Microangiopathy in diabetic polyneuropathy revisited

OBJECTIVE

Microangiopathy is a major cause in diabetic polyneuropathy (DPN). This review examines evidence from both human and animal studies to elucidate the important microvascular factors in DPN.

MATERIALS AND METHODS

This is a literature review of articles published on PubMed in English.

RESULTS

There is an abundance of evidence linking endoneurial microvascular abnormalities to peripheral nerve dysfunction and pathology in patients with diabetes. These structural changes result in an abnormal diffusion barrier leading to endoneurial hypoxia. Furthermore, the functional changes of endoneurial microvessels characterized by reduced vasodilation and potentiated vasoconstriction also exacerbate the endoneurial hypoxia. Although reduced endoneurial blood flow has also been widely reported in established DPN, there is some evidence that blood flow may be elevated early in the course of the disease. Capillary dysfunction in DPN, which reduces the amount of oxygen and glucose that can be extracted by the tissue for a given blood flow, may explain that the tissue may be hypoxic even in the context of normal or elevated nerve blood flow. The pathogenesis of painful DPN also remains unclear although neural hemodynamic changes have been demonstrated both in the peripheral and central nervous system, offering potential new insights for the treatments of this distressing condition.

CONCLUSIONS

Compelling experimental and human work has highlighted the close association connection between endoneurial microangiopathy and diabetic polyneuropathy. Future investigations will need to investigate the role of microvascular factors both in the periphery and the central nervous system in the pathogenesis of painful DPN.

[Desquamative interstitial pneumonia: report of one case and review of literature]

Objective: To analyze the clinical features, diagnosis, and treatment of desquamative interstitial pneumonia(DIP). Methods: The clinical manifestation, radiology, and pathology were analyzed in one patient with DIP in Beijing Hospital following review of the literatures. Results: The patient was a 55-year-old male presented with cough, shortness of breath and hypoxemia.Previous history of smoking and exposure to a variety of metals. A CT scan of the chest revealed diffuse ground-glass densities. A diagnosis of desquamative interstitial pneumonia (DIP) was confirmed by a thoracoscopic open lung biopsy. After treatment with hormone, the condition improved.A total of 66 cases were included in this study, the smoking groupof 20 cases, non-smokers of 46 cases.The smoking group was older than the non-smoking group [(47.5±12.1)years vs (26.1±22.5) years]; the present of chest pain, shortness of breath(4/20 vs 0/46; 8/20 vs 3/46) was higher in smoking group than in non-smoking group, and ground glass opacity in the chest image(15/20 vs 20/46) was also higher in smoking group than in non-smoking group.Pulmonary function showed more diffuse dysfunction(12/14 vs 6/13) in smoking group than in non-smoking group. Conclusions: As a rare disorder, DIP is associated with current or former cigarette smoking and many other risk factors. The clinical presents of non-smoker is atypical.DIP is curable to glucocorticoid and has a good prognosis.There is a possible of recurrence.

Clinical analysis of Hashimoto thyroiditis coexistent with papillary thyroid cancer in 1392 patients

Papillary thyroid carcinoma (PTC) is the most common malignant tumour of the thyroid. The effect of the concurrent presence of Hashimoto's thyroiditis (HT) and PTC is still under debate. The aim of this study is to investigate the influence of coexistent HT on prognostic outcomes and the association of coexistent HT with clinicopathological features. The demographic and clinicopathological data of 1,392 patients who underwent surgery in our hospital from 2007 to 2016 was collected and analysed. Among 1,392 PTC patients, the rate of HT was 25.6%. There were significant differences in the mean levels of thyroid stimulating hormone (3.27 vs. 2.41 μIU/L, p < 0.01), thyroperoxidase antibodies (110.31 vs. 131.2 U/ml, p < 0.01) and thyroglobulin antibodies (131.90 vs. 113.53 ng/ml, p < 0.01) between the two groups. PTC patients with HT had the following characteristics compared to patients without HT: smaller tumour size (p < 0.01), female predominance (p < 0.01) and higher rate of multifocality (p = 0.024). In addition, patients with HT had a significantly lower rate of lymph node metastasis (LNM) and advanced TNM stage than patients without HT (all p < 0.01). Multivariate analysis found that both age and multifocality were significantly associated with central LNM in HT patients (p < 0.01, p = 0.019, respectively). Extrathyroidal invasion and TSH level were also significant independent factors for lateral LNM in HT patients (p < 0.008, p = 0.04, respectively). HT is associated with a significantly higher risk of PTC. The coexistence of HT in PTC patients is associated with favourable clinical outcomes compared to PTC without HT. Total thyroidectomy and prophylactic central compartment lymphadenectomy should be a choice for PTC patients with HT.

