Publications by authors named "Mark Gruppetta"

20 Publications

  • Page 1 of 1

Adrenal insufficiency in HIV/AIDS: a review.

Expert Rev Endocrinol Metab 2021 Sep 14:1-12. Epub 2021 Sep 14.

Department of Diabetes, Endocrinology and General Medicine, Mater Dei Hospital, Msida, Malta.

Introduction: Adrenal insufficiency (AI) is one of the most common potentially life-threatening endocrine complications in people living with human immunodeficiency virus (PLHIV) infection and acquired immunodeficiency syndrome (AIDS).

Areas Covered: In this review, the authors explore the definitions of relative AI, primary AI, secondary AI and peripheral glucocorticoid resistance in PLHIV. It also focuses on the pathophysiology, etiology, diagnosis and management of this endocrinopathy in PLHIV. A literature review was conducted through Medline and Google Scholar search on the subject.

Expert Opinion: Physicians need to be aware of the endocrinological implications of HIV infection and its treatment, especially CYP3A4 enzyme inhibitors. A high index of clinical suspicion is needed in the detection of AI, especially in PLHIV, as it may present insidiously with nonspecific signs and symptoms and may be potentially life threatening if left untreated. Patients with overt primary and secondary AI require glucocorticoid replacement therapy. Overt primary AI also necessitates mineralocorticoid replacement. On the other hand, the management of relative AI remains controversial. In order to reduce the risk of adrenal crisis during periods of stress, the short-term use of glucocorticoids may be necessary in relative AI.
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http://dx.doi.org/10.1080/17446651.2021.1979393DOI Listing
September 2021

Biochemically silent phaeochromocytoma presenting with non-specific loin pain.

BMJ Case Rep 2021 Aug 16;14(8). Epub 2021 Aug 16.

Department of Diabetes and Endocrinology, Mater Dei Hospital, Msida, Malta.

A 55-year-old woman presented with a 4-month history of right-sided non-specific loin pain and 6 kg weight loss. A CT scan of the abdomen and pelvis showed an incidental 4.5 cm right-sided adrenal lesion which was not typical of an adrenal adenoma. This was further confirmed on MRI of the adrenals. Biochemical investigations to investigate for a functional adrenal lesion included serum catecholamines and metanephrines, an aldosterone to renin ratio and an overnight dexamethasone suppression test. These were all negative. A laparoscopic adrenalectomy was performed in view of the large size of the lesion. Histology was consistent with a phaeochromocytoma, which confirmed the diagnosis of a non-secreting phaeochromocytoma. Non-secreting phaeochromocytomas are rare and usually found in patients with known genetic mutations. Adrenal lesions not related to any mutations similar to our case are even rarer and reported even less in the literature.
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http://dx.doi.org/10.1136/bcr-2021-244258DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8370509PMC
August 2021

Hypercalcaemia due to ovarian small cell carcinoma of the hypercalcaemic type.

BMJ Case Rep 2021 Jul 30;14(7). Epub 2021 Jul 30.

Department of Diabetes and Endocrinology, Mater Dei Hospital, L-Imsida, Malta.

A 37-year-old woman presented with a few days' history of lower abdominal pain and an incidental finding of hypercalcaemia. A thorough workup ensued, and the cause was found to be an exceptionally rare ovarian tumour-ovarian small cell carcinoma of the hypercalcaemic type. Acute treatment of hypercalcaemia consisted of aggressive intravenous fluids and bisphosphonates. She underwent surgery to remove the tumour and is currently receiving systemic platinum/etoposide chemotherapy combination to be followed by pelvic radiotherapy. This case highlights the wide range of differential diagnosis for hypercalcaemia and the importance of a stepwise and thorough approach during investigations. We discuss the pathophysiology of malignancy-related hypercalcaemia, focusing especially on parathyroid hormone-related peptide-associated hypercalcaemia.
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http://dx.doi.org/10.1136/bcr-2021-243571DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8327804PMC
July 2021

Ectopic ACTH secretion from a metastatic gastric carcinoma with neuroendocrine component.

BMJ Case Rep 2021 May 6;14(5). Epub 2021 May 6.

Department of Diabetes and Endocrinology, Mater Dei Hospital, Msida, Malta.

