Differences In Clinical Course Research Articles

Differences in Clinical Course, Genetics, and the Microbiome Between Familial and Sporadic Inflammatory Bowel Diseases.

Family history is the strongest risk factor for developing Crohn's disease [CD] or ulcerative colitis [UC]. We investigated whether the proximity of relationship with the affected relative and concordance for type of inflammatory bowel disease [IBD] modifies the effect of family history on phenotype and disease severity. This cross-sectional study included patients with a confirmed diagnosis of IBD in a clinical registry. Family history of IBD was assessed by a questionnaire ascertaining presence of disease in a first-first-degree, second-second-degree or distant relative. Our primary outcomes were disease phenotype as per the Montreal classification and severity measured by need for immunomodulator, biologic, or surgical therapy. Genotyping was performed on the Immunochip and faecal samples were subjected to 16S rRNA microbiome sequencing. Our study included 2136 patients with IBD [1197 CD, 939 UC]. Just under one-third [32%] of cases ere familial IBD [17% first-degree, 21% second-degree]. Familial IBD was diagnosed at an earlier age, both in CD [26 vs 28 years, p = 0.0006] and UC [29 vs 32 years, p = 0.01]. Among CD patients, a positive family history for CD was associated with an increased risk for complicated disease in the presence of an affected family member (odds ratio [OR] 1.48, 95% confidence interval [CI] 1.07-2.03). However, this effect was significant only for first-degree relatives [OR 1.82, 95% CI 1.19-2.78]. A family history of CD in first-degree relatives was associated with complicated CD. Family history discordant for type of IBD or in distant relatives did not influence disease phenotype or natural history.

Genomic Stability in Syndromic Basal Cell Carcinoma

Basal cell cancers (BCCs) are characterized by upregulation of Hedgehog pathway through loss of PTCH1 or activation of SMO, and SMO inhibitors, such as vismodegib, are effective therapies for advanced BCCs. Although most BCCs are sporadic, rare individuals with basal cell nevus syndrome (BCNS) harbor germline defects in PTCH1 and develop up to hundreds of tumors that are histopathologically indistinguishable from sporadic BCCs. Interestingly, BCNS-BCCs are more responsive to SMO inhibitors than sporadic BCCs, with minimal development of resistance. Given differences in clinical course and therapy response, we sought to characterize BCCs in the setting of BCNS. We found that BCNS individuals with low tumor burden demonstrated significantly fewer UV signature somatic mutations and lower overall somatic mutational load compared to BCNS individuals with high burden, supporting a role of UV exposure in driving BCC development in BCNS individuals. However, compared with sporadic BCCs, BCNS-BCCs have a significantly lower mutational load, lower proportion of UV mutagenesis, increased genomic stability, and harbor fewer functionally resistant SMO mutations at baseline, explaining why BCNS-BCCs lack intrinsic resistance to SMO inhibitors. BCNS-BCCs appear to have reduced mutator phenotype compared with sporadic BCCs, which may contribute to their relatively more indolent clinical course and responsiveness to therapy.

Hepcidin and metallothioneins as molecular base for sex-dependent differences in clinical course of experimental autoimmune encephalomyelitis in chronic iron overload

Multiple sclerosis is a chronic demyelinating disease of the central nervous system characterised by inflammatory and degenerative changes. It is considered that disease arises from the influence of environmental factors on genetically susceptible individuals. Recent researches, using magnetic resonance imaging, connected iron deposits in different brain regions with demyelinating process in multiple sclerosis patients. Although iron is an essential trace element important for many biological functions it could be harmful because iron excess can induce the production of reactive oxygen species, development of oxidative stress and lipid peroxidation which leads to demyelination. In experimental autoimmune encephalomyelitis model, the most common experimental animal model for multiple sclerosis, we recently found that chronic iron overload influences the clinical course of disease in Dark Agouti rats. In female rats iron overload accelerated the onset of disease, while in male rats it accelerated the progression of disease and increased mortality rate. We hypothesize that those differences arise on molecular level in different expression of stress response proteins hepcidin and metallothioneins in male and female iron overloaded rats. They are both upregulated by metal ions in both sexes. Hepcidin is additionally upregulated by estrogen in female rats and therefore causes higher degradation of iron exporter ferroportin and sequestration of iron in the cells, lowering the possibility for the development of oxidative stress. Antioxidative effect of metallothioneins could be increased in female rats because of their ability to reversibly exchange metal ions with the estrogen receptor. In case of iron excess metallothioneins release zinc, which is normally bound to them. Zinc binds to estrogen receptor and leaves metallothioneins binding domains free for iron, causing at least provisional cytoprotective effect. To test this hypothesis, we propose to determine and compare serum levels of hepcidin and estrogen using ELISA essay as well as expression and distribution of acute stress response proteins hepcidin and metallothioneins, iron and estrogen receptor in the brain and spinal cord tissue using immunohistochemistry in control and chronic iron overloaded male and female rats in experimental autoimmune encephalomyelitis model. It would be also possible to perform the same immunohistochemistry in the brain tissue of multiple sclerosis patients post mortem. The results of experiments could contribute to better understanding of cytoprotective mechanisms in chronic iron overload that could have possible therapeutic applications in iron disturbances. In order to elucidate whether common measure of systemic iron status, like ferritin, haemoglobin concentration and transferrin saturation levels, may be used to distinguish physiologic from potentially harmful iron levels in local disease, for example multiple sclerosis and Still’s disease, well-designed clinical trials would be of great interest.