[Effect of different parts of skull thickness on stereotactic electroencephalogram in children]

Objective: To investigate the thickness of cranial bone in different parts of children skull during stereotactic electroencephalogram (SEEG) and its effect on electrode fixation. Methods: From October 2016 to March 2017, 13 children with SEEG by robot of surgery assistant (ROSA) were selected. The basic case information and electrode design scheme were collected. The skull thickness of each electrode channel was measured on post-operation CT, and the loosening of the fixed screws were recorded. The thickness of skull in frontal bone, temporal bone, parietal bone and occipital bone was statistically processed by SPSS statistical software. Results: There were total 113 electrodes in 13 children with epilepsy. There were 45 electrodes at frontal bone, of which the thickness was (5.7±2.8)mm. There were 34 electrodes at temporal bone, of which the thickness was (3.5±1.3)mm.There were 16 electrodes at parietal bone, of which the thickness was (6.0±2.5)mm.There were 18 electrodes at occipital bone, of which the thickness was (6.9±0.5)mm. Statistics showed that there was significant difference between differnt bone (F=15.340, P<0.01). There were 4 electrodes loosening, 1 at frontal bone and 3 at temporal bone, when the screws were removed. There was no adverse event related to the implantation of electrodes. Conclusions: The children's skull thickness is thinner than adults. The screw loosening is exist in some cases, but it has no effect on SEEG recording. No SEEG related adverse events are found in this group. Therefore, ROSA guided SEEG is safe and reliable in children with epilepsy.

[Clinical features and diagnosis of childhood leukoencephalopathy with cerebral calcifications and cysts in four cases]

Objective: To investigate the clinical features and diagnostic bases of childhood leukoencephalopathy with cerebral calcifications and cysts (LCC). Methods: The clinical data involving manifestations and laboratory examinations of 4 children with LCC admitted to Beijing Children's Hospital Affiliated to Capital Medical University from 2012 to 2017 were retrospectively summarized. Each patient had a follow-up visit ranging from 4 months to 5 years and 9 months after initial examination. Results: Patients consisted of 2 males and 2 females, whose age of onset was respectively 2 years and 9 months, 6 years and 2 months, 7 years and 10 months, and 5 years and 1 month. The main clinical symptoms of these cases included headache, dizziness, partial seizure and claudication, and two of these cases had insidious onset. Cerebral calcifications and cysts with leukoencephalopathy were detected by neuroimaging in all patients. In addition, multifocal microhemorrhages and calcifications were observed by magnetic susceptibility-weighted imaging (SWI) series in 3 patients. Brain biopsy performed on 1 case disclosed a neuronal reduction in the cerebral cortex, loosening of focal white matter, multifocal lymphocyte infiltration, fresh hemorrhages, and gliosis, as well as angiomatous changes of blood vessels with hyalinized thicken-wall, stenotic or occlusive lumina and calcification deposits. The compound heterozygous mutations of n.*10G>A and n.82A>G in SNORD118 were identified in 1 case by target-capture next-generation sequencing. Sanger sequencing verified that the variant n.*10G>A was a novel mutation and it was of paternal-origin, while the variant n.82A>G was of maternal-origin, which had already been reported to be pathogenic to LCC. Follow-up study had shown continued partial seizure in 1 case and remissive claudication in another, while the remaining 2 cases had a relatively favorable outcome without obvious neurological symptoms at present time. Conclusions: The clinical manifestations of LCC are nonspecific, and the onset of the disease tends to be insidious. The triad neuroimaging findings of cerebral calcifications, cysts and leukoencephalopathy are essential to the diagnosis of the disease, and the signals of microhemorrhages revealed by SWI series provide another eloquent reference for the diagnosis. As biopsy is invasive and usually unavailable in the early stage, gene assessment, instead of pathological data, should be the gold standard in the diagnosis of LCC.