An elderly gentleman was admitted to hospital with severe hypokalaemia of 1.75mmol/L. A background of a recently diagnosed metastatic gastric carcinoma with a neuroendocrine component pointed towards the diagnosis of ectopic ACTH secretion causing this dangerous electrolyte imbalance. He was treated with aggressive potassium supplementation and the adrenal steroid synthesis blocker metyrapone to acutely control his Cushing's syndrome. Chemotherapy consisting of carboplatin/etoposide combination was initiated but unfortunately the patients' health deteriorated, and he died three months after his initial diagnosis. This case highlights the accelerated presentation of hypercortisolism due to ectopic ACTH secretion. It discusses the classification of neuroendocrine tumours and their varied prognosis depending on the underlying tumour grade. It emphasises the importance of having a multidisciplinary team to be able to care for two underlying pathologies simultaneously: both the severe hypercortisolism and his metastatic gastric tumour.
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http://dx.doi.org/10.1136/bcr-2020-240290DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8103837PMC
May 2021

Cotrimoxazole-induced hyperkalaemia in a patient with known hypoaldosteronism.

BMJ Case Rep 2021 Mar 4;14(3). Epub 2021 Mar 4.

Department of Diabetes and Endocrinology, Mater Dei Hospital, Msida, Malta.

A70-year-old man, with established hypoadrenalism due to a previous bilateral adrenalectomy, was admitted with recurrent episodes of postural dizziness and presyncope. He had been discharged from hospital 3 weeks earlier on a 1-month course of cotrimoxazole following a diagnosis of prostatitis. His electrolytes on admission showed new onset hyponatraemia and hyperkalaemia.His usual glucocorticoid replacement dose was doubled in view of a presumed diagnosis of hypocortisolaemia. However, the hyperkalaemia persisted. On rereviewing his treatment, we suspected a possible diagnosis of cotrimoxazole-induced hyperkalaemia. Cotrimoxazole was stopped and ciprofloxacin started instead. His fludrocortisone replacement was doubled for 3 days after stopping treatment to decrease his postural symptoms. His postural symptoms improved, his serum potassium decreased to normal levels and he was safely discharged.It is essential to remember that cotrimoxazole, a commonly used antibiotic, can induce a potentially fatal hyperkalaemia especially in patients with known hypoadrenalism.
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http://dx.doi.org/10.1136/bcr-2020-239543DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7934741PMC
March 2021

Lithium-associated hyperparathyroidism.

Br J Hosp Med (Lond) 2020 Nov 17;81(11):1-9. Epub 2020 Nov 17.

Department of Diabetes and Endocrinology, Mater Dei Hospital, Msida, Malta.

Lithium is a mood stabiliser widely used in the treatment and prophylaxis of mania, bipolar disorders and recurrent depression. Treatment with lithium can give rise to various endocrine and metabolic abnormalities, including thyroid dysfunction, nephrogenic diabetes insipidus and hypercalcaemia. Lithium may induce hypercalcaemia through both acute and chronic effects. The initial acute effects are potentially reversible and occur as a result of lithium's action on the calcium-sensing receptor pathway and glycogen synthase kinase 3, giving rise to a biochemical picture similar to that seen in familial hypocalciuric hypercalcaemia. In the long term, chronic lithium therapy leads to permanent changes within the parathyroid glands by either unmasking hyperparathyroidism in patients with a subclinical parathyroid adenoma or possibly by initiating multiglandular hyperparathyroidism. The latter biochemical picture is identical to that of primary hyperparathyroidism. Lithium-associated hyperparathyroidism, especially in patients on chronic lithium therapy, is associated with increased morbidity. Hence, regular monitoring of calcium levels in patients on lithium therapy is of paramount importance as early recognition of lithium-associated hyperparathyroidism can improve outcomes. This review focuses on the definition, pathophysiology, presentation, investigations and management of lithium-associated hyperparathyroidism.
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http://dx.doi.org/10.12968/hmed.2020.0457DOI Listing
November 2020

Clinical reasoning: exploring its characteristics and enhancing its learning.

Br J Hosp Med (Lond) 2020 Oct 16;81(10):1-9. Epub 2020 Oct 16.

Department of Medicine, Faculty of Medicine and Surgery, University of Malta, Mater Dei Hospital, Msida, Malta.

Clinical reasoning is an extensive and intricate field, dealing with the process of thinking and decision making in practice. Its study can be quite challenging because it is context and task dependent. Educational frameworks such as the conscious competence model and the dual process reasoning model have been developed to help its understanding. To enhance the learning of clinical reasoning, there are significant areas that can be targeted through learning processes. These include knowledge adequacy; ability to gather appropriate patient data; use of proper reasoning strategies to address specific clinical questions; and the ability to reflect and evaluate on decisions taken, together with the role of the wider practice community and the activity of professional socialisation. This article explores the characteristics of clinical reasoning and delves deeper into the various strategies that prove useful for learning.
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http://dx.doi.org/10.12968/hmed.2020.0227DOI Listing
October 2020

A current perspective into young female sex hormone replacement: a review.

