Psychomotor semiology in depression: a standardized clinical psychomotor approach

BACKGROUND

Although psychomotor symptoms are associated with the clinical symptomatology of depression, they are rarely assessed and standardized clinical evaluation tools are lacking. Psychomotor retardation is sometimes assessed through direct patient observations by clinicians or through a clinical observation grid, in the absence of a standardized psychomotor assessment. In this pilot study, we evaluated the feasibility of standardized psychomotor examination of patients with major depressive disorder (MDD) and detailed a psychomotor semiology in these patients.

METHODS

We used a standardized psychomotor assessment to examine 25 patients with MDD and 25 age- and sex-matched healthy controls (HC) and compared their psychomotor profiles. Using standardized tests, we assessed muscle tone and posture, gross motor skills, perceptual-motor skills, and body image/organization. Clinical assessments of depressive symptoms (levels of psychomotor retardation, anxiety, and self-esteem) comprised this detailed psychomotor examination.

RESULTS

All participants were examined using the standardized psychomotor assessment. The main results of the psychomotor examination highlighted low body image of MDD participants (p < 0.001). Significant differences between groups were found in passive muscle tone, posture, emotional control, jumping, manual dexterity, walking, and praxis. Among these psychomotor variables, body image, passivity, jumping and rhythm scores predicted an MDD diagnosis.

CONCLUSIONS

Beyond the psychomotor retardation known to be present in MDD patients, this examination revealed an entire psychomotor symptomatology characterized by elevated muscle tone, poor body image associated with poor self-esteem, slowness in global motor skills and manual praxis, and poor rhythmic adaptation. In light of these results, we encourage clinicians to consider using a standardized tool to conduct detailed psychomotor examination of patients with depressive disorders.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT04031937 , 24/07/2019.

[Linking Interventional Cardiology clinical registry data with French hospital administrative data: Development and validation of deterministic record linkage]

BACKGROUND

To recreate the in-hospital healthcare pathway for patients treated with coronary angiography or percutaneous coronary intervention, we linked the interventional cardiology registry (ACIRA) and the pseudonymized French hospital medical information system database (PMSI) in the Aquitaine region. The objective of this study was to develop and validate a deterministic merging algorithm between these exhaustive and complementary databases.

METHODS

After a pre-treatment phase of the databases to standardize the 11 identified linking variables, a deterministic linking algorithm was developed on ACIRA hospital stays between December 2011 and December 2014 in nine interventional cardiology centers as well as the data from the consolidated PMSI databases of the Aquitaine region from 2011 to 2014. Merging was carried out through 12 successive steps, the first consisting in strict linking of the 11 variables. The performance of the algorithm was analyzed in terms of sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). Strategies complementary to the initial algorithm (change in the order of variables and base preprocessing) were tested. Comparative analysis of merged/unmerged patients explored potential causes of mismatch.

RESULTS

The algorithm found 97.2% of the 31,621 ACIRA stays to have sensitivity of 99.9% (95% CI [99.9; 99.9]), specificity of 97.9% (95% CI [97.7; 98.1]), PPV of 99.9% (95% CI [99.9; 99.9]) and NPV of 96.9% (95% CI [96.7; 97.1]). Complementary strategies did not yield better results. The unmerged patients were older, and hospitalized mostly in 2012 in two interventional cardiology centers.

CONCLUSION

This study underscored the feasibility and validity of an indirect deterministic pairing to routinely link a registry of practices using hospital data to pseudonymized medico-administrative databases. This method, which can be extrapolated to other health events leading to hospitalization, renders it possible to effectively reconstruct patients' hospital healthcare pathway.

Long-acting pasireotide improves clinical signs and quality of life in Cushing's disease: results from a phase III study

PURPOSE

Cushing's disease (CD) is associated with significant clinical burden, increased mortality risk, and impaired health-related quality of life (HRQoL). This analysis explored the effect of long-acting pasireotide on clinical signs of hypercortisolism and HRQoL in a large subset of patients with CD.

METHODS

In this phase III study (clinicaltrials.gov: NCT01374906), 150 adults with CD and a mean urinary free cortisol (mUFC) level between 1.5 and 5.0 times the upper limit of normal (ULN) started long-acting pasireotide 10 or 30 mg every 28 days with dose increases/decreases permitted based on mUFC levels/tolerability (minimum/maximum dose: 5/40 mg). Changes in clinical signs of hypercortisolism and HRQoL were assessed over 12 months of treatment and were stratified by degree of mUFC control for each patient.

