The role of mTOR as target for treatment of adrenal tumors

Adrenal tumors (AT) include benign and malignant cortical tumors, named adrenocortical adenomas (ACAs) and adrenocortical carcinomas (ACCs), respectively and benign and malignant pheochromocytomas (PCCs). The malignant ATs are aggressive tumors with a poor prognosis, for which additional treatments are required. The mTOR pathway has been suggested to play a role in AT pathogenesis. The main aim of the present thesis was to explore the role of mTOR pathway as a potential target for new treatment option in ATs. The results of the studies included in the present thesis describe expression of the main components of the mTOR pathway in normal adrenal, adrenal hyperplasia, ACAs and ACCs, and the effects of the mTOR-inhibitors on ACC cell proliferation and cortisol production and on PCC cell proliferation. The effects of mTOR inhibitors alone or in combination with other drugs were also explored in ACC (in combination with mitotane or OSI-906) and PCC (in combination with OSI-906) cell lines, demonstrating that these drugs, or a combination of drugs, might represent new treatment options for a subset of patients with these adrenal tumors. In addition to the mTOR and IGF pathway, the presence of molecular events potentially targetable with currently developed targeted drugs in a large series of ACC samples, were investigated, which demonstrated that no simple targetable molecular event emerged. Moreover, based on genomic alterations, the cell cycle appeared to be the most relevant new potential therapeutic target for patients with advanced ACC. In conclusion, the results of these studies support the role of the mTOR pathway as a potential target for the treatment of patients with ACCs or malignant PCCs, but they underline that better results are expected by combining treatments and by selecting patients. A need to move into the direction of a more personalized approach for the treatment of patients with malignant ATs is emphasized

Complications of Cushing's syndrome: state of the art

Cushing's syndrome is a serious endocrine disease caused by chronic, autonomous, and excessive secretion of cortisol. The syndrome is associated with increased mortality and impaired quality of life because of the occurrence of comorbidities. These clinical complications include metabolic syndrome, consisting of systemic arterial hypertension, visceral obesity, impairment of glucose metabolism, and dyslipidaemia; musculoskeletal disorders, such as myopathy, osteoporosis, and skeletal fractures; neuropsychiatric disorders, such as impairment of cognitive function, depression, or mania; impairment of reproductive and sexual function; and dermatological manifestations, mainly represented by acne, hirsutism, and alopecia. Hypertension in patients with Cushing's syndrome has a multifactorial pathogenesis and contributes to the increased risk for myocardial infarction, cardiac failure, or stroke, which are the most common causes of death; risks of these outcomes are exacerbated by a prothrombotic diathesis and hypokalaemia. Neuropsychiatric disorders can be responsible for suicide. Immune disorders are common; immunosuppression during active disease causes susceptibility to infections, possibly complicated by sepsis, an important cause of death, whereas immune rebound after disease remission can exacerbate underlying autoimmune diseases. Prompt treatment of cortisol excess and specific treatments of comorbidities are crucial to prevent serious clinical complications and reduce the mortality associated with Cushing's syndrome

Laboratorial validation of an automated assay for the determination of adenosine deaminase activity in pleural fluid and cerebrospinal fluid