Expert Rev Endocrinol Metab 2020 11 6;15(6):405-414. Epub 2020 Sep 6.

Department of Medicine, Faculty of Medicine and Surgery, University of Malta, Mater Dei Hospital , Msida, Malta.

Introduction: Hormone replacement in females with hypogonadism is advocated to address the various clinical aspects of estrogen deficiency.

Areas Covered: This article focuses on hormone replacement in young females with hypogonadism, including a rationale as to why hormone replacement in such patients differs from treatment in postmenopausal females, a summary of symptoms encountered by females with hypogonadism and a comprehensive discussion of the various treatment options available, specifically focusing on the latest advances in the subject. A Medline search was conducted using different combinations of relevant keywords, giving preference to recent publications.

Expert Opinion: Whilst traditionally oral contraceptive pills (containing ethynyl estradiol) were commonly used as a form of hormone replacement, it is now increasingly recognized that this is not the optimal treatment option. Physiological hormone replacement with transdermal estradiol is found to be superior. Evidence suggests that micronized progesterone may be associated with fewer side effects, although its effect on endometrial protection is not yet proven. Synthetic progestins confer varying degrees of androgenic and thromboembolic properties which should be kept in mind when prescribing individualized treatment. Further studies in different sub-cohorts of female patients with hypogonadism might help address the specific needs of individual patients.
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http://dx.doi.org/10.1080/17446651.2020.1816820DOI Listing
November 2020

Isolated second-phase diabetes insipidus post-transsphenoidal surgery.

BMJ Case Rep 2020 Jun 30;13(6). Epub 2020 Jun 30.

Department of Diabetes and Endocrinology, Mater Dei Hospital, Msida, Malta.

A 57-year-old woman presented with severe lethargy, dizziness and nausea 1 week after transsphenoidal resection of a growth hormone secreting pituitary adenoma. She was found to have severe hyponatremia of 115 mmol/L. Importantly, she was neurologically intact and clinically euvolaemic. Her fluid intake was restricted and her sodium levels increased to 131 mmol/L over 4 days. She made a full recovery.She was diagnosed with isolated second-phase diabetes insipidus, a state of symptomatic hypoosmolar hyponatremia that usually occurs 7-10 days after transsphenoidal surgery. The sodium levels improve with fluid restriction.
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http://dx.doi.org/10.1136/bcr-2020-235499DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7328762PMC
June 2020

Identification of an p.Gly292fs Frameshift Mutation Presenting as Diabetes During Pregnancy in a Maltese Family.

Clin Med Insights Case Rep 2019 20;12:1179547619831034. Epub 2019 Feb 20.

Department of Medicine, Mater Dei Hospital, Msida, Malta.

The diagnosis of maturity onset diabetes of the young (MODY) is a challenging process in view of the extensive clinical and genetic heterogeneity of the disease. Mutations in the gene encoding hepatocyte nuclear factor 1α () are responsible for most forms of monogenic diabetes in Northern European populations. Genetic analysis through a combination of whole exome sequencing and Sanger sequencing in three Maltese siblings and their father identified a rare duplication/frameshift mutation in exon 4 of that lies within a known mutational hotspot in this gene. In this report, we provide the first description of an -MODY3 phenotype in a Maltese family. The findings reported are relevant and new to a regional population, where the epidemiology of atypical diabetes has never been studied before. This report is of clinical interest as it highlights how monogenic diabetes can be misdiagnosed as either type 1, type 2, or gestational diabetes. It also reinforces the need for a better characterisation of monogenic diabetes in Mediterranean countries, particularly in island populations such as Malta with a high prevalence of diabetes.
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http://dx.doi.org/10.1177/1179547619831034DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6383084PMC
February 2019

Stress-induced hyperglycaemia.

Br J Hosp Med (Lond) 2018 Nov;79(11):634-639

Consultant, Department of Diabetes and Endocrinology, Mater Dei Hospital, Msida, Malta.