RESULTS

Patients with controlled mUFC at month 12 (n = 45) had the greatest improvements from baseline in mean systolic (- 8.4 mmHg [95% CI - 13.9, - 2.9]) and diastolic blood pressure (- 6.0 mmHg [- 10.0, - 2.0]). Mean BMI, weight, and waist circumference improved irrespective of mUFC control. Significant improvements in CushingQoL total score of 5.9-8.3 points were found at month 12 compared with baseline, irrespective of mUFC control; changes were driven by improvements in physical problem score, with smaller improvements in psychosocial score.

CONCLUSIONS

Long-acting pasireotide provided significant improvements in clinical signs and HRQoL over 12 months of treatment, which, in some cases, occurred regardless of mUFC control. Long-acting pasireotide represents an effective treatment option and provides clinical benefit in patients with CD.

CLINICAL TRIAL REGISTRATION NUMBER

NCT01374906.

Long-term treatment of Cushing's disease with pasireotide: 5-year results from an open-label extension study of a Phase III trial

BACKGROUND

Treating hypercortisolism in patients with Cushing's disease after failed surgery often requires chronic medication, underlining the need for therapies with favourable long-term efficacy and safety profiles.

METHODS

In a randomised, double-blind study, 162 adult patients with persistent/recurrent or de novo Cushing's disease received pasireotide. Patients with mean urinary free cortisol at/below the upper limit of normal or clinical benefit at month 12 could continue receiving pasireotide during an open-ended, open-label phase, the outcomes of which are described herein.

RESULTS

Sixteen patients received 5 years of pasireotide treatment. Among these, median (95% confidence interval) percentage change from baseline in mean urinary free cortisol was -82.6% (-89.0, -41.9) and -81.8% (-89.8, -67.4) at months 12 and 60. Eleven patients had mean urinary free cortisol ≤ upper limit of normal at month 60. Improvements in clinical signs were sustained during long-term treatment. The safety profile of pasireotide at 5 years was similar to that reported after 12 months. Fifteen of 16 patients experienced a hyperglycaemia-related adverse event; glycated haemoglobin levels were stable between months 6 and 60. Adverse events related to hyperglycaemia, bradycardia, gallbladder/biliary tract, and liver safety were most likely to first occur by month 6; adverse event severity did not tend to worsen over time.

CONCLUSIONS

This represents the longest prospective trial of a medical therapy for Cushing's disease to date. A subset of patients treated with pasireotide maintained biochemical and clinical improvements for 5 years, with no new safety signals emerging. These data support the use of pasireotide as an effective long-term therapy for some patients with Cushing's disease.

A grounded theory of service providers’ perceptions of a recovery-oriented transformation of a mental health service

Recovery-oriented mental health service programs are often rather based on ideological or political considerations than on empirical evidence.

At Klinikum Bremerhaven Reinkenheide, we have included peer support workers in our teams in order to improve the quality of our treatment program and the recovery attitudes of the staff members.

To control and evaluate this process an independent investigator conducted 13 (T1: February 2012), respectively 15 (T2: September 2013) interviews with different stakeholders of the change process. The interviews were transcribed and analysed for the categories level of information, confidence, participation and profession/working conditions/team structure.

The main result of T1 was that nursing staff fostered the projected transformation while physicians and psychologists focused on risk management and worried about losing their role. As implication of the T1 results, we offer a continuous in-house-training to improve interprofessional teamwork and social psychiatric expertise. At T2 all interviewed participants judged the involvement of the peer support workers positively. Many oft the interviewees expressed though that from their point of view their participation had decreased and/or, the reorganisation was already terminated. As implication of T2, we now try to improve our internal communication and cooperation and strengthen the involvement of all stakeholder groups.

Besides the employment of peer support workers, it is essential in a recovery-oriented transformation of mental health services:

– to train staff members continuously and;

– to involve all stakeholder groups continuously in the change management.

A third survey is projected for 2017 to implement further requirements for a successful change process.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Recovery of adrenal function after chronic secondary adrenal insufficiency in patients with hypopituitarism

OBJECTIVE

Previous studies have reported recovery of secondary adrenal insufficiency (SAI) in patients with pituitary disorders, generally immediately after pituitary surgery; however, data regarding recovery of long-term SAI are lacking. We conducted a study to assess the longer term recovery rate of SAI in patients with pituitary disorders.

