Allelic losses on chromosome band 11q13 in aldosterone-producing adrenal tumors

We examined loss of heterozygosity (LOH) in 14 aldosterone-producing adrenal tumors, with six linearly ordered restriction fragment length polymorphism (RFLP) markers that map within a 12-cM region containing the MEN1 locus on 11q13. Among 11 tumors that were informative for at least one marker, five showed LOH at one or more loci, and two distinct regions of deletion were identified. The proximal region overlapped with the location of the MEN1 locus previously predicted by linkage analyses in MEN1 families and the commonly deleted region in hyperparathyroid tumors. This suggests that one of the genes associated with development of aldosterone-producing adrenal tumors may coincide with the MEN1 locus, and that a second gene, distal to the MEN1 locus, may also play a role in the development of this type of tumor.

Cerebral phosphate metabolism in first-degree relatives of patients with schizophrenia

OBJECTIVE

Most phosphorus-31 magnetic resonance spectroscopy ((31)P-MRS) studies have described measures of lower membrane anabolism or greater catabolism in the frontal lobes of patients with schizophrenia. The purpose of the present study was to evaluate whether these findings can also be detected in young subjects at genetic risk for schizophrenia.

METHOD

Fourteen children and siblings of patients with schizophrenia (mean age=16.7 years) and 14 comparison subjects (mean age=16.9 years) were included in a (31)P-MRS study of the frontal lobe.

RESULTS

The high-risk subjects had significantly lower mean ratios of phosphomonoesters to phosphodiesters (0.25 versus 0.31) and higher mean phosphodiester values (37.59% versus 34.87%) than comparison subjects.

CONCLUSIONS

These findings suggest greater phospholipid breakdown even in young first-degree relatives of patients with schizophrenia. This suggestion is discussed with respect to the membrane phospholipid hypothesis of schizophrenia.

Clinical utility of multigene analysis in over 25,000 patients with neuromuscular disorders

Objective

Molecular genetic testing for hereditary neuromuscular disorders is increasingly used to identify disease subtypes, determine prevalence, and inform management and prognosis, and although many small disease-specific studies have demonstrated the utility of genetic testing, comprehensive data sets are better positioned to assess the complexity of genetic analysis.

Methods

Using high depth-of-coverage next-generation sequencing (NGS) with simultaneous detection of sequence variants and copy number variants (CNVs), we tested 25,356 unrelated individuals for subsets of 266 genes.

Results

A definitive molecular diagnosis was obtained in 20% of this cohort, with yields ranging from 4% among individuals with congenital myasthenic syndrome to 33% among those with a muscular dystrophy. CNVs accounted for as much as 39% of all clinically significant variants, with 10% of them occurring as rare, private pathogenic variants. Multigene testing successfully addressed differential diagnoses in at least 6% of individuals with positive results. Even for classic disorders like Duchenne muscular dystrophy, at least 49% of clinically significant results were identified through gene panels intended for differential diagnoses rather than through single-gene analysis. Variants of uncertain significance (VUS) were observed in 53% of individuals. Only 0.7% of these variants were later reclassified as clinically significant, most commonly in RYR1, GDAP1, SPAST, and MFN2, providing insight into the types of evidence that support VUS resolution and informing expectations of reclassification rates.

Conclusions

These data provide guidance for clinicians using genetic testing to diagnose neuromuscular disorders and represent one of the largest studies demonstrating the utility of NGS-based testing for these disorders.

31P-MR spectroscopy in children and adolescents with a familial risk of schizophrenia