Stress-induced hyperglycaemia is an important clinical entity. It is an adaptive immune-neurohormonal response to physiological stress in an attempt to increase metabolic substrates to struggling organs during a time of crisis. However, this acute hyperglycaemia is also responsible for a number of detrimental effects implying that treatment is necessary. Hence, admission hyperglycaemia is not necessarily equivalent to a diagnosis of diabetes mellitus but the blood glucose level needs to be interpreted in context of the patient's presenting complaint and previous glycaemic status. Stress-induced hyperglycaemia is associated with increased morbidity and short-term mortality. Thus prompt recognition of stress-induced hyperglycaemia and high risk hyperglycaemic patients with the stress hyperglycaemia ratio can help improve inpatient management. Patients with stress-induced hyperglycaemia who have recovered from their acute illness should be followed up as they remain at risk for incident diabetes. This review focuses on the definition, pathophysiology, targets, management and significance of stress-induced hyperglycaemia.
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http://dx.doi.org/10.12968/hmed.2018.79.11.634DOI Listing
November 2018

Beer, hyponatraemia and cardiac conduction defects.

BMJ Case Rep 2018 Mar 14;2018. Epub 2018 Mar 14.

Department of Medicine, Mater Dei Hospital, Msida, Malta.

The authors report a case of a 68-year-old man who was diagnosed with an irreversible second-degree atrioventricular (AV) Mobitz II 2:1 block temporally associated with profound hyponatraemia. The cause of the hyponatraemia was beer potomania. The co-occurrence of reversible first, second and third-degree heart blocks and hyponatraemia has been described in a few published case reports. However, this case is noteworthy as the AV block persisted, despite correction of serum sodium concentration as opposed to other published cases, which meant that the patient required a permanent pacemaker.
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http://dx.doi.org/10.1136/bcr-2018-224260DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5878273PMC
March 2018

Expression of cell cycle regulators and biomarkers of proliferation and regrowth in human pituitary adenomas.

Pituitary 2017 Jun;20(3):358-371

Division of Endocrinology, Department of Medicine, Faculty of Medicine and Surgery, Mater Dei Hospital, University of Malta, Msida, MSD2090, Malta.

Purpose: The pathogenesis of pituitary adenomas (PA) is complex. Ki-67, pituitary tumour transforming gene (PTTG), vascular endothelial growth factor (VEGF), cyclin D1, c-MYC and pituitary adenylate cyclase-activating peptide (PACAP) protein expression were analysed and correlated with tumour and patient characteristics.

Methods: 74 pituitary tumour samples (48 non-functional PA, 26 functional PAs); Immunohistochemical analysis of protein expression, retrospective analysis of MR images and in vitro analysis of octreotide treatment was carried out on GH3 cells.

Results: PTTG expression was negatively associated with age and positively with PA size, regrowth and Ki-67 index. Cyclin D1 correlated with Ki-67 and tumour size. c-MYC negatively correlated with size of tumour and age; and correlated with PTTG expression. Somatostatin analogue treatment was associated with lower Ki-67, PTTG and Cyclin D1 expression while T2 hypointense PAs were associated with lower PTTG, cyclin D1, c-MYC and Ki-67. In vitro analyses confirmed the effect of somatostatin analogue treatment on Pttg and Cyclin D1 expression.

Conclusions: Interesting and novel observations on the differences in expression of tumour markers studied are reported. Correlation between Ki-67 expression, PTTG nuclear expression and recurrence/regrowth of PAs, emphasizes the role that Ki-67 and PTTG expression have as markers of increased proliferation. c-MYC and PTTG nuclear expression levels were correlated providing evidence that PTTG induces c-MYC expression in PAs and we propose that c-MYC might principally have a role in early pituitary tumorigenesis. Evidence is shown that the anti-proliferative effect of somatostatin analogue treatment in vivo occurs through regulation of the cell cycle.
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http://dx.doi.org/10.1007/s11102-017-0803-0DOI Listing
June 2017

Carbimazole-induced exudative pleural effusions.

BMJ Case Rep 2016 Apr 4;2016. Epub 2016 Apr 4.

Diabetes and Endocrine Centre, Mater Dei Hospital, Msida, Malta Department of Medicine, University of Malta Medical School, Msida, Malta.