METHODS

We identified all SAI patients in the Halifax Neuropituitary Database from 1 November 2005 to 30 September 2014, who had required glucocorticoid therapy for ≥3 months, and had a minimum follow-up of 6 months. Patients with ACTH-secreting adenomas, those receiving glucocorticoids only in the routine peri-operative period for pituitary surgery and those on glucocorticoids for nonpituitary conditions were excluded. SAI was defined as either basal serum cortisol < 130 nm and/or a subnormal cortisol response to ACTH-(1-24) stimulation test or insulin tolerance test response.

RESULTS

Fifty-one patients fulfilled the criteria. Nine (17·6%) patients had complete recovery of SAI over a median of 20 months (range: 8-51) after initiating glucocorticoid replacement. Patients with smaller tumour size had increased likelihood of hypothalamic-pituitary-adrenal (HPA) axis recovery, whereas those with secondary hypogonadism or growth hormone deficiency were less likely to recover. Those with initial cortisol >175 nm had an almost one in two chance of recovery.

CONCLUSION

Results from our study show that approximately one in six patients with SAI recover adrenal function, even up to 5 years after diagnosis. We recommend that patients with SAI undergo regular testing to assess recovery in order to prevent unnecessary glucocorticoid therapy.

[Recovery and Inclusion: A Field Report on 5 Years of Peer Support in Psychiatry]

We report on 5 years of hands-on experience with the inclusion of peers as recovery companions in the psychiatric teams at Klinikum Bremerhaven-Reinkenheide. It was our aim to offer those affected the possibility of professional inclusion into peer support and organize our department more strongly in line with recovery principles as result of their work. Currently, seven peer support people are permanent employees at our department. Their salaries are covered by the nursing budget. We discuss the preconditions of our model, implementation of the program, changes that occurred, but also problems that arose.

Management of patients with Cushing's disease: a Canadian cost of illness analysis

BACKGROUND

Cushing's disease (CD) is a rare disorder caused by increased pituitary secretion of adrenocorticotropic hormone (ACTH) resulting in elevated production of cortisol. It is associated with multiple adverse cardiovascular, metabolic, musculoskeletal and mental consequences. Patients with CD require substantial health care resources both in terms of treatments with a curative intent and control of disease related co-morbidities. In this study, a cost of illness analysis was conducted to estimate the direct cost of CD care in Canada.

METHODS

This was a retrospective cohort study of 86 CD patients. Data collection included patient demographic and disease related information, existing comorbidities, treatments received and all clinical outcomes. In addition, healthcare resource utilization to manage CD was also collected. Once the mean cost per patient was determined, the overall disease prevalence was used to estimate the total direct cost of illness in Canada.

RESULTS

The sample included 86 CD patients, with a mean age of 43 years at diagnosis, 72% were female. All received a first line intervention consisting of transsphenoidal pituitary surgery (78%), bilateral adrenalectomy (5%), radiation therapy (5%) or medical therapy ± radiation (13%). In addition, 18 and 14 patients subsequently received a second and third line intervention, respectively. The mean cost was $85,946 per patient over the first three lines of therapy. Combining this estimate with the reported disease prevalence (5.5 patients per 100,000 [95%CI: 4.2 to 6.8]), the total direct cost of CD in Canada was estimated to be approximately $80.6 million (95%CI: $61.5 to $99.6 million) over the first 3 lines of therapy.

CONCLUSIONS

CD is a debilitating condition that is associated with substantial health care costs. Strategies that provide clinical cure or long term disease control need to be identified to reduce patient morbidity and to save health care costs in patients who remain uncontrolled.

Outpatient parenteral antimicrobial therapy for infective endocarditis: a cost-effective strategy

OBJECTIVES

We evaluated the benefit/risk ratio of outpatient parenteral antimicrobial therapy (OPAT) in infective endocarditis (IE).

METHOD

We performed an observational retrospective study of definite IE (Duke criteria) treated in an infectious diseases unit in 2012. We compared patients having completed the treatment in hospital (H), and those deemed sufficiently stable, and with adequate home environment, for OPAT. The costs were estimated through hospital bills, and, for OPAT, through the costs of drugs and their administration (material, staff), transportation, and outpatient visits.

