Addition Of Hydrocortisone Research Articles

Effect of elevated temperature and hydrocortisone addition on the proliferation of fibroblasts

Hyperthermia along with hydrocortisone (HC) are proven teratogens that can negatively influence embryo development during early pregnancy. Proliferation of cells is one of the main developmental processes during the early embryogenesis. This study was focused on testing the effect of elevated temperature and HC addition on proliferation of cells in in vitro cultures. The V79-4 cell line was treated with HC and cultured in vitro at 37 °C or 39 °C, respectively. To reveal the effect of both factors, the proliferation of cells cultured under different conditions was evaluated using various approaches (colony formation assay, generation of growth curves, computation of doubling times, and mitotic index estimation). Our results indicate that a short-term exposure to elevated temperature slightly stimulates and a long-term exposure suppresses cell proliferation. However, HC (0.1 mg/ml) acts as a stimulator of cell proliferation. Interestingly, the interaction of HC and long-term elevated temperature (39 °C) exposure results in at least partial compensation of the negative impact of elevated temperature by HC addition and in higher proliferation if compared with cells cultured at 39 °C without addition of HC.

Characterization of agouti-signaling protein (ASIP) in the bovine ovary and throughout early embryogenesis

The oocyte expresses certain genes during folliculogenesis to regulate the acquisition of oocyte competence. Oocyte competence, or oocyte quality, is directly related to the ability of the oocyte to result in a successful pregnancy following fertilization. Presently, approximately 40 % of bovine embryos will develop to the blastocyst stage in vitro. Characterization of factors regulating these processes is crucial to improve the efficiency of bovine in vitro embryo production. We demonstrated that the secreted protein, agouti-signaling protein (ASIP) is highly abundant in the bovine oocyte and aimed to characterize its spatiotemporal expression profile in the ovary and throughout early embryonic development. In addition to oocyte expression, ASIP was detected in granulosa, cumulus, and theca cells isolated from antral follicles. Both gene expression data and immunofluorescent staining indicated ASIP declines with oocyte maturation which may indicate a potential role for ASIP in the attainment of oocyte competence. Microinjection of zygotes using small interfering RNA targeting ASIP led to a 16 % reduction in the rate of development to the blastocyst stage. Additionally, we examined potential ASIP signaling mechanisms through which ASIP may function to establish oocyte developmental competence. The expression of melanocortin receptor 3 and 4 and the coreceptor attractin was detected in the oocyte and follicular cells. The addition of cortisol during in vitro maturation was found to increase significantly oocyte ASIP levels. In conclusion, these results suggest a functional role for ASIP in promoting oocyte maturation and subsequent embryonic development, potentially through signaling mechanisms involving cortisol.

Methotrexate Induced Central Nervous System Manifestations in Children Receiving Treatment for Acute Lymphoid Malignancies

Methotrexate (MTX) is an essential part of most chemotherapy regimens for acute lymphoblastic leukemia (ALL). It is administered intrathecally (IT), intravenously, and orally during ALL therapy. We performed a retrospective chart review to assess the central nervous system (CNS) manifestations induced by MTX in all children who received ALL therapy at our institution between July 2013 and June 2023. A list of patients with the ICD-9/10 codes for ALL or ALLy was obtained from the Electronic Medical Records for the study time period. Data collected included demographics, cytogenetics, laboratory test results, MTX pharmacological data if available, and details of the treatment of CNS manifestations attributable to MTX. Lastly, we had a single neuroradiologist re-review all the brain Magnetic Resonance Imaging (MRI) obtained in patients with MTX induced CNS manifestations. Sixty-five children were treated for ALL during the study decade. The average age at diagnosis was 4.7 ± 4 years. Our cohort consisted of 38 males and 27 females. Twelve of 65 patients (19%) developed MTX-induced CNS manifestations. The average age at the onset of symptoms was 5.3 ± 2 years. Ten patients had received a dose of IT MTX within 2 weeks of experiencing symptoms. Symptoms included raised intracranial pressure (ICP) (64%), headache (36%), confusion (36%), altered mental status (29%), and altered level of consciousness (29%). Treatment of MTX-induced CNS manifestations consisted of therapeutic drainage of cerebrospinal fluid (CSF) with their scheduled IT chemotherapy administration (65%), acetazolamide (57%), theophylline + leucovorin + dextromethorphan (64%), and addition of hydrocortisone with IT medications (36%). In 3 (25%) patients the subsequent doses of MTX were delayed. The symptoms of CNS manifestations resolved in 100% of cases and MTX was able to be readministered in all the patients. Only one patient had recurrence of CNS manifestations twice after rechallenging with MTX; however, with specific symptomatic treatment, was able to tolerate the remainder of the IT therapy inclusive of MTX. Brain MRIs were obtained in all patients. Initial imaging studies yielded normal results in 6 (50%) patients. Abnormal findings included subcortical white matter changes, vividly observed on T2/FLAIR MRI. These changes were represented by regions of acute hyperintensity seen in diffuse bilateral cerebral hemispheres (33%), parietal regions (33%), frontoparietal regions (17%), occipital regions (17%) and the left parietooccipital region (17%). A follow up MRI was performed 3 to 8 months after the initial MRI and was repeated up to 6 times over a course of 6 years in a patient. The earliest MRI improvement was evident after 3 months of initial imaging. About 20% of patients developed MTX induced CNS manifestations in our cohort. IT MTX was the most common culprit. Raised ICP, on opening pressure measured during IT procedures happened to be the most common finding. This has not widely been reported previously under MTX induced CNS complications in published data. One of the suspected etiologies is the inflammation of arachnoid villi impairing CSF drainage. These patients responded well to acetazolamide and therapeutic drainage of CSF. Finally subcortical while matter changes on T2/FLAIR MRI was a common CNS manifestation.

