CRANIOPHARYNGIOMA - CLINICAL AND THERAPEUTIC OUTCOME DATA IN A MIXED COHORT OF ADULT AND PAEDIATRIC CASES.

BACKGROUND: Craniopharyngiomas are benign but locally invasive tumours of the sellar region that arise from ectopic embryonic remnants of Rathke's pouch, affecting both children (adamantinomatous type -aCP) and adults (papillary type -pCP) and associated with significant morbidity. OBJECTIVE: To study the clinical presentation of CRF as well as the posttreatment evolution of craniopharyngioma in children versus adults in a large mixed cohort. MATERIAL AND METHODS: We performed a retrospective review of CRF patients evaluated in the National Institute of Endocrinology in Bucharest between 1990 and 2016. RESULTS: A total of 107 patients (72 adults, 35 children) with a mean follow-up of 6.2 years were included. The presenting symptoms were mostly headache, visual impairment, symptoms of hypopituitarism, diabetes insipidus. Some symptoms or hormonal abnormalities were significantly more prevalent in the children group (p<0.05): nausea/ vomiting (47.8% vs 16.7%), photophobia (21.7% vs 5.6%), diabetes insipidus(28.5% vs 8.3%), GH deficiency (68.8% vs 17.1%). Impaired visual acuity (67.6%of cases) or visual fields (71.4%) were more frequent in adults compared to children (44.1%; 51.6%). The tumor dimensions were similar in both groups (3.05± 1.05 cm in children; 2.7± 1.07 cm in adults). Massive suprasellar extension reaching the third ventricle was frequently present in all cases. All cases underwent surgery but only a minority of those not cured received postoperative adjuvant radiotherapy. Frequent postoperative complications were: aggravation of the endocrine deficit (>80% of cases in both groups needed chronic replacement therapy), central diabetes insipidus (68.2% children, 34.3% of adults). CONCLUSIONS: Despite similar tumor dimensions and extension compared to adults, craniopharyngioma in children is more frequently associated with signs of intracranial pressure. The results and complications of treatment are similar in adults and children.

Increased copeptin levels in metabolic syndrome from a Romanian population.

Rationale: Arginine vasopressin (AVP) is secreted under conditions of water deprivation. Since AVP has a low half-life in the plasma, the C-terminal fragment of AVP-precursor (copeptin) was used to estimate the AVP levels. High copeptin levels increase the risk for the development of diabetes mellitus. Aim: This study was aimed to measure copeptin levels in the metabolic syndrome (MetS) in Romanians using a competitive enzyme immunoassay. Methods and results: Patients prone to present MetS (n = 63) were compared to controls (n = 42). In the MetS group, the syndrome was confirmed in 93.6%. Affected patients displayed 85.7% obesity and insulin resistance (HOMAIR of 4.9 ± 0.4 versus 1.1 ± 0.8 in controls). Low HDL-cholesterol was less represented (47.5%). Copeptin levels were 0.6 ± 0.0 in MetS versus 0.42 ± 0.0 ng/ mL in controls (P < 0.004). Higher copeptin (0.79 to 1.83 ng/ mL) was associated with MetS, P < 0.0018, OR 20, 95%CI [3.03 - 131.7]. In ANOVA, high copeptin was equally explained by MetS or obesity (P < 0.05,α = 3.8). The best correlation was found with high triglyceride levels (P < 0.013,α = 6.3) while the correlation with HOMAIR remained not significant. Discussion: These data indicated a concordant correlation between increased copeptin and MetS or its components. In the light of epidemiological data, indicating that more than 50% of the European population has a lower daily water intake and a fraction of 25% displaying high copeptin, our data further sustained that copeptin may be a good biomarker for MetS and/ or obesity, which should be further investigated with other members of the osmoregulation pathway at both pathogenesis and genetic levels.

Perioperative evaluation of cardiac surgical risk: particularities in the emergency surgery - from the guidelines to the clinical practice.

