ARMC5-associated Bilateral Macronodular Adrenocortical Hyperplasia: A Novel Germline Variant Associated with Concomitant Papillary Thyroid Carcinoma and Meningioma

Introduction/Objective

Germline mutations in the tumor suppressor gene Armadillo-containing repeat protein 5 gene (ARMC5) have been very recently recognized as a cause for a familial form of bilateral macronodular adrenocortical hyperplasia (BMAH), itself a rare cause of Cushing syndrome. In patients with ARMC5 mutations, scattered case reports have also shown an association with meningiomas and cancers of the pancreas, breast, colon, and thyroid.

Methods/Case Report

We present the case of BMAH, arising in a 61-year-old female with a history of metastatic papillary thyroid carcinoma and meningioma. The patient presented with bilateral but asymmetric adrenal enlargement (right greater than left) and Cushing syndrome. Given history of thyroid cancer and meningioma, genetics referral was ordered. Counseling revealed a pedigree without a strongly evident familial pattern of hereditary endocrine neoplasia characteristic of any of the more common inherited dispositions to endocrine neoplasia. Additionally, a targeted capture-based NGS germline genetic sequencing study for variants in 12 genes associated with associated with hereditary thyroid cancer was performed and negative. However, based on recent scholarship regarding ARMC5, follow-up germline NGS and Sanger sequencing studies encompassing the entire coding sequences of ARMC5 were ordered. These identified a germline, heterozygous, novel (not in ClinVar) but likely pathogenic variant in (c.802C>T, p.Arg268*), providing a likely explanation for the patient’s BMAH. In attempt to control the patient’s Cushing symptoms, right-sided adrenalectomy was performed, revealing a 220g adrenal gland with marked multinodular hyperplasia with solid, nested, and tubular architecture.

Results (if a Case Study enter NA)

NA

Conclusion

While case reports exist describing an association between other ARMC5 mutations and BMAH with concomitant meningiomas and/or malignancies, greater study is needed in order to better characterize the phenotypic spectrum of this disease. Our experience with this case not only reports a novel, apparently pathogenic mutation, but it documents its association with BMAH and, additionally, papillary thyroid carcinoma and meningioma.

Impact of Insulin Injection and Infusion Routines on Lipohypertrophy and Glycemic Control in Children and Adults with Diabetes

INTRODUCTION

Proper insulin injection/infusion is essential to optimize insulin absorption and action. Guidelines on insulin injection techniques are available. Lipohypertrophy (LH) is a local complication of insulin therapy, which results in erratic absorption and impaired glycemic control.

METHODS

Children and adults with type 1 diabetes on insulin injection or infusion were enrolled in the study. Subjects were interviewed and filled in a questionnaire on injection/infusion routines. Sites of injection/infusion were examined by trained diabetes educators, and capillary HbA1c was obtained.

RESULTS

One hundred sixty-nine subjects (104 children) with type 1 diabetes were enrolled; 119 were on multiple daily injection (MDI) and 50 on insulin pump therapy. Seventy-two percent and 82% of children and adults, respectively, rotate site at every injection; 78% of pump users change infusion set and 74% rotate site at 2-3 days. Thirty-nine percent and 32% of children and adults had LH. HbA1c was lower in children and adults with no LH (P < 0.001). An association was seen between LH and rotation frequency in children (P = 0.026). LH was the most common skin complication in the MDI group, while nodules, allergy marks and hyperpigmentation were seen in pump users.

CONCLUSION

Proper injection/infusion routines impact glycemic control and skin health. Education and examination of injection sites remain a crucial part of diabetes management.

Parent inclusion in early intensive behavior interventions for young children with ASD: a synthesis of meta-analyses from 2009 to 2011

This paper presents a comprehensive synthesis of six meta-analyses of early intensive behavioral interventions (EIBI) for young children with autism spectrum disorders published from 2009 to 2011. Analysis was conducted in three steps to account for different formats of treatment delivery and the extent to which parents took part in treatment. The three components of the synthesis were (a) descriptive analysis, (b) effect size analysis, and (c) mediator analysis via partial correlation and linear regressions. We completed the analysis by obtaining standardized mean difference effect sizes for 13 comparative studies ordered by comparison study type and 22 mean change effect sizes ordered by treatment delivery type. Results suggest that EIBI leads generally to positive medium-to-large effects for three available outcome measures: intellectual functioning, language skills and adaptive behaviors. Although favorable effects were apparent across comparative studies, analysis by type of delivery format revealed that EIBI programs that include parents in treatment provision are more effective. Mediator analyses suggest that treatment variables and child characteristics impact program effectiveness when accounting for the extent of parent inclusion. Clinical implications toward individualized treatment tailoring are discussed.