OBJECTIVE: The incidence of tuberculosis worldwide has emphasized the need for better assays designed to diagnose the disease, principally the extrapulmonary form. The objective of the present study was to validate the performance of an automated method for the determination of adenosine deaminase (ADA) activity in pleural fluid (PF) and cerebrospinal fluid (CSF), comparing it with a conventional method (the modified Giusti method). METHODS: In total, 134 samples were selected from among those tested in our laboratory: 94 PF samples and 40 CSF samples. The ADA activity was determined using the two methods. Inter- and intra-assay precision was determined, linear regression analysis was performed, simple concordance tests were conducted, and the means of the differences were calculated. RESULTS: The correlation coefficients for PF and CSF samples were, respectively, 0.96 and 0.95. Inter-assay precision was determined using 21 replicates at 3 different activity levels: low, medium and high. The percentage coefficient of variation (%CV) was, respectively, 5.9, 8.1 and 5.8 for PF samples, compared with 21.9, 18.6 and 13.8 for CSF samples. Intra-assay precision in %CV was 1.3 and 11.7, respectively, for PF and CSF samples. The concordance between the methods in PF and CRF samples was, respectively, 96.8% and 100%, considering the reference values for the diagnosis of TB to be 40 U/L (conventional) and 30 U/L (automated) in PF samples, versus 9 U/L (for both methods) in CSF samples. CONCLUSIONS: The results validate the use of the automated method of determining ADA activity in PF and CSF samples as an alternative to the conventional method.OBJETIVO: A incidência global de tuberculose reforça a necessidade de melhores ensaios para o diagnóstico desta doença, principalmente da tuberculose extrapulmonar. O objetivo do trabalho foi validar o desempenho de um método automatizado para a determinação da atividade de adenosina desaminase (ADA) no líquido pleural (LP) e no líquido cefalorraquidiano (LCR), comparando-o com um método convencional (Giusti modificado). MÉTODOS: Selecionaram-se 134 amostras da rotina laboratorial: 94 de LP e 40 de LCR. Foram realizadas as determinações da atividade de ADA através dos dois métodos. Calculou-se a precisão inter- e intra-ensaios, análise de regressão linear, testes de concordância simples e médias das diferenças. RESULTADOS: Os coeficientes de correlação para as amostras de LP e LCR foram, respectivamente, 0,96 e 0,95. A precisão interensaio foi determinada pela média de 21 amostras replicadas em ensaios diferentes para 3 níveis de atividade: baixa, média e alta. Os coeficientes de variação em porcentagem (%CV) foram, respectivamente, 5,9, 8,1 e 5,8 para amostras de LP; e 21,9, 18,6 e 13,8 para amostras de LCR, respectivamente. A precisão intra-ensaio em %CV foi, respectivamente, 1,3 e 11,7% para amostras de LP e LCR. A concordância entre os dois métodos em amostras de LP e LCR foi, respectivamente, 96,8% e 100%, considerando-se como valores de referência para o diagnóstico de TB 40 U/L (convencional) e 30 U/L (automatizado) em amostras de LP, e 9 U/L em amostras de LCR para os dois métodos. CONCLUSÕES: Os resultados validaram o método automatizado de determinação da atividade de ADA para o uso em amostras de LP e LCR como alternativa ao método convencional.Universidade Federal de São Paulo (UNIFESP) Departamento de PsicobiologiaLaboratório da Associação Fundo de Incentivo à Psicofarmacologia/Medicina LaboratorialUniversidade Federal de São Paulo (UNIFESP) Hospital São PauloUNIFESP, Depto. de PsicobiologiaUNIFESP, Hospital São PauloSciEL

Implications for the use of acid preservatives in 24-hour urine for measurements of high demand biochemical analytes in clinical laboratories

Background: Evaluate the level of interference of biochemists dosages in the 24-hour urine using or not the 6 mol/l HCl acid in different concentrations and conditions and its implications in the most demanded analytes in clinical laboratory.Methods: Twenty-two volunteers collected three 24-hour urine in 3 conditions: with 5 ml/l and 20 ml/l of 6 mol/l HCl in the container, and without acid preservative. the samples collected without preservative were separated in aliquots and added 5 ml/l of 6 mol/l HCl after 24 h. Analytes, uric acid creatinine, urea, chlorides, glucose, magnesium, sodium, potassium, microalbumin, proteins, amylase, aldosterone, calcium, cortisol, phosphorus, citric acid, oxalate, and metanephrines, were determined.Results: Uric acid, glucose, microalbumin, protein, amylase and aldosterone showed that %CV ranging from 16 to 57% in the presence of acid preservative. Analytes that need acid preservative cortisol, citric acid and oxalate showed %CV ranging from 6 to 27% with r=0.66, r=0.77, r=0.70 respectively provided 5 ml/l after delivery and r=0.31, r=0.70 and r=0.48 without preservative acid when compared with the gold standard (with 20 ml/l of 6 mol/l HCl).Conclusions: Glucose, microalbumin, protein, amylase and aldosterone urinary did not show good performance in the presence of acid preservative. Analytes that need acid preservative showed variation acceptable in condition 5 ml/l of 6 mol/l HCl added after 24 h. (C) 2011 Elsevier B.V. All rights reserved.Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)Associacao Fundo de Pesquisa a Psicobiologia (AFIP)Universidade Federal de São Paulo, Dept Psicobiol, UNIFESP, BR-04024002 São Paulo, BrazilAssoc Fundo Incent Psicofarmacol, AFIP Med Diagnost, São Paulo, BrazilUniversidade Federal de São Paulo, Dept Psicobiol, UNIFESP, BR-04024002 São Paulo, BrazilWeb of Scienc