HIPSC model reveals M1 macrophages cause atrial arrhythmia correlated to electrophysiological remodelling of atrial cardiomyocytes in 2D and 3D engineered heart tissue

Abstract Atrial fibrillation (AF) is the most common sustained arrhythmia with an estimated prevalence of 1.5–2%. Current treatments lack effectiveness and do not prevent recurrence. Inflammation is reported in AF patients, however, a causal connection remains elusive. In this study, we investigated the arrhythmic effects of pro-inflammatory macrophages (M1) on human induced pluripotent stem cell (hiPSC)-derived atrial cardiomyocytes (aCM), to better understand their role in AF. Macrophages are known to play a role in cardiac electrophysiology, but their role in arrhythmia is unclear. Three healthy hiPSC lines were differentiated to aCM and M1. Multi-electrode array recordings of isogenic, 2D cocultures of M1 and aCM showed a significant increase in beat rate irregularity compared to control conditions (P<0.001). Furthermore, spike amplitude of aCM and M1 cocultures was significantly decreased (P<0.001). Arrhythmias occurred only after activation of macrophages in the coculture. Addition of anti-inflammatory glucocorticoids significantly reduced beat irregularity in aCM and M1 cocultures compared to vehicle (1.9-fold decrease for Hydrocortisone, P<0.005) further supporting macrophage mediated inflammation to be the cause of the arrhythmia. RNA sequencing of aCM and M1 cocultures revealed aberrant expression of arrhythmia associated cardiac sodium and atrial potassium ion channels (SCN5A, KCNA5). Normal expression was restored through hydrocortisone addition. In addition, inflammation-induced arrhythmia was observed in 3D engineered heart tissues containing hiPSC derived aCM, M1 and cardiac fibroblasts. Tissues showed a significant increase in beating irregularity (P<0.005) compared to controls and had a significant, median reduction (>30%) of contraction amplitude (P<0.05). Our findings suggest a causal relationship between M1 and the occurrence of atrial arrhythmia. The reduction of arrhythmia using glucocorticoids correlates to clinical observations, that show their use being linked to reduced post operative AF burden. These results strongly support the relevance of the proposed hiPSC coculture model and elucidate a new potential AF mechanism.

Effects of cortisol on granulosa cell function during follicle maturation in the horse

