Investigating the role of somatic sequencing platforms for phaeochromocytoma and paraganglioma in a large UK cohort.

Funder: NIHR Cambridge Biomedical Research CentreFunder: Gottfried and Julia Bangerter–Rhyner FoundationFunder: www.amend.org.ukFunder: Barts CharityFunder: Cambridge NIHR BRC Stratified Medicine Core Laboratory NGS HubFunder: Freiwillige Akademische GesellschaftOBJECTIVES: Phaeochromocytomas and paragangliomas (PPGL) are rare neuroendocrine tumours with malignant potential and a hereditary basis in almost 40% of patients. Germline genetic testing has transformed the management of PPGL enabling stratification of surveillance approaches, earlier diagnosis and predictive testing of at-risk family members. Recent studies have identified somatic mutations in a further subset of patients, indicating that molecular drivers at either a germline or tumour level can be identified in up to 80% of PPGL cases. The aim of this study was to investigate the clinical utility of somatic sequencing in a large cohort of patients with PPGL in the United Kingdom. DESIGN AND PATIENTS: Prospectively collected matched germline and tumour samples (development cohort) and retrospectively collected tumour samples (validation cohort) of patients with PPGL were investigated. MEASUREMENTS: Clinical characteristics of patients were assessed and tumour and germline DNA was analysed using a next-generation sequencing strategy. A screen for variants within 'mutation hotspots' in 68 human cancer genes was performed. RESULTS: Of 141 included patients, 45 (32%) had a germline mutation. In 37 (26%) patients one or more driver somatic variants were identified including 26 likely pathogenic or pathogenic variants and 19 variants of uncertain significance. Pathogenic somatic variants, observed in 25 (18%) patients, were most commonly identified in the VHL, NF1, HRAS and RET genes. Pathogenic somatic variants were almost exclusively identified in patients without a germline mutation (all but one), suggesting that somatic sequencing is likely to be most informative for those patients with negative germline genetic test results. CONCLUSIONS: Somatic sequencing may further stratify surveillance approaches for patients without a germline genetic driver and may also inform targeted therapeutic strategies for patients with metastatic disease

Improved functionalization of oleic acid-coated iron oxide nanoparticles for biomedical applications

Superparamagnetic iron oxide nanoparticles can providemultiple benefits for biomedical applications in aqueous environments such asmagnetic separation or magnetic resonance imaging. To increase the colloidal stability and allow subsequent reactions, the introduction of hydrophilic functional groups onto the particles’ surface is essential. During this process, the original coating is exchanged by preferably covalently bonded ligands such as trialkoxysilanes. The duration of the silane exchange reaction, which commonly takes more than 24 h, is an important drawback for this approach. In this paper, we present a novel method, which introduces ultrasonication as an energy source to dramatically accelerate this process, resulting in high-quality waterdispersible nanoparticles around 10 nmin size. To prove the generic character, different functional groups were introduced on the surface including polyethylene glycol chains, carboxylic acid, amine, and thiol groups. Their colloidal stability in various aqueous buffer solutions as well as human plasma and serum was investigated to allow implementation in biomedical and sensing applications.status: publishe

Mineralocorticoid hypertension and hypokalaemia induced by posaconazole

We describe severe hypokalaemia and hypertension due to a mineralocorticoid effect in a patient with myelodysplastic syndrome taking posaconazole as antifungal prophylaxis. Two distinct mechanisms due to posaconazole are identified: inhibition of 11β hydroxylase leading to the accumulation of the mineralocorticoid hormone 11-deoxycorticosterone (DOC) and secondly, inhibition of 11β hydroxysteroid dehydrogenase type 2 (11βHSD2), as demonstrated by an elevated serum cortisol-to-cortisone ratio. The effects were ameliorated by spironolactone. We also suggest that posaconazole may cause cortisol insufficiency. Patients taking posaconazole should therefore be monitored for hypokalaemia, hypertension and symptoms of hypocortisolaemia, at the onset of treatment and on a monthly basis. Treatment with mineralocorticoid antagonists (spironolactone or eplerenone), supplementation of glucocorticoids (e.g. hydrocortisone) or dose reduction or cessation of posaconazole should all be considered as management strategies

Mesenteric Variceal Haemorrhage and Ectopic Cushing's Syndrome as Presenting Features of a Pancreatic Neuroendocrine Tumour Recurrence

