Adrenocortical Suppression in Children with Nephrotic Syndrome Treated with Low-Dose Alternate Day Corticosteroids

Corticosteroids form the mainstay of therapy for all forms of nephrotic syndrome. The long-term use of this medication is associated with serious side effects including adrenocortical suppression. The primary objective of this study was to identify adrenocortical suppression (assessed by single morning serum cortisol levels) in children with nephrotic syndrome on treatment with low-dose alternate day steroids. This cross-sectional study was conducted in the Department of Pediatrics in a tertiary care hospital from January 2014 to January 2015. Seventy children (1–18 years) with nephrotic syndrome (steroid sensitive and resistant) who were in remission and on low-dose alternate day steroids for at least 8 weeks or had received steroids of 2 mg/kg/d for at least 2 weeks in the last 1 year (infrequent relapsers) were enrolled. Relevant history was taken, clinical examination was done and blood samples were drawn for serum cortisol, lipid profile, kidney function tests, fasting blood sugar, glycated hemoglobin (HbA_1c), and serum albumin. Forty percent (28/70) children had adrenocortical suppression as assessed by low morning serum cortisol levels. The mean serum cortisol levels were 188 nmol/L and were significantly lower in frequently relapsing individuals (85.9 nmol/L) as compared to other types of nephrotic syndrome (P = 0.05). The prevalence of adrenocortical suppression was higher in steroid-resistant patients (57%) as compared to 28% in frequently relapsing and 11% in steroid-dependent patients. Fifty-seven percent of patients with adrenocortical suppression had short stature while 50% had obesity. All individuals had normal serum HbA_1c levels. The cumulative steroid doses and total duration of corticosteroid therapy were significantly higher in patients with adrenocortical suppression. Children with nephrotic syndrome treated with low-dose alternate day steroids have a high prevalence of adrenocortical suppression on screening with single morning cortisol sample. Those with frequently relapsing or steroid-resistant diseases are at a higher risk of suppression.

PTH [1-34]-induced alterations predispose the mandibular condylar cartilage to mineralization

OBJECTIVE

To study the effects of intermittent parathyroid hormone (PTH [1-34]) on the mandibular condylar cartilage (MCC) and subchondral bone in adult female mice.

MATERIALS AND METHODS

Twenty-two, 20-week-old female mice were used for in vivo experiments. The experimental mice (n=11) received daily intraperitoneal injections of PTH [1-34] for 3 weeks, while control mice (n=11) received intraperitoneal injections of 0.9% saline solution. Mice were euthanized and then micro-computed tomography (micro-CT); histology and immunostaining were carried out to assess the response.

RESULTS

Intermittent PTH [1-34] led to early MCC breakdown and surface irregularities. Micro-CT analyses indicated that PTH [1-34] treatment led to increased bone volume fraction, tissue density and trabecular thickness, while decreasing the trabecular spacing. Histological analyses showed decreased proteoglycan secretion, increased bone turnover (TRAP staining) and increased mineralization. Furthermore, PTH [1-34] treatment showed increased apoptosis of the cells. Our immunohistochemistry showed increased expression of pSMAD158 in the MCC and subchondral bone with PTH administration, whereas sclerostin (SOST) expression was decreased.

CONCLUSIONS

Intermittent PTH [1-34] results in early mineralization of the MCC, which may result in cartilage degeneration. Our results identified a novel mechanism by which PTH [1-34] induces alteration in the microarchitecture of the MCC and the subchondral bone.