Follicle maturation and acquisition of developmental competence by the oocyte require an interplay between granulosa cells and the oocyte, involving Growth Differentiation Factor 9 (GDF9) and Bone Morphogenetic Protein 15 (BMP15) mediated modulation of follicular steroidogenesis. In the horse, dynamic intrafollicular concentrations of cortisol were associated with follicle growth and oocyte maturation, suggesting a functional relationship between cortisol and oocyte-derived factors. The aim of this study was to analyze effects of cortisol on steroidogenic activity, apoptosis and proliferative capacity of equine granulosa cells, as well as the relationship with the oocyte-derived factor GDF9. For this purpose, granulosa cells were collected three times in four mares each during the breeding season by transvaginal aspiration in the absence of a dominant follicle. Cells collected on the same day were pooled and then seeded on 12-well plates to grow to 70-80% confluence before being stimulated with 100 ng/ml IGF1 for 24h, in the presence or absence of cortisol in increasing concentrations: 50, 100 and 150 ng/ml. These concentrations were previously observed in antral follicles before deviation (50 ng/ml) and after deviation (120 ng/ml). In blocking experiments, cells were preincubated with 20 uM H89 (protein kinase A inhibitor). All experiments were repeated three times. GraphPad software was used for statistical analysis with one-way analysis of variance (ANOVA), followed by non-parametric multiple comparison post-hoc test.Expression of Star was similar in all groups (P>0.05), independent of cortisol concentration and was decreased (P<0.05) after preincubation with H89. Transcriptional levels of HSD3B2 were higher (P<0.001) after adding IGF1 and cortisol simultaneously, but not separately. The rise in HSD3B2 levels was independent of cortisol dose used (P>0.05). Blocking of Star with H89 increased GDF9 expression (P<0.01), both in the presence and absence of cortisol. Interestingly, addition of cortisol alone in all analyzed dosages raised BCL2 levels (P<0.05) and this effect was inhibited by H89 (P<0.05). However, there was no effect on CASP3 levels (P>0.05), regardless of treatment used. A higher proliferating capability of equine granulosa cells, as assessed by PCNA levels, was observed in response to IGF1 treatment (P<0.05), but only in the presence of 150 ng/ml cortisol. Despite apparently elevated, the expression of Ki67 marker in response to IGF1 in the presence of cortisol proved to be not significant (P>0.05). Taken together, our results demonstrate enhanced steroidogenesis as well as reduced apoptosis in equine granulosa cells in response to cortisol. Moreover, reduced steroidogenic activity (i.e. decreased expression of genes involved in progesterone synthesis) of granulosa cells increased GDF9 expression, which has previously been shown to be detrimental for the acquisition of developmental competence by the oocyte.

Hydrocortisone vs. Vasopressin for the Management of Adults Patients with Septic Shock Refractory to Norepinephrine: A Multicenter Retrospective Study.

Significant practice variation exists when selecting between hydrocortisone and vasopressin as second line agents in patients with septic shock in need of escalating doses of norepinephrine. The goal of this study was to assess differences in clinical outcomes between these two agents. This was a multicenter, retrospective, observational study conducted across ten hospitals within Ascension Health. Adult patients with presumed septic shock receiving norepinephrine prior to initiation of hydrocortisone or vasopressin between December 2015 and August 2021 were assessed for inclusion. The primary outcome, mortality within 28 days of study drug initiation, was assessed using multivariable logistic regression and propensity score matching performed with a 1:1 ratio. A total of 768 patients were included with a median (interquartile range) SOFA score of 10 (8-13), norepinephrine dose of 0.3 mcg/kg/min (0.1-0.5 mcg/kg/min), and lactate of 3.8 mmol/L (2.4-7.0 mmol/L) at initiation of the study drug. A significant difference in 28-day mortality was noted favoring hydrocortisone as an adjunct to norepinephrine after controlling for potential confounding factors (OR 0.46 [95% CI, 0.32-0.66]); similar results were seen following propensity score matching. Compared to vasopressin, hydrocortisone initiation was also associated with a higher rate of hemodynamic responsiveness (91.9% vs. 68.2%, p<0.01), improved resolution of shock (68.8% vs. 31.5%, p<0.01), and reduced recurrence of shock within 72 hours (8.7% vs. 20.7%, p<0.01). Addition of hydrocortisone to norepinephrine was associated with a lower 28-day mortality in patients with septic shock, compared to the addition of vasopressin.

Fluid and vasopressor therapy in sepsis

Sepsis is one of the most common and lethal conditions in intensive care medicine. Besides adequate treatment of the infection, timely hemodynamic management is essential to treat tissue hypoperfusion due to sepsis. Adequate fluid resuscitation plays acentral role, and this should be carried out with dynamic monitoring of the hemodynamic response. However, apositive fluid balance is associated with poor outcome. Vasopressor therapy is required in case of inadequate response to fluid resuscitation, with norepinephrine considered the first choice. With increasing norepinephrine dose, addition of hydrocortisone or vasopressin may contribute to maintaining the hemodynamic state, although the prognostic advantage of these drugs has not been demonstrated. While dobutamine may be considered in patients with septic cardiomyopathy, the evidence for inotropic therapy in sepsis is limited.

Therapy of sepsis

Sepsis as a development of an acute infection-related organ dysfunction significantly increases the risk of death for the patient. Therefore, fast and consistent management is required. The sepsis bundle is a convenient algorithm for initial sepsis therapy within the first hour of sepsis diagnosis consisting of blood cultures, lactate measurement, antibiotics, fluid resuscitation, and vasopressor therapy. Cristalloid solutions are first choice for fluid therapy but albumin and gelatine may be considered if colloid solutions are required. Norepinephrine is the vasopressor of first choice. After initial therapy, further fluid resuscitation should be guided by dynamic criteria. Vasopressin may be added as an additional vasopressor. Goal of resuscitation is to achieve lactate clearance. In shock refractory to therapy, addition of hydrocortisone (200mg/day) should be considered. Further additional therapies such as immunoglobulins, blood purification, and metabolic resuscitation (combination of hydrocortisone, thiamine, vitamine C) are currently not supported by studies and should not be considered as standard therapy.

