Plasma advanced glycation end products (AGEs), receptors for AGEs and their correlation with inflammatory markers in middle school-age children

AIM

Advanced glycation end products (AGEs) and/or their receptors (RAGE) are significantly positively correlated with adiposity, inflammation, dyslipidemia, and insulin resistance in adults. However, the relationships between AGEs, RAGE, and adiposity-related comorbidites in children have not been well studied.

METHODS

In a cross-sectional study of 88 children (age 11-15 years) from the New York area enrolled in the Reduce Obesity and Diabetes (ROAD) study, we examined the correlation of the AGE N(ε)-(carboxymethyl)lysine (CML), soluble RAGE (sRAGE), and endogenous secretory RAGE (esRAGE) with adiposity, inflammatory markers [interleukin-6 (IL-6), C-reactive protein, tumor necrosis factor-α], adiponectin, lipids, insulin sensitivity, and insulin secretory capacity.

RESULTS

Pediatric CML levels were ~20% below average adult levels. CML was significantly (p < 0.05) positively correlated with age and insulin sensitivity and negatively with adiposity, dyslipidemia and IL-6. sRAGE correlated positively with esRAGE and negatively with adiposity and IL-6. Both sRAGE and esRAGE correlated negatively with insulin secretory capacity.

CONCLUSION

Our findings suggest that unlike adults, CML is negatively associated with adiposity and adiposity-related comorbidity risk in children. As in adults, sRAGE and esRAGE were, to varying degrees, negatively correlated with body fatness and risk factors for adiposity-related comorbidities.

Mycophenolate mofetil in multiple sclerosis: a multicentre retrospective study on 344 patients

OBJECTIVES

Mycophenolate mofetil (MMF) is an immunosuppressive agent, sometimes used as a disease-modifying therapy for multiple sclerosis (MS). Several studies have reported the relative safety of this treatment but, to date, its efficacy has rarely been described. We performed a retrospective study to assess the safety and efficacy of MMF in patients with MS.

METHODOLOGY

Three French MS centres included all of their patients treated by MMF. The main outcome criterion was annualised relapse rate (ARR) in the 1 year period after onset of MMF compared with the 1 year control period. Treatment with another immunosuppressive drug, such as mitoxantrone or cyclophosphamide, in the 2 years preceding initiation of MMF was included in a subgroup analysis. MMF safety and progression of the Expanded Disability Status Scale (EDSS) score were also assessed.

RESULTS

344 patients were included; 149 patients were previously treated with another immunosuppressant (IS group). Mean MMF treatment duration was 25.3±1.1 months. During the 1 year control period, ARR was 1.11±0.08, and for the 1 year treatment period, ARR was reduced significantly to 0.35±0.05 (p<0.0001, Wilcoxon paired test). Adverse events (occurring in 11% of patients) were mainly digestive disorders, benign infections, asthenia and transitory lymphopenia. Concerning the progression of disability, in the subgroup of patients without previous immunosuppressant treatment, EDSS remained stable between initiation and 1 year after the beginning of MMF.

INTERPRETATION

Our results suggest that MMF can improve or stabilise MS patients and can be used as an alternative therapy.

Unique B cell differentiation profile in tolerant kidney transplant patients

Operationally tolerant patients (TOL) display a higher number of blood B cells and transcriptional B cell signature. As they rarely develop an allo-immune response, they could display an abnormal B cell differentiation. We used an in vitro culture system to explore T-dependent differentiation of B cells into plasma cells. B cell phenotype, apoptosis, proliferation, cytokine, immunoglobulin production and markers of differentiation were followed in blood of these patients. Tolerant recipients show a higher frequency of CD20(+) CD24(hi) CD38(hi) transitional and CD20(+) CD38(lo) CD24(lo) naïve B cells compared to patients with stable graft function, correlating with a decreased frequency of CD20(-) CD38(+) CD138(+) differentiated plasma cells, suggestive of abnormal B cell differentiation. B cells from TOL proliferate normally but produce more IL-10. In addition, B cells from tolerant recipients exhibit a defective expression of factors of the end step of differentiation into plasma cells and show a higher propensity for cell death apoptosis compared to patients with stable graft function. This in vitro profile is consistent with down-regulation of B cell differentiation genes and anti-apoptotic B cell genes in these patients in vivo. These data suggest that a balance between B cells producing IL-10 and a deficiency in plasma cells may encourage an environment favorable to the tolerance maintenance.

[Maintaining opioid abstinence long after inpatient treatment with opioid substitution in an addictology hospital unit]

OBJECTIVES

Assess the effectiveness of hospital detoxification of opiate substitution treatment (OST) in patients who failed to withdraw as outpatients.

METHODS

Retrospective study, conducted among patients admitted for withdrawal of OST in an addiction unit between 2005 and 2011. Referent physicians were interviewed about outcomes at M2, M3, M6 and M12.

RESULTS

47 patients were hospitalized for OST withdrawal. The opioid abstinence rates at 2, 6 and 12 months were 60, 28 and 21 %. No death occurred within 12 months after withdrawal. The only variables significantly associated with the M3 opioids abstinence were : age at admission and among the patients admitted for buprenorphine withdrawal, a low dose of buprenorphine at admission.

CONCLUSION

OST withdrawal in a specialized inpatient unit among patients with failure of outpatient withdrawal appears as an option, with an efficacy at least comparable to other methods of detoxification. It allows a comprehensive care and to prevent the risk of overdose.

The rationale for performing MR imaging before surgery for primary hyperparathyroidism

OBJECTIVE

The purpose of this study was to evaluate prospectively Magnetic Resonance Imaging (MRI) for the preoperative localization of hyperfunctioning parathyroid glands.