RESULTS

Eighteen out of 39 consecutive patients presenting with IE received OPAT, with a mean hospital stay of 23.5days (vs 34.7days for H group, P=0.014). No severe adverse event related to OPAT was reported. The global saving was estimated at 267,307euros, or 14,850euros per patient.

CONCLUSIONS

OPAT in selected patients presenting with IE seems effective, safe, and reduces costs by approximately 15,000euros per patient.

Youngsters do not pay attention to conversational rules: is this so for nonhuman primates?

The potentiality to find precursors of human language in nonhuman primates is questioned because of differences related to the genetic determinism of human and nonhuman primate acoustic structures. Limiting the debate to production and acoustic plasticity might have led to underestimating parallels between human and nonhuman primates. Adult-young differences concerning vocal usage have been reported in various primate species. A key feature of language is the ability to converse, respecting turn-taking rules. Turn-taking structures some nonhuman primates' adult vocal exchanges, but the development and the cognitive relevancy of this rule have never been investigated in monkeys. Our observations of Campbell's monkeys' spontaneous vocal utterances revealed that juveniles broke the turn-taking rule more often than did experienced adults. Only adults displayed different levels of interest when hearing playbacks of vocal exchanges respecting or not the turn-taking rule. This study strengthens parallels between human conversations and nonhuman primate vocal exchanges.

Transient efficacy of octreotide and pasireotide (SOM230) treatment in GIP-dependent Cushing's syndrome

We studied a 55-year old woman presenting with features of Cushing's syndrome associated with metabolic abnormalities including severe hypertension and type 2 diabetes. Urinary free cortisol excretion was within normal limits, but an unusual diurnal cortisol rhythm was observed with low morning and high postprandial levels, associated with the absence of cortisol suppression after dexamethasone, suggesting the possibility of GIP-dependent Cushing's syndrome. The diagnosis was confirmed by further investigations, showing significant plasma cortisol responses after a mixed meal test and after oral, but not intravenous glucose administration, as well as ACTH-independent bilateral macronodular adrenal hyperplasia (AIMAH). An aberrant increase in cortisol was also observed after glucagon and terlipressin injections. The patient was first treated with octreotide 100-250 μg thrice daily for 6 months, then with the new multi-ligand somatostatin analogue (SOM 230) 450-900 μg twice daily for 3 months. Although inducing a significant acute suppression of post-prandial cortisol response, both drugs had no effects on the clinical and metabolic abnormalities associated with Cushing's syndrome and new tests performed at the end of each treatment period confirmed escape of post-meal cortisol suppression to therapy. The patient finally underwent a bilateral adrenalectomy, which markedly improved her medical condition and allowed in vitro confirmation by real time RT-PCR quantification of a high aberrant expression of GIP receptor mRNA in adrenal tissue. This case report illustrates the lack of sustained efficacy of somatostatin analogues on GIP-dependent Cushing's syndrome, independent of their affinity for the different somatostatin receptor subtypes.

Clinical and biochemical features of seven adult adrenal ganglioneuromas

BACKGROUND

Adrenal ganglioneuroma (GN) is seldom considered in the differential diagnosis of adrenal lesions, and its clinical presentation is not well known.

OBJECTIVE

Our aim was to describe the clinical, biochemical, and radiological features of adrenal GNs in adults.

METHODS

Seven adults underwent endocrine investigation for adrenal lesions that were confirmed to be adrenal GNs.

RESULTS

Mean age of the seven patients was 49 yr (range, 23 to 71 yr). Average tumor diameter was 5.0 cm (range, 1.5 to 10.4 cm). In five patients, the adrenal lesions were found incidentally. A 49-yr-old female carried a germline mutation in MSH2 gene. A 57-yr-old female presented with mild virilization and increased testosterone levels. Bilateral adrenal venous sampling revealed testosterone production from her right adrenal lesion. All tumors showed nonenhanced attenuation between 25 and 40 Hounsfield units on computed tomography scan. Magnetic resonance imaging revealed low- to iso-signal intensity on T1-weighted imaging and high-signal intensity on T2-weighted imaging. [(18)F]-2-Fluoro-deoxy-d-glucose-positron emission tomography scan (n = 5) disclosed a mean standard uptake value of 2.4. Three tumors were composite pheochromocytoma-GN. Microsatellite instability study and immunohistochemical analysis of MSH2 protein in a patient carrying a MSH2 mutation showed normal MSH2 protein expression and low microsatellite instability, indicating that the adrenal GN was not related to the patient's MSH2 germline defect.