Sensitivity to PI3K and AKT inhibitors is mediated by divergent molecular mechanisms in subtypes of DLBCL

AbstractActivated B-cell-like (ABC) and germinal center B-cell-like diffuse large B-cell lymphoma (DLBCL) represent the 2 major molecular DLBCL subtypes. They are characterized by differences in clinical course and by divergent addiction to oncogenic pathways. To determine activity of novel compounds in these 2 subtypes, we conducted an unbiased pharmacologic in vitro screen. The phosphatidylinositol-3-kinase (PI3K) α/δ (PI3Kα/δ) inhibitor AZD8835 showed marked potency in ABC DLBCL models, whereas the protein kinase B (AKT) inhibitor AZD5363 induced apoptosis in PTEN-deficient DLBCLs irrespective of their molecular subtype. These in vitro results were confirmed in various cell line xenograft and patient-derived xenograft mouse models in vivo. Treatment with AZD8835 induced inhibition of nuclear factor κB signaling, prompting us to combine AZD8835 with the Bruton's tyrosine kinase inhibitor ibrutinib. This combination was synergistic and effective both in vitro and in vivo. In contrast, the AKT inhibitor AZD5363 was effective in PTEN-deficient DLBCLs through downregulation of the oncogenic transcription factor MYC. Collectively, our data suggest that patients should be stratified according to their oncogenic dependencies when treated with PI3K and AKT inhibitors.

Comparison of outcome and clinical characteristics of bacteremia caused by methicillin-resistant, penicillin-resistant and penicillin-susceptible Staphylococcus aureus strains

Background: The aim of this study was to assess the association of methicillin resistance and penicillinase production with clinical characteristics and outcome of Staphylococcus aureus bacteremia.Methods: For 126 patients with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia, 378 age- and gender-matched controls with methicillin-susceptible Staphylococcus aureus (MSSA) bacteremia were selected. Of controls, 126 had bacteremia caused by penicillin-susceptible strains (PSSA) and 252 by penicillinase-producing strains (PRSA). Underlying diseases, clinical course and mortality were retrospectively assessed.Results: Patients with MRSA bacteremia were more often smokers than patients with MSSA bacteremia (OR 2.34, 95% CI 1.27–4.32). MRSA bacteremia was more often healthcare-associated (OR 4.23, 95% CI 2.47–7.24), associated with central venous catheters (OR 2.09, 95% CI 1.27–3.47), glucocorticoid therapy (OR 1.82, 95% CI 1.12–2.93) and prior surgery (OR 2.32, 95% CI 1.43–3.76). Patients with MRSA bacteremia received appropriate empiric antibiotic (31%) less often than controls (98%). Mortality within 28 days was higher in MRSA bacteremia (26.8%) than in MSSA bacteremia (15.5%) (OR 2.00, 95% CI 1.20–3.34), PRSA bacteremia (17.0%) (OR 1.79 95% CI 1.04–3.09) or PSSA bacteremia (12.5%) (OR 2.56 95% CI 1.27–5.15). The difference remained after adjusting for underlying diseases and foci. There was no significant difference in clinical course between PRSA and PSSA bacteremias.Conclusions: MRSA bacteremia was associated with poorer outcome than either PRSA or PSSA bacteremia. We corroborated several risk factors found in previous studies.