Hydrocortisone or Placebo to Reduce Dexamethasone-Induced Neurobehavioral Side Effects: Results of a Phase 3 National, Double-Blind, Placebo-Controlled Randomized Trial with Crossover Design

Background The introduction of dexamethasone for the treatment of pediatric acute lymphoblastic leukemia (ALL) significantly contributed to the current overall survival rate of more than 90% in high-income countries. The downside however, is that dexamethasone can induce serious side effects, of which neurobehavioral side effects are experienced as detrimental with respect to health-related quality of life (HRQoL) by both patients and parents. Our previous study suggests that children who suffer most from neurobehavioral side effects might benefit from physiological hydrocortisone addition to dexamethasone treatment. We aimed to validate this finding in a prospective large cohort of pediatric ALL patients. Methods Our phase 3, double-blind, randomized controlled trial with crossover design included ALL patients (3-18 years) during medium risk maintenance therapy in a national tertiary hospital between May 17, 2018 and August 5, 2020. A baseline measurement before and after one five-day dexamethasone course was performed to identify patients with clinically relevant dexamethasone-induced neurobehavioral problems, defined as a rise of ≥5 points on the Strengths and Difficulties Questionnaire (SDQ) Total Difficulties score. These patients were subsequently randomized to receive an intervention during the following four five-day dexamethasone courses. The intervention consisted of two courses hydrocortisone (physiological dose of 10mg/m2/day in a circadian rhythm), followed by two courses placebo, or vice versa. Neurobehavioral problems were assessed before and after each course using the parent-reported SDQ as primary endpoint. Secondary endpoints were sleep problems, HRQoL, hunger feeling, and parental stress, measured with separate questionnaires and actigraphy. A generalized mixed model was estimated to study the intervention effect. Findings Of 79 included patients, 52 (66%) experienced clinically relevant dexamethasone-induced neurobehavioral problems. Both hydrocortisone and placebo significantly and relevantly decreased dexamethasone-induced neurobehavioral problems measured with the SDQ (estimated effect hydrocortisone: -8.19 (95%-confidence interval (CI) -12.35 to -4.04), estimated effect placebo: -6.75 (95%-CI -10.95 to -2.56) (table 1 and figure 1). This indicates that, when adding hydrocortisone or placebo to dexamethasone treatment, the SDQ Total Difficulties score is estimated to be 8.19 or 6.75 points lower than without the addition of hydrocortisone or placebo. Since one SD of SDQ norm values is between 4 and 6 points, the decrease on the SDQ after hydrocortisone or placebo addition is more than 1 SD, and therefore clinically significant. The strength of the effect was similar in both interventions. There was no benefit from hydrocortisone or placebo in reducing sleep problems, hunger, parental stress or improving HRQoL. Interpretation Clinically relevant dexamethasone-induced neurobehavioral problems decreased equally and significantly after both hydrocortisone and placebo addition. Using the placebo effect in clinical practice could be a powerful and innovative way to diminish neurobehavioral problems in children who experience clinically relevant dexamethasone-induced side effects. Moreover, the high proportion of patients who experience clinically relevant dexamethasone-induced neurobehavioral problems might be caused by a nocebo effect of dexamethasone. By offering both interventions (hydrocortisone and open-label placebo) in clinical practice and by diminishing the nocebo effect of dexamethasone, we hope to improve dexamethasone-induced side effects in those patients who suffer most. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Rapid and green synthesis of highly luminescent MoS2 quantum dots via microwave exfoliation of MoS2 powder and its application as a fluorescence probe for cortisol detection in human saliva

We have introduced a simple, straightforward, green, and fast microwave exfoliation of MoS2 powder to prepare highly luminescent MoS2 quantum dots (QDs). The microwave irradiation of MoS2 powder was evaluated in the different solvents, including EtOH 30%, MeOH 30%, NaOH 1 M, and NH4OH 1 M in both open and closed microwave system setups. The results indicated that the highest luminescent MoS2 QDs is obtained when MoS2 powder was dispersed in 1 M ammonium solution and exposed to 850 W microwave radiation in a closed microwave system at 30 bars for 30 min. Different microscopic and spectroscopic techniques were used to characterize as-prepared MoS2 QDs. The MoS2 QDs have shown the maximum emission at 413 nm with excitation at 310 nm. The Quantum yield of as-prepared QDs was 1.98%. Cu2+, Pb2+, Cd2+, Ag+, Fe3+, and Al3+ quenched the luminescence intensity of MoS2 QDs. The luminescence of MoS2 QDs-Ag+ and Cu2+ mixtures were recovered on addition of cortisol with the higher emission recovery for Cu2+ ion. Therefore, proof-of-concept for cortisol sensing in human saliva was evaluated and discussed using off-on protocol. A linear cortisol calibration curve was obtained in the range of 100 ng mL−1 to 500 ng mL−1, with a detection limit of 16 ng mL−1 (S / N = 3). The method was successful in determining the cortisol content of saliva.

