Adrenocortical carcinoma and succinate dehydrogenase gene mutations: an observational case series

OBJECTIVE

Germline loss-of-function mutations in succinate dehydrogenase (SDHx) genes results in rare tumor syndromes that include pheochromocytoma, paraganglioma, and others. Here we report a case series of patients with adrenocortical carcinoma (ACC) that harbor SDHx mutations.

PATIENTS AND RESULTS

We report four unrelated patients with ACC and SDHx mutations. All cases presented with Cushing syndrome and large adrenal masses that were confirmed to be ACC on pathology. All four ACC specimens were found to have truncating mutations in either SDHC or SDHA, while cases 1, 2 and 3 also had the mutations confirmed in the germline: Case 1: SDHC c.397C > T, pR133X; Case 2: SDHC c.43C > T, p.R15X; Case 3: SDHA c.91C > T, p.R31X; Case 4: SDHA c.1258C > T, p.Q420X. Notably, Case 1 had a father and daughter who both harbored the same SDHC germline mutation, and the father had a paraganglioma and renal cell carcinoma. A combination of next generation sequencing, and/or immunohistochemistry, and/or mass spectroscopy was used to determine whether there was loss of heterozygosity and/or loss of SDH protein expression or function within the ACC. Potential evidence of loss of heterozygosity was observed only in Case 2.

CONCLUSIONS

We observed truncating mutations in SDHA or SDHC in the ACC and/or germline of four unrelated patients. Given how statistically improbable the concurrence of ACC and pathogenic germline SDHx mutations is expected to be, these observations raise the question whether ACC may be a rare manifestation of SDHx mutation syndromes. Further studies are needed to investigate the possible role of SDH deficiency in ACC pathogenesis.

The impact of statin use on the efficacy of abiraterone acetate in patients with castration-resistant prostate cancer

BACKGROUND

Statins compete with DHEAS for influx through the SLCO2B1 transporter, which may prolong time to progression (TTP) on androgen deprivation therapy. Abiraterone acetate (AA) may also undergo SLCO-mediated transport. Based on preclinical findings showing antagonism, we hypothesized that statins may compete with AA for influx via SLCO2B1 and could negatively impact drug efficacy.

METHODS

We queried two institutional clinical databases (Dana-Farber Cancer Institute [DFCI], Johns Hopkins University [JHU]) for CRPC patients treated with AA. Treatment duration was a surrogate for TTP. Associations between statin use and AA duration were estimated using the Kaplan-Meier method. Multivariable Cox regression modeling adjusted for known prognostic factors.

RESULTS

Of the 224 DFCI and 270 JHU patients included, the majority (96%) had metastatic disease. Nearly half (41% and 45%) were statin users. In the DFCI cohort, there was a trend toward longer AA duration in statin users: 14.2 versus 9.2 months (HR 0.79, 95%CI: 0.57-1.09, P = 0.14). There was no association between statin use and AA duration in the JHU cohort: 8.3 versus 8.0 months (HR 0.89, 95%CI: 0.69-1.16, P = 0.38) in the statin users versus non-users, except for a trend in patients that had not previously received docetaxel or enzalutamide (HR 0.79; 95%CI: 0.57-1.10).

CONCLUSIONS

Contrary to our initial hypothesis, there was a trend toward longer (rather than shorter) AA duration in statin users in the entire DFCI cohort and in the enzalutamide- and docetaxel-naïve JHU patients. Together, these results do not support the hypothesis that statins interfere with AA efficacy.

Delusion proneness and 'jumping to conclusions': relative and absolute effects

BACKGROUND

That delusional and delusion-prone individuals 'jump to conclusions' is one of the most robust and important findings in the literature on delusions. However, although the notion of 'jumping to conclusions' (JTC) implies gathering insufficient evidence and reaching premature decisions, previous studies have not investigated whether the evidence gathering of delusion-prone individuals is, in fact, suboptimal. The standard JTC effect is a relative effect but using relative comparisons to substantiate absolute claims is problematic. In this study we investigated whether delusion-prone participants jump to conclusions in both a relative and an absolute sense.

METHOD

Healthy participants (n = 112) completed an incentivized probabilistic reasoning task in which correct decisions were rewarded and additional information could be requested for a small price. This combination of rewards and costs generated optimal decision points. Participants also completed measures of delusion proneness, intelligence and risk aversion.