Granulomatosis with polyangiitis: Rheumatoid arthritis overlap syndrome: A case report

Antineutrophil cytoplasm antibody (ANCA)-associated vasculitis (AAV) may rarely be associated with other immune-mediated diseases. Knowledge of these overlap syndromes is important in early recognition of potential complications and differences in clinical courses and management pathways. In this paper we describe the case of a male Egyptian patient, 52 years old, with hypertension and rheumatoid arthritis on disease-modifying antirheumatic drugs, with a recent history of ocular and renal manifestations suggesting vasculitis, who presented to our Emergency Department with acute interstitial pneumonitis, which was successfully treated with high-dose steroids. His clinical course had deteriorated because of self-stoppage of the maintenance dose of steroid and appearance of bilateral nodular infiltrates in the lungs on the chest radiographs. His cytoplasmic c-ANCA autoantibodies were positive, in addition to the histopathological examination of open lung biopsy, which was consistent with granulomatosis with polyangiitis. He was successfully treated with high-dose steroids and cyclophosphamide. We reported a new case of granulomatosis with polyangiitis developing during adalimumab therapy for rheumatoid arthritis. This clinical observation must be considered in all patients treated with antitumor necrosis factor. On the basis of the previously published cases of AAV associated with rheumatoid arthritis as well as our case, the suggestion of a rare form of an AAV autoimmune overlap should be recognized and investigated for rapid initiation of appropriate management.

Calcium urolithiasis course in young stone formers is influenced by the strength of family history: results from a retrospective study.

The role of the strength of family history of stones (FHS), i.e., degree of relatives with the disease, on the course of calcium urolithiasis (CU) is not fully understood, particularly in young patients where genetic background has the greatest influence on disease expression. Thus, with a retrospective cross-sectional design, we examined baseline clinical parameters and urinary chemistries of 369 subjects (196M) with CU and 96 controls (41M) aged between 15 and 25 at the time of the first visit at our stone clinic. Subjects with metabolic syndrome traits, known causes of CU or CU onset before the age of 15 were excluded. Clinical and metabolic parameters were compared among stone formers (SF) and controls, stratified by gender, thepresence and type of FHS determined through the kinship coefficient of relatives with stones. No significant differences in clinical course were found between SF with and without FHS, except for the presence of bilateral stones (OR 2.01, 95% CI 1.20-3.39, p<0.01). A significant age-, sex- and disease duration-adjusted trend for a higher number of colics (p for trend=0.001), number of stones (p for trend=0.002), stone rate (p for trend=0.003) and the presence of retained stones (OR 1.60, 95% CI 1.14-2.21, p=0.006) was detected with increasing FHS strength. Urinary chemistries were unaffected by FHS in both SF and controls, except for a higher calcium excretion in females with FHS (p<0.05). The type of FHS, thus, significantly influences the clinical course of CU in young SF, mainly irrespective of urinary factors.

MEN1 redefined, a clinical comparison of mutation-positive and mutation-negative patients.

BackgroundMultiple Endocrine Neoplasia type 1 (MEN1) is diagnosed when two out of the three primary MEN1-associated endocrine tumors occur in a patient. Up to 10–30 % of those patients have no mutation in the MEN1 gene. It is unclear if the phenotype and course of the disease of mutation-negative patients is comparable with mutation-positive patients and if these patients have true MEN1. The present study aims to describe and compare the clinical course of MEN1 mutation-negative patients with two out of the three main MEN1 manifestations and mutation-positive patients during long-term follow-up.MethodsThis is a cohort study performed using the Dutch MEN1 database, including > 90 % of the Dutch MEN1 population.ResultsA total of 293 (90.7 %) mutation-positive and 30 (9.3 %) mutation-negative MEN1 patients were included. Median age of developing the first main MEN1 manifestation was higher in mutation-negative patients (46 vs. 33 years) (P = 0.007). Mutation-negative patients did not develop a third main MEN1 manifestation in the course of follow-up compared to 48.3 % of mutation-positive patients (P < 0.001). Median survival in mutation-positive patients was estimated at 73.0 years (95 % CI, 69.5–76.5) compared to 87.0 years (95 % CI not available) in mutation-negative patients (P = 0.001).ConclusionsMutation-positive and mutation-negative MEN1 patients have a different phenotype and clinical course. Mutation-negative patients develop MEN1 manifestations at higher age and have a life expectancy comparable with the general population. The apparent differences in clinical course suggest that MEN1 mutation-negative patients do not have true MEN1, but another MEN1-like syndrome or sporadic co-incidence of two neuro-endocrine tumors.Electronic supplementary materialThe online version of this article (doi:10.1186/s12916-016-0708-1) contains supplementary material, which is available to authorized users.