[Clinical and genetic characteristics of congenital myasthenia syndrome with episodic apnea caused by CHAT gene mutation: a report of 2 cases]

Objective: To investigate the clinical and genetic features of congenital myasthenia syndrome with episodic apnea (CMS-EA) caused by gene mutation of choline acetyltransferase (CHAT) Methods: The clinical data of 2 patients with congenital myasthenia syndrome were collected, and both were diagnosed from 2013 to 2015 in Beijing Children's Hospital, Capital Medical University. The clinical features and gene mutation characteristics were analyzed, and the patients were followed-up for therapeutic efficacy. Results: The two patients (case 1 and case 2) had the onset soon after birth and at 3 months after birth respectively. The two patients were admitted to the PICU due to dyspnea, cyanotic episodes that required intubation. The patients had repeated apnea and became ventilator dependent. Case 1 died due to refusal of any treatment. Case 2 had a tracheotomy, and gradually weaned from ventilator after using pyridostigmine. The hospitalization of case 2 lasted 162 days. Case 2 was followed up to the age of 3 years and 4 months, and was extubated and was maintained on oral neostigmine but still had fluctuating ptosis and minor physical and mental retardation. Both cases were negative for anti-AChR, anti-acetylcholinesterase, anti-MuSK antibodies. Neostigmine test was negative in case 1 and suspiciously positive in case 2. Low-frequency repetitive nerve stimulation testing of case 2 was negative. Cranial MRI scans of both cases showed brain atrophy-like change. Genetic testing showed compound heterozygous deletions (exon 4, 5, 6) and pathogenic variant c.914T>C (p.I305T) in CHAT in case 1, compound heterozygous variants c.1007T>C (p.I336T) and c.64C>T (p.Q22X) in CHAT in case 2. To our knowledge, compound heterozygous deletions (exon 4, 5, 6) and p.Q22X were novel, previously unreported variants. Conclusion: CMS-EA usually presents at birth or in the neonatal period with hypotonia, ptosis, dysphagia due to severe bulbar weakness, and respiratory insufficiency with cyanosis and apnea. Early treatment with pyridostigmine is helpful to the improvement of clinical symptoms and prognosis.

MicroRNA-543 functions as an osteogenesis promoter in human periodontal ligament-derived stem cells by inhibiting transducer of ERBB2, 2

BACKGROUND AND OBJECTIVE

Previous research has indicated that altered expression of microRNAs (miRNAs) is in connection with osteogenesis of human periodontal ligament-derived stem cells (hPDLSCs). We investigated the mechanisms by which miR-543 promotes osteogenic differentiation of hPDLSCs.

MATERIAL AND METHODS

First, the expression of miR-543 in hPDLSCs cultured with or without an osteogenic inductive cocktail was explored. Then, the function of miR-543 during osteogenesis of hPDLSCs was investigated by overexpressing and inhibiting miR-543. Next, 3 databases were used to predict target genes of miR-543 and a luciferase report was used to validate the direct regulation of miR-543 on the target gene. Further, a rescue experiment using co-transfection of miR-543 mimic and target mimic was performed to evaluate whether overexpressing the target gene could partly rescue the efficiency of overexpressing miR-543 on osteogenesis in hPDLSCs.

