165 research outputs found
Successful Asfotase Alfa Treatment in an Adult Dialysis Patient With Childhood-Onset Hypophosphatasia
Hypophosphatasia is an inherited disease characterized by reduced alkaline
phosphatase activity, extracellular accumulation of inorganic pyrophosphate,
and impaired bone mineralization. Asfotase alfa (AA) is a recombinant human
alkaline phosphatase therapy approved for treatment of pediatric-onset
hypophosphatasia. Studies show promising outcome in AA-treated children with
hypophosphatasia; however, data on adults with pediatric-onset
hypophosphatasia are scarce. We report on a 59-year-old woman with childhood-
onset hypophosphatasia and a history of multiple fractures and orthopedic
procedures. Owing to renal failure (histological diagnosis: focal segmental
glomerulosclerosis), hemodialysis was started in 2013. By the end of 2015, the
patient was unable to walk, could only stand for 30 seconds, and was
completely dependent on help for activities of daily living. After 13 months
of AA therapy, the patient showed a dramatic increase in quality of life
(increased mobility), reduction in pain medication, and a significant
improvement in bone mineralization throughout the skeleton, including
consolidation of existing fractures and no occurrence of new fractures. This
case report demonstrates a relevant therapeutic success of AA treatment in an
adult hemodialysis patient with childhood onset of hypophosphatasia
Apparent mineralocorticoid excess syndrome: an overview
Apparent mineralocorticoid excess (AME) syndrome results from defective 11beta-hydroxysteroid dehydrogenase type 2 (11beta-HSD2). This enzyme is co-expressed with the mineralocorticoid receptor (MR) in the kidney and converts cortisol (F) to its inactive metabolite cortisone (E). Its deficiency allows the unmetabolized cortisol to bind to the MR inducing sodium retention, hypokalemia, suppression of PRA and hypertension. Mutations in the gene encoding 11beta-HSD2 account for the inherited form, but a similar clinical picture to AME occurs following the ingestion of bioflavonoids, licorice and carbenoxolone, which are competitive inhibitors of 11beta-HSD2. Reduced 11beta-HSD2 activity may explain the increased sodium retention in preeclampsia, renal disease and liver cirrhosis. Relative deficiency of 11beta-HSD2 activity can occur in Cushing's syndrome due to saturation of the enzyme and explains the mineralocorticoid excess state that characterizes ectopic ACTH syndrome. Reduced placental 11beta-HSD2 expression might explain the link between reduced birth weight and adult hypertension. Polymorphic variability in the HSD11B2 gene in part determines salt sensitivity, a forerunner for adult hypertension onset. AME represents a spectrum of mineralocorticoid hypertension with severity reflecting the underlying genetic defect in the 11beta-HSD2; although AME is a genetic disorder, several exogenous compounds can bring about the symptoms by inhibiting 11beta-HSD2 enzyme. Substrate excess as seen in Cushing's syndrome and ACTH ectopic production can overwhelm the capacity of 11beta-HSD2 to convert F to E, leading up to an acquired form of AME
Проблеми побудови відкритої та гнучкої методичної системи навчання математичних методів фізики у педагогічних університетах
(uk) Розглядаються тенденції розвитку фундаментальної фізико-математичної освіти, зближення природничо-наукового та гуманітарного, що уможливлюють розв’язання проблеми побудови відкритої та гнучкої науково-обґрунтованої методичної системи навчання математичних методів фізики у педагогічних університетах.(en) The article examines progressive trends of fundamental physical and mathematical education, rapprochement of naturally scientific and humanitarian, that makes possible to solve the problem of constructing the open and flexible scientifically reasonable methodical systeme of mathematical methods of physics teaching inpedagogical universities
Long-term outcome of primary bilateral macronodular adrenocortical hyperplasia after unilateral adrenalectomy
CONTEXT Unilateral adrenalectomy has been proposed in selected patients with primary bilateral macronodular adrenocortical hyperplasia (PBMAH), but its long-term outcome is unclear.
OBJECTIVE The aim of this study was to analyze long-term clinical and biochemical outcome of unilateral adrenalectomy versus bilateral adrenalectomy in patients with PBMAH in comparison to outcome of cortisol-producing adenoma (CPA) treated by unilateral adrenalectomy.
DESIGN Retrospective observational study in three German and one Italian academic tertiary care center.
PATIENTS AND METHODS 25 PBMAH patients after unilateral adrenalectomy (unilat-ADX-PBMAH), 9 patients with PBMAH and bilateral adrenalectomy (bilat-ADX-PBMAH) and 39 patients with CPA and unilateral adrenalectomy (unilat-ADX-CPA) were included.