DESIGN

Prospective study of 58 consecutive patients with biochemically confirmed primary hyperparathyroidism who underwent preoperative MRI.

SETTING

The setting is a referral centre.

PATIENTS

Fifty-six of the 58 consecutive patients (41 women, 17 men) were studied by both preoperative MRI and 99mTC MIBI scintigraphy, and two by MRI alone. The same surgeon, using the information from both MRI and 99mTC MIBI, performed surgery in 58 patients, including 19 with a history of neck surgery. Initial interpretation of each MR study was done independently by one radiologist and the surgeon and then results were compared. At surgery, the operative duration, the precise anatomical location, weight, and dimensions as well as complete histopathological evaluations of all excised glands were recorded.

MAIN OUTCOME MEASURE

In addition to the prospective assessment of MRI, this study compared performance of MRI with double-phase 99mTC MIBI scintigraphy for preoperative localization of hyperfunctioning parathyroid glands.

RESULTS

All patients became normocalcaemic after surgery. MRI and 99mTC MIBI imaging revealed 53 of 58 (91%) and 47 of 56 (84%) of abnormal glands, respectively. Sensitivities of MRI and 99mTC MIBI were respectively 94.3 and 88.0. Positive predictive values were 96.15 and 93.60. When MRI and 99mTC MIBI were interpreted together, the sensitivity and positive predictive values both raised to 98.10. Median operative duration was 30 minutes (ranges 20-300 minutes, mean 65).

CONCLUSION

MRI has better sensitivity and positive predictive value than 99mTC MIBI scintigraphy for the detection of hyperfunctioning parathyroid glands. The combination of the two studies provides an additional increase in sensitivity and positive predictive value leading to a more precise anatomical localization of the abnormal parathyroid glands reducing both the extent of the surgical dissection and the operative duration.

The Time Complexity of A* with Approximate Heuristics on Multiple-Solution Search Spaces

We study the behavior of the A* search algorithm when coupled with a heuristic h satisfying (1-epsilon1)h*

The influence of the law on patient's rights on the practice of the Flemish paediatricians anno 2010

BACKGROUND

The law on patients' rights in Belgium was issued in 2002. The new legal framework recommends the establishment of a true dialogue between physician and patient, and it assigns decisive priority to the adolescent rather than to the physician or his parents.

PURPOSE AND METHODS

The purpose of this study is to map the current interpretation of the paediatrician and the realisation of the law in practice. The answers of 117 Flemish paediatricians to an anonymous questionnaire were analyzed.

RESULTS

Only 7.8% of the paediatricians state that they know the law well. 15.5% experience the law as a burden. 20.9% have adopted a different attitude when rendering care to adolescents under impulse of this law. 6.2% say they do not strictly follow the law. 27.8% think that the emancipating thought is too far-reaching. Most paediatricians apply protocols to interpret the traditional values that are stamped as being good medical practice: high quality care (81%), free patient's choice (70.7%), adequate pain control (77.4%). On the other hand paediatricans seldom dispose of procedures regarding the more emancipated amenities in the law such as obtaining informed consent (16.4%), access to the medical file (24.8%) and safe-guarding the privacy (13%). In practice most of the physicians offer the possibility of a free choice in 80% of the cases. All questioned physicians strive for a high quality care, for adequate pain control and for a careful maintained medical file. 79.1% of the physicians transfer to the parents all medical information regarding the adolescent. Proper experience and expertise (80.7%), case by case completed, are most often used as the basis for the judgment about the competence of the adolescent. From the patient's side, little advance is taken to exercise his own rights. Barely 1% of the adolescents consulting a paediatrician use their legal right to autonomously consent to a medical intervention. In barely 0.16% access is requested to the medical file. Practically no complaints are received regarding the law on patients' rights (0.1% in intramural setting, versus 0.001% extramural).

CONCLUSION

The law on patients' rights is, after 8 years of issuance, badly penetrated in the paediatric practice. On the one hand this is due to a poor knowledge of the law as well from the side of the physician as from the side of the adolescent and/or his parents. On the other hand 42.2% of the paediatricians experience difficulties with the practical interpretation of the law because of the lack of applicable guidelines. An important obstacle is the fact that more than a quarter of the paediatricians do not agree with the in the law foreseen autonomy of the adolescents. For that reason, paediatricians urgently need to be instructed in these matters. It is the moral duty of the Society of Paediatrics to organize workshops on these matters and develop clear guidelines concerning this law. Proper application of the legal context, the handling of the watertight procedures and the necessary communication in this respect is indispensable for the confidence and will lower the barrier for adolescents to use the healthcare system.

Misleading diagnosis of renal artery stenosis by magnetic resonance angiography in a patient with primary aldosteronism

A 24-year-old woman presented with severe hypertension. A diagnostic evaluation for secondary hypertension was undertaken. A duplex ultrasonography followed by a magnetic angiography suspected fibromuscular dysplasia. Unexpectedly, a contrast-enhanced angiography performed for renal angioplasty showed normal renal arteries. Primary aldosteronism was then evoked on the basis of decreased plasma renin and increased plasma aldosterone and aldosterone/renin ratio. After a CT-scan disclosed a left adrenal tumour, the patient underwent a left laparoscopic adrenalectomy. Pathological findings confirmed a benign adrenocortical adenoma. Blood pressure and aldosterone levels were normalized after surgery. Thus, clinicians should be aware of false-positive results of magnetic resonance angiography that could hide other causes of secondary hypertension.