Failure of functional imaging with gallium-68-DOTA-D-Phe1-Tyr3-octreotide positron emission tomography to localize the site of ectopic adrenocorticotropic hormone secretion: a case report

<p>Abstract</p> <p>Introduction</p> <p>The diagnostic efficacy of biochemical and imaging modalities for investigating the causes of Cushing's syndrome are limited. We report a case demonstrating the limitations of these modalities, especially the inability of functional imaging to help localize the site of ectopic adrenocorticotropic hormone secretion.</p> <p>Case presentation</p> <p>A 37-year-old Arabian woman presented with 12 months of progressive Cushing's syndrome-like symptoms. Biochemical evaluation confirmed adrenocorticotropic hormone -dependent Cushing's syndrome. However, the anatomical site of her excess adrenocorticotropic hormone secretion was not clearly delineated by further investigations. Magnetic resonance imaging of our patient's pituitary gland failed to demonstrate the presence of an adenoma. Spiral computed tomography of her chest only revealed the presence of a non-specific 7 mm lesion in her left inferobasal lung segment. Functional imaging, including a positron emission tomography scan using 18-fluorodeoxyglucose and gallium-68-DOTA-D-Phe1-Tyr3-octreotide, also failed to show increased metabolic activity in the lung lesion or in her pituitary gland. Our patient was commenced on medical treatment with ketoconazole and metyrapone to control the clinical features associated with her excess cortisol secretion. Despite initial normalization of her urinary free cortisol excretion rate, levels began to rise eight months after commencement of medical treatment. Repeated imaging of her pituitary gland, chest and pelvis again failed to clearly localize a source of her excess adrenocorticotropic hormone secretion. The bronchial nodule was stable in size on serial imaging and repeatedly reported as having a nonspecific appearance of a small granuloma or lymph node. We re-explored the treatment options and endorsed our patient's favored choice of resection of the bronchial nodule, especially given that her symptoms of cortisol excess were difficult to control and refractory. Subsequently, our patient had the bronchial nodule resected. The histological appearance of the lesion was consistent with that of a carcinoid tumor and immunohistochemical analysis revealed that the tumor stained strongly positive for adrenocorticotropic hormone. Furthermore, removal of the lung lesion resulted in a normalization of our patient's 24-hour urinary free cortisol excretion rate and resolution of her symptoms and signs of hypercortisolemia.</p> <p>Conclusion</p> <p>This case report demonstrates the complexities and challenges in diagnosing the causes of adrenocorticotropic hormone -dependent Cushing's syndrome. Functional imaging may not always localize the site of ectopic adrenocorticotropic hormone secretion.</p

Depression literacy among Australians of Chinese-speaking background in Melbourne, Australia

<p>Abstract</p> <p>Background</p> <p>This study investigated the knowledge of depression and preference for professional help, medications and treatment methods among Australians of Chinese-speaking background, and the perceptions of this population of the causes of mental illness.</p> <p>Methods</p> <p>Adopting a cluster convenience sampling method, the study recruited 200 Chinese-speaking subjects from four major areas in metropolitan Melbourne where many Chinese live. The respondents were presented with a vignette describing an individual with depression and then asked questions to assess their understanding of depression and preference for professional help, medications and treatment methods. A comparative approach was used to compare the findings with those of a previous study of the mental health literacy of Australian and Japanese adults.</p> <p>Results</p> <p>Compared to the Australian and Japanese samples, a much lower percentage of Chinese-speaking Australians (14%) could correctly identify major depression described in the vignette, and a higher percentage believed that counseling professionals could be helpful. Higher percentages of those who believed that close family members could be helpful were found in the Chinese-speaking Australian and Japanese samples, and these two groups also expressed more uncertainty about the usefulness or harmfulness of certain medications compared to the Australian sample. Higher percentages of respondents in both the Chinese-speaking Australian and the Australian sample considered "lifestyle changes" to be helpful compared to the Japanese sample. In the Chinese-speaking sample, 30%, 17.4%, 33% and 27% of the respondents rated "traditional Chinese medicine doctors," "Chinese herbal medications," "taking Chinese nutritional foods/supplements" and "<it>qiqong</it>" as helpful. Many perceived "changing <it>fungshui</it>" and "traditional Chinese worship" to be harmful. Regarding the perception of causes of mental illness, items related to psychosocial perspectives including "life stress" and "interpersonal conflict" were rated highly by the respondents, whereas traditional beliefs including "punishment for misdeeds conducted by ancestors" and "demon possession" had the lowest ratings.</p> <p>Conclusions</p> <p>Campaigns to increase the mental health literacy of Chinese-speaking Australians are needed. The abovementioned socially and culturally driven beliefs need to be taken into consideration in the development of culturally relevant education programs.</p