Pancreatic neuroendocrine tumours can have varied and complex presentations. Whilst hormone hypersecretion often induces characteristic clinical syndromes, non-specific symptoms may arise due to localized tumour effects. Malignant invasion of local vasculature is an increasingly recognized complication of these neoplasms and can be associated with significant morbidity. Herein, we present the case of a 47-year-old male with a recurrence of a pancreatic neuroendocrine tumour who presented with unusual upper gastrointestinal bleeding. The tumour had recurred within the superior mesenteric vein, replacing the vessel and invading its branches. This resulted in porto-mesenteric hypertension and the formation of bleeding mesenteric varices. The patient subsequently developed progressive metabolic disturbances and was diagnosed with ectopic Cushing's syndrome, despite his primary tumour having been non-functional. This case demonstrates not only a rare pattern of tumour recurrence but also the potential for pancreatic neuroendocrine tumours to de-differentiate and change from non-functional to hormone secreting, a phenomenon which may complicate diagnosis and management

Teaching referral skills to medical students

BACKGROUND: Referrals are an important and frequent part of a junior doctor’s work. Difficulty with making successful referrals is also very common. Despite this, training in referral skills is not routinely carried out in medical schools. RESULTS: We designed and delivered a 1-h interactive lecture to final year medical students to teach referral skills. The lecture was delivered on six occasions to up to 70 students at each session. 191 students attended and provided evaluation. 68 % of students had no previous training in referral skills and 99 % felt that referral skills should be included in the undergraduate curriculum. 90 % reported that the lecture had improved their understanding of referral techniques and 83 and 80 % felt that the lecture had improved their ability and confidence, respectively. CONCLUSIONS: Referral skills can be successfully taught in a large group lecture setting. We recommend that the teaching of referral skills is incorporated into all medical schools’ curricula

ENU mutagenesis identifies the first mouse mutants reproducing human β-thalassemia at the genomic level

Forward genetic screens have been performed in many species to identify phenotypes in specific organ systems. We have undertaken a large-scale N-ethyl-N-nitrosourea (ENU) mutagenesis screen to identify dominant mutations that perturb erythropoiesis in mice. Mutant mice that displayed an erythrocyte mean cell volume (MCV) greater than three standard deviations from the population mean were identified. Two of these lines, RBC13 and RBC14, displayed a hypochromic, microcytic anemia, accompanied by a marked reticulocytosis, splenomegaly and diminished red cell survival. Timed pregnancies from heterozygous intercrosses revealed that a quarter of the embryos displayed severe anemia and did not survive beyond embryonic day (E) 18.5, consistent with homozygous β-thalassemia. Genetic complementation studies with a β-thalassemia mouse line reproduced the embryonic lethality in compound heterozygotes and a genomic custom capture array and massively parallel sequencing of the β-globin locus identified the causative mutations. The RBC13 line displayed a nonsense mutation at codon 40 in exon 2 of the β-major gene, invoking parallels with the common β39 thalassemia mutation seen in humans. The RBC14 line exhibited a mutation at the polyadenylation signal of the β-major gene, exactly replicating a human β-thalassemia mutation. The RBC13 and RBC14 lines are the first β-thalassemia mouse models that reproduce human β-thalassemia at the genomic level, and as such highlight the power of ENU mutagenesis screens in generating mouse models of human disease

Inherited mutations in the SDH complex increase metastatic malignant potential of paragnglioma and phaeochromocytoma tumours

<p>Phaeochromocytomas (PCC) and paraganglioma (PGL) are neural crest tumours arising from the chromaffin producing cells of the adrenal medulla or sympathetic/parasympathetic system respectively. Recently, in part due to advances in high throughput sequencing, our understanding of the genetic predisposition to these tumours has greatly increased. To date, 13 genes have been implicated in the pathogenesis of these conditions (ten available for testing at our centre). Recent studies indicate that ~30–40% of patients with PCC/PGL may harbour a genetic predisposition to the condition. We aimed to determine the frequency that metastatic PCC/PGL was associated with mutations in known susceptibility genes.</p> <p>The genetic profile of all individuals diagnosed with metastatic PCC and PGL in our centre was ascertained and compared to individuals with PCC/PGL without evidence of metastasis. Over the past 5 years 82 individuals with a diagnosis of PCC or PGL fulfilled the criteria for genetic testing. This included 16 individuals with metastatic disease. Among the patients with confirmed metastatic disease 13/16 (81%) had a genetic mutation identified in SDHB, SDHA, or SDHD predisposing to PCC and PGL. However, among those patients with no metastatic disease identified to date, only 42% (29/69) had a genetic mutation identified (P=0.001). Among the subjects with metastatic PCC, 11/13 had mutations (85%) in SDHB.</p> <p>Our results imply that the identification of a mutation in the known PCC/PGL susceptibility genes confers an increased metastatic potential and also subjects with metastatic disease are most likely to harbour mutations in SDHB. Subjects with metastatic PGL/PCC are highly likely to have a genetic predisposition. In addition, identification of those individuals with PGL/PCC with a genetic mutation should be considered at high-risk for harbouring tumours with metastatic malignant potential.</p