RATIONALE: Cardiac risk in patients undergoing surgery depends on many factors from the patient's cardiovascular history to the surgical procedure itself, with its particularities, the type of anesthesia, fluid exchanges and the supervision of the patient. Therefore, this risk must be carefully considered and it determines the endorsement of perioperative measures with important medical implications. OBJECTIVE: Perioperative cardiac risk evaluation guidelines were published since 2010 and they represent a highly important assessmnet tool. Emergency surgery requires an adaptation of the guidelines to the actual medical situations in extreme conditions. METHODS, RESULTS, DISCUSSION: Analyzing the way the perioperative evaluation itself is conducted is an extremely important tool. Quantifying the clinical application of the guidelines, one can monitor real parameters and find solutions for improving medical care. The current study was conducted on a representative sample of 8326 patients, respecting the recommendation strategies for calculating the surgical risk adapted for the emergency surgery setting. The dominant conclusion is the need to develop a standardized form, summarized for quick and objective assessment of perioperative cardiac risk score. Only a complex medical team could calculate this score while the decisional team leader for the surgical patient remains the surgeon.

Physiopathological aspects of the subclinical alterations of thyroid function associated with acute coronary syndromes.

The subclinical modification of thyroid function represents an important risk factor for the development of acute coronary syndromes, neglected up to this day. Knowledge of the physiopathological processes implicated in the alteration of thyroid function that induces cardiovascular dysfunction is a necessity for the understanding of the phenomena and for the finding of the adequate therapeutic solutions. While recognizing the thyroid dysfunction as a modifiable risk factor for the acute coronary syndrome, we encountered a new challenge for the clinical research regarding its implications. The ability to manage the altered thyroid homeostasis may represent a new stage of prevention at a population level for the reduction of the cardiac risk, a stage which implies a risk factor that may remain clinically mute for a long period of time if left undiagnosed, however influencing the development of the acute coronary syndromes.

Efficacy and tolerability of amlodipine/valsartan combination therapy in hypertensive patients not adequately controlled on amlodipine monotherapy.

UNLABELLED: ABSTRACT (ARB), in essential hypertensive patients not adequately controlled by amlodipine monotherapy. METHODS: This was a multi-centre, randomised, double-blind, active-controlled study in patients with essential hypertension. After a washout period followed by a single-blind amlodipine 10 mg run-in period, patients with mean sitting diastolic blood pressure (msDBP) > or =90 mmHg and <110 mmHg were randomised to receive amlodipine/valsartan (10/160 mg o.d.) or amlodipine (10 mg o.d.) for 8 weeks. TRIAL REGISTRATION NUMBER: NCT00171002. MAIN OUTCOME MEASURES: The primary efficacy variable was change from baseline in msDBP at study endpoint. Secondary efficacy variables were change from baseline in mean sitting systolic blood pressure (msSBP), responder rate (msDBP <90 mmHg or > or =10 mmHg reduction from baseline) and DBP control rate (msDBP <90 mmHg). RESULTS: Of the 1283 patients enrolled in single-blind period, 944 were randomised to receive amlodipine/valsartan 10/160 mg (n = 473) and amlodipine 10 mg (n = 471). Statistically significant greater reductions (p < 0.0001) from baseline in msSBP/msDBP were observed with combination therapy (12.9/11.4 mmHg) compared to monotherapy (10.0/9.3 mmHg). Responder rate was significantly greater (p = 0.0011) with combination therapy (79.0%) compared to monotherapy (70.1%). The percentage of patients with controlled DBP was also significantly (p < 0.0001) higher with combination therapy (77.8%) compared to monotherapy (66.5%). Incidence of peripheral oedema was slightly higher with amlodipine monotherapy (9.4%) compared to combination therapy (7.6%). CONCLUSION: The combination of amlodipine/valsartan in this 8-week double-blind study provided additional BP control and was well tolerated in patients inadequately controlled with amlodipine monotherapy. Results should be interpreted with the knowledge that study entry criteria may limit application to a wider population.

[Thrombolysis: Bucarest registry]. / La thrombolyse. Registre roumain de Bucarest.