Carbimazole, an antithyroid drug, is associated with a significant number of side effects, but pleuropulmonary complications are rare. We report the case of a 42-year-old Caucasian man who developed dyspnoea secondary to bilateral exudative pleural effusions while on carbimazole therapy. Extensive investigations, including a vasculitic screen, ruled out other potential causes for this patient's clinical presentation. This patient's pleural effusions gradually resolved within a few months of stopping carbimazole therapy, suggesting a role for the latter in the aetiopathogenesis of his presentation. Clinicians should consider discontinuing treatment with carbimazole and introducing alternative antithyroid therapy in this setting, once other potential causes of a pleural effusion have been systematically ruled out.
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http://dx.doi.org/10.1136/bcr-2016-215080DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4840707PMC
April 2016

Epidemiology and radiological geometric assessment of pituitary macroadenomas: population-based study.

Clin Endocrinol (Oxf) 2016 08 24;85(2):223-31. Epub 2016 Apr 24.

Department of Medicine, Faculty of Medicine and Surgery, University of Malta, Mater Dei Hospital, Msida, Malta.

Context: Pituitary adenomas are relatively common tumours with diverse clinical features. Epidemiological data are important to help quantify health burden.

Objective: To provide in-depth epidemiological data on macroadenomas and radiologically characterize macroadenomas.

Design: Population-based retrospective analysis, Prevalence as at 2014; Incidence based on data from 2000 to 2014, Retrospective analysis of baseline MRI.

Setting: The Maltese islands.

Patients: 173/136 patients with macroadenomas for prevalence/incidence estimates respectively, 122 baseline MRI for radiological characterization.

Main Outcome Measures: Prevalence rates, Standardized Incidence rates (SIR), MRI findings.

Results: The prevalence for macroadenomas was 40·67/100 000 people and the SIR was 1·90/100 000/year. Giant pituitary adenomas (>40 mm) constituted 4·8% of the whole cohort of PAs and the SIR was 0·18/100 000/year. Giant prolactinomas constituted 4·7% of all the prolactinomas and the SIR was 0·07/100 000/year, while giant NFPA constituted 6·0% of all NFPA and the SIR was 0·12/100 000/year. There was a statistically significant difference in the degree of suprasellar extension (P < 0·001) and infrasellar extension (P = 0·028) between the different macroadenoma subtypes and in the vertical extension indices (median vertical extension index NFPA 3·0 mm; PRLoma -7·7 mm; GH-secreting PA -1·7 mm; P < 0·001). Pituitary macroadenomas with cavernous sinus invasion were statistically significantly larger than those without cavernous sinus invasion (P < 0·001). NFPA had predominantly a superior extension into the cavernous sinus (63·6%) compared to the functional PAs which had predominantly an inferior extension into the cavernous sinus (59·1%) (P = 0·032).

Conclusions: The various macroadenoma subtypes' epidemiological data are presented and differences between growth patterns among the various subtypes are highlighted.
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http://dx.doi.org/10.1111/cen.13064DOI Listing
August 2016

Prevalence and incidence of pituitary adenomas: a population based study in Malta.

Pituitary 2013 Dec;16(4):545-53

Department of Medicine, Faculty of Medicine and Surgery, Mater Dei Hospital, University of Malta, Msida, MSD2090, Malta.

Epidemiological data is important to correctly quantify the extent of disease and needed health care resources. The aim of the study was to establish the prevalence and incidence of pituitary adenomas (PAs) in the same well defined population, with in-depth analysis of the various subtypes. The design involved a retrospective cross-sectional analysis of PA patients diagnosed prior to 31 July 2011 for prevalence estimates and those diagnosed between July 2000 and July 2011 for incidence estimation. A thorough search for patients with PAs was carried out in central hospital registries including outpatients departments, surgical registries, radiological department and specialty clinic databases. Prevalence rates/100,000 and Standardised incidence ratios (SIR)/100,000/year were worked out. The respective prevalence rates and SIR for PAs overall were 75.7/100,000, and 4.27/100,000/year, for Prolactinomas 35.0/100,000 and 2.05/100,000/year, for nonfunctioning PA 25.9/100,000 and 1.79/100,000/year and for GH-secreting PAs 12.5/100,000 and 0.31/100,000/year. The overall prevalence for macroadenomas was 32.8/100,000 and SIR was 1.49/100,000/year. The prevalence rate in males for PAs overall was 46.3/100,000 and SIR was 2.08/100,000/year and in females 104.8/100,000 and SIR was 6.58/100,000/year. Females had a lower proportion of macroadenomas than males (29.5 vs. 75.0%; P < 0.001) and macroadenomas tended to present at a later age compared to microadenomas (48 vs. 34.5; P < 0.001). The highest SIR was reached in the 30-39 age group at 7.42/100,000/year. Our data confirm the considerable disease burden that PAs bear on health care resources. Males and females have similar prevalence and SIR rates for macroadenomas but there is a significant increase in SIR in females of child bearing age compared to males. These observations may have important implications in terms of the economic burden and need for early intervention.
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http://dx.doi.org/10.1007/s11102-012-0454-0DOI Listing
December 2013

Epidemiology, treatment trends and outcomes of acromegaly.

