High energy proton induced radiation damage of rare earth permanent magnet quadrupoles.

Permanent magnet quadrupoles (PMQs) are an alternative to common electromagnetic quadrupoles especially for fixed rigidity beam transport scenarios at particle accelerators. Using those magnets for experimental setups can result in certain scenarios, in which a PMQ itself may be exposed to a large amount of primary and secondary particles with a broad energy spectrum, interacting with the magnetic material and affecting its magnetic properties. One specific scenario is proton microscopy, where a proton beam traverses an object and a collimator in which a part of the beam is scattered and deflected into PMQs used as part of a diagnostic system. During the commissioning of the PRIOR (Proton Microscope for Facility for Antiproton and Ion Research) high energy proton microscope facility prototype at Gesellschaft für Schwerionenforschung in 2014, a significant reduction of the image quality was observed which was partially attributed to the demagnetization of the used PMQ lenses and the corresponding decrease of the field quality. In order to study this phenomenon, Monte Carlo simulations were carried out and spare units manufactured from the same magnetic material-single wedges and a fully assembled PMQ module-were deliberately irradiated by a 3.6 GeV intense proton beam. The performed investigations have shown that in proton radiography applications the above described scattering may result in a high irradiation dose in the PMQ magnets. This did not only decrease the overall magnetic strength of the PMQs but also caused a significant degradation of the field quality of an assembled PMQ module by increasing the parasitic multipole field harmonics which effectively makes PMQs impractical for proton radiography applications or similar scenarios.

Prevalence of bacterial vaginosis in Grenadian women of reproductive age / Prevalencia de la vaginosis bacteriana en mujeres granadinas en edad reproductiva

OBJECTIVES: To determine the prevalence of bacterial vaginosis (BV) among Grenadian women of reproductive age using the routinely collected Pap smear data for the period January 2009 to December 2011. METHODS: A retrospective review of a cross-section of Pap smears was obtained for women between the ages of 15 and 49 years, using the national centralized data bank at the General Hospital in St George's, Grenada. Women aged younger or older than the sample group, as well as those who were reported as being menopausal or hysterectomized were excluded from the study. Demographic and laboratory data were collected and descriptive statistics reported. RESULTS: The prevalence of BV was 19.5% for the three-year period among the 2677females included in the analysis with the 20-29-year age group having the largest percentage of infection (43.6%). An increase in the trend of prevalence between 2009 (16.1%) and 2011 (21.4%) was also observed. Candida vaginalis and Trichomonas vaginalis were present in 3.6% and 0.85%, respectively. Additionally, atypical cells of unknown significance and cervical dysplasia were documented in 5.3% and 1.8% of the smears, respectively. CONCLUSION: Practicing physicians in Grenada need to consider increased screening for BV in women who may present with non-specific symptoms. Further research is necessary to determine the predisposing factors in Grenadian women and associations with the disease and to assist in the development of national education programmes to alter behavioural practices that could result in the acquisition and persistence of BV among women of reproductive age in Grenada.

OBJETIVOS: Determinar la prevalencia de vaginosis bacteriana (VB) entre mujeres granadinas de edad reproductiva utilizando datos de pruebas de Papanicolaou rutinariamente recolectados durante el período de enero de 2009 a diciembre de 2011. MÉTODOS: Se realizó una revisión retrospectiva de una muestra representativa de Papanicolau de mujeres entre las edades de 15 a 49 años, usando el Banco Nacional de Datos centralizados en el Hospital General de Saint George, Granada. Las mujeres de edad más jóvenes o mayores que el grupo de muestra, así como aquellas que se registraron como menopáusicas o histerectomizadas fueron excluidas del estudio. Datos demográficos y del laboratorio fueron recogidos, y se reportó la estadística descriptiva. RESULTADOS: La prevalencia de BV fue de 19,5% para el período de tres años entre las 2677 hembras incluyeron en el análisis, presentando el grupo de edad de 20-29 años el mayor porcentaje de infección (43,6%). También se observó un aumento en la tendencia de la prevalencia entre 2009 (16,1%) y 2011 (21,4%). Candida vaginalis y Trichomonas vaginalis estuvieron presentes en 3,6% y 0,85%, respectivamente. Además, se documentaron las células anormales de significación desconocida y displasia cervical en 5,3% y 1,8% de los frotis, respectivamente. CONCLUSIÓN: Los médicos en ejercicio en Granada necesitan considerar el aumento del tamizaje para la detección de BV en mujeres que puedan presentarse con síntomas no específicos. Se necesita continuar las investigaciones a fin de determinar los factores de predisposición en las mujeres Granadinas y las asociaciones con la enfermedad. Asimismo, es necesario ayudar al desarrollo de programas nacionales de educación encaminados a modificar aquellas conductas que podrían conducir a la adquisición y la persistencia delaBV entre las mujeres de edad reproductiva en Granada.