TOR complex 2 in fission yeast is required for chromatin-mediated gene silencing and assembly of heterochromatic domains at subtelomeres

The conserved serine/threonine protein kinase target of rapamycin (TOR) is a major regulator of eukaryotic cellular and organismal growth and a valuable target for drug therapy. TOR forms the core of two evolutionary conserved complexes, TOR complex 1 (TORC1) and TORC2. In the fission yeast Schizosaccharomyces pombe, TORC2 responds to glucose levels and, by activating the protein kinase Gad8 (an orthologue of human AKT), is required for well-regulated cell cycle progression, starvation responses, and cell survival. Here, we report that TORC2-Gad8 is also required for gene silencing and the formation of heterochromatin at the S. pombe mating-type locus and at subtelomeric regions. Deletion of TORC2-Gad8 resulted in loss of the heterochromatic modification of histone 3 lysine 9 dimethylation (H3K9me2) and an increase in euchromatic modifications, including histone 3 lysine 4 trimethylation (H3K4me3) and histone 4 lysine 16 acetylation (H4K16Ac). Accumulation of RNA polymerase II (Pol II) at subtelomeric genes in TORC2-Gad8 mutant cells indicated a defect in silencing at the transcriptional level. Moreover, a concurrent decrease in histone 4 lysine 20 dimethylation (H4K20me2) suggested elevated histone turnover. Loss of gene silencing in cells lacking TORC2-Gad8 is partially suppressed by loss of the anti-silencer Epe1 and fully suppressed by loss of the Pol II-associated Paf1 complex, two chromatin regulators that have been implicated in heterochromatin stability and spreading. Taken together, our findings suggest that TORC2-Gad8 signaling contributes to epigenetic stability at subtelomeric regions and the mating-type locus in S. pombe.

Abstract P4-06-03: Characteristics of CHEK2 mutation carriers in a large academic health center in Michigan

Background: Germline mutations in CHEK2, a cell-cycle checkpoint kinase, are associated with increased susceptibility to breast, colon, and other cancers. The clinical characteristics and cancer risks of patients with CHEK2 mutations is under investigation.

Methods: Patients identified with a pathogenic germline CHEK2 mutation between September 2013 and April 2017 were evaluated. Clinical multigene panel testing using next generation sequencing technologies was utilized. All patients received comprehensive pre- and post-test genetic counseling. Genetic testing results, demographics, tumor characteristics and outcomes were analyzed.

Results: A total of 107 CHEK2 mutation carriers were identified, of whom 88 (82%) were females. The vast majority were Caucasian (99%), and of those, 17 (16%) had Ashkenazi Jewish ancestry. The median age at time of genetic testing was 52 (range: 22-89). The most common mutations identified were: I157T (28%), c.1100delC (27%), p.S428F (15%) and c.1427C>T (9%). Seven of these patients (7%) were found to carry a second pathogenic cancer risk mutation: BRCA, ATM, NBN, NF1, and MUTYH. One patient was found to carry 3 pathogenic mutations (1100delC, ATM, and BRCA). Sixty-three (59%) patients had a prior diagnosis of malignancy, with a mean age of diagnosis of 53. Of the 88 females, the most common type of malignancy was breast cancer (55%), with a mean age of diagnosis of 52 (range: 35-79). Of the 19 males, breast cancer was seen in 4 patients. The most common known histopathology was invasive ductal carcinoma (72%), followed by DCIS (15%), invasive lobular carcinoma (9%), and papillary carcinoma (4%). Majority of the patients had breast tumors with low or moderate grade (62%), less than two centimeters (61%), node negative (70%), and estrogen/progesterone receptor positive/HER2neu negative (96%). Two patients had triple negative breast cancers. Of the 48 female mutation carriers with breast cancer, 38% underwent bilateral mastectomy. The 1- and 5-year survival was 100% with a median follow up of 57 months. Five of the 48 females developed a contralateral breast cancer, with a median time to contralateral recurrence of 6 years (range: 3-17). Two patients developed in-breast tumor recurrence at 9 and 19 years, respectively. Other cancers observed were papillary thyroid cancer (3 patients), melanoma (2 patients), and prostate (2 patients). One patient developed angiosarcoma of the chest wall two years after radiation therapy.