Based on a previous report [9] on alterations of membrane phosphorus metabolism in asymptomatic family members of schizophrenic patients, the aim of the present study was to extend and improve the evaluation and data processing of (31)P spectroscopic data obtained from a larger study population by including an analysis of the broad spectral component (BC) of membrane phospholipids (PL). Eighteen children and siblings of patients with schizophrenia and a gender- and age-matched control group of 18 healthy subjects without familial schizophrenia were investigated with phosphorus magnetic resonance spectroscopy ((31)P-MRS) by using image selected in vivo spectroscopy (ISIS) in the dorsolateral prefrontal regions (DLPFR) of the brain. Spectral analysis was performed by using both the full and truncated FID to estimate metabolic peak ratios of different (31)P metabolites and the intensity and linewidth of the broad component. A significantly higher PDE level (p<0.01) and increased linewidth of the PDE components were observed for the high-risk group compared with the control group (p=0.02). No significant differences were observed for PME as well as for other (31)P-metabolites. No differences were observed between the left and right hemispheres for different normalised (31)P-metabolic levels. Decreased intensities (p=0.03) and smaller linewidths (p=0.01) were obtained for the broad component in the high-risk group. Impairments of membrane metabolism that are typical for schizophrenic patients are partially observed in adolescent asymptomatic family members of schizophrenics, including increased levels of low molecular PDE compounds indicating increased membrane degradation processes, no changes for PME, and decreased intensities and linewidths of the BC indicating changes in the composition and fluidity of membrane phospholipids. Despite limitations to completely suppress fast-relaxing components by dismissing initial FID data points, the spectroscopic results indicate additional changes in the membrane metabolism of high-risk subjects beyond changes of synthesis and degradation.

Hip fracture in the elderly: a re-analysis of the EPIDOS study with causal Bayesian networks

Objectives

Hip fractures commonly result in permanent disability, institutionalization or death in elderly. Existing hip-fracture predicting tools are underused in clinical practice, partly due to their lack of intuitive interpretation. By use of a graphical layer, Bayesian network models could increase the attractiveness of fracture prediction tools. Our aim was to study the potential contribution of a causal Bayesian network in this clinical setting. A logistic regression was performed as a standard control approach to check the robustness of the causal Bayesian network approach.

Setting

EPIDOS is a multicenter study, conducted in an ambulatory care setting in five French cities between 1992 and 1996 and updated in 2010. The study included 7598 women aged 75 years or older, in which fractures were assessed quarterly during 4 years. A causal Bayesian network and a logistic regression were performed on EPIDOS data to describe major variables involved in hip fractures occurrences.

Results

Both models had similar association estimations and predictive performances. They detected gait speed and mineral bone density as variables the most involved in the fracture process. The causal Bayesian network showed that gait speed and bone mineral density were directly connected to fracture and seem to mediate the influence of all the other variables included in our model. The logistic regression approach detected multiple interactions involving psychotropic drug use, age and bone mineral density.

Conclusion

Both approaches retrieved similar variables as predictors of hip fractures. However, Bayesian network highlighted the whole web of relation between the variables involved in the analysis, suggesting a possible mechanism leading to hip fracture. According to the latter results, intervention focusing concomitantly on gait speed and bone mineral density may be necessary for an optimal prevention of hip fracture occurrence in elderly people.

Chronic adverse events and quality of life after radiochemotherapy in anal cancer patients. A single institution experience and review of the literature

PURPOSE

To report on chronic adverse events (CAE) and quality of life (QOL) after radiochemotherapy (RCT) in patients with anal cancer (AC).

PATIENTS AND METHODS

Of 83 patients who had received RCT at our department between 1988 and 2011, 51 accepted the invitation to participate in this QOL study. CAE were evaluated using the Common Terminology Criteria for Adverse Events (CTCAE) v. 4.0 and QOL was assessed with the Functional Assessment of Cancer Therapy-Colorectal (FACT-C) questionnaire.

RESULTS

CAE could be evaluated in 49 patients. There was a tendency toward a higher rate of grade 3 CAE in female patients, i.e. 18 out of 37 (49 %) vs. 2 out of 12 (17 %) male patients (p = 0.089). The most common grade 3 CAE were dyspareunia and vaginal symptoms (itching, burning and dryness) in 35 and 22 % of female patients, respectively, followed by stool incontinence in 13 % of all patients (6 out of 49). Both FACT-C and CAE information were available for 42 patients, allowing evaluation of the impact of CAE on QOL. The median total FACT-C score was 110 (40-132) out of a possible maximum of 136. The absence of grade 3 CAE (115 vs. 94, p = 0.001); an interval of ≥ 67 months after the end of the treatment (111 vs. 107, p = 0.010), no stool incontinence vs. grade 3 stool incontinence (111 vs. 74, p = 0.009), higher education (114 vs. 107, p = 0.013) and no dyspareunia vs. grade 3 dyspareunia (116 vs. 93, p = 0.012) were significantly associated with a higher median FACT-C score.

CONCLUSION

The majority of AC patients treated with RCT have acceptable overall QOL scores, which are comparable to those of the normal population. Patients with grade 3 CAE-particularly dyspareunia and fecal incontinence-have a poorer QOL compared to patients without CAE. In order to improve long-term QOL, future strategies might aim at a reduction in dose to the genitalia and more intensive patient support measures.