Physical activity and optimal self-rated health of adults with and without diabetes

<p>Abstract</p> <p>Background</p> <p>Regular physical activity can improve people's overall health and contribute to both primary and secondary prevention of many chronic diseases and conditions including diabetes. The aim of this study was to examine the association between levels of physical activity and optimal self-rated health (SRH) of U.S. adults with and without diabetes in all 50 states and territories of the Unites States.</p> <p>Methods</p> <p>We estimated the prevalence of optimal SRH by diabetes status of 430,912 adults aged 18 years and older who participated in the 2007 state-based survey of the Behavioral Risk Factor Surveillance System (BRFSS). Prevalence ratios were produced with multivariate Cox regression models using levels of physical activity as a predictor and status of optimal SRH as an outcome variable while controlling for sociodemographic and behavioral health risk factors.</p> <p>Results</p> <p>The prevalence of reporting optimal SRH was 53.3%, 52.2%, and 86.2% for adults with type 1 diabetes, type 2 diabetes, and without diabetes, respectively. Also in the aforementioned order, adults who reported being active had an increased likelihood of 81%, 32%, and 18% for reporting optimal SRH, when compared with adults who reported being inactive.</p> <p>Conclusions</p> <p>Regular physical activity of adults, particularly adults with diabetes, is associated with optimal SRH. The findings of this study underscore the importance of advising and motivating adults with diabetes so that physical activity can be integrated into their lifestyle for diabetes care. Additionally, a population-based effort to promote physical activity in communities may benefit adults in general by improving their overall health and well-being.</p

Age-Related Immunity to Meningococcal Serogroup C Vaccination: An Increase in the Persistence of IgG2 Correlates with a Decrease in the Avidity of IgG

Contains fulltext : 97618.pdf (publisher's version ) (Open Access)Background All children and adolescents between 1 and 19 years of age in The Netherlands received a single meningococcal serogroup C conjugate (MenCC) vaccine in 2002. During follow-up 4–5 years later, the persistence of MenC polysaccharide-specific IgG was found to be dependent on age of vaccination with higher IgG levels in the oldest immunized age categories. Methods and Findings Two cross-sectional population-based serum banks, collected in 1995/1996 and in 2006/2007, were used for this study. We measured MenC polysaccharide-specific IgM, the IgG1 and IgG2 subclasses and determined the avidity of the IgG antibodies. We report that the age-related persistence of IgG after immunization with the MenCC vaccine seemed to result from an increase of IgG2 levels with age, while IgG1 levels remained stable throughout the different age-cohorts. Furthermore, an age-related increase in IgM levels was observed, correlating with the persistence of IgG antibodies with age. It is noteworthy that the increase in IgG2 correlated with a reduced IgG-avidity with age. Conclusion These date indicate that the classical characteristics of a T-cell-dependent antibody response as elicited by protein based vaccines might not be completely applicable when conjugate vaccines are administered to older children and adolescents up to 18 years of age. The response elicited by the MenCC vaccine seemed to be more a mixture of both T cell dependent and T cell independent responses in terms of humoral immunological characteristics

Higher quality of life and lower depression for people on art in Uganda as compared to a community control group

Provision of antiretroviral treatment (ART) to people living with HIV (PLWH) has increased globally. Research measuring whether ART restores subjective well-being to "normal" levels is lacking, particularly in resource limited settings. The study objectives are to compare quality of life and depression symptoms for PLWH on ART to a general community population and to explore factors to explain these differences, including socio-economic status and the impact of urban or rural residence. PLWH on ART (n = 263) were recruited from ART delivery sites and participants not on ART (n = 160) were recruited from communities in Wakiso District, Uganda. Participants were interviewed using the translated World Health Organisation Quality of Life brief measure, the Hopkins Symptom Checklist depression section, and questions about socioeconomic status, residence as urban or rural and, for PLWH on ART, self-reported adherence and use of HIV counselling. Compared to the community sample and controlling for location of residence, PLWH on ART had significantly higher quality of life (QOL) for physical, psychological and environment domains, but not the social domain. These differences were not due to socio-economic status alone. Depression scores were significantly lower for PLWH on ART. Both comparisons controlled for the effect of location of residence. People on ART self-reported high adherence and the majority had used HIV counselling services. Our findings show better QOL amongst PLWH on ART compared to a general community sample, which cannot be explained solely by differences in socio-economic status nor location of residence. The general community sample results point towards the challenges of life in this setting. Access to health services may underpin this difference and further research should explore this finding, in addition to identification of psychological mechanisms that relate to better QOL. ART provision infrastructure has clear benefits. Further work should consider sustainability and replication for other health conditions. © 2014 Martin et al