Study protocol: DexaDays-2, hydrocortisone for treatment of dexamethasone-induced neurobehavioral side effects in pediatric leukemia patients: a double-blind placebo controlled randomized intervention study with cross-over design

BackgroundDexamethasone, a highly effective drug in treating pediatric acute lymphoblastic leukemia (ALL), can induce serious neurobehavioral side effects. These side effects are experienced by patients and parents as detrimental with respect to health related quality of life (HRQoL). Based on previous studies, it has been suggested that neurobehavioral side effects are associated to cortisol depletion of the mineralocorticoid receptor in the brain. Our previously reported randomized controlled trial, the Dexadagen study (NTR3280), suggests that physiological hydrocortisone addition during dexamethasone treatment may overcome clinically relevant neurobehavioral problems in patients who experience these problems during dexamethasone treatment. With our current study, we aim to replicate these results in a targeted larger sample before further implementing this intervention into standard of care.MethodsIn a national center setting, pediatric ALL patients between 3 and 18 years are enrolled in an Identification study, which identifies patients with clinically relevant dexamethasone-induced neurobehavioral side effects using the Strengths and Difficulties Questionnaire (SDQ). Contributing factors, such as genetic susceptibility, dexamethasone pharmacokinetics as well as psychosocial and family factors are studied to determine their influence in the inter-patient variability for developing dexamethasone-induced neurobehavioral side effects.Patients with clinically relevant problems (i.e. a rise of ≥ 5 points on the SDQ Total Difficulties Score after 5 days of dexamethasone) are subsequently included in a randomized double-blind placebo-controlled trial with a cross-over design. They receive two courses placebo followed by two courses hydrocortisone during dexamethasone treatment, or vice versa, each time at least 16 days without study medication in between. The primary endpoint is change in SDQ score. The secondary endpoints are sleep (measured with actigraphy and the Sleep Disturbance Scale for Children) and HRQoL (Pediatric Quality of Life Questionnaire).DiscussionThe results of our current study may contribute to the management of future ALL patients who experience dexamethasone-induced neuropsychological problems as it may improve HRQoL for patients who suffer most from dexamethasone-induced neurobehavioral side effects. Furthermore, by investigating multiple risk factors that could be related to inter-patient variability in developing these side effects, we might be able to identify and treat patients who are at risk earlier during treatment.Trial registrationMedical Ethical Committee approval number: NL62388.078.17. Affiliation: Erasmus Medical Centre. Netherlands Trial Register: NL6507 (NTR6695). Registered 5 September 2017

An Investigation of the Effect of Catecholamines and Glucocorticoids on the Growth and Pathogenicity of Campylobacter jejuni.

Campylobacter spp. are major causes of foodborne illness globally, and are mostly transmitted through the consumption and handling of poultry. Campylobacter infections have widely variable outcomes, ranging from mild enteritis to severe illness, which are attributed to host interactions and the virulence of the infecting strain. In this study, in order to investigate the effect of host stress on the growth and pathogenicity of C. jejuni, three strains associated with human infection and two strains from broilers were subject to growth, motility, adhesion and invasion assays, in response to exposure to catecholamines; epinephrine, norepinephrine and the glucocorticoid neuroendocrine hormones corticosterone, cortisol and cortisone which are associated with stress in humans and broilers. Catecholamines resulted in significantly increased growth, adhesion and invasion of Caco-2 cells. Corticosterone promoted growth in one of five strains, and cortisone resulted in a significant increase in motility in two out of five strains, while no significant differences were observed with the addition of cortisol. It was concluded that stress-associated hormones, especially catecholamines, may promote growth and virulence in Campylobacter.