Role of the mTOR pathway in normal and tumoral adrenal cells

The mammalian target of rapamycin (mTOR) is a kinase of the phosphoinositide 3-kinase (PI3Ks)/protein kinase B (PKB or AKT) signaling pathway, which is one of the most important intracellular mediators of the activity of growth factors receptors, including vascular endothelial growth factor (VEGF) and insulin-like growth factors (IGFs). Dysregulation of the mTOR pathway has been found in many human tumors. Therefore, the mTOR pathway is considered as a target for antineoplastic therapy in several malignancies. Presently, the role and functions of mTOR and its signaling pathway in the normal and pathological adrenal gland has not been clarified yet. However, many growth factors and growth factor receptors, which are considered to play a role in the pathogenesis of adrenal tumors, can at least in part exert their effects through the activation of PI3K/AKT/mTOR pathway. Dysregulation of AKT has been reported in adrenocortical carcinomas and adrenomedullary tumors, named pheochromocytomas. Adrenocortical carcinomas and malignant pheochromocytomas are aggressive tumors with poor prognosis and scant treatment options. Therefore, new treatment options are warranted for these malignancies. On the basis of the current knowledge, mTOR could play a role in the pathogenesis of both adrenocortical carcinomas and pheochromocytomas. Moreover, mTOR inhibitors, interfering with the activation of several mitogenic and angiogenic factors, could be considered as a novel treatment opportunity for the management of malignant adrenal tumors

Markers of endothelial activation and autoantibodies in rheumatoid arthritis

Rheumatoid arthritis (RA) is an inflammatory chronic disease characterized by the production of antibodies and participation of the vascular endothelium in its pathogenesis. OBJECTIVES: to analyze the correlation of serum levels of the intercellular adhesion molecule 1 (ICAM-1), von Willebrand factor (vWF), Rheumatoid factor (RF), and anti-cyclic citrulinated peptide (anti-CCP) with clinical, laboratory, and radiological parameters of RA. METHODS: Serum levels of ICAM-1, vWF, RF, and anti-CCP were measured in 38 RA patients and 24 controls. Disease activity was measured by the DAS-28 score and functional capa-city was assessed using the HAQ score. The American College of Rheumatism criteria defined the functional class. Hand and fist X-rays were analyzed using the Sharp's score. Statistical analysis utilized the chi-square, Student's t, Kolmogorov-Smirnov, and Mann-Whitney tests, as appropriate, as well as the Spearman's correlation coefficient. RESULTS: Age range was from 52 ± 12.5 and 49 ± 9.4 years-old in RA and controls, respectively. Disease duration range was 68 ± 66.6 months. Serum vWF levels had a positive significant correlation to disease evolution, whereas RF and anti-CCP correlated to the Sharp score. Serum vWF and ICAM-1 levels correlated to DAS-28, while only vWF correlated with HAQ and Sharp scores. CONCLUSION: This study shows that RF and anti-CCP autoantibody levels are correlated to disease prognosis rather than activity. Serum vWF levels are positively correlated to both activity and severity parameters of the disease.A artrite reumatóide (AR) é uma doença crônica inflamatória, caracterizada pela produção de auto-anticorpos e participação do endotélio vascular em sua patogênese. OBJETIVOS: Analisar a correlação da molécula de adesão intercelular (ICAM-1), o fator de von Willebrand (vWF), o fator reumatóide (FR) e o anticorpo antipeptídeo citrulinado cíclico (anti-CCP) com parâmetros de atividade clínica, laboratorial e alterações radiológicas da AR. MÉTODOS: Em 38 pacientes e 24 indivíduos que não apresentavam artrite reumatóide foram dosados FR, anti-CCP, vWF e ICAM-1 no soro. A atividade da doença foi definida pelo escore do DAS-28. O Health Assessment Questionnaire (HAQ) definiu a capacidade funcional, e os critérios revisados do American College of Rheumatology, a classe funcional. Radiografias de mãos e punhos quantificaram o índice de Sharp modificado. RESULTADOS: A idade dos pacientes foi de 52 ± 12,5 anos e dos indivíduos que não apresentavam artrite reumatóide, de 49 ± 9,4 anos. O tempo de doença foi de 68 ± 66,6 meses. O vWF apresentou correlação significativa com o tempo de evolução da doença. Os auto-anticorpos tiveram correlação significativa com o índice de Sharp. A correlação do vWF e a ICAM-1 foi significativa com o DAS-28, mas apenas o vWF se correlacionou com o HAQ e com índice de Sharp. CONCLUSÃO: Esse estudo demonstrou que os auto-anticorpos não estão correlacionados com a atividade da doença, mas com seu prognóstico e sua gravidade por meio da relação destes com o índice de Sharp. O vWF apresentou correlação significativa com os parâmetros de atividade e gravidade da doença.Universidade Estadual de Ciências da Saúde de AlagoasUniversidade Federal de São Paulo (UNIFESP)Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM)Associação Fundo de Incentivo à Psicofarmacologia Medicina LaboratorialUniversidade de São Paulo Faculdade de Medicina Laboratório de Poluição Atmosférica ExperimentalFaculdade de Medicina do ABCUNIFESP-EPM Departamento de PsicobiologiaUNIFESP, EPM, Depto. de PsicobiologiaSciEL