CONCLUSIONS

We describe one of the largest series of adult adrenal GNs. Adrenal GNs may secrete testosterone or be part of a composite tumor with pheochromocytoma. The association of adrenal GN with MSH2 mutation seems to be a coincidental finding.

Aberrant hormone receptors in primary aldosteronism

The mechanisms involved in the renin-independent regulation of aldosterone secretion in primary aldosteronism are poorly understood. In ACTH-independent Cushing's syndrome, cortisol secretion can be regulated by the aberrant expression of G-protein coupled receptors (GPCRs) in unilateral tumors and bilateral macronodular adrenal hyperplasia. By analogy, some recent studies identified overexpression or function of several GPCR as a potential cause for excess aldosterone production in some aldosteronomas and in bilateral idiopathic hyperaldosteronism. Initial studies have used in vitro techniques, while the clinical aldosterone responses were not assessed. More recently, several receptors have been shown to be expressed in aldosterone-producing adrenal tumors in vitro and to regulate aberrantly renin-independent aldosterone secretion in vivo. The prevalence of aberrant hormone receptors in primary aldosteronism could be elevated, but larger systematic studies are required to establish its true frequency. The identification of aberrant adrenal GPCRs by in vivo functional studies offers the potential for novel pharmacological therapies that either suppress the endogenous ligands or block the receptor with specific antagonists.

What ecological factors can affect albumen corticosterone levels in the clutches of seabirds? Timing of breeding, disturbance and laying order in rockhopper penguins (Eudyptes chrysocome chrysocome)

Female birds deposit corticosterone into their eggs. Elevated concentrations of this hormone may interfere with the development of their offspring, and mothers should thus regulate corticosterone levels deposited into the eggs adaptively. However, if females are unable to regulate deposition, then the corticosterone concentration in eggs should reflect that in female plasma and should be influenced by stressors to the females. We measured corticosterone levels in the albumen of rockhopper penguins, and assessed their relationship with hatching order, human disturbance and laying date. Rockhopper penguins (Eudyptes chrysocome chrysocome) lay two eggs, of which the second egg (B-egg) is larger and hatches faster than the first egg (A-egg). The chick hatching from the B-egg is also much more likely to survive than its sibling. Albumen corticosterone concentrations were lower in B-eggs. However, as B-eggs contained more albumen than A-eggs, the total corticosterone deposited in the albumen was not significantly different between the two eggs. Daily disturbance by human observers during albumen production did not influence albumen corticosterone levels. Laying date had an effect on total albumen corticosterone through a higher albumen mass. However, we observed a high individual component in the composition of eggs from the same clutch. Thus, more work is required to explore the hypotheses of passive versus active transfer to eggs and to understand the adaptive value of contrary effects on the amount and concentration of corticosterone.

Food-dependent Cushing's syndrome

It has recently been proposed that other hormones than ACTH can control cortisol production in Cushing's syndrome with bilateral adrenal hyperplasia. We present a case of food-dependent Cushing's syndrome. After a positive response of cortisol production during mixed meals, several tests identified glucose-dependent insulinotropic polypeptide (GIP) as the driving hormone responsible for the cortisol overproduction. Identification of aberrant hormone receptor expression is of importance because it may create a possibility for pharmacological treatment.

Treatment of adrenocorticotropin-dependent Cushing's syndrome: a consensus statement

OBJECTIVE

Our objective was to evaluate the published literature and reach a consensus on the treatment of patients with ACTH-dependent Cushing's syndrome, because there is no recent consensus on the management of this rare disorder.

PARTICIPANTS

Thirty-two leading endocrinologists, clinicians, and neurosurgeons with specific expertise in the management of ACTH-dependent Cushing's syndrome representing nine countries were chosen to address 1) criteria for cure and remission of this disorder, 2) surgical treatment of Cushing's disease, 3) therapeutic options in the event of persistent disease after transsphenoidal surgery, 4) medical therapy of Cushing's disease, and 5) management of ectopic ACTH syndrome, Nelson's syndrome, and special patient populations.

EVIDENCE

Participants presented published scientific data, which formed the basis of the recommendations. Opinion shared by a majority of experts was used where strong evidence was lacking.