RESULTS

Replicating the standard relative finding, we found that delusion proneness significantly predicted task decisions, such that the more delusion prone the participants were, the earlier they decided. This finding was robust when accounting for the effects of risk aversion and intelligence. Importantly, high-delusion-prone participants also decided in advance of an objective rational optimum, gathering fewer data than would have maximized their expected payoff. Surprisingly, we found that even low-delusion-prone participants jumped to conclusions in this absolute sense.

CONCLUSIONS

Our findings support and clarify the claim that delusion formation is associated with a tendency to 'jump to conclusions'. In short, most people jump to conclusions, but more delusion-prone individuals 'jump further'.

Infliximab reverses inflammatory muscle wasting (sarcopenia) in Crohn's disease

BACKGROUND

Muscle wasting or sarcopenia arising from chronic inflammation is found in 60% of patients with Crohn's disease. Transcriptional protein NF-κB reduces muscle formation through MyoD transcription and increases muscle breakdown by proteolysis.

AIM

As TNF is a potent activator of NF-κB, and anti-TNF agent infliximab (IFX) prevents NF-κB activation, to determine whether or not Crohn's patients treated with IFX gain muscle volume and strength.

METHODS

We performed a prospective, repeated-measures cohort study in adult Crohn's disease patients with an acute disease flare. Patients were instructed not to vary diet or activity. Concomitant medications were kept stable. At week 1 (pre-treatment), week 16 (post-IFX induction) and week 25 (post-first IFX maintenance dose), we assessed (i) MRI volume of quadriceps femoris at anatomical mid-thigh; (ii) maximal concentric quadriceps contractions strength at three specific speeds of contraction; (iii) physical activity by validated instrument (IPAQ); (iv) Three-day food record of intake and composition (food-weighing method); (v) Serum levels of IL6.

RESULTS

Nineteen patients (58% female; mean age 33.2 ± 10.7 years) were recruited. IFX increased muscle volume in both legs from baseline (right, 1505 cm(3) ) to week 25 (right, 1569 cm(3) ; P = 0.010). IFX also increased muscle strength in both legs from baseline (right 30°/s, 184.8 Nm) to week 25 (right 30°/s, 213.6 Nm; P = 0.002). Muscle volume gain correlated with male gender (P = 0.003). Significant gains in muscle volume and strength were unrelated to prednisolone use. Serum IL6 levels decreased by week 25 (P = 0.037).

CONCLUSION

The anti-TNF agent infliximab reverses inflammatory sarcopenia in patients with Crohn's disease.

Directed differentiation of human embryonic stem cells towards a pancreatic cell fate

AIMS/HYPOTHESIS

The relative lack of successful pancreatic differentiation of human embryonic stem cells (hESCs) may suggest that directed differentiation of hESCs into definitive endoderm and subsequent commitment towards a pancreatic fate are not readily achieved. The aim of this study was to investigate whether sequential exposure of hESCs to epigenetic signals that mimic in vivo pancreatic development can efficiently generate pancreatic endodermal cells, and whether these cells can be further matured and reverse hyperglycaemia upon transplantation.

MATERIALS AND METHODS

The hESCs were sequentially treated with serum, activin and retinoic acid (RA) during embryoid body formation. The patterns of gene expression and protein production associated with embryonic germ layers and pancreatic endoderm were analysed by RT-PCR and immunostaining. The developmental competence and function of hESC-derived PDX1-positive cells were evaluated after in vivo transplantation.

RESULTS

Sequential treatment with serum, activin and RA highly upregulated the expression of the genes encoding forkhead box protein A2 (FOXA2), SRY-box containing gene 17 (SOX17), pancreatic and duodenal homeobox 1 (PDX1) and homeobox HB9 (HLXB9). The population of pancreatic endodermal cells that produced PDX1 was significantly increased at the expense of ectodermal differentiation, and a subset of the PDX1-positive cells also produced FOXA2, caudal-type homeobox transcription factor 2 (CDX2), and nestin (NES). After transplantation, the PDX1-positive cells further differentiated into mature cell types producing insulin and glucagon, resulting in amelioration of hyperglycaemia and weight loss in streptozotocin-treated diabetic mice.

CONCLUSIONS/INTERPRETATION

Our strategy allows the progressive differentiation of hESCs into pancreatic endoderm capable of generating mature pancreatic cell types that function in vivo. These findings may establish the basis of further investigations for the purification of transplantable islet progenitors derived from hESCs.