The Fundamentals : a testimony to the truth (1917) Vol. 2

The inspiration of the Bible - definition, estent and proof / Rev. James M. Gray Inspiration / L.W. Munhall The moral glory of Jesus Christ, a proof of inspiration / Rev. William G. Moorehead The testimony of the scriptures to themselves / Rev. George S. Bishop Testimony of the organic unity of the Bible to its inspiration / Arthur T. Pierson Fulfilled prophecy a potent argument for the Bible / Arno C. Gaebelein Life in the word / Philip Mauro Is there a God? . Rev. Thomas Whitelaw God in Christ the only revelation of the fatherhood of God / Robert E. Speer The deity of Christ / Prof. Benjamin B. Warfield The virgin birth of Christ / Rev. Prof. James Orr The God-man / John Stock The person and work of Jesus Christ / Bishop Nuelsen The certainity and importance of the bodily resurrection of Jesus Christ from the dead / R.A. Torrey The personality and deity of the Holy Spirit / R.A. Torrey The Holy Spirit and the sons of God / Rev. W.J. Erdman Observations on the conversion and apostleship of St.. Paul / Lord Lyttelton Christianity no fable / Rev. Thomas Whitelawhttps://digitalcommons.biola.edu/the-fundamentals/1013/thumbnail.jp

Achievement of therapeutic mitotane concentrations in management of advanced adrenocortical cancer: a single centre experience in 47 patients

Introduction: Multi-modal therapy for adrenocortical carcinoma (ACC) includes surgery, therapy with the adrenolytic agent mitotane and systemic chemotherapy. Achievement of therapeutic mitotane concentrations (≥14 mg/l) has been related to improved outcomes. Aim: To evaluate the effectiveness of a defined* high dose protocol mitotane therapy in patients with advanced ACC (stages III and IV). Methods: Review of patients presenting to KCH with stage III or IV ACC and the mitotane concentration achieved through the Lysosafe monitoring service. Results: N=57 patients were referred and first diagnosed with ACC (2008-17) of whom 44 patients had stage III or IV disease at diagnosis and were managed actively with surgery and/or mitotane therapy. 40/44 patients underwent surgical resection of the primary tumour;11/22 patients with stage IV disease subsequently received systemic chemotherapy [10 patients received a combination of etoposide, doxorubicin and cisplatin (EDP) and 1 patient received a combination of carboplatin and etoposide]. 38/44 patients were initiated on mitotane therapy. The median overall survival of patients with stage IV disease was 25.3 months. The median survival for stage III has not been reached. An additional 9 patients had prior management, including surgery, elsewhere and were referred for mitotane initiation. A total of 47 patients were therefore included in the mitotane pharmacokinetic analysis. Six patients were excluded: 3 patients died shortly after mitotane initiation, 1 patient withdrew due to a severe reaction and 2 patients had not completed 12 weeks therapy at the time of submission. Of the remaining 41 patients, 33 commenced the ‘high dose’ protocol and the remainder the ‘low dose’ protocol. For patients on the high dose protocol, 25/33 (76%) reached a mitotane concentration ≥14 mg/l within 12 weeks of initiation of therapy, compared to 3 patients from the low dose protocol group (P=0.084). In the high dose protocol group, 21 patients (84%) maintained therapeutic drug concentrations in ≥50% of the subsequent follow-up samples and 12 patients (48%) maintained therapeutic drug concentrations in ≥75% of subsequent samples. Conclusion: The use of high dose protocol mitotane therapy is a successful strategy to achieve and maintain therapeutic drug concentrations when treating patients with advanced ACC (stages III and IV). In combination with an assertive surgical approach and optimal chemotherapy, this has resulted in outcomes that compare favourably (median OS 25.5 months in stage IV disease) with previously published series which describe a median OS <12 months