Adrenal vein sampling is safe; increasing the selectivity index cutoffs lowers the number of usable adrenal vein samplings; higher lateralization index cutoff values lead to missing a proportion of aldosterone-producing adenomas. The improved selectivity rate provided by adrenocorticotropic hormone stimulation should be weighed against the loss of correct lateralization.
Abstract-Adrenocorticotropic hormone administration was proposed to overcome the biases associated with pulsatile aldosterone secretion during adrenal venous sampling, but the usefulness of different protocols of stimulation was never systematically assessed. We, therefore, compared the effects of a high dose (HD; 250 g IV as a bolus), a very low dose (VLD; 250 pg IV), and an intermediate dose (ID; 50 g/h) of adrenocorticotropic hormone on the selectivity index (SI) and the lateralization index in primary aldosteronism patients, using the diagnosis of aldosterone-producing adenoma, based on pathology and follow-up data, as a reference. The HD (nϭ47) significantly increased plasma cortisol concentration in infrarenal inferior vena cava (ϩ79%) blood and the SI on both sides (SI RIGHT ϩ113% and SI LEFT ϩ131%), as compared with baseline values. The ID (nϭ14) also markedly increased both plasma cortisol concentration inferior vena cava (ϩ93%) and the SI (SI RIGHT ϩ690% and SI LEFT ϩ410%); the very low dose (nϭ6) had no effect on either the plasma cortisol concentration or SI. In the patients with unilateral aldosterone-producing adenoma, the increase of selectivity with the HD and ID was counterbalanced by a confounding effect on the correct identification of the aldosterone-producing adenoma side, which was attributed to the wrong side in 3.0% and 12.5% with HD and ID, respectively. In conclusion, the HD and the ID, but not the very low dose, adrenocorticotropic hormone stimulation protocol facilitated the ascertainment of selectivity of adrenal vein catheterization. However, this favorable effect was overridden by a confounding effect on the identification of lateralized aldosterone excess to the aldosterone-producing adenoma side. Hence, we do not recommend adrenocorticotropic hormone stimulation.
We conducted a population-based birth cohort study of approximately 203,000 babies born in northeastern Italy (1989-2012) to investigate perinatal variables, early infections leading to hospital admission, and antibiotic use in the first 12 months of life as possible risk factors for celiac disease (CD). Incident CD cases were identified from pathology reports, hospital discharge records, and exemptions from prescription charges for clinical tests. Multivariate Poisson regression models were fitted to estimate incidence rate ratios (IRRs). A total of 1,227 children had CD; CD was histopathologically confirmed in 866 (71%). Female sex, maternal age, and high maternal educational level were found to be significantly associated with CD. Gastrointestinal infections were strongly associated with a subsequent diagnosis of CD (IRR = 2.04, 95% confidence interval (CI): 1.30, 3.22). Antibiotic use was significantly associated with CD onset (IRR = 1.24, 95% CI: 1.07, 1.43), with a dose-response relationship for number of courses (P-trend < 0.01). Cephalosporin use strongly increased the risk of CD (IRR = 1.42, 95% CI: 1.18, 1.73). Use of antibiotics (supported by the dose-response relationship) and gastrointestinal infections in the first year of life may facilitate the early onset of CD by altering intestinal microflora and the gut mucosal barrier. Perinatal factors, including cesarean section, had little influence on the risk of childhood CD.
Abstract-Adrenal vein sampling is the gold standard for identification of surgically curable primary aldosteronism, but its accuracy might be hindered by blood dilution from accessory vein blood. We prospectively investigated the presence of accessory veins draining into adrenal veins and their effect on the selectivity index (SI) Key Words: adrenal vein sampling Ⅲ aldosterone Ⅲ aldosteronism Ⅲ adrenocorticophic hormone Ⅲ catheterization P rimary aldosteronism (PA), the most common endocrine cause of curable arterial hypertension, 1 is usually attributed to aldosterone-producing adenoma (APA) and, less commonly, to unilateral 2 or bilateral adrenal hyperplasia. 3 The former two conditions are characterized by lateralized aldosterone secretion and are best treated by adrenalectomy, whereas the latter, featuring bilateral aldosterone excess, requires lifelong antihypertensive therapy on the basis of mineralocorticoid receptor antagonists.Discrimination between unilateral aldosterone excess and bilateral adrenal hyperplasia is feasible with NP59 scintigraphy or adrenal vein sampling (AVS). Because NP59 has a low sensitivity and is not generally available, 3,4 AVS is currently considered the gold diagnostic standard for identifying the surgically curable forms of PA. 5,6 However, interpretation of AVS results requires attention to several issues and particularly to the criteria to be used for assessing selectivity and establishing the lateralization of aldosterone excess. 7,8 With regard to selectivity, experience has shown that selective catheterization can be consistently achieved on the left side, whereas on the right side the success rate is lower. 7 The difficulty of selectively cannulating the right adrenal vein, is due to its brevity and direct draining in the inferior vena cava (IVC), while the training and experience of the operator do not seem to fully account for this lower success rate. 3,7 Because, on the right side, the adrenal vein often shares egress in the IVC with accessory hepatic veins, we hypothesized that the dilution of adrenal vein blood with blood draining from the liver, which carries a low cortisol concentration, might account for the lower success rate of catheterization on this side. However, there was no information on how common accessory hepatic veins are and on their impact on the selectivity of an AVS index. Therefore, this study was designed to prospectively investigate these questions. Patients and MethodsThe patients to be submitted to AVS were selected among those with a diagnosis of PA, as described previously, 1 who had no contraindications to general anesthesia and surgery. They were asked to sign a written consent to undergo not only AVS but also laparoscopic adrenalectomy in case a lateralized aldosterone secretion was eventually identified. 3,9
Several epidemiological studies reported an association between antibiotic consumption in the first year of life and later asthma, but results are conflicting and affected by potential biases. We examined this controversial issue in a population-based birth cohort. Using administrative data, we identified 143,163 children born in 1995-2011 in Friuli-Venezia Giulia (Italy) (median follow-up 5.25 years, 927,350 person-years). Antibiotic prescriptions in the first year of life and subsequent treated asthma (defined as ≥2 anti-asthmatic drug prescriptions within a 12-month period) were retrieved from drug prescription records. We estimated incidence rate ratios (IRR) using Poisson regression models, adjusted for perinatal variables and for hospitalizations for infections in the first year of life. We identified 34,957 new-onset asthma cases. Antibiotic consumption in the first year of life increased the risk of new-onset asthma [IRR 1.51, 95% confidence interval (CI) 1.48-1.54] with a dose-response relationship (p-trend <0.001). The risk was highest for asthma identified at 13-35 months of life (IRR 2.07, 95% CI 2.00-2.14), but remained statistically significant for asthma identified at 36-71 months (IRR 1.17, 95% CI 1.14-1.21) and at ≥72 months (IRR 1.15, 95% CI 1.08-1.22). Antibiotics increased the risk of current asthma at ≥6 years (IRR 1.35, 95% CI 1.30-1.41) and at ≥13 years of age (IRR 1.19, 95% CI 1.08-1.33). Antibiotic exposure in infancy is associated with an increased risk of asthma up to adolescence. The association detected at older ages is not explained by reverse causation; however, confounding by respiratory infections not leading to hospital admission cannot be excluded.
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