RESULTS Baseline clinical and biochemical parameters were comparable in unilat-ADX-PBMAH, bilat-ADX-PBMAH and unilat-ADX-CPA. Directly after surgery, 84% of the unilat-ADX-PBMAH patients experienced initial remission of Cushing's syndrome. In contrast, at last follow-up (median 50 months) 32% of the unilat-ADX-PBMAH patients were biochemically controlled compared to nearly all patients in the other two groups (p=0.000). Adrenalectomy of the contralateral side had to be performed in 12% of the initially unilat-ADX-PBMAH patients. 3 of 20 unilat-ADX-PBMAH patients (15%) died during follow-up presumably of Cushing's syndrome related causes whereas no deaths occurred in the other two groups (p=0.008). Deaths occurred exclusively in patients who were not biochemically controlled after unilateral ADX.
CONCLUSIONS Our data suggest that unilateral adrenalectomy of PBMAH patients leads to clinical remission and a lower incidence of adrenal crisis, but less sufficient biochemical control of hypercortisolism potentially provoking a higher mortality
Outcome after resection of Adrenocortical Carcinoma liver metastases: a retrospective study
Background: Metastatic Adrenocortical Carcinoma (ACC) is a rare malignancy with a poor 5-year-survival rate (<15%). A surgical approach is recommended in selected patients if complete resection of distant metastasis can be achieved. To date there are only limited data on the outcome after surgical resection of hepatic metastases of ACC. Methods: A retrospective analysis of the German Adrenocortical Carcinoma Registry was conducted. Patients with liver metastases of ACC but without extrahepatic metastases or incomplete tumour resection were included. Results: Seventy-seven patients fulfilled these criteria. Forty-three patients underwent resection of liver metastases of ACC. Complete tumour resection (R0) could be achieved in 30 (69.8%). Median overall survival after liver resection was 76.1 months in comparison to 10.1 months in the 34 remaining patients with unresected liver metastases (p < 0.001). However, disease free survival after liver resection was only 9.1 months. Neither resection status (R0/R1) nor extent of liver resection were significant predictive factors for overall survival. Patients with a time interval to the first metastasis/recurrence (TTFR) of greater than 12 months or solitary liver metastases showed significantly prolonged survival. Conclusions: Liver resection in the case of ACC liver metastases can achieve long term survival with a median overall survival of more than 5 years, but disease free survival is short despite metastasectomy. Time to recurrence and single versus multiple metastases are predictive factors for the outcome
Functional Implications of LH/hCG Receptors in Pregnancy-Induced Cushing Syndrome
Context: Elevated human choriogonadotropin (hCG) may stimulate aberrantly
expressed luteinizing hormone (LH)/hCG receptor (LHCGR) in adrenal glands,
resulting in pregnancy-induced bilateral macronodular adrenal hyperplasia and
transient Cushing syndrome (CS). Objective: To determine the role of LHCGR in
transient, pregnancy-induced CS. Design, Setting, Patient, and Intervention:
We investigated the functional implications of LHCGRs in a patient presenting,
at a tertiary referral center, with repeated pregnancy-induced CS with
bilateral adrenal hyperplasia, resolving after parturition. Main Outcome
Measures and Results: Acute testing for aberrant hormone receptors was
negative except for arginine vasopressin (AVP)–increased cortisol secretion.
Long-term hCG stimulation induced hypercortisolism, which was unsuppressed by
dexamethasone. Postadrenalectomy histopathology demonstrated steroidogenically
active adrenocortical hyperplasia and ectopic cortical cell clusters in the
medulla. Quantitative polymerase chain reaction showed upregulated expression
of LHCGR, transcription factors GATA4, ZFPM2, and proopiomelanocortin (POMC),
AVP receptors (AVPRs) AVPR1A and AVPR2, and downregulated melanocortin 2
receptor (MC2R) vs control adrenals. LHCGR was localized in subcapsular, zona
glomerulosa, and hyperplastic cells. Single adrenocorticotropic
hormone–positive medullary cells were demonstrated in the zona reticularis.
