in successfully treated patients with acromegaly

OBJECTIVE

Posttreatment assessment of disease activity and definition of cure of acromegaly, using measurement of GH secretion, remains problematic. Furthermore, with our efforts to achieve tight biochemical control of the disease it is foreseeable that a proportion of patients may be rendered GH deficient, thus requiring testing for GH deficiency. The aim of our study was to evaluate residual GH secretion in cured patients with acromegaly.

DESIGN AND METHODS

At baseline, circulating GH, IGF-I, IGFBP-3, leptin and lipid (cholesterol and tri-glycerides) levels were measured in 33 acromegalic patients nine years after treatment with surgery of whom 6 were additionally irradiated. Two tests were performed: the GH suppression test--oral glucose tolerance test (OGTT) and the GH provocation test--ghrelin test (1 microg/kg i.v. bolus) and the results were compared with 11 age- and sex-matched control subjects.

RESULTS

According to the consensus criteria (normal IGF-I levels and post-OGTT GH nadir <1 microg/l), 21 treated acromegalic patients were cured, 6 had discordant IGF-I and GH nadir values during OGTT, while 6 had persistent acromegaly. After the GH provocative test with ghrelin (cut-off for severe GH deficiency is GH <3 microg/l), we detected 9 severely GH deficient patients (GHD) among 21 cured acromegalic patients. Mean GH peak (+/-s.e.m.) response to the ghrelin test in GHD acromegalics was significantly lower compared with acromegalics with sufficient GH secretory capacity and control subjects (1.2 +/- 0.2 microg/l vs 20.1 +/- 2.4 microg/l vs 31.1 +/- 2.5 microg/l respectively, P<0.0001). Mean IGF-I and IGFBP-3 levels were not different between GHD and GH-sufficient cured acromegalics. Leptin levels and body mass index (BMI) were significantly higher in GHD male acromegalics compared with GH-sufficient male acromegalics. GHD female acromegalics tended to have higher BMIs while leptin levels were not different.

CONCLUSIONS

The assessment of residual GH secretory capacity by the GH provocation test is necessary in the long-term follow-up of successfully treated acromegalics since a large proportion of these patients are rendered GH deficient.

Ghrelin has partial or no effect on appetite, growth hormone, prolactin, and cortisol release in patients with anorexia nervosa

CONTEXT

Anorexia nervosa (AN) is an eating disorder characterized by self-induced starvation. Gastric hormone ghrelin, potent orexigen, and natural GH secretagogue are increased in AN. Although exogenous ghrelin stimulates appetite, GH, prolactin, and cortisol release in humans, its effects have not been studied, during infusions, in AN patients.

OBJECTIVE

The objective of the study was to determine the effects of ghrelin on appetite, sleepiness, and neuroendocrine responses in AN patients.

DESIGN

This was an acute interventional study.

SETTING

The study was based at a hospital. Investigated

SUBJECTS

Twenty-five young women, including nine patients diagnosed with AN with very low body weight, six AN patients who partially recovered their body weight but were still amenorrheic, and 10 constitutionally thin female subjects, without history of eating disorder, weight loss, with regular menstrual cycles, were included in the study.

INTERVENTION

Each patient received 300-min iv infusion of ghrelin 5 pmol/kg.min and was asked to complete Visual Analog Scale questionnaires hourly.

MAIN OUTCOME MEASURES

Visual Analog Scale scores for appetite and sleepiness, GH, prolactin, and cortisol responses were measured.

RESULTS

At baseline, AN patients had significantly higher ghrelin, GH, and cortisol levels and significantly lower leptin than constitutionally thin subjects. GH responses to ghrelin infusion were blunted in patients with AN. Ghrelin administration did not significantly affect appetite but tended to increase sleepiness in AN patients.

CONCLUSIONS

Ghrelin is unlikely to be effective as a single appetite stimulatory treatment for patients with AN. Our results suggest that AN patients are less sensitive to ghrelin in terms of GH response and appetite than healthy controls. Ghrelin effects on sleep need further studies.

Leptin TRH and ghrelin: influence on energy homeostasis at rest and during exercise

The hypothalamus has long been recognized as a major site in the central nervous system (CNS) where a spectrum of internal and external environmental information is integrated for energy homeostasis. The isolation and sequencing of leptin in the mid 90 s, together with the demonstration of leptin administration's ability to correct the obesity syndrome in leptin-deficient ob/ob mice and humans by suppressing food intake and weight gain in laboratory rodents, confirmed the hypothesized existence of a direct humoral signal from adipose tissue to the hypothalamus, thus integrating the energy-related signals. In the 80 s, neuropeptide Y (NPY) was identified as a potent appetite-stimulating neuropeptide produced, released and acting locally within the hypothalamus. This is recognized as a major physiological appetite transducer and central neurochemical substrate receiving, interpreting and processing incoming information on energy status. More recently, ghrelin, produced in the stomach and released into the general circulation, has drawn attention as the other limb of the feedback circuit that stimulates appetite at NPY network level. Prolonged fasting suppresses serum leptin, while suppressing TSH secretion. Intervention with leptin replacement can prevent fasting-induced changes in TSH, suggesting that leptin regulates TSH. Low leptin levels in sportsmen and sportswomen as well as in recreational runners are consistent with reduction in body fat, but are also influenced by the presence of low insulin, hypothyroxemia, and elevated cortisol levels. These metabolic adaptations to chronic energy deficits indicate a role in leptin regulation. A study within the general population found that activity levels and leptin were significantly negatively associated in both sexes. Circulating ghrelin levels, however, do not change during energy expenditure.