The pivotal role of micro-environmental cells in a human blood\u2013brain barrier in vitro model of cerebral ischemia: functional and transcriptomic analysis

BackgroundThe blood–brain barrier (BBB) is altered in several diseases of the central nervous system. For example, the breakdown of the BBB during cerebral ischemia in stroke or traumatic brain injury is a hallmark of the diseases’ progression. This functional damage is one key event which is attempted to be mimicked in in vitro models. Recent studies showed the pivotal role of micro-environmental cells such as astrocytes for this barrier damage in mouse stroke in vitro models. The aim of this study was to evaluate the role of micro-environmental cells for the functional, paracellular breakdown in a human BBB cerebral ischemia in vitro model accompanied by a transcriptional analysis.MethodsTranswell models with human brain endothelial cell line hCMEC/D3 in mono-culture or co-culture with human primary astrocytes and pericytes or rat glioma cell line C6 were subjected to oxygen/glucose deprivation (OGD). Changes of transendothelial electrical resistance (TEER) and FITC-dextran 4000 permeability were recorded as measures for paracellular tightness. In addition, qPCR and high-throughput qPCR Barrier chips were applied to investigate the changes of the mRNA expression of 38 relevant, expressed barrier targets (tight junctions, ABC-transporters) by different treatments.ResultsIn contrast to the mono-culture, the co-cultivation with human primary astrocytes/pericytes or glioma C6 cells resulted in a significantly increased paracellular permeability after 5 h OGD. This indicated the pivotal role of micro-environmental cells for BBB breakdown in the human model. Hierarchical cluster analysis of qPCR data revealed differently, but also commonly regulated clustered targets dependent on medium exchange, serum reduction, hydrocortisone addition and co-cultivations.ConclusionsThe co-cultivation with micro-environmental cells is necessary to achieve a functional breakdown of the BBB in the cerebral ischemia model within an in vivo relevant time window. Comprehensive studies by qPCR revealed that distinct expression clusters of barrier markers exist and that these are regulated by different treatments (even by growth medium change) indicating that controls for single cell culture manipulation steps are crucial to understand the observed effects properly.

Regulation of Differentiation of HC11 Mouse Breast Epithelial Cells by the Signal Transducer and Activator of Transcription-3.

The differentiation of the mouse breast epithelial cell line HC11 is known to require confluence as well as the addition of hydrocortisone, insulin and prolactin. Since confluence, which triggers the engagement of the cell-to-cell adhesion molecule E-cadherin, induces a dramatic increase in the activity of signal transducer and activator of transcription-3 (Stat3), we examined the role of Stat3 in HC11 cell differentiation. Stat3 inhibition abolished differentiation, indicating that Stat3 activity is critically required. However, expression of the mutationally activated form of Stat3 (Stat3C), rather than promoting, it was found to block cell differentiation, even when expressed in low levels, and in the absence of full neoplastic conversion. The strength of the E-cadherin/Stat3 signal is key for the outcome of the differentiation process.

SUN-175 Severe Lactic Acidosis Due to Intentional Suicide Attempt with Metformin and Its ICU Management

Background: Metformin is a biguanide used in treatment of Type 2 Diabetes Mellitus. Deliberate suicide attempt with Metformin is rare and manifests as severe lactic acidosis with mortality rate of 30%. Clinical Case: A 58-year old male with Type 2 Diabetes Mellitus was brought to the Emergency Department (ED) after intentional overdose with 30 grams of Metformin. Upon arrival to the ED, he was semiconscious and confused. His BP: 99/54 mmHg, HR: 88 bpm, RR: 18, Temp: 98.2°F, and saturating 100% on ambient air. Blood chemistry panel revealed Creatinine of 3.14 mg/dL (n: 0.6-1.30 mg/dL), anion gap of 26 mEq/L (n: 8-12 mEq/L), lactic acid of 19.8 mmol/L (n: 0.8-2.1 mmol/L), and blood glucose of 198 mg/dL (n: 74-106 mg/dL). Urine drug screen, serum salicylate, acetaminophen, alcohol, Methanol, and Ethelyn Glycol levels were negative. Metformin concentration was later found to be 41 mcg/ml (n: 0.10 mcg/ml). He received activated charcoal in the ED and ICU was urgently consulted. Patient ultimately developed acute respiratory failure due to severe acidosis (ABG; pH: 6.97 (n: 7.35-7.45), pCO2: 27 mmHg (n: 35-48 mmHg), and HCO3: 6.2 mEq/L (n: 18-23 mEq/L)). He was intubated for airway support and was placed on mechanical ventilation. Due to persistent hypotension, he was started on pressor support with Phenylephrine as well as continuous infusion of sodium bicarbonate 8.4% at 200 ml/hr. Patient’s blood glucose dropped to as low as 22 mg/dL (n: 74-106 mg/dL) and thus he was started on intravenous infusion of Dextrose 5% Normal Saline at 100 ml/hr to avoid life threatening hypoglycemic coma. Nephrology was consulted for emergent dialysis. Patient’s condition quickly deteriorated due to severe lactic acidosis thus requiring two additional pressor support with infusion of Norepinephrine and Vasopressin as well as addition of Hydrocortisone and oral Midodrine. His renal function worsened, and he became oliguric. Patient subsequently received intermittent hemofiltration for 2 consecutive days for duration of 3 hours and 8 hours, respectively. After initiation of hemofiltration, patient’s condition gradually improved, his blood pressure stabilized, his creatinine & lactic acid levels normalized, and he was successfully extubated. He made a full recovery and was safely discharged home after 13 days of hospitalization. His Metformin level on discharge was 0.10 mcg/ml (n: 0.10 mcg/ml). Patient has been followed closely at our out-patient clinic since discharge and remains in good health. Conclusion: Metformin overdose/toxicity is a serious condition associated with significant mortality and should be considered in diabetic patients presenting with severe lactic and metabolic acidosis. Our recommendations for management of Metformin associated lactic acidosis includes; timely recognition, decontamination, ICU admission and emergent hemodialysis for correction of severe metabolic abnormalities.