Eur J Intern Med 2012 Dec 22;23(8):e206-7. Epub 2012 Aug 22.

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http://dx.doi.org/10.1016/j.ejim.2012.07.010DOI Listing
December 2012

Expression and clinical significance of Wnt players and survivin in pituitary tumours.

Endocr Pathol 2012 Jun;23(2):123-31

Department of Medicine, Faculty of Medicine and Surgery, Mater Dei Hospital, University of Malta, Msida, Malta.

Deregulation of the Wnt pathway has been implicated in oncogenesis of numerous tissues including the pituitary gland. Immunohistochemical localization and quantification of β-catenin, Cyclin D1, c-MYC and Survivin expression in 47 pituitary adenomas (35 non-functioning, seven GH-secreting, three prolactinomas, two ACTH-secreting tumour) and six normal controls was undertaken in this study and correlation of protein expression to patient and tumour characteristics analysed. β-catenin was strictly membrane-bound with no difference observed between normal and tumour tissue. In contrast, Cyclin D1 and c-MYC localization was nuclear and significantly higher in tumour versus normal tissue (p < 0.05). c-MYC expression correlated negatively with age at diagnosis (p = 0.006, R = -0.395) while Cyclin D1 expression correlated positively with age (p = 0.036, R = 0.306) and was higher in males than in females (p = 0.036). c-MYC expression was significantly lower in patients with functional tumours requiring octreotide treatment and in patients with non-functioning tumours suffering from hypopituitarism. Survivin expression was extremely low in tumours and absent in normal controls. Involvement of the canonical Wnt pathway appears to be minimal, given the segregation of β-catenin to the membrane. Our data suggest that c-MYC may have an important role in early pituitary tumorigenesis while Cyclin D1 is likely to promote tumour growth at a later stage. We also report a novel gender difference in Cyclin D1 expression, the biological significance of which merits further analysis. The reported reduction of c-MYC in functional tumours subsequently treated with octreotide further supports a role of c-MYC in early tumorigenesis and not in recurrence. The decrease in c-MYC in patients with hypopituitarism provides the first in vivo evidence for hormonal regulation of c-MYC expression.
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http://dx.doi.org/10.1007/s12022-012-9197-8DOI Listing
June 2012

Long-term survival after acute myocardial infarction and relation to type 2 diabetes and other risk factors.

Clin Cardiol 2010 Jul;33(7):424-9

Diabetes and Endocrine Centre, Mater Dei Hospital, Msida, Malta.

Background: Diabetes mellitus (DM) is well established as a short-term prognostic indicator after myocardial infarction (MI), but little long-term data are available.

Hypothesis: The objective of the study was to assess the impact of DM and other patient characteristics at baseline on long-term mortality after acute MI.

Methods: Patients who were hospitalized with MI from December 1990 to November 1992 were recruited. Baseline data were recorded and patients were followed up through January 31, 2008, to assess their survival rates. Survival curves were generated by the Kaplan-Meier method. The main outcome measure was long-term survival (median 16.6 y).

Results: The study followed 337 patients (mean age 66.4 y, 61.1% men) for a median of 16.6 years. Using Cox regression analysis, survival was associated with history of MI (hazard ratio [HR]: 1.47, P = 0.016), DM at baseline (HR: 1.31, P = 0.038), and age (HR: 1.061 for each additional year, P < 0.001). By multivariable regression, cardiovascular mortality was also associated with previous MI (HR: 1.58, P = 0.017), DM at baseline (HR: 1.69, P = 0.001), and age (HR: 1.075 for each additional year, P < 0.001). There was no statistically significant difference between the HRs for history of MI and history of DM.

Conclusions: Diabetic patients with MI have a higher long-term all-cause and cardiovascular mortality. Our data also show that in patients with MI, DM confers the same level of risk as a previous MI. This extends to patients with documented MI, our concept of diabetes being a coronary heart disease equivalent. Based on this and on data from the literature, we propose that it would be more accurate to consider DM as an MI equivalent rather than a coronary heart disease equivalent.
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http://dx.doi.org/10.1002/clc.20776DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6653194PMC
July 2010
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