RESULTS

miR-543 was upregulated during osteogenic differentiation of hPDLSCs. Functional experiments showed that overexpressing miR-543 could enhance osteogenesis, while inhibiting miR-543 resulted in reduced formation of mineralized nodules. The transducer of ERBB2, 2 (TOB2) was identified as a target gene of miR-543 and luciferase report revealed that miR-543 interacts directly with the 3'-untranslated repeat sequence of TOB2 mRNA. Overexpression of miR-543 inhibited the expression of TOB2 in both mRNA and protein levels while inhibiting miR-543 increased. Furthermore, the rescue experiment confirmed the promotional role of miR-543 TOB2 expression could be abrogated by overexpressing TOB2, which also had the effect of reducing osteogenic differentiation.

CONCLUSION

Our research confirmed that miR-543 is a promoter of osteogenesis in hPDLSCs, acting by inhibiting its target gene TOB2, which suggests that miR-543 may be a potential therapy for bone loss in periodontitis.

First-onset mental disorders after cancer diagnosis and cancer-specific mortality: a nationwide cohort study

Background

The diagnosis of cancer is strongly associated with the risk of mental disorders even in patients with no previous history of mental disorders. Accumulating data suggest that mental distress may accelerate tumor progression. We hypothesized therefore that mental disorders after a cancer diagnosis may increase the risk of cancer-specific mortality.

Patients and methods

We conducted a nationwide cohort study including 244 261 cancer patients diagnosed in Sweden during 2004-2009 and followed them through 2010. Through the Swedish Patient Register, we obtained clinical diagnoses of all mental disorders and focused on mood-, anxiety-, and substance abuse disorders (ICD10: F10-F16, F18-F19, F32-F33, F40-F41, and F43-45) that are commonly diagnosed among patients with cancer. We further classified the studied mental disorders into first-onset or recurrent mental disorders. We used Cox regression to estimate multivariable hazard ratios (HRs) with 95% confidence intervals (CIs) as a measure of the association between mental disorders after cancer diagnosis and cancer-specific mortality, adjusting for age, sex, calendar period, educational level, cancer stage, and cancer type at diagnosis.

Results

After cancer diagnosis, 11 457 patients were diagnosed with mood-, anxiety-, and substance abuse disorders; of which 7236 were first-onset mental disorders. Patients with a first-onset mental disorder were at increased risk of cancer-specific mortality (HR: 1.82, 95% CI: 1.71-1.92) while patients with a recurrent mental disorder had much lower risk elevation (HR: 1.14, 95% CI: 1.05-1.24). The increased cancer-specific mortality by first-onset mental disorders was observed for almost all cancer sites/groups and the association was stronger for localized cancers (HR: 2.00, 95% CI: 1.73-2.31) than for advanced cancers (HR: 1.49, 95% CI: 1.32-1.69).

Conclusions

Patients with a first-onset common mood-, anxiety-, or substance abuse disorder after cancer diagnosis may be at increased risk of cancer-specific death.

Is prophylactic central neck dissection necessary for cN0 differentiated thyroid cancer patients at initial treatment? A meta-analysis of the literature

Central lymph node metastases are common in patients with differentiated thyroid cancer (DTC). The management of preoperatively nodenegative (cN0) DTC is still under debate. The aim of this study was to analyse the difference in recurrence and surgical complications between thyroidectomy (TT) alone and TT combined with prophylactic central neck dissection (pCND) as initial treatments to DTC patients with cN0 and evaluate the clinic significance of pCND for these patients. PubMed, Ovid, Cochrane Library, and Web of Science databases were systematically searched using multiple search terms. Twenty-three articles with 6,823 patients were identified. The quality of evidence was assessed by Jadad quality scores and the Newcastle-Ottawa Quality assessment scale. The results showed that compared with patients who underwent TT alone, patients who underwent TT plus pCND had a significant higher rate of transient recurrent laryngeal nerve injury (p = 0.023), transient hypocalcaemia (p < 0.01) and permanent hypocalcaemia (p<0.01). There was a trend towards lower central neck recurrence rate in TT plus pCND (p < 0.01). Combined TT and pCND as initial treatment for DTC patients with cN0 may reduce the risk of recurrence, but increases the incidence of some complications. Methodologically high-quality comparative studies are needed for further evaluation.