Effect of acute stressors, adrenocorticotropic hormone administration, and cortisol release on milk yield, the expression of key genes, proliferation, and apoptosis in goat mammary epithelial cells

Cortisol is essential to milk synthesis; however, different acute stressors and the exogenous administration of adrenocorticotropic hormone (ACTH) decrease milk yield. Therefore, the effect of cortisol on milk yield and its influence on the survival of mammary epithelial cells have not been fully elucidated. In this context, the objective of this study was to evaluate the effect of cortisol on the expression of growth hormone receptor (GHR), insulin-like growth factor type 1 (IGF1), insulin-like growth factor type 1 receptor (IGF1R), insulin-like growth factor-binding protein 3 and 5 (IGFBP3 and IGFBP5), BAX, and BCL2 genes on the proliferation and apoptotic rates of mammary epithelial cells, and on milk yield in Saanen goats. In the present study, 3 experiments were conducted: (1) comparing the in vivo effects of first milking, vaccination, vermifugation, preventive hoof trimming, and the administration of ACTH or a placebo on cortisol release in dairy goats; (2) studying the in vivo effects of immediate increases in cortisol on the mammary gland of lactating goats; and (3) studying the in vitro effects of a prolonged increase in cortisol on mammary epithelial cells obtained from lactating goats. Cortisol release by goats increased significantly after ACTH administration compared with that observed after a placebo, and the cortisol profiles after first milking, vaccination, vermifugation, hoof trimming, and ACTH administration were similar. However, there was no effect of the immediate increase in cortisol in vivo on IGF-1 release, milk yield, milk quality, or the apoptosis and proliferation rates, nor was there any effect on the expression of the target genes. Furthermore, no interaction was observed between IGF-1 and cortisol in either the in vivo or in vitro experiments. However, the addition of cortisol in vitro significantly increased the expression of the GHR and IGF1R genes, which stimulate cell proliferation, and the BAX gene, which causes apoptosis. These contrasting results can explain why cortisol did not change the rates of proliferation or apoptosis in epithelial cells. Indeed, cortisol supplementation in vitro did not change the number or apoptotic rate of epithelial cells over the course of 5 d. Finally, further studies must be performed to understand the effect of cortisol on the expression of the GHR, IGF1R, and BAX genes by epithelial cells and the roles of these genes in milk synthesis during early lactation.

Hydrocortisone as an Intervention for Dexamethasone-Induced Adverse Effects in Pediatric Patients With Acute Lymphoblastic Leukemia: Results of a Double-Blind, Randomized Controlled Trial.

Dexamethasone is a key component in the treatment of pediatric acute lymphoblastic leukemia (ALL), but can induce serious adverse effects. Recent studies have led to the hypothesis that neuropsychological adverse effects may be a result of cortisol depletion of the cerebral mineralocorticoid receptors. We examined whether including a physiologic dose of hydrocortisone in dexamethasone treatment can reduce neuropsychologic and metabolic adverse effects in children with ALL. We performed a multicenter, double-blind, randomized controlled trial with a crossover design. Of 116 potentially eligible patients (age 3 to 16 years), 50 were enrolled and were treated with two consecutive courses of dexamethasone in accordance with Dutch Childhood Oncology Group ALL protocols. Patients were randomly assigned to receive either hydrocortisone or placebo in a circadian rhythm (10 mg/m(2)/d) during both dexamethasone courses. Primary outcome measure was parent-reported Strength and Difficulties Questionnaire in Dutch, which assesses psychosocial problems. Other end points included questionnaires, neuropsychological tests, and metabolic parameters. Of 48 patients who completed both courses, hydrocortisone had no significant effect on outcome; however, a more detailed analysis revealed that in 16 patients who developed clinically relevant psychosocial adverse effects, addition of hydrocortisone substantially reduced their Strength and Difficulties Questionnaire in Dutch scores in the following domains: total difficulties, emotional symptoms, conduct problems, and impact of difficulties. Moreover, in nine patients who developed clinically relevant, sleep-related difficulties, addition of hydrocortisone reduced total sleeping problems and disorders of initiating and maintaining sleep. In contrast, hydrocortisone had no effect on metabolic parameters. Our results suggest that adding a physiologic dose of hydrocortisone to dexamethasone treatment can reduce the occurrence of serious neuropsychological adverse effects and sleep-related difficulties in pediatric patients with ALL.