[Patient safety in anesthesiology : Multimodal strategies for perioperative care]

The concept of patient safety is more of a presence in modern day medicine than ever before. All measures and processes aiming at preempting and preventing critical incidents and accidents in patient care are collectively grouped under this concept. With the Declaration of Helsinki in 2010 modern anesthesiology has undertaken a fundamental role in the clinical implementation and perioperative clinicians are confronted with a multitude of theories, models, methods and tools targeted at improving or facilitating optimized patient safety. One of the biggest challenges lies in their synergistic combination to create a functioning concept for perioperative risk management while also incorporating individual strengths and weaknesses. The aim of the present paper is to provide a structured overview of the various components presently available for increasing perioperative patient safety.

Serum cytokines predict efficacy and toxicity, but are not useful for disease monitoring in lung cancer treated with PD-(L)1 inhibitors

Introduction

PD-(L)1 inhibitors (IO) have improved the prognosis of non-small-cell lung cancer (NSCLC), but more reliable predictors of efficacy and immune-related adverse events (irAE) are urgently needed. Cytokines are important effector molecules of the immune system, whose potential clinical utility as biomarkers remains unclear.

Methods

Serum samples from patients with advanced NSCLC receiving IO either alone in the first (1L, n=46) and subsequent lines (n=50), or combined with chemotherapy (ICT, n=108) were analyzed along with age-matched healthy controls (n=15) at baseline, after 1 and 4 therapy cycles, and at disease progression (PD). Patients were stratified in rapid progressors (RP, progression-free survival [PFS] <120 days), and long-term responders (LR, PFS >200 days). Cytometric bead arrays were used for high-throughput quantification of 20 cytokines and other promising serum markers based on extensive search of the current literature.

Results

Untreated NSCLC patients had increased levels of various cytokines and chemokines, like IL-6, IL-8, IL-10, CCL5, G-CSF, ICAM-1, TNF-RI and VEGF (fold change [FC]=1.4-261, p=0.026-9x10^-7) compared to age-matched controls, many of which fell under ICT (FC=0.2-0.6, p=0.014-0.002), but not under IO monotherapy. Lower baseline levels of TNF-RI were associated with longer PFS (hazard ratio [HR]= 0.42-0.54; p=0.014-0.009) and overall survival (HR=0.28-0.34, p=0.004-0.001) after both ICT and IO monotherapy. Development of irAE was associated with higher baseline levels of several cytokines, in particular of IL-1β and angiogenin (FC=7-9, p=0.009-0.0002). In contrast, changes under treatment were very subtle, there were no serum correlates of radiologic PD, and no association between dynamic changes in cytokine concentrations and clinical outcome. No relationship was noted between the patients' serologic CMV status and serum cytokine levels.

Conclusions

Untreated NSCLC is characterized by increased blood levels of several pro-inflammatory and angiogenic effectors, which decrease under ICT. Baseline serum cytokine levels could be exploited for improved prediction of subsequent IO benefit (in particular TNF-RI) and development of irAE (e.g. IL-1β or angiogenin), but they are not suitable for longitudinal disease monitoring. The potential utility of IL-1/IL-1β inhibitors in the management and/or prevention of irAE in NSCLC warrants investigation.

[31P-MR spectroscopy of the brain in patients with anorexia nervosa: characteristic differences in the spectra between patients and healthy control subjects]

PURPOSE

To investigate whether 31 P-MR spectroscopy can detect reduced concentrations of high-energy phosphates, like PCr and NTP, caused by decreased metabolic activity in the brain of patients with anorexia nervosa (AN) and, furthermore, whether any impairment of the cerebral membrane metabolism can be derived from the spectra.

MATERIAL AND METHODS

10 female patients, age range 12 - 20 years and mean BMI (body mass index) of 14.8 +/- 1.6 kg/m 2, with clinically diagnosed AN (ICD-10, F50.0) and 10 healthy control subjects, age range 12 - 21 years and mean BMI 19.0 +/- 2.1 kg/m 2, without nutritional disturbances: were investigated. 31P-MR spectroscopy was performed with a 1.5 T MRI unit using single volume selection in the frontal/prefrontal region of brain. Relative metabolic concentrations were quantified by normalizing the peak areas of the metabolites with the total area of the complete phosphorous spectrum, P tot, as well as with the peak area of beta-NTP.