Chondroitin sulfate β-1,4-N-acetylgalactosaminyltransferase-1 (ChGn-1) polymorphism: Association with progression of multiple sclerosis

Chondroitin sulfate proteoglycans (CSPGs) are a constituent of the matrix of the central nervous system (CNS), likely participating as regulatory molecules in the process of demyelination, remyelination, axonal degeneration and regeneration in the CNS. ChGn-1 is a key enzyme for production of CSPGs and knock-out mice of this gene showed better recovery from spinal cord injury. We hypothesized that the clinical course of multiple sclerosis (MS) is influenced by the level of expression of ChGn-1 gene. We recruited 147 patients with MS and 181 healthy control subjects and analyzed single nucleotide polymorphisms (SNPs) of this gene. We found the coding SNP (cSNP: rs140161612) in approximately 10% of patients with MS as well as normal controls. The cSNP is changed from serine to leucine at position 126 (p.S126L). The expressed ChGn-1 mutant proteins exhibited no enzyme activities in COS-1 cells. In men, patients who had MS with S126L had a slower disease progression. This cSNP might be associated with the sex differences in clinical course of MS.

Enhanced expression of melanoma progression markers in mouse model of sleep apnea

IntroductionObstructive sleep apnea has been associated with higher cancer incidence and mortality. Increased melanoma aggressivity was reported in obstructive sleep apnea patients. Mice exposed to intermittent hypoxia (IH) mimicking sleep apnea show enhanced melanoma growth. Markers of melanoma progression have not been investigated in this model. ObjectiveThe present study examined whether IH affects markers of melanoma tumor progression. MethodsMice were exposed to isocapnic IH to a nadir of 8% oxygen fraction for 14 days. One million B16F10 melanoma cells were injected subcutaneously. Immunohistochemistry staining for Ki-67, PCNA, S100-beta, HMB-45, Melan-A, TGF-beta, Caspase-1, and HIF-1alpha were quantified using Photoshop. ResultsPercentage of positive area stained was higher in IH than sham IH group for Caspase-1, Ki-67, PCNA, and Melan-A. The greater expression of several markers of tumor aggressiveness, including markers of ribosomal RNA transcription (Ki-67) and of DNA synthesis (PCNA), in mice exposed to isocapnic IH than in controls provide molecular evidence for a apnea–cancer relationship. ConclusionsThese findings have potential repercussions in the understanding of differences in clinical course of tumors in obstructive sleep apnea patients. Further investigation is necessary to confirm mechanisms of these descriptive results.

TLR2, TLR4 and TLR9 genotypes and haplotypes in the susceptibility to and clinical course of Chlamydia trachomatis infections in Dutch women.

Chlamydia trachomatis infections demonstrate remarkable differences in clinical course that are approximately 40% based on host genetic variation. Here, we study the single nucleotide polymorphisms (SNPs) and their haplotypes in TLR2, TLR4 and TLR9 (TLR2 +2477G>A; TLR2 -16934T>A; TLR4+896A>G; TLR9 -1237T>C and TLR9 +2848G>A) in relation to the susceptibility to, and severity of C. trachomatis infections. We analysed the five SNPs in a cohort of 770 Dutch Caucasian women either attending a sexually transmitted diseases outpatient clinic (n = 731) or having complaints of subfertility (n = 39). Haplotype analyses showed a trend for TLR2 haplotype I (-16934T/+2477G) to protect against the development of symptoms and tubal pathology (Ptrend = 0.03) after Chlamydia infection. In the susceptibility cohort, TLR9 haplotype III (-1237C/+2848A) showed a significant decreasing trend in the development of symptoms after C. trachomatis infection (P = 0.02, OR: 0.55, 95%CI: 0.33-0.91). Logistic regression of the TLR2 haplotypes, TLR4+896A>G, and TLR9 haplotypes showed that the TLR2 haplotype combinations AG-TA and AG-TG confer risk (OR 3.4 (P = 0.01) and 1.6 (P = 0.03)), while the TLR9 haplotype combination TG-TA protects against C. trachomatis infections (OR: 0.4, P = 0.004). Our study shows that both TLR2 and TLR9 genes and SNP combinations do influence the clinical course of Chlamydia infections.