CONSENSUS PROCESS

Participants met for 2 d, during which there were four chaired sessions of presentations, followed by general discussion where a consensus was reached. The consensus statement was prepared by a steering committee and was then reviewed by all authors, with suggestions incorporated if agreed upon by the majority.

CONCLUSIONS

ACTH-dependent Cushing's syndrome is a heterogeneous disorder requiring a multidisciplinary and individualized approach to patient management. Generally, the treatment of choice for ACTH-dependent Cushing's syndrome is curative surgery with selective pituitary or ectopic corticotroph tumor resection. Second-line treatments include more radical surgery, radiation therapy (for Cushing's disease), medical therapy, and bilateral adrenalectomy. Because of the significant morbidity of Cushing's syndrome, early diagnosis and prompt therapy are warranted.

Familial adrenocorticotropin-independent macronodular adrenal hyperplasia with aberrant serotonin and vasopressin adrenal receptors

ACTH-independent macronodular adrenocortical hyperplasia (AIMAH) is rare and generally presents as a sporadic disease. We describe a familial case of AIMAH with in vivo and in vitro demonstration of aberrant 5-HT4 and vasopressin adrenal receptors. Two sisters presented with clinical and biological features of mild Cushing's syndrome with bilateral macronodular adrenal enlargement on computerized tomography (CT)-scan evaluation. In vivo pharmacological tests showed a significant increase in plasma cortisol after terlipressin and metoclopramide administration. Unilateral adrenalectomy was performed in one of these patients. Reverse transcriptase-PCR analysis of the hyperplastic tissue revealed expression of 5-HT4 receptor isoforms (a), (b), (c), (i), and (n), and of vasopressin receptors, V1 and V2. Their father and brother were overweight, had easy bruisability and presented with biological features of subclinical Cushing's syndrome. CT scan showed moderate adrenal enlargement. In vivo pharmacological screening tests for the detection of adrenal aberrant receptors in the brother were negative. Finally, three out of the two sisters' children were evaluated. They had neither clinical nor biological features of Cushing's syndrome. Their adrenal glands were normal on CT-scan evaluation. In vivo evaluation for the detection of aberrant adrenocortical receptors performed in one of these subjects was negative. In conclusion, this study shows that (i) familial AIMAH could be an autosomal dominantly inherited disorder; (ii) aberrant 5-HT4 serotonin and vasopressin receptors can be expressed in familial AIMAH; and (iii) phenotypic expression of familial AIMAH could be varied in a same family and more pronounced in female than in male patients.

Yolk androgens in the barn swallow (Hirundo rustica): a test of some adaptive hypotheses

Maternal effects such as androgen in avian eggs can mediate evolutionary responses to selection, allowing manipulation of offspring phenotype and promoting trans-generational adaptive effects. We tested the predictions of two adaptive hypotheses that have been proposed to explain female variation in yolk androgen allocation in birds, using the barn swallow Hirundo rustica as a model. We found no support for the first hypothesis proposing that yolk androgen varies as a function of breeding density in order to prepare offspring for different breeding densities. However, we found experimental support for the hypothesis that female yolk androgen allocation depends on mate attractiveness and that it constitutes an example of differential allocation. Females increased the concentration of androgens in their eggs when mated to males with experimentally elongated tails. Female phenotypic quality as measured by arrival date and clutch size was positively related to egg androgen concentration, consistent with the hypothesis that this is a costly investment, constrained by female condition. We found correlative evidence of a direct relationship between egg androgen concentration and performance of offspring as measured by mass increase.

Correlation between nutritional biomarkers and breast cancer: a case-control study