RESULTS

Significant differences between the two groups were observed for the metabolic ratios PDE/P tot, PDE/beta-NTP and alpha-NTP/P tot which were lower in the patient group except for alpha-NTP/P tot. These ratios also revealed a statistically significant correlation with the BMI (r PDE/Ptot = 0.747, r PDE/beta-NTP = 0.57, r alpha-NTP/Ptot = -0.56; p </= 0.1). Reduced relative concentrations of PCr/P tot, beta-NTP/P tot or Pi/P tot were not encountered.

CONCLUSION

The lowered PDE/P tot ratio for patients with AN and its correlation with BMI suggests that decreased BMI induces compositional changes of the phospholipids in the brain, which decrease the fraction of mobile phospholipids.

Detection of renin mRNA in aldosterone-producing adenomas by polymerase chain reaction

1. Ribonucleic acid (RNA) was extracted from two normal human adrenal cortices and from five aldosterone-producing adenomas (APA). 2. The five APA could be categorized, on the basis of in vivo aldosterone responsiveness to angiotensin infusion and upright posture, into two APA responsive to both stimuli, two responsive only to angiotensin infusion, and one unresponsive to either stimulus. 3. RNA was reverse transcribed and coamplified by polymerase chain reaction (PCR) with an internal standard of renin complementary DNA (cDNA) containing a 60 base pair insertion. Renin mRNA in the APA was compared with normal adrenals. 4. Renin mRNA was greater than normal in the two APA responsive to both stimuli and less than, or similar to normal, in the two APA responsive only to angiotensin infusion. Renin mRNA was also less than, or similar to normal, in the APA unresponsive to either stimulus. 5. These findings support a possible role for adrenal renin in the development and biochemical behaviour of angiotensin-responsive APA.

Radiotherapy in stage I-III follicular non-Hodgkin lymphoma. Retrospective analysis of a series of 50 patients

PURPOSE

The goal of this work was to analyze the response rate and outcome of patients with stage I-III follicular lymphoma (FL) treated with radiotherapy (RT) alone.

PATIENTS AND METHODS

The records of 50 consecutive patients with stage I-III FL treated with RT alone at our department from 1988-2009 were analyzed. The median age was 60 years (range 32-80 years) with a median follow-up duration of 8 years (range 4-11 years). Clinical staging was performed according to the Ann Arbor system. Stage I: 30 patients (60%), stage II: 15 patients (30%), stage III: 5 patients (10%). Thirty-two patients (64%) presented with nodal disease, 14 patients (28%) presented with disease in extranodal sites, and 4 patients (8%) had nodal and extranodal involvement. The RT field encompassed only the involved Ann Arbor nodal regions (involved-field RT) in 26 patients (52%), mantle and whole abdominopelvic fields in 6 patients (12%), mantle field in 10 patients (20%), whole abdominopelvic fields in 5 patients (10%), and a so-called mini-mantle in 3 patients (6%). The total RT dose ranged from 26-56 Gy (median 40 Gy) in daily fractions of 1.2-2.5 Gy.

RESULTS

Complete remission (CR) and partial remission (PR) were observed in 39 (76%) and 9 (20%) patients, respectively. Only 2 of 8 patients (25%) with tumor bulk > 5 cm reached CR, whereas 37 of 42 patients (88%) with a maximum lymphoma diameter < 5 cm achieved CR (p = 0.0001). The median overall survival (OS) and median event-free survival (EFS) were 18 years (CI 95% 10-26 years) and 7 years (6-8 years), respectively. The 2-, 5-, and 10-year OS were 96 ± 3%, 90 ± 5%, and 70 ± 9%, respectively. The 2-, 5-, and 10-year EFS were 90 ± 5%, 70 ± 7%, and 38 ± 9%, respectively. Fifteen patients developed a recurrence outside the radiation field (30%) and 4 patients developed an in-field recurrence (8%). All in-field recurrences were observed in regions without clinical (macroscopic) involvement, which were irradiated with a dose of ≤ 26 Gy. Pretreatment maximum lymphoma diameter < 5 cm (p = 0.039) and complete remission after RT (p = 0.021) were significantly associated with a better OS in the univariate analysis.