The end-point of this retrospective study was to evaluate the standard of care in terms of in-hospital morbidity and mortality for patients with acute myocardial infarction (AMI) treated by thrombolysis within the first 12 hours from the start of the symptoms in five cardiology centers from Bucarest for a period of 5 years (2000-2004). This retrospective registry on a central database included 1814 patients (73.63% men, mean age 59.9 +/- 11.8 years), presented in an average time of 211.63 minutes from pain start. The most frequently used fibrinolitic was streptokinase (66.21%), administered most often in 30 minutes and for a subgroup in 20 minutes--accelerated regimen, with a good efficiency for the reperfusion of the culprit vessel evaluated non-invasively (clinical, electrical and biological methods). The global in-hospital mortality was 11.1%. The only predictors of in-hospital mortality were female gender and advanced age (>75 years) [p < 0.05]. The rate of haemorrhagic complications was not different from the one described by other clinical studies. The treatment by anticoagulants, antiaplatelets agents like aspirin, ACE inhibitors and statins were significant determinants of in-hospital survival. In the subgroup followed-up for 1 year (315 patients), the most frequent complication was the heart failure. In conclusion, in Bucarest, where availability of primary angioplasty in AMI was limited, thrombolysis with streptokinase was still very much used, with acceptable low in-hospital mortality and relatively high rate of artery reperfusion appreciated by non-invasive methods.

Aldosterone and cardiovascular pathology: from bench to bedside.

Thirty years ago, aldosterone was an unidimensional hormone considered responsible for salt and water homeostasis. The current role of aldosterone in pathology is very complex. Recognition of mineralocorticoid receptors throughout the body has raised the importance of aldosterone in understanding the pathophysiology of previously unknown cardiovascular effects. This came from the first documentation of aldosterone receptors outside the kidney, making it not only an endocrine hormone, but a paracrine one, too. Aldosterone is contemporary appreciated to play an important role as a cardiac and vascular risk hormone. Aldosterone-mediated actions include the expression of several genes: collagen genes; genes controlling tissue growth factors and plasminogen activator inhibitor type 1; genes mediating inflammation. Aldosterone receptor blocking agents improve cardiovascular structure, function, and prognosis. They appear to provide additive benefit when used in conjunction with either an ACE inhibitor or an angiotensin receptor blocker.

Renin-Angiotensin-Aldosterone system inhibition in prevention of diabetes mellitus.

The number of people with diabetes grows worldwide. The complications resulting from this disease are a significant cause of morbidity and mortality. World Health Organization estimates that, while in the year 2000 the number of people with diabetes was about 177 million, by 2025, this will increase to at least 300 million. The diabetes epidemic, without primary prevention, will continue to grow. Individuals with type 2 diabetes are at a significantly higher risk for coronary heart disease, peripheral vascular disease, and stroke, and they have a greater probability of having hypertension, dyslipidemia, and obesity. A number of clinical trials provide evidences that RAAS inhibition could be helpful at preventing new onset of type 2 diabetes mellitus. Pharmacologic treatment that antagonize the renin-angiotensin system (RAS) provide more benefits, not only in patients after myocardial infarction and in congestive heart failure, but also in persons with hypertension and type 2 diabetes mellitus.

[Chest pain and electrocardiographic changes in the presence of stenosis of the left common coronary artery]. / Angor et modifications électrocardiographiques en présence d'une sténose du tronc commun de l'artère coronaire gauche.

Twelve-lead electrocardiogram were studied in 40 consecutive patients with angiographic left main coronary artery disease. The ECG were analysed during chest pain. The most frequent pattern was a ST elevation (> 0.1 mV) in lead a VR alone or with ST depression (> 0.2 mV) in the anterior or lateral leads. In coronary artery disease patients, the 12-lead electrocardiogram at rest remains the best test to detect patients at higher risk for massive myocardial infarction or death.

Is cardiac involvement in collagen diseases important? A clinical study in 917 patients.