A case-control study to explore associations between retinoids, tocopherols, total and beta-carotenes and breast cancer was conducted by analysing concentrations of these biomarkers in adipose tissue, cheek cells and plasma. A total of 414 French-Canadians in Montreal with new diagnoses of breast cancer were age-matched to 429 population-based controls. Subjects were interviewed using a questionnaire, and biological samples from 287 cases and 112 controls were collected within 3 months of the diagnosis. Mean beta carotene concentrations in cheek cells were significantly lower among controls. Odds ratios (ORs) from logistic regression analysis were used to compare higher and lower tercile concentrations. Significant positive associations were observed in adipose tissue for retinoid [OR=2.11; 95% CI (1.09-4.08)] and beta carotene [OR=3.18; 95% CI (1.70-5.93)]; in cheek cells for beta carotene [OR=2.22; 95% CI (1.21-4.50)] and for total carotenes [OR=2.94; 95% CI (1.59-5.42)] and in plasma for beta carotene [OR=1.53; 95% CI (0.80-2.93)] and total carotenes [OR=1.04; 95% CI (0.53-2.05)]. Among the control groups, significant Pearson correlations were observed between cheek cells and adipose tissue for total carotenes (r=0.27; p=0.01) and cheek cells and plasma (r=0.22; p=0.04). In contrast to previous works, this study shows that high concentrations of retinoids and carotenes in adipose tissue and cheek cells are associated with increased risk of breast cancer. However, all these studies are limited by small sample size. Although our study tested a limited number of controls, important associations were observed. These results suggest that the effect of disease on biomarkers is fundamental to the interpretation of epidemiological data. We suggest either that the high levels of these biomarkers found in cancer patients in this study may be due to the disease process that affects the pharmacokinetics of the biomarker or that the disease causes a change in dietary habits. In addition, in studies involving the application of biomarkers to cancer epidemiology it is imperative that a typical biomarker concentration is not associated with breast cancer risk before further examination of the methodological limitations of epidemiological studies investigating this relationship. Therefore, sample size, selection bias, information bias, and confounding should be considered in the design of studies investigating the aetiological relationship between biomarkers and breast cancer.

Analysis of the putative regulatory region of the gastric inhibitory polypeptide receptor gene in food-dependent Cushing's syndrome

Gastric inhibitory polypeptide (GIP)-dependent Cushing's syndrome (CS) results from the ectopic expression of non-mutated GIP receptor (hGIPR) in the adrenal cortex. We evaluated whether mutations or polymorphisms in the regulatory region of the GIPR gene could lead to this aberrant expression. We studied 9.0kb upstream and 1.3kb downstream of the GIPR gene putative promoter (pProm) by sequencing leukocyte DNA from controls and from adrenal tissues of GIP- and non-GIP-dependent CS patients. The putative proximal promoter region (800 bp) and the first exon and intron of the hGIPR gene were sequenced on adrenal DNA from nine GIP-dependent CS, as well as on leukocyte DNA of nine normal controls. Three variations found in this region were found in all patients and controls; at position -4/-5, an insertion of a T was seen in four out of nine patients and in five out of nine controls. Transient transfection studies conducted in rat GC and mouse Y1 cells showed that the TT allele confers loss of 40% in the promoter activity. The analysis of the 8-kb distal pProm region revealed eight distal single nucleotide polymorphisms (SNPs) without probable association with the disease, since frequencies in patients and controls were very similar. In conclusion, mutations or SNPs in the regulatory region of the GIPR gene are unlikely to underlie GIP-dependent CS.

The use of information technology for the management of intensive insulin therapy in type 1 diabetes mellitus

OBJECTIVE

The purpose of the study was to evaluate the safety of a computer program used by the patient for the adjustment of insulin doses to achieve tight glycemic control in type 1 diabetic subjects on intensive insulin therapy.

METHODS

Ten type 1 diabetic patients participated in the study. Using the basal-bolus (UL-Humalog) insulin regimen, they were randomized in a crossover design to 2 intensive treatment periods of 8 weeks each, one with and the other without the assistance of a computer program via the Internet. They measured their capillary blood glucose regularly, and the results were entered on a daily basis into their log-book or in the computer. During intensive treatment with the computer, the software would provide recommendation for insulin dose adjustment according to specific algorithms. When on intensive treatment without computer assistance, they would adjust their own insulin dose according to the same algorithms.

RESULTS

The study subjects followed 89% of the recommendations made by the computer. With the computer, subjects made more insulin dose adjustments (98 versus 50) than without. Intensive treatments with and without computer assistance resulted in a similar improvement of pre-meal/post-prandial capillary blood glucose from 7.6 +/- 2.7/9.5 +/- 2.5 to 6.7 +/- 2.3/8.8 +/- 2.5 and 6.7 +/- 2.6/9.0 +/- 2.6 mmol/L, respectively. Glygated hemoglobin also improved from 7.7 +/- 0.9% to 7.2 +/- 0.7 and 7.3 +/- 0.8%, respectively. The incidence of minor hypoglycemia was similar under both intensive treatments (7.9 +/- 4.0 and 7.1 +/- 5.0/patient/28 days, respectively). Both treatments increased patient behavior while patient knowledge of their disease was improved only during computer assistance. There was no effect on quality of life. The study subjects greatly appreciated the software and wanted to continue using it.