About the question of comorbidity of bronchial asthma and allergic rhinitis at school age

The aim of research was to establish clinical and epidemiological features of bronchial tubes remodeling in schoolchildren with bronchial asthma with comorbid allergic pathology for optimization of the dynamic observation and management of the main disease.Methods: There were examined 114 schoolchildren with bronchial asthma separated into 2 clinical groups depending on comorbid allergic pathology presence: 1 clinical group – 55 patients without comorbid allergic pathology, 11 group – patients with clinical sings of other forms of allergic pathology. Schoolchildren underwent the complex clinical examination: numerical score using constellational clinical and instrumental control scale of bronchial asthma (BA), spirograph examination, examination of the content of vascular endothelial growth factor (VEGF), extracellular cationic proteins in supernatant fluid of sputum, the general immunoglobulin of Е (IgE) class and interleukin-4 and -5 (Il-4, Il-5) in the serum of peripheral blood.Results: There were detected the probable differences in clinical course of BA that indicated the heavier character of disease in the 11 group of comparison. The content of VEGF and eosinophilic cationic proteins (ECP) in sputum of patients with comorbid allergic rhinitis exceeded the mean indicators of 1 group in 1,4 times. In patients of 11 clinical group took place the tendency to prevalence of allergic inflammation markers IgE and IL-4, IL5in the blood serum.Conclusions: Comorbid clinical course of allergic rhinitis in children with bronchial asthma favors the heavier and longer course of the main disease and activates the processes of neoanginogenesis of respiratory tracks with following remodeling of bronchial tubes. An examination of sputum for the content eosinophilic cationic proteins and vascular endothelial growth factor is necessary for schoolchildren with bronchial asthma with comorbid allergic rhinitis for optimization of basic anti-inflammatory treatment

A New Outlook on Clinical Course of Juvenile Dermatomyositis - Experience of a Single Center

Introduction: Juvenile dermatomyositis (JDM) is the most common inflammatory myopathy in children. Diagnostic criteria by Bohan & Peter are originally formulated for adults. A wide range of differences in clinical course of dermatomyositis between adults and children has provoked to set a new look at the existing criteria. Objective: The aim of our study was to analyze the clinical course and reaction to administered drug therapy in association with laboratory and electromyographic findings in pediatric patients with dermatomyositis. Materials and methods: The retrospective analysis included 5 children with JDM hospitalized in Department of Pediatric Cardiology and Rheumatology Medical University of Lodz, Poland between October 2000 and November 2014. Demographic data, characteristics of clinical symptoms, laboratory tests, EMG and muscle biopsy reports and reaction to administered treatment were analyzed. Results: Muscle weakness was the most common symptom observed in 80% of patients. Other symptoms present in more than a half of patients included heliotrope rash (60%) and Gottron sign (60%). Muscle enzyme levels were significantly elevated in 4 out of 5 patients. Electromyography (EMG) was performed in 3 patients and was positive in every case, as well as muscle biopsy. Initial therapy involved prednisone 1mg/kg b.w./day in all patients combined with disease modifying anti-rheumatic drug, whether methotrexate was the most common choice (60%). Complications which occurred in presented patients involve: rhabdomyolysis, severe calcinosis and contractures of elbows, exacerbation after reduction of GCS dose, hypertriglyceridemia, steatohepatitis, tachycardia.

Immune tolerance strategies in siblings with infantile Pompe disease — Advantages for a preemptive approach to high-sustained antibody titers

Enzyme replacement therapy (ERT) has led to a significant improvement in the clinical course of patients with infantile Pompe disease (IPD), an autosomal recessive glycogen storage disorder characterized by the deficiency in lysosomal acid α-glucosidase. A subset of IPD patients mounts a substantial immune response to ERT developing high sustained anti-rhGAA IgG antibody titers (HSAT) leading to the ineffectiveness of this treatment. HSAT have been challenging to treat, although preemptive approaches have shown success in high-risk patients (those who are cross-reactive immunological material [CRIM]-negative). More recently, the addition of bortezomib, a proteasome inhibitor known to target plasma cells, to immunotherapy with rituximab, methotrexate, and intravenous immunoglobulin has shown success at significantly reducing the anti-rhGAA antibody titers in three patients with HSAT. In this report, we present the successful use of a bortezomib-based approach in a CRIM-positive IPD patient with HSAT and the use of a preemptive approach to prevent immunologic response in an affected younger sibling. We highlight the significant difference in clinical course between the two patients, particularly that a pre-emptive approach was simple and effective in preventing the development of high antibody titers in the younger sibling, thus supporting the role of immune tolerance induction (ITI) in the ERT-naïve high-risk setting.

Central Nervous System Demyelination and Remyelination is Independent from Systemic Cholesterol Level in Theiler's Murine Encephalomyelitis.