Cardiac involvement in collagen diseases was studied in 917 patients representing all the cases of collagen diseases diagnosed in the "N. Gh. Lupu" Institute of Internal Medicine between 1985 and 1987. The prevalence of the various cardiac disorders was studied within every disease or group of diseases diagnosed according to clinical, ECG, radiologic and when necessary echocardiographic data. Collagen heart disease was diagnosed in 38.2% of the patients. In the case of systemic lupus erythematosus, of polyarteritis nodosa and of progressive systemic sclerosis this proportion exceeds 50%. The most frequent cardiac disorders were the rhythm and conduction disturbances, detected in 112 patients (12.2%). The cardiomyopathies and myocarditis, not infrequent (7.4%) represented an element of severity influencing the evolution and prognosis of disease. Myocardial ischemia secondary to coronary vasculitis syndromes has proved to be an important pathogenic mechanism of cardiac disorders. By their frequency and severity, the cardiac involvements in collagen diseases have proved important, becoming sometimes a central diagnostic, therapeutic and prognostic problem.

Cardiac involvement in progressive systemic sclerosis and polymyositis: a comparative study in 116 patients.

A comparative study was carried out in 116 patients-51 with progressive systemic sclerosis (PSS) and 65 with polymyositis (PM) to detect the cardiac involvements secondary to these two collagen diseases. Different forms of cardiac involvement could be detected in 51% of the patients with PSS and in 18.5% of those with PM. The most frequent cardiac dysfunctions were disturbances of rhythm and conduction probably due to the coronary vascular changes in PSS and to processes of fibrosis and degenerescence of the specific myocardial fibers in PM. Myocardial lesions expressed by myocarditis and cardiomyopathies are not infrequent and have important prognostic implications. In the group of patients studied the valvular cardiopathies and clinically evident pericardites were rare. Cardiac involvement clearly proved more frequent in PSS - in which the pathogenic mechanism is mainly vascular - than in PM. This emphasizes the great importance of coronary circulation disturbances in the pathogenesis of collagen heart diseases.

Pacemaker therapy in a group of 132 patients with sick sinus syndrome--indications and results.

Of the 132 patients with sick sinus syndrome (SSS) studied, 62 (47.8%) required pacemaker implantation thus showing the severity of the arrhythmic syndrome. The pacing requirement varied according to the SSS arrhythmic form with a maximum in the tachy-brady syndrome (53.5%) and in major sinus bradyarrhythmias--S--A block and sinus arrest (54.1%). The presence of syncopes (in 32.6% of the patients) represented the main indication for pacing. Very good results (100% efficiency) were obtained in the bradycardic forms. In the tachy-brady syndrome electrostimulation solved completely the bradycardic component and was able, alone, to suppress the tachyarrhythmic episodes in 18.4% of the patients. By associating pacing with antiarrhythmic drugs favourable results were obtained in an additional proportion of 65.8% of the patients. In the rest of 15.8% of the cases the results were partial.

Influence of pregnancy, birth and abortion on the evolution of systemic lupus erythematosus.

The effect of pregnancy, birth and abortion on systemic lupus erythematosus (SLE) was studied in 225 patients with or without a history of pregnancy and abortion. It was observed that pregnancy, birth and abortion aggravate the evolution of disease in patients with active SLE. The tissue autoantibodies studies presented a low titer in patients in whom pregnancy had occurred in the course of disease. Antimeasles antibodies presented a high titer in patients with a history of gestation. These data suggest that gestation induces immune changes which aggravate SLE.

The relationship between systemic lupus erythematosus and tuberculosis.

Investigation of 280 cases of systemic lupus erythematosus (SLE) admitted during 15 consecutive years to the "N. Gh. Lupu" Institute of Internal Medicine, Bucharest, revealed association of this disease with tuberculosis (tb) in 51 cases (19%). In most of these patients, tb onset preceded that of SLE; in the others it was either concomitant or it occurred later, in the course of SLE evolution. It is assumed that tb is favouring SLE development, probably by antigenic oversollicitation in patients with genetic immune deficiencies. When it occurs in the late stages of SLE, association of tb is of severe prognosis.