Methylation pattern variation between goats and rats during the onset of puberty

Puberty is initiated by increased pulsatile gonadotropin-releasing hormone (GnRH) release from the hypothalamus. Epigenetic repression is thought to play a crucial role in the initiation of puberty, although the existence of analogous changes in methylation patterns across species is unclear. We analysed mRNA expression of DNA methyltransferases (DNMTs) and methyl-binding proteins (MBPs) in goats and rats by quantitative real-time PCR (qRT-PCR). DNA methylation profiles of hypothalamic were determined at the pre-pubertal and pubertal stages by bisulphite sequencing. In this study, expression of DNMTs and MBPs mRNA showed different patterns in goats and rats. Global methylation variation was low in goats and rats, and the profile remained stable during puberty. Gene ontology (GO) and Kyoto Encyclopedia of Gene and Genomes (KEGG) pathway analysis revealed the involvement of 62 pathways in puberty in goats and rats including reproduction, type I diabetes mellitus and GnRH signalling pathways and found that Edn3, PTPRN2 and GRID1 showed different methylation patterns during puberty in goats and rats and similar variation patterns for Edn3 and PTPRN2 were showed. These indicated that Edn3 and PTPRN2 would play a role in the timing of puberty. This study provides evidence of the epigenetic control of puberty.

[Small vessel-childhood primary angiitis of the central nervous system: a case report and literature review]

Objective: To summarize the clinical and pathological features of small vessel-childhood primary angiitis of the central nervous system (SV-cPACNS), discuss the immune therapy and increase the attention to brain biopsy in SV-cPACNS. Methods: The clinical data, pathology of brain biopsy, treatment and outcome of an SV-cPACNS patient hospitalized in Beijing Children's Hospital in February 2016 were analyzed retrospectively. The cases reported at Pubmed, CNKI and Wanfang databases from 2007 to 2017 were searched, the clinical and pathological features, immunotherapy and prognosis of the disease were summarized according to the literature review. Results: A 70 months old girl had 6 times relapses during 5 months' disease course. Symptoms included convulsions, limb paralysis, blurred vision and speech difficulty. Multiple cortical lesions were found successively in brain MRI but CT angiography was negative. The pathology of brain biopsy revealed thickening of small vessel walls together with lymphocytic infiltration. After the treatment with rituximab, remission was achieved and remained stable without recurrence in 1 year follow up. A total of 44 pathologically confirmed cases reported in nearly 10 years were retrieved. Male to female ratio was 1∶3.5. The average onset age was 9.8 years. Clinical manifestations included seizures (37/45, 82%), headache (35/45, 78%), cognitive decline (28/45, 62%), speech regression(20/45, 44%), paralysis (15/45, 33%), and so on; 70% (19/27) patients experienced relapses. Erythrocyte sedimentation rate and C-reactive protein slightly elevated, antinuclear antibody and other autoimmune antibodies were mostly negative. Mild lymphocytosis in cerebrospinal fluid was found in 67%(29/43) patients. 53%(23/43) patients had elevated CSF protein level, several had elevated IgG and positive oligoclonal band. Bilateral multifocal lesions were revealed in 80% (36/45) brain MRIs, meanwhile all angiographies were unremarkable. The pathology showed small angiitis and immunohistochemistry positive for CD3 and CD20. Twenty-seven patients had detailed therapeutic information; 25 of them received immunosuppressive agents, including cyclophosphamide, mycophenolate mofetil and rituximab. One patient died, 26 patients achieved remission with 54% (22/44) had neurological sequelae. Conclusions: SV-cPACNS had varied clinical manifestations, there was no specificity in laboratory and imaging examination and angiography was often negative. The definite diagnosis relied on brain biopsy, which showed lymphocytic inflammation of small vessels. SV-cPACNS tended to relapse and induce neurologic deterioration. Treatment required long-term use of steroids and immunosuppressive agents. Rituximab could be an effective agent.