Variation in diabetes care by age: opportunities for customization of care

BACKGROUND: The quality of diabetes care provided to older adults has usually been judged to be poor, but few data provide direct comparison to other age groups. In this study, we hypothesized that adults age 65 and over receive lower quality diabetes care than adults age 45–64 years old. METHODS: We conducted a cohort study of members of a health plan cared for by multiple medical groups in Minnesota. Study subjects were a random sample of 1109 adults age 45 and over with an established diagnosis of diabetes using a diabetes identification method with estimated sensitivity 0.91 and positive predictive value 0.94. Survey data (response rate 86.2%) and administrative databases were used to assess diabetes severity, glycemic control, quality of life, microvascular and macrovascular risks and complications, preventive care, utilization, and perceptions of diabetes. RESULTS: Compared to those aged 45–64 years (N = 627), those 65 and older (N = 482) had better glycemic control, better health-related behaviors, and perceived less adverse impacts of diabetes on their quality of life despite longer duration of diabetes and a prevalence of cardiovascular disease twice that of younger patients. Older patients did not ascribe heart disease to their diabetes. Younger adults often had explanatory models of diabetes that interfere with effective and aggressive care, and accessed care less frequently. Overall, only 37% of patients were simultaneously up-to-date on eye exams, foot exams, and glycated hemoglobin (A1c) tests within one year. CONCLUSION: These data demonstrate the need for further improvement in diabetes care for all patients, and suggest that customisation of care based on age and explanatory models of diabetes may be an improvement strategy that merits further evaluation

Vacinação contra hepatite B e exposição ocupacional no setor saúde em Belo Horizonte, Minas Gerais

OBJETIVO: Identificar fatores associados à vacinação contra hepatite B em trabalhadores da saúde. MÉTODOS: Estudo transversal com 1.808 trabalhadores da saúde do setor público de Belo Horizonte, MG, em 2009. Questionário autoadministrado foi usado e a situação vacinal foi analisada considerando características sociodemográficas, estilo de vida, características e condições de trabalho. Análises estatísticas univariada (p < 0,20) e múltipla foram realizadas utilizando regressão de Poisson (p < 0,05) para avaliação de fatores associados à vacinação. RESULTADOS: Declararam ter sido vacinados 85,6% dos trabalhadores, 74,9% dos quais receberam esquema completo da vacina. Não ter sido vacinado associou-se a não ter companheiro, a escolaridade em nível médio/técnico ou superior incompleto e a características do trabalho, como atuar na vigilância ou setor administrativo/serviços gerais e não utilizar equipamentos de proteção individual. CONCLUSÕES: Foram identificados grupos com menor cobertura vacinal. São necessários esforços para garantir o acesso e a adesão à vacinação a todos os grupos ocupacionais.OBJECTIVE: To identify factors associated with vaccination against hepatitis B among healthcare workers. METHODS: This was a cross-sectional study on 1,808 public-sector healthcare workers in Belo Horizonte, Southeastern Brazil, in 2009. A self-administered questionnaire was used and the vaccination situation was analyzed taking sociodemographic characteristics, lifestyle and working conditions and characteristics into consideration. Univariate (p < 0.20) and multiple (p < 0.05) statistical analyses were performed using Poisson regression to evaluate factors associated with vaccination. RESULTS: Of the workers, 85.6% declared that they had been vaccinated, although only 74.9% of the vaccinated professionals had received a complete imunization schedule. Not having been vaccinated was associated with not having a partner; having high school, technical or incomplete higher education level; work characteristics such as working in surveillance or the administrative/general services sector; and not using personal protection equipment. CONCLUSIONS: Groups with lower vaccination coverage were identified. Efforts are required to ensure access and adherence to vaccination among healthcare workers, such as awareness-raising mechanisms.OBJETIVO: Identificar factores asociados con la vacunación contra hepatitis B en trabajadores de la salud. MÉTODOS: Estudio transversal con 1.808 trabajadores de la salud del sector público de Belo Horizonte, Sudeste de Brasil, en 2009. Se usó cuestionario auto-administrado y se analizó la situación de la vacunación considerando características sociodemográficas, estilo de vida, características y condiciones de trabajo. Se realizaron análisis estadísticos univariado (p< 0,20) y múltiple utilizando regresión de Poisson (p< 0,05) para evaluación de factores asociados con la vacunación. RESULTADOS: Declararon haber sido vacunados 85,6% de los trabajadores, 74,9% recibieron esquema completo de vacunación. No haber sido vacunado se asoció a no tener compañero, a la escolaridad en nivel medio/técnico o superior incompleto y a características de trabajo, como actuar en la vigilancia o sector administrativo/servicios generales y no utilizar equipamientos de protección individual. CONCLUSIONES: Se identificaron grupos con menor cobertura de vacunación. Son necesarios esfuerzos para garantizar el acceso y la adhesión a la vacunación entre los trabajadores de la salud, como ejemplo de mecanismos de sensibilización

