[Medical-surgical integrated approach in the treatment of non-paraneoplasic hyperparathyroidism: our experience]

OBJECTIVE

Hyperparathyroidism is a generalized alteration of calcium, phosphorus and bone metabolism due to an increased secretion of parathyroid hormone (PTH). In addition to the paraneoplastic ectopic type, we can distinguish three eutopic types of hyperparathyroidism, i.e., the primary form, mostly due to a benign or malignant tumor of parathyroid gland, the secondary form, typical of kidney disease and tertiary form, due to the progression of secondary forms. There is not agreement, in medical literature, on the treatment of these patients. To establish the correct therapeutic approach in patients with hyperparathyroidism, we have followed a group of symptomatic subjects suffering from primary, secondary and tertiary hyperparathyroidism, taking into account the therapeutic needs.

MATERIALS AND METHODS

We followed for 12 months 155 patients suffering from primary, secondary and tertiary hyperparathyroidism; 82 were in end stage kidney disease, 93 were hypertensive. Subjects with primary forms has been treated, before parathyroidectomy, with idration (physiological solution of NaCl), bisphosphonates i.v. (pamidronate 60-90 mg in 4-6h) and, if serum calcium was higher than 12 mg/dl, loop diuretics (furosemide 40 mg/day). Subjects with secondary forms has been treated with hypophosphoric diet, phosphate bindings (calcium carbonate 1 g/day) and oral calcitriol (1 microg/d) before subtotal parathyroidectomy. After surgery it was administered support therapy with calcium gluconate (40 ml/day) and vitamin D (2.5mg/d) until serum calcium normalization.

RESULTS

There were 55 cases of post surgery hypertensive attack treated with clonidine (300 microg/d); 8 months later there was not relapses but in all patients there was reduction of serum calcium concentration that required a substitutive treatment (calcium 1 g/day and calcitriol 1 microg/day). There was 1 case of heavy hypocalcemic state treated with calcium gluconate i.v. (40 ml/day).

CONCLUSIONS

A correct approach to a non-paraneoplastic hyper-parathyroid patient need of an integration of both current medical and surgical options. In primary forms the first option is the surgical approach supported by medical treatment. In secondary forms medical approach is preferable to control renal and vascular complications, while surgical therapy is to prefer in non-responders to medical therapy forms.

[Medical-surgical integrated approach in the treatment of non-paraneoplasic hyperparathyroidism: our experience]

OBJECTIVE

Hyperparathyroidism is a generalized alteration of calcium, phosphorus and bone metabolism due to an increased secretion of parathyroid hormone (PTH). In addition to the paraneoplastic ectopic type, we can distinguish three eutopic types of hyperparathyroidism, i.e., the primary form, mostly due to a benign or malignant tumor of parathyroid gland, the secondary form, typical of kidney disease and tertiary form, due to the progression of secondary forms. There is not agreement, in medical literature, on the treatment of these patients. To establish the correct therapeutic approach in patients with hyperparathyroidism, we have followed a group of symptomatic subjects suffering from primary, secondary and tertiary hyperparathyroidism, taking into account the therapeutic needs.

METHODS

We followed for 12 months 155 patients suffering from primary, secondary and tertiary hyperparathyroidism; 82 were in end stage kidney disease, 93 were hypertensive. Subjects with primary forms has been treated, before parathyroidectomy, with hydration (physiological solution of NaCl), bisphosphonates i.v. (pamidronate 60-90 mg in 4-6h) and, if serum calcium was higher than 12 mg/dl, loop diuretics (furosemide 40 mg/day). Subjects with secondary forms has been treated with hypo-phosphoric diet, phosphate bindings (calcium carbonate 1 g/day) and oral calcitriol (1 microg/d) before subtotal parathyroidectomy. After surgery it was administered support therapy with calcium gluconate (40 ml/day) and vitamin D (2.5mg/d) until serum calcium normalization.

RESULTS

There were 55 cases of post surgery hypertensive attack treated with clonidine (300 microg/d); 8 months later there was not relapses but in all patients there was reduction of serum calcium concentration that required a substitutive treatment (calcium 1 g/day and calcitriol 1 microg/day). There was 1 case of heavy hypocalcemic state treated with calcium gluconate i.v. (40 ml/day).

CONCLUSIONS

A correct approach to a non-paraneoplastic hyper-parathyroid patient need of an integration of both current medical and surgical options. In primary forms the fi rst option is the surgical approach supported by medical treatment. In secondary forms medical approach is preferable to control renal and vascular complications, while surgical therapy is to prefer in non-responders to medical therapy forms.

[Hyperhomocysteinemia, oxidative stress, endothelial dysfunction in postmenopausal women]

AIM

Menopause seems to accelerate the development of atherosclerosis and cardiovascular diseases. Several studies show a significant correlation between elevated homocysteine serum levels and increased cardiovascular risk. Oxidative stress is involved in the pathophysiology of endothelial dysfunction and atherosclerosis. Our study aim was to assess the correlations between intima-media thickness, homocysteine serum levels and oxidative stress both in fertile and postmenopausal women.