Conclusion: Our study describes the unique clinical characteristics of CHEK2 mutation carriers in a US-based clinic at Beaumont Health. Majority of breast cancers were early stage, hormone receptor positive and demonstrated excellent outcomes. Despite the early stage, a significant proportion of patients underwent bilateral mastectomy. Additional pathogenic mutations were identified in 10% of patients; validating the importance of panel testing in assessing cancer risk. Future studies are needed to better define the clinical presentation, cancer risks, mutational spectrum, and outcomes of CHEK2 mutation carriers in order to provide tailored screening and management guidelines for this emerging population.

Citation Format: Blankenship LM, Yadav S, Yumpo Cardenas P, Zakalik D. Characteristics of CHEK2 mutation carriers in a large academic health center in Michigan [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-06-03.

Final overall survival analysis for the phase II RECORD-3 study of first-line everolimus followed by sunitinib versus first-line sunitinib followed by everolimus in metastatic RCC

Background

RECORD-3 compared everolimus and sunitinib as first-line therapy, and the sequence of everolimus followed by sunitinib at progression compared with the opposite (standard) sequence in patients with metastatic renal cell carcinoma (mRCC). This final overall survival (OS) analysis evaluated mature data for secondary end points.

Patients and methods

Patients received either first-line everolimus followed by second-line sunitinib at progression (n = 238) or first-line sunitinib followed by second-line everolimus (n = 233). Secondary end points were combined first- and second-line progression-free survival (PFS), OS, and safety. The impacts of neutrophil lymphocyte ratio (NLR) and baseline levels of soluble biomarkers on OS were explored.

Results

At final analysis, median duration of exposure was 5.6 months for everolimus and 8.3 months for sunitinib. Median combined PFS was 21.7 months [95% confidence interval (CI) 15.1–26.7] with everolimus-sunitinib and 22.2 months (95% CI 16.0–29.8) with sunitinib-everolimus [hazard ratio (HR)_{EVE-SUN/SUN-EVE}, 1.2; 95% CI 0.9–1.6]. Median OS was 22.4 months (95% CI 18.6–33.3) for everolimus-sunitinib and 29.5 months (95% CI 22.8–33.1) for sunitinib-everolimus (HR_{EVE-SUN/SUN-EVE}, 1.1; 95% CI 0.9–1.4). The rates of grade 3 and 4 adverse events suspected to be related to second-line therapy were 47% with everolimus and 57% with sunitinib. Higher NLR and 12 soluble biomarker levels were identified as prognostic markers for poor OS with the association being largely independent of treatment sequences.

Conclusions

Results of this final OS analysis support the sequence of sunitinib followed by everolimus at progression in patients with mRCC. The safety profiles of everolimus and sunitinib were consistent with those previously reported, and there were no unexpected safety signals.

Clinical Trials number

ClinicalTrials.gov identifier, NCT00903175

Neutrophil Gelatinase-associated Lipocalin: As a Predictor of Early Diabetic Nephropathy in Type 2 Diabetes Mellitus

This study was carried out to look for diagnostic and prognostic role of neutrophil gelatinase-associated lipocalin (NGAL) in early diabetic nephropathy (DN) in type 2 diabetes individuals. NGAL was measured in both urinary and serum sample of 144 type 2 diabetes individuals stratified into three categories based on urinary albumin-creatinine ratio and 54 control populations with estimated glomerular filtration rate >60 mL/min/1.73 m² and serum creatinine <1.2 mg/dl. The serum NGAL (sNGAL), urine NGAL (uNGAL), and uNGAL/urine creatinine were significantly higher in diabetic individuals than in the control populations with significant difference in between the groups (P < 0.05). Difference of above values between control value and normoalbuminuria was also statistically significant (P < 0.05). Again, sNGAL and uNGAL correlate positively with albuminuria (P < 0.05). Tubular injury may precede glomerular injury in diabetic individuals, and NGAL can be used as a biomarker to diagnose DN even earlier to incipient nephropathy. Both sNGAL and uNGAL can predict albuminuria and be used as a noninvasive tool for diagnosis, staging, and progression of DN.