Prevalence of bacterial vaginosis in Grenadian women of reproductive age.

OBJECTIVES: To determine the prevalence of bacterial vaginosis (BV) among Grenadian women of reproductive age using the routinely collected Pap smear data for the period January 2009 to December 2011. METHODS: A retrospective review of a cross-section of Pap smears was obtained for women between the ages of 15 and 49 years, using the national centralized data bank at the General Hospital in St George's, Grenada. Women aged younger or older than the sample group, as well as those who were reported as being menopausal or hysterectomized were excluded from the study. Demographic and laboratory data were collected and descriptive statistics reported. RESULTS: The prevalence of BV was 19.5% for the three-year period among the 2677 females included in the analysis with the 20-29-year age group having the largest percentage of infection (43.6%). An increase in the trend of prevalence between 2009 (16.1%) and 2011 (21.4%) was also observed. Candida vaginalis and Trichomonas vaginalis were present in 3.6% and 0.85%, respectively. Additionally, atypical cells of unknown significance and cervical dysplasia were documented in 5.3% and 1.8% of the smears, respectively. CONCLUSION: Practicing physicians in Grenada need to consider increased screening for BV in women who may present with non-specific symptoms. Further research is necessary to determine the predisposing factors in Grenadian women and associations with the disease and to assist in the development of national education programmes to alter behavioural practices that could result in the acquisition and persistence of BV among women of reproductive age in Grenada.

Perceived safety of donor blood and blood substitutes for transfusion: the role of informational frame, patient groups and stress appraisals.

Patients express concerns about the safety of donated blood. Do they have similar concerns about potential 'blood substitutes' and does the way information is presented on these options alter patients' perceptions? A two (informational frame: gain or loss) by four (transfusion type: human donor blood, human haemoglobin, bovine haemoglobin or perfluorocarbon emulsion substitutes) by three (patient group: adult haemophiliac/leukaemia patients, relatives/friends of haemophiliac/leukaemia patients and controls) between-subjects design was used. There were 82 patients, 118 relatives/friends and 263 controls from the UK. Blood substitutes were perceived as being significantly less safe than donor blood. Perceptions of safety were greater when transfusion information (regardless of transfusion type or patient group) was presented as gains rather than losses. Different demographic and psychological factors predicted perceived safety (e.g. sex) and perceived risk (e.g. age and experience).

Epithelioid sarcoma: clinical, MR imaging and pathologic findings.

OBJECTIVE: To report and describe the MR imaging features of eight new cases of this rare soft tissue sarcoma and correlate them with the clinical and histologic findings. DESIGN AND PATIENTS. Retrospective analysis was carried out for the MR imaging characteristics and histologic findings of eight patients with pathologically proven epithelioid sarcoma and the literature was reviewed. Findings were correlated in each case with the patient's clinical presentation and eventual outcome. RESULTS: The patients, whose primary tumors ranged from 2.5 cm to 19 cm in maximum dimension, were 1 to 90 years of age. Tumors involved the extremities ( n=5), the scalp ( n=2) and the paraspinal muscles ( n=1). Five tumors presented as well-defined, frequently painful, deeply situated masses and three as subcutaneous nodules or cutaneous ulcers with no palpable mass. Four patients had associated regional lymphadenopathy and one had distant metastases at diagnosis. MR imaging showed tumor infiltration of adjacent tissues in seven patients. Signal characteristics reflected varying degrees of cellularity, and the presence of necrosis, hemorrhage, fibrosis, hyalinization and inflammation. Bone marrow involvement was demonstrated in one patient. Clinical outcomes were generally poor. CONCLUSIONS: Epithelioid sarcoma is an aggressive soft tissue sarcoma with a varied clinical presentation, growth pattern, MR signal characteristics and histologic picture. The tumor favors the distal extremities and is commonly infiltrative and accompanied by enlarged regional lymph nodes. This neoplasm may present as an intramuscular mass but should also be suspected in patients with ulcerating cutaneous nodules with or without regional lymphadenopathy.

Progressively developed myocardial apoptotic cell death during late phase of reperfusion.