MATERIALS AND METHODS

We have investigated 34 fertile women (mean age = 42 +/- 2 yrs; BMI = 21 kg/m2 and 34 postmenopausal women (48 +/- 3 yrs; BMI = 22 +/- 2 kg/m2).

RESULTS

Results show increased levels of homocysteine, oxidative stress and intima-media tickness (IMT) in postmenopausal women. having a positive correlation with IMT.

CONCLUSIONS

The positive correlations between serum levels of homocysteine and IMT in postmenopausal women reinforce the idea that a hyperhomocysteinemia may play a role in the progression of atherosclerosis. The lack of estrogens could be a pathophysiologic risk factor for endothelial damage via an augmented oxidative stress. Clin

[Heterozygosis H63D in patients with steatohepatitis and chronic hepatitis C]

OBJECTIVE

Classic hereditary hemochromatosis is an autosomal recessive iron-overload disorder associated with mutation of the HFE gene. The homozygous genetic defect predisposes to a chain of events that may culminate in severe damage in multiple organs. Pathologic implications of heterozygous defect are still questionable; in fact since these individuals may have slight increases in intra-cellular iron, it has been questioned whether this would enhance damage from other diseases. We investigated whether steatohepatitis and chronic hepatitis C can be worsened by heterozygosis for C282Y and H63D.

PATIENTS AND METHODS

We investigated 216 subjects with Steatohepatitis and/or chronic hepatitis C diagnosed by ultrasonography and liver biopsy with histological assessment compared with 110 healthy subjects. In all subjects we performed Saturated Transferrine, Plasma Ferritin and the research of HFE mutation by a Real Time Method. A statistical analysis was performed.

RESULTS

A H63D mutation was present in 32/108 patients with Steatohepatitis, in 30/108 patients with chronic hepatitis C and in 22/110 healthy subjects. A C282Y mutation was present in 2/108 patients with chronic hepatitis C, in 4/108 with steatohepatitis and in 2/108 healthy subjects. No significant difference was present about incidence of this mutation between pathological and healthy subjects. No significant differences have observed between pathological groups and normal group about the degree of histological damage.

CONCLUSIONS

Our study revealed that steatohepatitis and chronic hepatitis C cannot be worsened by heterozygosis for C282Y and H63D.

A case of progression from type II cryoglobulinaemia to Waldenstrom's macroglobulinaemia in a patient with chronic hepatitis C

Hepatitis C infection is associated with B-cell lymphoproliferative disorders, including mixed cryoglobulinaemia and B-cell lymphoma. A direct pathogenetic role of this infection in lymphomagenesis has been suggested but the molecular basis for viral induced B-cell proliferation is still unknown. We report an unusual case of a patient affected by chronic hepatitis C who presented severe type II cryoglobulinaemia and subsequently lymphoplasmacytoid lymphoma consistent with Waldenstrom's macroglobulinaemia and type I cryoglobulinaemia. In this patient antiviral treatment induced beneficial effects.

Randomized clinical trial to compare the effects of methadone and buprenorphine on the immune system in drug abusers

RATIONALE

Buprenorphine may be a useful alternative option to methadone in addicts. Opioids can produce severe changes in the immune system.

OBJECTIVES

The objectives of this study are to compare the effect of sublingual buprenorphine and methadone on the immune system and to compare the two substances on the drying-out program compliance.

METHODS

We studied 62 randomized outpatients for a period of 12 months. Subjects (55 males and 7 females; mean age 25+/-4 years; average history of heroin abuse being 2 years) on maintenance treatment were assigned in two groups (A and B). Methadone chloride (medium dose 100 mg/day) was administered to group A, whereas group B received sublingual buprenorphine (32.40+/-2.8 mg/day). Urine toxicological screening, plasma levels of TNF-alpha interleukin-1, interleukin-beta, lymphocyte CD14 and a self-rating depression questionnaire were measured.

RESULTS

Urine screening was negative for opiates in 17.6% of group A and in 10.7% of group B (p<0.001; r = 0.62). Depression score was 62+/-2 in group A and 55+/-3 in group B (p < 0.01). Cytokine and CD14 revealed higher concentrations both in groups A and B without significant differences (p > 0.05) between the two groups.

CONCLUSIONS

The effects of buprenorphine and methadone tested on the immune system were overlapping in our patients. The elevated cytokine levels observed may suggest that the two drugs stimulate immunologic hyperactivation of an immune system that was formerly inhibited by heroin. Furthermore, our data suggest that buprenorphine can be a valid alternative to methadone in maintenance treatment of chronic heroin abuse and referred a marked decline in depression.