Cognitive and adaptive functioning after liver transplantation for maple syrup urine disease: a case series

MSUD is a complex metabolic disorder that has been associated with central nervous system damage, developmental delays, and neurocognitive deficits. Although liver transplantation provides a metabolic cure for MSUD, changes in cognitive and adaptive functioning following transplantation have not been investigated. In this report, we present data from 14 patients who completed cognitive and adaptive functioning testing pre- and one yr and/or three yr post-liver transplantation. Findings show either no significant change (n=8) or improvement (n=5) in IQ scores pre- to post-liver transplantation. Greater variability was observed in adaptive functioning scores, but the majority of patients evidenced no significant change (n=8) in adaptive scores. In general, findings indicate that liver transplantation minimizes the likelihood of additional central nervous system damage, providing an opportunity for possible stabilization or improvement in neurocognitive functioning.

The Third Injection Technique Workshop in Athens (TITAN)

The first Injection Technique workshop brought together endocrinologists and injection experts from around the world in Strasbourg in 1997. From its work came groundbreaking recommendations which advanced best practices in areas such as the use of a skin fold when injecting. The second Injection Technique workshop, with an expanded format including nurses and diabetes educators, took place in Barcelona in 2000. The initial stimulus to use shorter injecting needles can be said to date from this meeting. The third Injection Technique workshop was held in Athens in September 2009 and involved 127 experts from across the globe. After a comprehensive review of all publications since 2000 as well as several unpublished studies, the attendees divided into smaller groups to debate and draft new injecting recommendations based on the new data and their collective experience. This paper summarizes all the formal presentations given at this practical consensus workshop.

New injection recommendations for patients with diabetes

AIM

Injections administered by patients are one of the mainstays of diabetes management. Proper injection technique is vital to avoiding intramuscular injections, ensuring appropriate delivery to the subcutaneous tissues and avoiding common complications such as lipohypertrophy. Yet few formal guidelines have been published summarizing all that is known about best practice. We propose new injection guidelines which are thoroughly evidence-based, written and vetted by a large group of international injection experts.

METHODS

A systematic literature study was conducted for all peer-reviewed studies and publications which bear on injections in diabetes. An international group of experts met regularly over a two-year period to review this literature and draft the recommendations. These were then presented for review and revision to 127 experts from 27 countries at the TITAN workshop in September, 2009.

RESULTS

Of 292 articles reviewed, 157 were found to meet the criteria of relevance to the recommendations. Each recommendation was graded by the weight it should have in daily practice and by its degree of support in the medical literature. The topics covered include The Role of the Professional, Psychological Challenges, Education, Site Care, Storage, Suspension and Priming, Injecting Process, Proper Use of Pens and Syringes, Insulin analogues, Human and Pre-mixed Insulins, GLP-1 analogs, Needle Length, Skin Folds, Lipohypertrophy, Rotation, Bleeding and Bruising, Pregnancy, Safety and Disposal.

CONCLUSION

These injecting recommendations provide practical guidance and fill an important gap in diabetes management. If followed, they should help ensure comfortable, effective and largely complication-free injections.