Relação entre trabalho por turnos e padrões de sono em enfermeiros

The scope of this study was to evaluate the sleep/wake cycle in shift work nurses, as well as their sleep quality and chronotype. The sleep/wake cycle was evaluated by keeping a sleep diary for a total of 60 nurses with a mean age of 31.76 years. The Horne & Östberg Questionnaire (1976) for the chronotype and the Pittsburgh Sleep Quality Index (PSQI) for sleep quality were applied. The results revealed a predominance of indifferent chronotypes (65.0%), followed by moderately evening persons (18.3%), decidedly evening persons (8.3%), moderately morning persons (6.6%) and decidedly morning persons (1.8%). The sleep quality perception was analyzed by the visual analogical scale, showing a mean score of 5.85 points for nighttime sleep and 4.70 points for daytime sleep, which represented a statistically significant difference. The sleep/wake schedule was also statistically different when considering weekdays and weekends. The PSQI showed a mean of 7.0 points, characterizing poor sleep quality. The results showed poor sleep quality in shift work nurses, possibly due to the lack of sport and shift work habits.Este estudo teve como objectivo analisar o ciclo vigília-sono em enfermeiros que trabalham por turnos, bem como a qualidade do sono e cronótipo. O ciclo vigília-sono foi avaliado através do diário de sono, num total de 60 enfermeiros, com idade média de 31.76 anos. Para o cronótipo utilizou-se o Questionário de Horne e Östberg, de 1976, e para medir a qualidade de sono calculou-se o Índice Qualidade de Sono de Pittsburg (PSQI). Os resultados do cronótipo mostraram uma predominância para tipo indiferente (65.0%), seguido do tipo Moderamente Vespertinos (18.3%), Definitivamente Vespertino (8.3%), Moderadamente Matutinos (6.6%) e Definitivamente Matutinos (1.8%). A percepção da qualidade do sono autorreportada pela Escala Analógica Visual (VAS) foi de 5.85 pontos, em média, para o sono nocturno e 4.70 para o sono diurno, diferença estatisticamente significativa. Os participantes demonstraram que o tempo de acordar e adormecer durante a semana e o fim-de-semana foram estatisticamente diferentes. No PSQI obteve-se uma média de 7.0 pontos, caracterizando o sono como de má qualidade. Os dados permitiram classificar o sono dos enfermeiros como de má qualidade. A falta de hábitos desportivos e o esquema de trabalho em turnos poderão ter influenciado na qualidade de sono.Universidade Federal de São Paulo (UNIFESP) Departamento de enfermagemUniversidade do Porto Faculdade de Psicologia e Ciências Educationais Laboratório de NeuropsicofisiologiaUNIFESP, Depto. de enfermagemSciEL