A Double Blind Randomised Clinical Trial to Prevent Serious Side Effects of Dexamethasone during Pediatric Acute Lymphoblastic Leukemia Treatment

Background/Objectives: Dexamethasone is highly effective in the treatment of pediatric acute lymphoblastic leukemia (ALL), but can induce serious metabolic and neuropsychological side effects. Recent studies have led to the hypothesis that neuropsychological side effects could be due to cortisol depletion of the cerebral mineralocorticoid receptor. We therefore studied whether adding a physiological dose of hydrocortisone to dexamethasone treatment reduces neuropsychological and metabolic side effects in children with ALL.Design/Methods: We performed a multicentre double-blind, randomised controlled trial with a crossover design. Patients (3-16 years) treated with dexamethasone pulses according to the DCOG ALL protocols were included. Patients received hydrocortisone 10 mg/m2/day in a circadian rhythm during one dexamethasone course and placebo during another dexamethasone course in a randomised order. The primary outcome measures were mood and behavior (parent-reported Strenght and Difficulties Questionnaire- Dut (SDQ)). Secondary outcome measures included sleep (Sleep Disturbance Scale for Children (SDSC)), neurocognitive function, and metabolic parameters.Results: 50 subjects were enrolled, of which 48 patients completed both courses. For the total group no significant effects were found. However, in the subgroup of children with clinically significant behavioral side effects, adding hydrocortisone resulted in a significant reduction of side effects on overall stress (-4.9 (=0.9 SD), P =0.00), mood (-1.8 (=0.9 SD), P =0.03), behavior (-1.0 (=0.7 SD), P =0.01), and impact (P <0.05). The subgroup with dexamethasone-related sleeping problems did benefit on total sleeping problems (-4.3, P< 0.05). In contrast, hydrocortisone addition did not affect metabolic parameters.Conclusion: This randomised controlled trial provides evidence that addition of a physiological dose of hydrocortisone in circadian rhythm during dexamethasone treatment in pediatric ALL patients reduces side effects on behavior, mood and sleep. This novel and simple intervention may be valuable for all patients on high-dose dexamethasone treatment. DisclosuresNo relevant conflicts of interest to declare.

Serum IL-6 Level in Breast Cancer Surgery: Evaluating the Addition of Hydrocortisone to Two Anesthetic Regimens

Background: This study was purposed to compare in vitro the volumetric accuracy of a newly introduced automatic infusion controller, AutoClamp with that of other commonly used infusion devices. Methods: In this prospective, randomized, controlled trial, 124 ASA I-II, female patients, aged 30-50 years, undergoing conservative breast cancer surgery were randomly assigned to one of four equal groups receiving either standard general anesthesia and two doses of hydrocortisone (Group GH, n=31), thoracic paravertebral block and two doses of hydrocortisone (Group PH, n=31), standard general anesthesia with no hydrocortisone (Group G, n=31), or thoracic paravertebral block with no hydrocortisone (Group P, n=31). IL-6 was measured at three time points: before operation, 6 and 12 hours postoperatively. CRP and cortisol were measured preoperatively and 6 hours postoperatively. Results: On comparing group PH and GH, there was significant decrease in IL-6 level in group PH compared to group GH at 6 hour (122.1±21.2 vs 135.8±29.8pg/dl), but insignificant difference at 24 hours (107.9±21.6 vs 106.8±15.9pg/dl). CRP showed significant decrease in the postoperative reading in group PH compared to group GH (1.63±0.32 vs 1.91±0.43mg/l), and also group PH showed significant decrease compared to the control group P (1.63±0.32 vs 2.2±0.54). Conclusion: addition of hydrocortisone to general anesthesia or thoracic paravertebral block attenuated production of IL-6 and CRP levels significantly postoperatively compared to either anesthetic regimen alone, but not the serum cortisol level, highlighting its role in modifying the stress response to surgery. However, the effect was more pronounced when combined with thoracic paravertebral block.

Commentary: The unliganded glucocorticoid receptor positively regulates the tumor suppressor gene BRCA1 through GABP beta.

Commentary: The unliganded glucocorticoid receptor positively regulates the tumor suppressor gene BRCA1 through GABP beta.