Postulated Vasoactive Neuropeptide Autoimmunity in Fatigue-Related Conditions: A Brief Review and Hypothesis

Disorders such as chronic fatigue syndrome (CFS) and gulf war syndrome (GWS) are characterised by prolonged fatigue and a range of debilitating symptoms of pain, intellectual and emotional impairment, chemical sensitivities and immunological dysfunction. Sudden infant death syndrome (SIDS) surprisingly may have certain features in common with these conditions. Post-infection sequelae may be possible contributing factors although ongoing infection is unproven. Immunological aberration may prove to be associated with certain vasoactive neuropeptides (VN) in the context of molecular mimicry, inappropriate immunological memory and autoimmunity

Global Retinoblastoma Presentation and Analysis by National Income Level.

Importance: Early diagnosis of retinoblastoma, the most common intraocular cancer, can save both a child's life and vision. However, anecdotal evidence suggests that many children across the world are diagnosed late. To our knowledge, the clinical presentation of retinoblastoma has never been assessed on a global scale. Objectives: To report the retinoblastoma stage at diagnosis in patients across the world during a single year, to investigate associations between clinical variables and national income level, and to investigate risk factors for advanced disease at diagnosis. Design, Setting, and Participants: A total of 278 retinoblastoma treatment centers were recruited from June 2017 through December 2018 to participate in a cross-sectional analysis of treatment-naive patients with retinoblastoma who were diagnosed in 2017. Main Outcomes and Measures: Age at presentation, proportion of familial history of retinoblastoma, and tumor stage and metastasis. Results: The cohort included 4351 new patients from 153 countries; the median age at diagnosis was 30.5 (interquartile range, 18.3-45.9) months, and 1976 patients (45.4%) were female. Most patients (n = 3685 [84.7%]) were from low- and middle-income countries (LMICs). Globally, the most common indication for referral was leukocoria (n = 2638 [62.8%]), followed by strabismus (n = 429 [10.2%]) and proptosis (n = 309 [7.4%]). Patients from high-income countries (HICs) were diagnosed at a median age of 14.1 months, with 656 of 666 (98.5%) patients having intraocular retinoblastoma and 2 (0.3%) having metastasis. Patients from low-income countries were diagnosed at a median age of 30.5 months, with 256 of 521 (49.1%) having extraocular retinoblastoma and 94 of 498 (18.9%) having metastasis. Lower national income level was associated with older presentation age, higher proportion of locally advanced disease and distant metastasis, and smaller proportion of familial history of retinoblastoma. Advanced disease at diagnosis was more common in LMICs even after adjusting for age (odds ratio for low-income countries vs upper-middle-income countries and HICs, 17.92 [95% CI, 12.94-24.80], and for lower-middle-income countries vs upper-middle-income countries and HICs, 5.74 [95% CI, 4.30-7.68]). Conclusions and Relevance: This study is estimated to have included more than half of all new retinoblastoma cases worldwide in 2017. Children from LMICs, where the main global retinoblastoma burden lies, presented at an older age with more advanced disease and demonstrated a smaller proportion of familial history of retinoblastoma, likely because many do not reach a childbearing age. Given that retinoblastoma is curable, these data are concerning and mandate intervention at national and international levels. Further studies are needed to investigate factors, other than age at presentation, that may be associated with advanced disease in LMICs