High dietary fat and/or cholesterol intake is a risk factor for multiple diseases and has been debated for multiple sclerosis. However, cholesterol biosynthesis is a key pathway during myelination and disturbances are described in demyelinating diseases. To address the possible interaction of dyslipidemia and demyelination, cholesterol biosynthesis gene expression, composition of the body's major lipid repositories and Paigen diet-induced, systemic hypercholesterolemia were examined in Theiler's murine encephalomyelitis (TME) using histology, immunohistochemistry, serum clinical chemistry, microarrays and high-performance thin layer chromatography. TME-virus (TMEV)-infected mice showed progressive loss of motor performance and demyelinating leukomyelitis. Gene expression associated with cholesterol biosynthesis was overall down-regulated in the spinal cord of TMEV-infected animals. Spinal cord levels of galactocerebroside and sphingomyelin were reduced on day 196 post TMEV infection. Paigen diet induced serum hypercholesterolemia and hepatic lipidosis. However, high dietary fat and cholesterol intake led to no significant differences in clinical course, inflammatory response, astrocytosis, and the amount of demyelination and remyelination in the spinal cord of TMEV-infected animals. The results suggest that down-regulation of cholesterol biosynthesis is a transcriptional marker for demyelination, quantitative loss of myelin-specific lipids, but not cholesterol occurs late in chronic demyelination, and serum hypercholesterolemia exhibited no significant effect on TMEV infection.

Phenotypic Heterogeneity of Potentially Curable Non–Small-Cell Lung Cancer: Cohort Study with Cluster Analysis

Significant differences in outcome are observed among lung cancer patients belonging to the same tumor node metastasis stage, suggesting phenotypic heterogeneity beyond this staging algorithm. We used a cluster analysis approach to classify patients into distinct phenotypes, and we attempted to validate the clinical relevance of these phenotypes by comparing outcome. We formed a cohort of all stage I to III non-small-cell lung cancer patients seen between January 2004 and October 2010 in a cancer center and followed until death or last follow-up appointment, with prospectively collected data on clinical and tumor characteristics. Multiple correspondence analysis was followed by hierarchical clustering to form homogenous clusters of patients. Overall survival and disease-free survival estimates were compared among clusters. The cohort included 367 patients (mean follow-up of 2.5 years), 173 of whom died during that period (191 deaths per 1000 person-years). A four-cluster model was identified, revealing distinct phenotypes with respect to baseline characteristics. Hazard ratios for mortality were 8.1, 5.0, and 3.7 (all statistically significant) for clusters 2, 1, and 3, respectively, when compared with cluster 4-with the most favorable outcome. Staging of patients with non-small-cell lung cancer for prognostic purposes may be improved by considering phenotypes that exhibit significant differences in clinical course and outcome.

Abstract 83: Usefulness of Serum Immunoglobulin G Levels Calculated in the Acute Phase of Kawasaki disease

Background: Intravenous gamma-globulin treatment (IVGG) is an established therapy for acute phase Kawasaki disease (KD). Since a lot of studies have already testified that the efficacy of IVGG is dose-dependent, a single large dose of IVGG has been accepted as a standard treatment of KD. Some reports described the increasing rate of serum Immunoglobulin G (IgG) after IVGG would have a relationship with efficacy of IVGG. It should, therefore, be very important to compass trends of serum IgG levels in each in KD patient. However, it is unable to frequently measure values of serum IgG in KD patients from the standpoint of medical expenses. If we can estimate IgG levels in KD patients from routine biochemical data without additional costs, that is very helpful to assess inflammatory status in acute phase of KD. Aim to this study: We hypothesized that serum levels of IgG in acute phase of KD patients could be extrapolated by serum values of total protein (TP) and albumin (Alb), and, we tried to establish a simple formula to estimate serum levels of IgG. Materials and methods: We enrolled 42 KD cases (27 ± 21 month, Male 24/Female 18) that were treated in Saga University Hospital, Japan from April of 2010 to August of 2014. All cases met the diagnostic criteria of KD. They were initially treated with IVGG and aspirin or flurbiprofen. 12 patients (28.6%) needed additional treatments such as steroid and cyclosporine A. In this study, we examined relations before and after treatments of serum TP and Alb and IgG in serum of them and tried to establish a simple formula to estimate serum levels of IgG in acute phase of KD. For statistical analysis, we used paired t-test. Results: We found that values obtained by subtracting serum values of IgG and Alb from TP were almost constant through acute phase in each KD patient, regardless of differences in clinical course and therapies. Therefore, we could estimate serum IgG values, once we checked levels of TP, Alb and IgG before treatment. Calculated IgG values were lineally correlated with values of directly measured IgG (P&lt;0.0001, r=0.90). From this finding, we would assess the course of IgG levels during acute phase of KD patients correctly. Conclusion: By estimation of IgG levels, we can grasp inflammatory status of KD and make appropriate therapeutic plans.