Influence of pollen quality on ovarian development in honeybee workers (Apis mellifera scutellata)

Protein-rich diets are known to promote ovarian and egg development in workers of the honeybee, Apis mellifera, even in the presence of a queen. Since the main source of protein for honeybees is pollen, its quality and digestibility might be important dietary factors determining reproductive capacity. We have compared the effect of two types of pollen-sunflower, Helianthus annuus, and aloe, Aloe greatheadii var davyana-on ovarian development in A. mellifera scutellata workers. Under queenright conditions in the field, worker bees exhibited greater ovarian development when feeding on aloe pollen than on sunflower pollen. In their midgut, we observed higher extraction efficiency for aloe (80%) than for sunflower (69%) pollen. This may be attributed to the morphology and size of the two kinds of pollen grains and explains, together with the high protein content of aloe pollen (32% dry mass in bee-collected pollen) compared to sunflower pollen (15%), why aloe pollen promoted higher ovarian development. However, in the laboratory workers sustained on aloe pollen had significantly less-developed ovaries and higher mortality than those fed sunflower pollen. These detrimental effects may be due to an unbalanced protein:carbohydrate ratio. We discuss the effects of unbalanced diets on the physiology and ecology of honeybee reproduction.

Improving glycaemic control of patients with Type 2 diabetes in a primary care setting: a French application of the Staged Diabetes Management programme

AIMS

To assess the impact of a French adaptation of the Staged Diabetes Management (SDM) programme on glycaemic control of people with Type 2 diabetes in primary care. Secondary endpoints were blood pressure, blood lipids, healthcare costs and quality of life.

METHODS

Prospective, randomized controlled study, of 1 years' duration. General practitioners (GPs) were recruited in four separate districts of a French region. They enrolled consecutive patients with Type 2 diabetes. GPs in the intervention group were educated in the SDM programme. GPs in the control group were asked to provide usual care. Healthcare costs were collected by medical departments of the Health Insurance systems. Quality of life was assessed with the Duke Health Profile.

RESULTS

Three hundred and forty patients enrolled by 57 GPs completed the study, 192 in the intervention group and 148 in the control group. Patients in the intervention group were managed more adequately in accordance with the guidelines (P < 0.05 for nine out of 10 items). HbA(1c) decreased by 0.31% in the intervention group and increased by 0.56% in the control group, resulting in a difference of 0.87% by the end of the study (P = 0.001). Blood pressure and blood lipids did not differ between groups. Occurrence of major complications was low and identical in both groups. Incremental costs during the study in the intervention group were 35 euros per patient per month, and this was not significantly different in comparison with the control group. Quality of life was not affected by the intervention.

CONCLUSIONS

Educating GPs in the French adaptation of the SDM programme improves glycaemic control in a primary care setting, without significantly increasing healthcare costs.

Enumeration of CD4(+) T-cells in the peripheral blood of HIV-infected patients: an interlaboratory study of the FACSCount system

The aim of the present study was to assess the interlaboratory reproducibility of the FACSCount system for the enumeration of peripheral blood (PB) CD4(+) T-cells. In each of the seven participating centers, both previously stained and unstained PB samples (n = 49) were received and either analyzed or stained and then analyzed. Interlaboratory reproducibility was checked in two different groups of centers (n = 3 and n = 4) where the study was performed in parallel. In addition, both the intralaboratory precision and accuracy of this system were analyzed in comparison with results obtained with conventional flow cytometry. Accordingly, upon comparing both methods, a high degree of correlation was observed in the total number of CD3(+) T-cells (coefficient of correlation of 0.9750 +/- 0.0184, slope of the best linear fit: 0. 9214 +/- 0.0311, y-intercept of 12 +/- 47) as well as in the number of CD3(+)/CD4(+) (coefficient of correlation of 0.9794 +/- 0.1457, slope of the best linear fit: 0.9463 +/- 0.0753, y-intercept of -11 +/- 36) and CD3(+)/CD8(+) (coefficient of correlation of 0.9728 +/- 0.0192, slope of the best linear fit: 0.9682 +/- 0.0735, y-intercept of 7 +/- 95) major subsets. In addition, low coefficients of variation (CV) were obtained for replicates, indicating the method's high degree of accuracy. The present study shows that with respect to the interlaboratory reproducibility reported for most techniques used for the enumeration of PB CD4(+) T-cells, the FACSCount system results in data with much lower coefficients of variance (CVs) (mean CV of less than 10%). Upon measuring the impact on results of different variables associated with either sample preparation or data acquisition and analysis, our study clearly shows that data acquisition and analysis does not influence the results by increasing variability since the coefficients of variation obtained for samples prepared in the same laboratory under the same conditions and read in different laboratories with different instruments were identical to those obtained for the replicates of the same samples read in each individual center. In contrast, interlaboratory variability, although low, significantly increased when sample preparation was carried out in different laboratories, suggesting that pipetting still represents the major source of variability in the FACSCount system.