[Analysis of 12 cases of exogenous lipoid pneumonia confirmed by pathology]

Objective: To study the etiological, clinical, radiological, diagnostic, therapeutic, and prognostic manifestations of exogenous lipoid pneumonia (ELP), and therefore to improve the diagnosis and treatment of this disease. Methods: The clinical data of 12 cases of ELP confirmed by pathology were retrospectively analyzed. Results: The patients consisted of 9 males and 3 females, with an average age of 73.8 years (range, 44 to 100 years). The underlying diseases were variable, including diseases affecting the general condition (multiple organ failure, chronic heart and renal insufficiency, pemphigoid, etc) and conditions with increased risk of aspiration (sequelae of cerebrovascular disease, Alzheimer's disease, advanced stage of nasopharyngeal carcinoma, paralytic ileus, etc). The 12 cases were all caused by Inhalation of mineral oil. Common symptoms included cough, sputum production and dyspnea. ELP had no special physical signs. Inflammation indexes, such as white blood cell, neutrophil percentage, ESR, C reactive protein, procalcitonin, D-Dimer, and blood lipid levels were usually normal. Radiological features of ELP mainly included consolidation, mass or nodules, with a little ground-glass opacity. Some patients had ventilation and/or diffusion dysfunction. The diagnostic methods included CT-guided percutaneous lung biopsy, thoracoscopy, thoracotomy or autopsy. Histopathological findings showed accumulation of large foamy macrophages in the alveolar spaces, with a few lipid deposition and polykaryocytes. The main treatment of ELP was cessation of lipid material contact. One case died of ELP, 6 died of other coexisting diseases, and the rest 6 improved with treatment and were discharged. The survival patients were all stable during a follow-up of 2-4.5 years. Conclusions: ELP was rare and its clinical manifestation was atypical. Its radiological manifestations were indistinguishable from pneumonia, lung cancer, interstitial lung diseases, etc. Pathological examination was the gold standard for diagnosis, and the preferred means of sampling was bronchoscopy. In cases whose diagnosis could not be confirmed by BALF, CT-guided percutaneous lung biopsy might be considered. The most important treatment is cessation of lipid material contact. The prognosis is good.

A system for detecting high impact-low frequency mutations in primary tumors and metastases

Tumor complexity and intratumor heterogeneity contribute to subclonal diversity. Despite advances in next-generation sequencing (NGS) and bioinformatics, detecting rare mutations in primary tumors and metastases contributing to subclonal diversity is a challenge for precision genomics. Here, in order to identify rare mutations, we adapted a recently described epithelial reprograming assay for short-term propagation of epithelial cells from primary and metastatic tumors. Using this approach, we expanded minor clones and obtained epithelial cell-specific DNA/RNA for quantitative NGS analysis. Comparative Ampliseq Comprehensive Cancer Panel sequence analyses were performed on DNA from unprocessed breast tumor and tumor cells propagated from the same tumor. We identified previously uncharacterized mutations present only in the cultured tumor cells, a subset of which has been reported in brain metastatic but not primary breast tumors. In addition, whole-genome sequencing identified mutations enriched in liver metastases of various cancers, including Notch pathway mutations/chromosomal inversions in 5/5 liver metastases, irrespective of cancer types. Mutations/rearrangements in FHIT, involved in purine metabolism, were detected in 4/5 liver metastases, and the same four liver metastases shared mutations in 32 genes, including mutations of different HLA-DR family members affecting OX40 signaling pathway, which could impact the immune response to metastatic cells. Pathway analyses of all mutated genes in liver metastases showed aberrant tumor necrosis factor and transforming growth factor signaling in metastatic cells. Epigenetic regulators including KMT2C/MLL3 and ARID1B, which are mutated in >50% of hepatocellular carcinomas, were also mutated in liver metastases. Thus, irrespective of cancer types, organ-specific metastases may share common genomic aberrations. Since recent studies show independent evolution of primary tumors and metastases and in most cases mutation burden is higher in metastases than primary tumors, the method described here may allow early detection of subclonal somatic alterations associated with metastatic progression and potentially identify therapeutically actionable, metastasis-specific genomic aberrations.