Hypopituitarism following traumatic brain injury

Recent studies have demonstrated that hypopituitarism, and in particular growth hormone (GH) deficiency, is common among survivors of traumatic brain injury (TBI) tested several months or years following head trauma. In addition, it has been shown that post-traumatic neuroendocrine abnormalities occur early and with high frequency. These findings may have significant implications for the recovery and rehabilitation of patients with TBI. Although data emerging after 2000 demonstrate the relevance of the problem, in general there is a lack of awareness in the medical community about the incidence and clinical repercussions of the pathology. Most, but not all, head trauma associated with hypopituitarism is the result of motor accidents. The subjects at risk are those who have suffered moderate-to severe head trauma although mild intensity trauma may precede hypopituitarism also. Particular attention should be paid to this problem in children and adolescents. Onset of pituitary deficits can evolve over years following injury. For the assessment of the GH-IGF axis in TBI patients, plasma IGF-I concentrations, plus dynamic GH testing is indicated. Some degree of hypopituitarism is found in 35-40% of TBI patients. Among multiple pituitary deficits, the most common ones were GHD and gonadotrophin deficiency. In most series 10-15% presented with severe GHD and 15% with partial GHD after stimulating GH secretion confirming that the most common isolated deficit is GHD. Psychometric evaluation together with neurocognitive testing shows variability of disability and the possibility that untreated TBI induced hypopituitarism contributes to the chronic neurobehavioral problems seen in many head-injured patients warrants consideration. Preliminary data, from small pilot, open-label studies show that subjects treated with GH experience significant improvements in concentration, memory, depression, anxiety and fatigue. In conclusion, pituitary failure can occur even in minor head injuries and is poorly recognized.

Are there alternative tests for diagnosis of acromegaly?

In acromegaly, clinical features are of the utmost importance, and biochemical confirmation is rarely difficult. However, some clinically manifest acromegalics have subtle abnormalities in GH secretion resulting in post-glucose GH nadir in the designated "normal" range with high IGF-I levels. Clinical decision may be based on the probability of the disease and elevated IGF-I levels. The TRH test or the frequent GH sampling test may help confirm acromegaly but on their own have no diagnostic advantage. A TRH-GH response is not specific to acromegaly, while frequent sampling is not practical. Other tests rarely add information beyond that obtained by usual investigations. Post-treatment assessment of the disease activity and definition of acromegaly cure, by measuring GH secretion, remain problematic. IGF-I levels seem to differentiate normality less clearly and discordance of GH and IGF-I results is frequent. Post-treatment probability for residual disease activity should include more clinical parameters such as insulin sensitivity, leptin and echocardiography. Furthermore, with efforts to achieve tight biochemical control of the disease it is foreseeable that a proportion of patients may be rendered GH deficient, requiring stimulatory testing. Acromegaly is a disfiguring and disabling illness, in which by definition, the disorder is caused by a pituitary GH-secreting adenoma resulting in high circulating levels of GH and IGF-I. The clinical features of acromegaly include those of GH and IGF-I on tissues and the effects of the pituitary tumor itself. There is no single cut-off value for GH with perfect discrimination between acromegaly and normality. The recommended post-glucose GH nadir value of 1 microg/l is now considered to be inappropriately high, and measurement of IGF-I levels although extremely valuable has its limitations. Furthermore, some acromegalics may have subtle abnormalities in GH secretion, resulting in post-glucose GH nadir in the designated "normal" range with elevated IGF-I levels.

Hypopituitarism following traumatic brain injury (TBI): call for attention

Recent studies have demonstrated that hypopituitarism, in particular GH deficiency, is common among survivors of traumatic brain injury (TBI) years tested several months or following head trauma. In addition, it has been shown that post-traumatic neuroendocrine abnormalities occur early and with high frequency. These findings may have significant implications for the recovery and rehabilitation of patients with TBI. Although data emerging after year 2000 demonstrate the relevance of the problem, in general there is a lack of awareness in the medical community about the incidence and clinical repercussions of the pathology. Most, but not all, head trauma associated with hypopituitarism is the result of motor vechicle accidents. The subjects at risk are those who have suffered moderate-to-severe head trauma, although mild intensity trauma may also precede hypopituitarism. Particular attention should be paid to this problem in children and adolescents; onset of pituitary deficits can evolve over years following injury. Plasma IGF-I concentrations, plus dynamic GH testing, are indicated for the assessment of the GH-IGF axis in TBI patients. Some degree of hypopituitarism is found in 35-40% of TBI patients. Among mulitple pituitary deficits, the most common ones were GH deficiency (GHD) and gonadotrophin deficiency. In most series, 12-15% presented with severe GHD and 14% with partial GHD after stimulating GH secretion, confirming that the most common isolated deficit is GHD. Psychometric evaluation and neurocognitive testing show variability of disability, and these measures are needed and important to support hormonal replacement. Preliminary data, from small pilot, open-label studies show that subjects treated with GH experience significant improvements in concentration, memory, depression, anxiety and fatigue. In conclusion, pituitary failure can occur even in minor head injuries and is poorly recognized.