[The effect of selenium and vitamin E on the healing process of experimental corneal lesions in the eye of the rabbit]

PURPOSE

Evaluation of antioxidants: selenium and vitamin E efficacy in the treatment of experimental corneal lesion.

MATERIAL AND METHODS

Solution of selenium in 0.9% NaCl, concentration 0.01 g/L, to which vitamin E was added to obtain suspension of 2.5 g/L was used in 9 rabbits. The cornea was damaged by removing the epithelium from the central area of 7 mm diameter. To the right eye selenium solution with vitamin E was instilled.

RESULTS

In two eyes in which antioxidants were used evident prompt healing of corneal ulceration was noticed. Mean lesion diameter in eyes treated with antioxidants was: on 1st day 5.44 mm, in 2nd day 1.61 mm and on the 3rd day 0.33 mm. In control eyes diameters were: 6.67 mm, 2.28 mm and 0.56 mm, respectively.

CONCLUSIONS

Solution used in our study was tolerated very well. Faster healing process was noticed in eyes where antioxidants were used.

Oleic acid stimulates rapid translocation of cholinephosphate cytidylyltransferase in type II cells

Activity of cholinephosphate cytidylyltransferase, the rate-limiting enzyme in phosphatidylcholine synthesis, increases rapidly in the lung after birth predominantly due to an increase in membrane-associated activity. Although there is strong evidence that enzyme translocation is a major regulatory mechanism in other cells, this mechanism has not been conclusively demonstrated in intact alveolar type II cells. In this study, we show that oleic acid stimulates rapid translocation of cytidylyltransferase activity and protein from cytosol to microsomes in both primary cultured fetal and adult type II cells and MLE12 cells, a cell line derived from murine distal respiratory epithelial cells. Shifts in subcellular distribution occurred within 5 min of exposure to 200 microM oleic acid. The magnitude of the increases in microsomal enzyme activity and immunoreactive protein levels was several-fold greater in d21 fetal cells than adult type II cells. Oleic acid-induced translocation was confirmed in in vitro translocation experiments. After incubating MLE12 cell postmitochondrial supernatants at 37 degrees C with oleic acid and separation of enzyme isoforms on glycerol density gradients, enzyme activity was decreased in gradient fractions corresponding to both cytosolic isoforms and microsomal activity increased 7.9-fold compared to the distribution of enzyme activity in postmitochondrial supernatants incubated at 4 degrees C without oleic acid. The increase in microsomal activity was associated with an increased incorporation of [14C]oleic acid in the membrane free fatty acid fraction. Developmental changes in type II cell membrane lipid composition may induce the rapid translocation/activation of cytidylyltransferase in the lung after birth.

Initial results of Central European Immunophenotyping Quality Control Program (CEQUAL)

The new Quality Control Program in Immunophenotyping for Central Europe (CEQUAL) was created in 1993. Its first formal send-around proficiency exercise, consisting of a stained stabilised preparation of leukocytes, took place in November 1993. Forty-one laboratories from Slovakia, Poland, Hungary, and the Czech Republic participated. Eighty-three percent of member laboratories returned results and list mode files. The results for each cell population were evaluated for central tendencies, variability, and overall distribution patterns. Extreme outliers were identified and list mode files reviewed for clues to the aberrerant values. When found these reasons were communicated back to member labs. When extreme outlier values were removed, all coefficient of variations (CVs) for lymphocyte populations were below 10%, except for NK cells, which had a CV of 14.8%. In future send-arounds, unstained and pathologic specimens will be used. This CEQUAL program is the first to function on such a broad international basis.