CONCLUSIONS

The study demonstrated that the use of computer software by the patient to adjust insulin doses for intensive insulin therapy is feasible and is not associated with increased adverse events.

Change in plasma cortisol and metabolites during the attendance period ashore in fasting lactating subantarctic fur seals

Lactating fur seals (Arctocephalus tropicalis) alternate foraging trips at sea and pup attendance periods ashore. During the onshore nursing periods, lactating females do not have access to food and meet both their own metabolic requirements and milk production from their body reserve. Blood and milk samples were collected from females captured soon after their arrival ashore from a foraging trip and before their departure. Milk lipid but not milk protein content was positively related to the body condition index (BCI) of the female. During the 4-day attendance period ashore, females lost body mass, and plasma cortisol levels increased, whereas plasma urea concentration decreased and beta-hydroxybutyrate (beta-OHB) remained unchanged. The increase in cortisol level took place while blood urea concentration decreased and beta-OHB remained at a low level suggesting that it was independent from the transition from phase II to phase III that is indicative of the depletion of lipid body store as described in penguins. Thus, our results suggest that the increase in cortisol level in relation to decreasing BCI may either contribute to the mobilization of protein stores to ensure milk production when easily mobilized stores are used and/or could act as a re-feeding signal which is triggered well before females have depleted their body store.

Diagnosis and complications of Cushing's syndrome: a consensus statement

In October 2002, a workshop was held in Ancona, Italy, to reach a Consensus on the management of Cushing's syndrome. The workshop was organized by the University of Ancona and sponsored by the Pituitary Society, the European Neuroendocrine Association, and the Italian Society of Endocrinology. Invited international participants included almost 50 leading endocrinologists with specific expertise in the management of Cushing's syndrome. The consensus statement on diagnostic criteria and the diagnosis and treatment of complications of this syndrome reached at the workshop is hereby summarized.

Behavioural dominance and Taenia crassiceps parasitism in BALB/c male mice

Behavioural dominance relationships in mouse populations are based upon fighting and antagonistic behaviour. Social rank is affected by the physiological states present in the mice. Experimental infection by Taenia crassiceps cysticerci induced physiological disorders and disrupted the dominant-subordinate status. Infected male mice showed strong perturbations in territorial behaviour and aggressiveness. Infected dominant male mice did not show a significant reversal of dominance order compared to uninfected mice. In addition, during confrontation between naive infected and healthy mice, infected animals more often assumed a subordinate status than healthy ones. The effects of the infection by T. crassiceps were more likely to prevent adult male mice from becoming behaviourally dominant than to reverse existing dominance relationships. The results are discussed on the basis of the parasite manipulation hypothesis and host optimal foraging and decision-making theories.

An adolescent with food-dependent Cushing's syndrome secondary to ectopic expression of GIP receptor in unilateral adrenal adenoma

ACTH-independent Cushing's syndrome may be secondary to the expression of ectopic hormone receptors in adrenal tissue. In food-dependent Cushing's syndrome the adrenals aberrantly express receptors for gastric inhibitory polypeptide (GIP). We present the first case of food- and GIP-dependent adrenal adenoma in an adolescent. A 15 year-old girl presented with signs of hypercortisolism. Urinary cortisol excretion was clearly elevated. Upon the finding of very low fasting plasma cortisol levels with a rise during the morning, food-dependent cortisol secretion was suspected. Hourly measurements of plasma cortisol and GIP levels during a day with and a day without meals showed meal- and GIP-related cortisol secretion. Plasma ACTH levels were undetectable. Abdominal computed tomography showed a tumor of 2.5 x 2.5 x 2 cm in the left adrenal. Unilateral adrenalectomy was performed and microscopic examination of the tumor showed an adrenocortical adenoma. Incubation of adenomatous cells prepared from this tumor with GIP resulted in increased cortisol secretion. Using RT-PCR amplification and cDNA hybridization, the GIP receptor was found to be overexpressed in the adenoma tissue but not in the adjacent adrenal tissue. Twelve months after the operation, hourly measurements of plasma cortisol, GIP and ACTH levels on a day with and a day without meals no longer showed GIP-related cortisol production. The present report shows that in an adolescent with corticotrophin-independent Cushing's syndrome, food-dependent hypercortisolism is a possible diagnosis.