Reply to Comment on "Solid-Liquid Work of Adhesion"

Extrand's interpretation in his "Comment on "Solid-Liquid Work of Adhesion" by Tadmor and Coworkers" may lead to an important discussion and physical understanding of the problem. Below, we compare the two approaches and elucidate the differences to put them in the right perspective.

Lung cancer: analysis of biomarkers and methods of diagnostic and prognostic value

This paper summarizes the overwhelming evidence that targeted therapy is better than chemotherapy for the treatment of lung cancer. The focus is on lung cancer because of the sheer magnitude of this disease especially in males. In India, lung cancer constitutes 6.9 per cent of all new cancer cases and 9.3 per cent of all cancer related deaths in both sexes (1). Currently the world we reside has a norm of developing cure to an abnormal state of living body (so called disease) based on evidences, recognized during the diagnosis of the disease. It is done to ensure optimized therapy of treatment and maximize the outcome. Personalized medicine is also an uprising norm. In this kind, all the variables such as host, environment, patient, etc. are considered for an individual case and the course of treatment is followed based on the standard options available. Its main objective is the best interest of the patient. Through a survey conducted in the northern belt of the country we tried to determine the biomarkers currently being used and the scope of targeted therapy. Thus, in its most basic form medicine is not only a science but is also an art.

Purification, characterization and retting of Crotolaria juncea fibres by an alkaline pectin lyase from Fusarium oxysporum MTCC 1755

Using solid-state fermentation, production of an industrially important pectin lyase from a fungal strain Fusarium oxysporum MTCC 1755 was attempted, which was further subjected to purification and characterization. The enzyme was purified by three steps, namely ammonium sulfate fractionation, cation-exchange chromatography on CM cellulose followed by gel filtration chromatography using Sephadex G-100 column. A 16-fold purification with 31.2% yield and 3.2 U/mg specific activity was achieved. The optimum pH of the purified enzyme was 9.0 and stability ranged from pH 5.0-7.0 for 24 h. Optimum temperature of purified enzyme was found to be 40 °C while temperature stability ranged from 10 to 50 °C for 30 min. The K _m and k _cat of the enzyme was 1.75 mg/ml and 83.3 s^-1, respectively. The purified enzyme was found to be highly stimulated by Ca²⁺ ions while sugars like mannitol and sorbitol, and salts like NaCl and CaCl₂ enhanced the thermostability. The purified pectin lyase was found suitable for retting of Crotolaria juncea fiber.

Abstract P5-08-14: Synchronous bilateral breast cancer compared to unilateral breast cancer: A population based study

Introduction: The clinical presentation and outcome of synchronous bilateral invasive breast cancer compared to unilateral breast cancer is not well studied. In this study, we present a population based comparison of tumor characteristics and survival between invasive unilateral and bilateral breast cancer.

Methods: Data from National Cancer Institute- Surveillance, Epidemiology and End Results (SEER) was analyzed to identify women who had a diagnosis of invasive ductal carcinoma (ICD-O-3: 8500/3) between the years 2000 and 2013. Women who were diagnosed with an invasive contralateral breast cancer within two months of initial diagnosis were classified under synchronous bilateral breast cancer group. Women who developed a contralateral breast cancer between three to twelve months of diagnosis were excluded. All women who did not develop a second breast cancer, or developed it after twelve months of initial diagnosis were classified under unilateral breast cancer group. Patients with an in-situ breast cancer diagnosis in the contralateral breast within twelve months of diagnosis of invasive ductal carcinoma were excluded. Patients with metastatic disease and unknown stage at presentation were excluded. Tumor characteristics and survival were compared between the two groups using the index case only. Mann-Whitney U test was used for continuous variables while Chi-square test was used for categorical variables. Kaplan-Meier curves and Cox proportional hazard regression models were used to compare survival. All data analysis was performed using SPSS 21.