CONCLUSION

RT is a curative option in the treatment of limited stage FL. If RT of microscopically uninvolved area is necessary, a reduction in the radiation dose should be carefully weighed against the risk of in-field recurrences.

Risk assessment for infected endocarditis in Staphylococcus aureus bacteremia patients: When is transesophageal echocardiography needed?

Aims:

Echocardiography is the main technique for the diagnosis of endocarditis in patients with Staphylococcus aureus bacteremia (SAB), but a consensus about performing transthoracic echocardiography or transesophageal echocardiography (TEE) as first-line tests is currently lacking. Recently, a new scoring system has been proposed by Palraj et al. to guide the use of TEE in this population. Our aim was to validate this scoring system or modify it, if necessary.

Methods and results:

Data from SAB patients admitted from 2012 to 2014 were collected. We tested the Palraj scores to stratify patients’ risk for endocarditis. Moreover, we analyzed our population to identify any other possible clinical predictors of endocarditis not included in the score. Endocarditis was diagnosed in 38 of 205 patients (18.5%). Palraj’s score was effective in the detection of patients at high risk of endocarditis. In addition, we identified the presence of cardiac devices, prolonged bacteremia and intravenous drug abuse (IVDA) as elements strongly correlated with endocarditis. Two scoring systems (Day-1 and Day-5) were derived including IVDA as a variable. Using a Day-1 cut-off value ≥5 and a Day-5 cut-off value ≥2, the ‘modified Palraj’s score’ showed sensitivities of 42.1% and 97.0% and specificities of 88.6% and 32.0% for Day-1 and Day-5 scores, respectively.

Conclusion:

We modify and expand upon an effective scoring system to identify SAB patients at high risk for endocarditis in order to guide use of TEE. The inclusion of IVDA in the criteria for the calculation of the scores improves its effectiveness.

Infrared spectroscopy refines chronological assessment, depositional environment and pyrolysis conditions of archeological charcoals

Based on infrared spectral characteristics, six archeological sample sets of charcoals from German (5) and Brazilian (1) sites, covering the time span from the nineteenth century CE to 3950 BCE, were compared to a chronological (present to the fifteenth century BCE) series of Austrian charcoals. A typical chronological trend of several bands (stretch vibrations: O–C–O of carboxylates at 1,585–1,565 and 1,385–1,375 cm⁻¹, C–O carboxylic acids at 1,260–1,250 cm⁻¹) that indicate oxidation and subsequently increasing hydrophilicity (O–H stretch vibration at about 3,400 cm⁻¹) was also contained in the archive samples. Three sample sets fit in the typical band development according to their age. For three sample sets this conformity was not observed. Despite the age of two sample sets (3950–2820 BCE), most charcoals were assigned to the Modern Period. Apart from the high degree of carbonization, anaerobic depositional conditions over a longer period of time seem to contribute to the surprising conservation. Non-removable mineral components in charcoals, as observed in a third sample set, strongly influence infrared band intensities and positions of organic compounds. The role of inorganic components in terms of charcoal aging, and the information we can obtain from spectral characteristics in an archeological context, are discussed.

Effect of intraoperative angiotensin-converting enzyme inhibition by quinaprilat on hypertension after coronary artery surgery

Activation of the renin-angiotensin system during cardiopulmonary bypass (CPB) may be involved in early postoperative hypertension after coronary artery bypass grafting (CABG). As hypertensive episodes may be deleterious in the immediate postoperative period, we have assessed the effects of prophylactic treatment with the angiotensin-converting enzyme inhibitor quinaprilat in an open study. During steady state CPB, patients received quinaprilat 0.02 mg kg-1 (group A, n = 10), quinaprilat 0.04 mg kg-1 (group B, n = 10) or saline solution (group C, n = 10) as an i.v. bolus dose. Sodium nitroprusside (SNP) was given after operation when systolic arterial pressure was > 150 mm Hg. Requirements for SNP 1 h after arrival in the ICU were significantly less in groups A (two of 10) and B (two of 10) than in group C (eight of 10). Also, patients in group C had a greater systolic arterial pressure compared with groups A and B. There were no significant differences between groups in diastolic arterial pressure, heart rate, cardiac index or cardiac filling pressures. We conclude that quinaprilat can be used during CABG to reduce the incidence of postoperative hypertension. Further studies of the efficacy and safety of this technique are necessary.