The role of adrenal adrenocorticotropic hormone was considered negligible due
to downregulated MC2R. Coexpression of CYP11B1/CYP11B2 and AVPR1A/AVPR2 was
observed in ectopic cortical cells in the medulla. hCG stimulation of the
patient’s adrenal cell cultures significantly increased cyclic adenosine
monophosphate, corticosterone, 11-deoxycortisol, cortisol, and androstenedione
production. CTNNB1, PRKAR1A, ARMC5, and PRKACA gene mutational analyses were
negative. Conclusion: Nongenetic, transient, somatic mutation-independent,
pregnancy-induced CS was due to hCG-stimulated transformation of LHCGR-
positive undifferentiated subcapsular cells (presumably adrenocortical
progenitors) into LHCGR-positive hyperplastic cortical cells. These cells
respond to hCG stimulation with cortisol secretion. Without the ligand, they
persist with aberrant LHCGR expression and the ability to respond to the same
stimulus
Urine steroid metabolomics as a diagnostic tool in primary aldosteronism
Primary aldosteronism (PA) causes 5-10% of hypertension cases, but only a minority of patients are currently diagnosed and treated because of a complex, stepwise, and partly invasive workup. We tested the performance of urine steroid metabolomics, the computational analysis of 24-hour urine steroid metabolome data by machine learning, for the identification and subtyping of PA. Mass spectrometry-based multi-steroid profiling was used to quantify the excretion of 34 steroid metabolites in 24-hour urine samples from 158 adults with PA (88 with unilateral PA [UPA] due to aldosterone-producing adenomas [APAs]; 70 with bilateral PA [BPA]) and 65 sex- and age-matched healthy controls. All APAs were resected and underwent targeted gene sequencing to detect somatic mutations associated with UPA. Patients with PA had increased urinary metabolite excretion of mineralocorticoids, glucocorticoids, and glucocorticoid precursors. Urine steroid metabolomics identified patients with PA with high accuracy, both when applied to all 34 or only the three most discriminative steroid metabolites (average areas under the receiver-operating characteristics curve [AUCs-ROC] 0.95-0.97). Whilst machine learning was suboptimal in differentiating UPA from BPA (average AUCs-ROC 0.65-0.73), it readily identified APA cases harbouring somatic KCNJ5 mutations (average AUCs-ROC 0.79-85). These patients showed a distinctly increased urine excretion of the hybrid steroid 18-hydroxycortisol and its metabolite 18-oxo-tetrahydrocortisol, the latter identified by machine learning as by far the most discriminative steroid. In conclusion, urine steroid metabolomics is a non-invasive candidate test for the accurate identification of PA cases and KCNJ5-mutated APAs.</p
Urine steroid metabolomics as a diagnostic tool in primary aldosteronism
Primary aldosteronism (PA) causes 5-10% of hypertension cases, but only a minority of patients are currently diagnosed and treated because of a complex, stepwise, and partly invasive workup. We tested the performance of urine steroid metabolomics, the computational analysis of 24-hour urine steroid metabolome data by machine learning, for the identification and subtyping of PA. Mass spectrometry-based multi-steroid profiling was used to quantify the excretion of 34 steroid metabolites in 24-hour urine samples from 158 adults with PA (88 with unilateral PA [UPA] due to aldosterone-producing adenomas [APAs]; 70 with bilateral PA [BPA]) and 65 sex- and age-matched healthy controls. All APAs were resected and underwent targeted gene sequencing to detect somatic mutations associated with UPA. Patients with PA had increased urinary metabolite excretion of mineralocorticoids, glucocorticoids, and glucocorticoid precursors. Urine steroid metabolomics identified patients with PA with high accuracy, both when applied to all 34 or only the three most discriminative steroid metabolites (average areas under the receiver-operating characteristics curve [AUCs-ROC] 0.95-0.97). Whilst machine learning was suboptimal in differentiating UPA from BPA (average AUCs-ROC 0.65-0.73), it readily identified APA cases harbouring somatic KCNJ5 mutations (average AUCs-ROC 0.79-85). These patients showed a distinctly increased urine excretion of the hybrid steroid 18-hydroxycortisol and its metabolite 18-oxo-tetrahydrocortisol, the latter identified by machine learning as by far the most discriminative steroid. In conclusion, urine steroid metabolomics is a non-invasive candidate test for the accurate identification of PA cases and KCNJ5-mutated APAs
What Is the Optimal Duration of Adjuvant Mitotane Therapy in Adrenocortical Carcinoma? An Unanswered Question
A relevant issue on the treatment of adrenocortical carcinoma (ACC) concerns the optimal duration of adjuvant mitotane treatment. We tried to address this question, assessing whether a correlation exists between the duration of adjuvant mitotane treatment and recurrence-free survival (RFS) of patients with ACC. We conducted a multicenter retrospective analysis on 154 ACC patients treated for ≥12 months with adjuvant mitotane after radical surgery and who were free of disease at the mitotane stop. During a median follow-up of 38 months, 19 patients (12.3%) experienced recurrence. We calculated the RFS after mitotane (RFSAM), from the landmark time-point of mitotane discontinuation, to overcome immortal time bias. We found a wide variability in the duration of adjuvant mitotane treatment among different centers and also among patients cared for at the same center, reflecting heterogeneous practice. We did not find any survival advantage in patients treated for longer than 24 months. Moreover, the relationship between treatment duration and the frequency of ACC recurrence was not linear after stratifying our patients in tertiles of length of adjuvant treatment. In conclusion, the present findings do not support the concept that extending adjuvant mitotane treatment over two years is beneficial for ACC patients with low to moderate risk of recurrence
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