Results: A total of 414,766 patients met our inclusion criteria. Of these, 3,590 patients were in the synchronous bilateral breast cancer group, while 411,176 were in the unilateral breast cancer group. Compared to unilateral breast cancer patients, bilateral breast cancer patients were slightly older (62 Vs 59, p&lt;0.05) and were more likely to have higher T, N or overall stage at presentation. Their tumors were also more likely to be estrogen or progesterone receptor positive (p&lt;0.05). Patients with bilateral breast cancer also had higher rates of mastectomy (63.3% Vs 39.1%, p&lt;0.05).

Patients with bilateral breast cancers had a significantly worse survival compared to patients with unilateral breast cancer (Table 1). In a multivariate Cox proportional hazard regression, adjusting for age at diagnosis, T-Stage, N-Stage, overall stage, hormone receptor status, type of surgical treatment and radiation therapy, bilateral breast cancers had a mortality hazard ratio of 1.48 (95% CI: 1.35 – 1.62, p&lt;0.001) compared to unilateral breast cancers.

Conclusions: Our study demonstrates that bilateral breast cancer has a worse prognosis compared to invasive unilateral breast cancer. These findings have important implications for patients, and contribute to our understanding of the unique outcomes of bilateral breast cancer which will guide treatment and follow up.

Table 1: Survival of unilateral vs bilateral breast cancer Unilateral breast cancerBilateral breast cancer5-year cause specific survival91.7%86.5%10-year cause specific survival86.1%77.7%

Citation Format: Yadav S, Zakalik D. Synchronous bilateral breast cancer compared to unilateral breast cancer: A population based study [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-08-14.

Sequential, Autologous Hematopoietic Stem Cell Transplant Followed by Renal Transplant in Multiple Myeloma

A 30-year-old female was symptomatic with headache, fatigue, and weakness since October 2011 and was told to have anemia. In January 2012, she was admitted outside with pulmonary edema. Investigations revealed advanced azotemia, anemia, and hypercalcemia. Urine showed 2 + proteins and 30–35 red blood cells. There was no history of oral ulcers, rash, Raynaud's phenomenon, or hemoptysis. She was evaluated for causes of rapidly progressive “renal failure.” Hemolytic work-up; antinuclear antibody, double-stranded DNA, and anti-neutrophil cytoplasmic antibody were negative. Kidney biopsy was done and interpreted as acute interstitial nephritis with hyaline casts. She was started on hemodialysis and treated with steroids and cyclophosphamide. She came to our institute in January 2012. Investigations showed evidence of paraproteinemia with kappa restriction. Bone marrow showed 15% plasma cells. Kidney biopsy was reviewed and was diagnostic of cast nephropathy. She was treated with 6 monthly cycles of dexamethasone and bortezomib. She achieved complete remission in July 2012. Maintenance doses of bortezomib were continued until May 2014. Autologous bone marrow transplantation was performed on June 06, 2014. Monthly, bortezomib was continued till April 2015. Subsequently, workup for renal transplantation was started with her father as her donor. Test for sensitization was negative. Renal transplantation was done on January 1, 2016, with prednisolone, mycophenolate, and tacrolimus. She achieved a serum creatinine of 0.6 mg% on the 4^th postoperative day. Thereafter, she continues to remain stable.