Análisis comparativo de los resultados del uso de neocuerdas frente a la resección de velo posterior en la cirugía reparadora de la insuficiencia mitral degenerativa

Introduction and objectivesThere is a lack of studies comparing the results of both techniques in MV repair procedures for correction of posterior leaflet prolapse in degenerative mitral regurgitation and most of what has been published analyses the short term postoperative course.The present study was carried out to evaluate results of mitral valve repair surgery with quadrangular resection or neochordae implantation in degenerative posterior leaflet prolapse, with a special emphasis in postoperative leaflet coaptation analysis using the coaptation length index. Methods98 patients were included in this study if they presented degenerative posterior leaflet prolapse as the main cause of mitral regurgitation, and received quadrangular resection or neochordae implantation for its correction. We compared clinical and echocardiographic follow-up data between both techniques. ResultsPerioperatively, there were no differences in surgical times, size of ring employed, risk of systolic anterior motion and residual intraoperative mitral regurgitation. During follow-up, there were no differences in clinical course or echocardiographic examination, except for the left ventricle end-dyastolic diameter, which had a statistically better regression in the resection sample (–12.3±8.7 vs –8.1±8.5mm, P<.05). The coaptation analysis was similar for both groups (coaptation length index: 0.25±0.15 for resection group vs 0.2±0.07 for neochordae, P=.08). ConclusionsOur results demonstrate that neochordae implantation technique for degenerative posterior mitral leaflet prolapse correction offers similar mid-term clinical and echocardiographic outcomes compared to quadrangular resection technique, including the grade of leaflet coaptation.

Issues in Categorization and Management of Pediatric Patients with Myeloproliferative Neoplasms

Myeloproliferative Neoplasms (MPN) are well characterized in adults, with symptoms including thrombotic episodes, severe bleeding episodes, splenomegaly, and transformation to AML. Accepted treatment algorithms are available for management and multiple clinical trials are being done in adult patients. Much has been done to understand the pathogenesis in adults, and mutations in JAK2, MPL, and most recently CALR are established as causative lesions in these disorders. In contrast, knowledge of these disorders in children is more rudimentary, with limited information available regarding long-term clinical outcomes in children. Children have a lower frequency of the known mutations; studies to identify alternative driver mutations in children are ongoing.Eight pediatric patients with MPN have been seen at Cornell during their illness. Seven were diagnosed with Essential Thrombocytosis (ET) and the eighth had an initial diagnosis of ET but later was diagnosed with myelofibrosis (MF). One patient did not have bone marrow testing but was diagnosed by her primary hematologist on the basis of extreme thrombocytosis, and JAK2V617F positive testing on peripheral blood when no cause of reactive thrombocytosis was identified. Table 1 summarizes key features of these patients. The average age of diagnosis for these children is 10 years and 3 months. The oldest patient was diagnosed in 2006 and has had the longest consecutive period of thrombocytosis, 8 years.These patients presented with a variety of symptoms, including headache, abdominal pain, fatigue, and bleeding. All the children experienced extreme thrombocytosis (platelet count > 1,000 x 109/L) during their illness. Despite the presence of acquired von Willebrand’s disease in at least three patients, none have experienced severe bleeding symptoms. There have been no reported severe thrombotic episodes, and any evaluations done for complaints of headache, chest pain, or palpitations have shown no CNS infarcts or cardiac abnormalities. One child developed pseudo tumor cerebri with no cerebral venous sinus thrombosis or CNS lesion detected. Four children have been treated with aspirin with no significant bleeding complications. Six of the eight had been treated with cytoreductive therapy (Hydroxyurea) by their primary hematologist at some point in their course, for various findings including extreme thrombocytosis, fatigue, erythromelalgia, and recurrent headache. All showed a good response in platelet count to Hydroxyurea treatment, none developed dose-limiting side effects, and the highest dose that was needed to relieve symptoms at any point was 35mg/kg. Four patients remain on therapy with Hydroxyurea.Genetic sequencing was positive for JAK2V617F in three of eight patients. All of these patients have received Hydroxyurea treatment, and the child with pseudotumor cerebri was JAK2V617F positive. Of the five patients who are negative for JAK2 mutation, four were tested for MPLW515K/L and all are negative. Two of these patients have had sequencing sent for CALR mutations, and one patient is negative for CALR mutation as well (one patient is pending.) Figure 1 summarizes the sequencing completed to date on these patients.This cohort of pediatric patients shows a lower frequency of the known causative mutations than their adult counterparts. There is variation in how these patients were managed by their primary hematologists, likely due to the lack of treatment guidelines in this patient population (Kucine et al, 2014.) With the apparent differences in clinical course and genetic drivers from adults with MPN, there is a clear need for further research on the outcomes and pathogenesis in pediatric patients with MPN. Our group is currently working to answer some of the questions regarding pathogenesis and outcomes in pediatric patients with MPN to allow for individualization of treatment recommendations and family guidance in these children.Table 1Summary of Eight Pediatric MPN PatientsPatientAge at Diagnosis (years)DiagnosisInitial SymptomsA9ETWeakness, ParesthesiasB7ETHeadacheC10ETHeadache, FatigueD7ETHeadacheE8ETBleedingF13MFAbdominal Pain, SplenomegalyG10ETHeadacheH19ETFatigue, Itching [Display omitted] ReferencesKucine N, Chastain KM, Mahler MB, Bussel JB. Primary thrombocytosis in children. Haematologica. 2014;99(4)620-28. DisclosuresOff Label Use: Hydroxyurea use in certain children with MPN is accepted practice but is technically off-label.