Attractiveness of facial averageness and symmetry in non-western cultures: in search of biologically based standards of beauty

Averageness and symmetry are attractive in Western faces and are good candidates for biologically based standards of beauty. A hallmark of such standards is that they are shared across cultures. We examined whether facial averageness and symmetry are attractive in non-Western cultures. Increasing the averageness of individual faces, by warping those faces towards an averaged composite of the same race and sex, increased the attractiveness of both Chinese (experiment 1) and Japanese (experiment 2) faces, for Chinese and Japanese participants, respectively. Decreasing averageness by moving the faces away from an average shape decreased attractiveness. We also manipulated the symmetry of Japanese faces by blending each original face with its mirror image to create perfectly symmetric versions. Japanese raters preferred the perfectly symmetric versions to the original faces (experiment 2). These findings show that preferences for facial averageness and symmetry are not restricted to Western cultures, consistent with the view that they are biologically based. Interestingly, it made little difference whether averageness was manipulated by using own-race or other-race averaged composites and there was no preference for own-race averaged composites over other-race or mixed-race composites (experiment 1). We discuss the implications of these results for understanding what makes average faces attractive. We also discuss some limitations of our studies, and consider other lines of converging evidence that may help determine whether preferences for average and symmetric faces are biologically based.

Changes in management of diabetic retinopathy by Australian ophthalmologists as a result of the NHMRC clinical guidelines

PURPOSE

To document changes in management of diabetic retinopathy by Australian ophthalmologists after release of the National Health and Medical Research Council (NHMRC) clinical guidelines.

METHODS

Self-administered questionnaires were mailed to Australian ophthalmologists prior to release of the NHMRC guidelines for the management of diabetic retinopathy, and at one and 2.5 years after release of the guidelines. The questionnaires elicited information about current management practices in relation to diabetic retinopathy

RESULTS

The response rate for the baseline and two follow-up surveys was 82%, 81%, and 80%, respectively. More than 85% of the ophthalmologists responded that the guidelines were useful in improving management, were easy to understand, and were already part of their routine clinical practice. A relatively small percentage (12%) felt that the guidelines made recommendations that were not practical or feasible. Contrary to the NHMRC guidelines, at the second follow-up survey, only 50% of the ophthalmologists said that they would almost never perform fluorescein angiography in eyes with mild non-proliferative diabetic retinopathy. The change from baseline to the second follow-up in the percentage of ophthalmologists who would perform cataract surgery after treating clinically significant macular oedema (as advised by the NHMRC guidelines) was statistically significant (baseline = 83.7%, 95% confidence limit = 80.4, 87.0; second follow up = 90.4, 95% confidence limit = 87.3, 93.5).

CONCLUSIONS

Distribution of the printed NHMRC Clinical Practice Guidelines: Management of Diabetic Retinopathy and full colour Retinopathy Chart resulted in a significant change in the recommended order of treatment of clinically significant macular oedema. However no significant change in the use of fluorescein angiography was documented.

Changes in attitudes and practices of optometrists in their management of diabetic retinopathy after the release of NHMRC guidelines. National Health and Medical Research Council

The purpose of this study was to document attitudes and practices of Australian optometrists in their management of diabetic retinopathy prior to the release of the National Health and Medical Research Council (NHMRC) Clinical Practice Guidelines for the Management of Diabetic Retinopathy and at two time points following their release. A self-administered questionnaire was mailed to a stratified random sample of 500 Australian optometrists at the three time points. The same sample was used for the first two surveys and a new random sample was drawn for the second follow-up survey. The response to the three questionnaires was 86%, 80% and 84%, respectively. More than 90% of optometrists reported receiving a copy of the guidelines and 82% reported receiving the supplementary Retinopathy Chart. Fifty-seven per cent reported having read the guidelines at least once in entirety and 65% reported that they refer to the Retinopathy Chart at least monthly in their clinical practice. There was a significant decrease in the number of optometrists who reported that patient unwillingness to be dilated and their fear of precipitating angle closure glaucoma were moderate or major barriers to performing dilated ophthalmoscopy. Concomitantly, the percentage of optometrists who reported that they often or always perform dilated ophthalmoscopy on new patients with diabetes increased significantly from 74.5% (95% confidence limit = 70.2, 78.8) to 81.5% (95% confidence limit = 77.5, 85.5). There have been some significant changes in the self-reported management practices of optometrists in relation to diabetic retinopathy since the release of the NHMRC guidelines and Retinopathy Chart.