Utilization of Antenatal care services in present pregnancy among the women attending in a Teaching Hospital for delivery

Aims: To study attendance of antenatal care services during present pregnancy by pregnant women coming for delivery in a teaching hospital of Kathmandu and to analyze the   impact of educational status, age group, gravida (number of pregnancy) and occupation of the women on antenatal care service utilization.Methods: Uncomplicated, term pregnant women who came for delivery in labour or for induction of labour or elective cesarean section were interviewed using semi-structured questionnaire.Results: Six hundred and four pregnant women were studied. Antenatal care coverage in studied population was found to be 94.8% with adequate (four) antenatal care visits in 83.4%. Women belonged to 20 to 30 years of age group and higher education status had higher rate of antenatal care attendance where as women who belonged to labor class (daily earner) had significantly lower rate of adequate antenatal care attendance. Number of pregnancy (gravida) of the women did not show association with rate of antenatal care attendance.Conclusions: Over all antenatal care attendance in this study is very high. Women of 20 to 30 years of age and higher education status had positive effect on antenatal care attendance, where as women who were daily earner or labour had higher rate of failure to attend antenatal care visits.

A nano-microstructured artificial-hair-cell-type sensor based on topologically graded 3D carbon nanotube bundles

A design for a unique artificial-hair-cell-type sensor (AHCTS) based entirely on 3D-structured, vertically aligned carbon nanotube (CNT) bundles is introduced. Standard microfabrication techniques were used for the straightforward micro-nano integration of vertically aligned carbon nanotube arrays composed of low-layer multi-walled CNTs (two to six layers). The mechanical properties of the carbon nanotube bundles were intensively characterized with regard to various substrates and CNT morphology, e.g. bundle height. The CNT bundles display excellent flexibility and mechanical stability for lateral bending, showing high tear resistance. The integrated 3D CNT sensor can detect three-dimensional forces using the deflection or compression of a central CNT bundle which changes the contact resistance to the shorter neighboring bundles. The complete sensor system can be fabricated using a single chemical vapor deposition (CVD) process step. Moreover, sophisticated external contacts to the surroundings are not necessary for signal detection. No additional sensors or external bias for signal detection are required. This simplifies the miniaturization and the integration of these nanostructures for future microsystem set-ups. The new nanostructured sensor system exhibits an average sensitivity of 2100 ppm in the linear regime with the relative resistance change per micron (ppm μm(-1)) of the individual CNT bundle tip deflection. Furthermore, experiments have shown highly sensitive piezoresistive behavior with an electrical resistance decrease of up to ∼11% at 50 μm mechanical deflection. The detection sensitivity is as low as 1 μm of deflection, and thus highly comparable with the tactile hair sensors of insects, having typical thresholds on the order of 30-50 μm. The AHCTS can easily be adapted and applied as a flow, tactile or acceleration sensor as well as a vibration sensor. Potential applications of the latter might come up in artificial cochlear systems. In particular, the stable mechanical bending of the sensor up to 90° opens up unique application opportunities.

Recurrence Risk of Febrile Seizures in Children

BACKGROUND

Identifying children with febrile seizure who are at risk for recurrence is important so that special attention can be given to them. The objective of this study was to identify the risk factors for recurrence of febrile seizures in children.

METHODS

This prospective hospital based study was conducted from July 2013 to August 2014 'among children of 6 months to 6 years of age at Bishweshwar Prasad Koirala Institute of Health Sciences (BPKIHS), Nepal. Children meeting the selection criteria were enrolled in study. Clinical, investigation, treatment and outcome parameters were analyzed.

RESULTS

A total of 92 children with febrile seizure were enrolled in study. Males accounted for 70% and females 30%. Simple febrile seizure was present in 48% and complex febrile seizures were seen in 52%. Recurrence of seizure was seen in one third of cases. Loss of consciousness was most common post-ictal phenomenon followed by confusion and lethargy. Upper respiratory infection was the most common precipitating factor. Generalized Tonic Clonic Seizure was the most common seizure type present in 79% of cases. Significant risk factors for recurrence occurred in males (p=0.088), age less than 1 year (p=0.003). Most of the recurrence occurred within one year of first seizure.

CONCLUSIONS

Febrile Seizure is common in males. Almost one third of children with febrile seizure are at risk for recurrence. The significant risk factors for recurrences are male gender and age <1year.