Global Methylation Analysis of Cyclin D1vs D2 Dysregulated Primary Myeloma Samples

Multiple myeloma (MM) may be classified according to D-type cyclin dysregulation. Amongst nonhyperdiploid cases, those with IgH translocations t(4;14) or t(14;16) express high levels of cyclin D2, and those with t(11;14) express elevated cyclin D1. Although translocation-based subgroups may behave differently, cyclin D2 dysregulated disease tends to progress with more proliferative disease and poorer outcomes compared to cyclin D1. The importance of methylation status has been described in MM, with the transition from MGUS to symptomatic MM characterised by global hypomethylation, and gene-specific hypermethylation differences between cytogenetic subtypes.To investigate the utility of methylation profiling between D1 and D2-dysregulated MM, we carried out a pilot study of global methylation changes between these groups. Primary bone marrow samples were collected from eight cyclin D1 patients with t(11;14), and eight D2 patients (four t(4;14) and four t(14;16)), and CD138+ cells purified by magnet-assisted selection. Following bisulfite conversion, samples were processed on llumina Infinium human methylation27 arrays. Methylation was classified with a beta score between 0 (unmethylated) and 1 (methylated). Initial analysis was performed using Illumina GenomeStudio, and subsequently with the Limma package in R. Differentially methylated probes were corrected for false discovery rate (FDR), with a threshold of 0.01 considered significant. Survival analyses were calculated from the date of sampling.Unsupervised clustering split the samples into two groups (group 1 and group2), which did not match with D-cyclin status, but did show clear differences in clinical course. Survival analysis between groups 1 and 2 showed trends toward differences in median overall survival (61.7 vs 11.9 months, p=0.06) and progression free survival (24.4 vs 7.2 months, p=0.34). Although not significant at the p<0.05 threshold, the survival curves suggest a difference that may become clearer in a larger cohort. Analysis of the probes between these groups revealed 1379 methylation variable positions (MVPs) which were significantly different. Interestingly, almost all of these (1376/1379) were hypermethylated in the poorer outcome Group 2. This suggests a difference in methylation status between two prognostic groups which warrants further investigation.We then went on to perform supervised clustering between the samples, splitting them into two groups (D1 and D2) based on their cyclin D status. This analysis did not reveal any MVPs even at a less stringent FDR-adjusted threshold of 0.05. However, we did observe that of the top 20 differentially methylated probes three were for the CCND1 gene, which in all cases showed relative hypomethylation in the cyclin D1 dysregulated samples. Other genes of potential interest with relative hypomethylation in the cyclin D1 group were DAB2 which has previously been reported to be hypermethylated in the t(4;14) OPM2 cell line, and AK3L1 – a kinase which interestingly, has been reported as showing vulnerability to targeted RNAi inhibition in two cyclin D2 dysregulated cell lines (KMS11 and JJN3).In this small cohort, although cyclin D1 vs cyclin D2 classification does not appear to be sufficient to define distinct methylation profiles, a group of genes with hypermethylation appears to be associated with poorer prognosis. The hypomethylation of CCND1 in cyclin D1 dyregulated samples, although below the significance threshold in this dataset, is consistent with previously described findings of CCND1 hypomethylation in t(11;14) cell lines, but our results in the D2 MM samples differ from previous reports of hypomethylation in all nonhyperdiploid primary samples. We intend to investigate this further and extend this analysis by prospective sampling and methylation analysis on a larger cohort of patients treated on a standard protocol. DisclosuresNo relevant conflicts of interest to declare.