Bone demineralization and vertebral fractures in endogenous cortisol excess: role of disease etiology and gonadal status

INTRODUCTION: The effects of endogenous cortisol (F) excess on bone mass and vertebral fractures have still not been thoroughly investigated. The aim of this cross-sectional case-control study was to investigate factors influencing bone demineralization and vertebral fractures in different conditions of F excess, i.e. Cushing's disease and adrenal and ectopic Cushing's syndrome. MATERIALS AND METHODS: Eighty consecutive patients and 80 controls were prospectively enrolled: 37 patients (21 females) with pituitary ACTH-secreting adenoma, 18 (14 females) with adrenocortical adenoma, 15 (11 females) with adrenal carcinoma of mixed secretion, and 10 (three females) with ectopic ACTH secretion. The groups had similar age. At diagnosis, bone mineral density (BMD) was determined by the dual-energy x-ray absorptiometry technique at the lumbar spine (L1-L4) and femoral neck; vertebral fractures were investigated by standard spinal radiographs. RESULTS: When comparing the groups with different etiology of F excess, the patients with ectopic ACTH secretion had higher F and lower BMD values than the other subgroups. Morning F (P = 0.03) and testosterone levels (P = 0.04) correlated with lumbar BMD. Vertebral fractures were found in 61 (76%) of the patients, were multiple in 52 (85%) of the cases, and clinically evident in 32 (52%). Only multiple fractures were more frequent in patients with ectopic ACTH hypersecretion (P < 0.05). Lumbar spine BMD was the best predictor of vertebral fractures (P < 0.01). Surprisingly, amenorrheic and eumenorrheic women had similar BMD values and fracture prevalence. CONCLUSION: A high prevalence (76%) of vertebral fracture was revealed, regardless of the etiology of the patients' hypercortisolism. The harmful effects of F excess at the spine were partly counterbalanced by the increased androgen production but were not affected by gonadal status in women

Bone mineral status and metabolism in patients with Williams-Beuren syndrome.

OBJECTIVE: To evaluate bone mineral status and metabolism in a cohort of patients with Williams-Beuren syndrome (WBS). PATIENTS: Thirty-one children (15 females, 16 males; mean age 9.6±2.74 years) and 10 young adults (6 females, 4 males; mean age 21.4±5.11 years) with WBS were cross-sectionally evaluated and compared with two age-, sex-, and body-size-matched paediatric (155 subjects, 75 females and 80 males; mean age 9.7±2.93 years) and adult (50 subjects, 30 females and 20 males; mean age 22.3±5.42 years) healthy controls. MEASUREMENTS: We evaluated ionised and total calcium, phosphate, parathyroid hormone (PTH), 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D, osteocalcin, bone alkaline phosphatase levels, and urinary deoxypyridinoline concentrations. We also calculated the phalangeal amplitude-dependent speed of sound (AD-SoS) and the bone transmission time (BTT) z-scores. RESULTS: WBS patients showed a significantly reduced AD-SoS z-score (p <0.001) and BTT z-score (p <0.001) compared with the controls. This finding persisted when we divided the sample into paediatric and adult patients. WBS patients also had significantly higher ionised (p <0.001) and total calcium (p <0.001) levels as well as higher PTH levels (p <0.001) compared with the controls. Furthermore, WBS children and adolescents had significantly lower serum osteocalcin levels (p <0.001) and urinary deoxypyridinoline concentrations (p <0.001) than controls. CONCLUSIONS: WBS subjects exhibit a significant reduction in bone mineral status and impaired bone metabolism. These findings point to the need for close monitoring of WBS patients