Performance evaluation of the FACSCount System: a dedicated system for clinical cellular analysis

Flow cytometers are instruments that can determine multiparameter data simultaneously and have a great potential in providing unique information about cells. The FACSCount System is designed as the first dedicated flow cytometer for the clinical laboratory. Its current configuration provides CD4, CD8, and CD3 absolute counts from 100 microliters of whole blood. Adapting the FACSCount System to the clinical setting are minimal sample handling, lysis free cell preparation, automated fluorescence gating, built-in calibrated reference beads, and appropriate error code reporting. Quality control checks ensure that reported CD4 counts, important for clinical follow-up and patient management, are accurate, precise, and reproducible across instruments over time.

The immune profile of multiple sclerosis: T-lymphocyte effects predominate over all other factors in cyclophosphamide-treated patients

It is widely believed that multiple sclerosis is a T-cell mediated autoimmune disease associated with abnormalities in immunoregulation. This large, prospective study evaluated the lymphocyte immunophenotypic profile of 246 MS patients, divided clinically into a remitting/relapsing group (n = 176) and a progressive group (n = 70), and compared their results to those of 117 healthy controls. All patients were found to have significantly elevated percentage and absolute numbers of IL2R+CD3+ cells as well as depressed percentages of CD45RA+CD4+ cells. However, when the factor of treatment with cyclophosphamide (CY) versus no treatment or treatment with other agents was used to group patients, dramatic declines in both percentages and absolute numbers of CD45RA+CD4+ cells were discovered. These declines were associated specifically with CY and and could be explained by this factor independent of the clinical state of the patient. The effects were seen in patients undergoing current treatment or in those exposed to CY in the near or remote past. These findings highlight the confounding effect of specific treatments on the immune profile of MS patients groups and suggest that there may be important implications for cellular function and clinical outcome in these and other patient groups.

Inaccuracy of self-reported weights and heights among American Indian adolescents

To determine the accuracy of self-reported weights and heights and of relative weight status in a sample of American Indian adolescents, a survey was conducted in middle and high schools on or near three Indian reservations-Navajo, Choctaw, and Blackfeet. Self-reported weights and heights were compared with measured weights and heights. Participants were 12 through 19 years old. (N = 806, 47.4% male). Overall, both boys and girls underreported weight (mean difference = self-reported - measured mean values)(-3.4 +/- 13.1 and -4.6 +/- 13.0 lb, respectively) and overreported height (0.6 +/- 2.1 and 0.2 +/- 2.6 in, respectively) However, underweight boys and girls overreported weight (normal: -1.6 +/- 7.9 and -1.4 +/- 6.3; overweight: -7.5 +/- 17.9 and -11.6 +/- 19.0 lb, respectively). Although correlations between measured and reported weight, height, and body mass index (BMI) were high, the sensitivity of relative weight categories based on BMI using self-reported weight and height compared with measured weight and height was poor: 66.7% for underweight (BMI < 15th percentile, based on a national reference population), 88.9% for normal weight, and 73.6% for overweight (> 85th percentile). These results call into question the accuracy of self-reported weight and height measurements among American Indian youth and are similar to findings among non-American Indian adolescents. Therefore, their use in prevalence studies should be avoided, and they should be used cautiously in other types of epidemiologic studies.

Toward comprehensive obesity prevention programs in Native American communities

Obesity is a particularly important challenge to the health status of Native Americans. This challenge is manifest in the increasing rates of non-insulin-dependent diabetes mellitus among Native Americans. Most studies of Native American infants, preschool children, schoolchildren, and adults have confirmed a high prevalence of overweight. Historical studies suggest that for many Native American communities the high rates of obesity are a relatively recent phenomenon. The specific reasons for the increase in obesity among Native Americans have not been determined, although it has been hypothesized that Native Americans have a genetic predisposition to overweight in a "westernized" environment of abundant food and decreased energy expenditure. Few detailed studies of diet or of physical activity levels of contemporary Native Americans have been published. Community-based interventions to modify diet and activity levels to prevent obesity in Native American communities are needed. Preliminary evidence from two formative school-based programs in the Southwest suggest that Native American communities are receptive to school-based interventions, and that such programs may be able to slow the rate of excess weight gain and to improve fitness in school children. Because of the cultural diversity among Native Americans, future studies should focus on collecting community- and region-specific data, and should emphasize the need for obesity prevention through culturally appropriate community- and school-based behavioral interventions.