Myocardial apoptosis is primarily triggered during reperfusion (R). The aim of this study was to test the hypothesis that R-induced apoptosis develops progressively during the late phase of R, and that R-induced apoptosis is associated with changes in expression of anti- and pro-apoptotic proteins and infiltrated inflammatory cells. Thirty-one dogs were subjected to 60 min of left anterior descending coronary occlusion followed by 6, 24, 48, and 72 h R, respectively. There was no group difference in collateral blood flow, measured by colored microspheres during ischemia. Necrotic cell death (TTC staining) was significantly increased during R, starting at 27 +/- 2% at 6 h R and increasing to 41 +/- 2% at 24 h R. There was no further change at 48 (37 +/- 3%) and 72 (36 +/- 6%) h R, respectively. TUNEL positive cells (% total normal nuclei) in the peri-necrotic zone progressively increased from 6 (26 +/- 2) to 24 (38 +/- 1), 48 (48 +/- 3) and 72 (59 +/- 4) h R, respectively. The number of detected TUNEL positive cells at these time points was consistent with an increased intensity of DNA ladders, identified by agarose gel electrophoresis. Compared with normal tissue, western blot analysis showed persistent reduction in expression of anti-apoptotic protein Bcl-2 from 6 (16 +/- 0.8%) to 72 h R (78 +/- 2%), and increase in expression of pro-apoptotic proteins including Bax from 6 (30 +/- 3%) to 72 h R (66 +/- 3%), and p53 from 6 (12 +/- 1%) to 72 h R (91 +/- 2%), respectively. Immunohistochemical staining revealed that infiltrated neutrophils (mm(2) myocardium) were significantly correlated with development of necrotic and apoptotic cell death from 6 to 24 h R, respectively (P < 0.05), while large macrophage infiltration seen during 48 to 72 h R were correlated with apoptotic cell death (P < 0.05). These results indicate that 1) necrosis peaked at 24 h R when apoptosis was still progressively developing during later R; 2) changes in Bcl-2 family and p53 proteins may participate in R-induced myocardial apoptosis; 3) inflammatory cells may play a role in triggering cell death during R. P < 0.05 vs. normal nuclei and tissue; P < 0.01 vs. 6 h R.

Cytotoxic T lymphocytes from humans with adenocarcinomas stimulated by native MUC1 mucin and a mucin peptide mutated at a glycosylation site.

MUC1 mucin peptides stimulated cytotoxic T lymphocytes (CTL) from humans with adenocarcinomas. Peripheral blood mononuclear cells, tumor-draining lymph node cells, or tumor-infiltrating lymphocytes were stimulated using mono-nuclear cells from humans with adenocarcinomas of breast or ovary, respectively, using (a) a native MUC1 mucin tandem repeat peptide of 20 amino acids (MUC1-mtr1) plus recombinant human interleukin-2 (IL-2), (b) the mutated (T3N) MUC1-mtr1 plus IL-2, or (c) immobilized anti-CD3 plus IL-2, or (d) IL-2 alone. The CTL stimulated by each of these four conditions were predominately CD4+. However, the CTL stimulated by either the native MUC1-mtr1 or (T3N) MUC1-mtr1 showed 5-10 times greater cytotoxicity of a breast cancer cell line that expresses MUC1 compared to CTL stimulated by either anti-CD3 + IL-2 or IL-2 alone. Each incubation condition generated CTL with different variable beta gene families of T-cell receptors, implying an oligoclonal expansion of a limited CTL repertoire for each. Thus, peptide-stimulated T cells showed expression of cytotoxic cells, which was not induced by nonspecific (anti-CD3 or IL-2) stimulation.

Prevalence of non-diabetic renal disease among African-American patients with type II diabetes mellitus.

OBJECTIVE: This study aimed to characterize the prevalence of non-diabetic renal disease among African-Americans (AA) with type II diabetes mellitus based on a biopsy series. No previous study has investigated the nature of renal lesions in AA with type II DM. MATERIAL AND METHODS: Thirty AA patients with type II DM who were being managed at an inner-city hospital had kidney biopsies to evaluate suspected non-diabetic renal disease (NDRD) between 1994 and 1998. The demographic, clinical and histopathological data on these patients were analysed retrospectively. Kidney biopsies were reviewed by light microscopy, immunofluorescence and electron microscopy. RESULTS AND CONCLUSIONS: Three patterns of glomerular disease were observed. Diabetic nephropathy alone was seen in 13 patients (41.9%), diabetic nephropathy coexisted with glomerulonephritis in 12 patients (38.7%), while NDRD was seen in six patients (19.4%).

Perfluorinated blood substitutes and artificial oxygen carriers.

Blood transfusion is a remarkably safe, routine clinical procedure. However, the need for sophisticated blood processing, storage and cross-matching, coupled with increasing concerns about the safety of blood products, has fuelled the search for safe and efficacious substitutes. Candidate materials based on modified haemoglobin (including recombinant molecules) or highly inert, respiratory gas-dissolving perfluorinated liquids (perfluorochemicals) have been developed. The latter are immiscible in aqueous systems and must, therefore, be injected as emulsions. Second-generation perfluorochemical emulsions are available and in clinical trials as temporary intravascular oxygen carriers during surgery, thereby reducing patient exposure to donor blood. One commercial product is currently under Phase III clinical evaluation, with regulatory approval expected within 1 2 years. Other biomedical applications for perfluorochemicals and their emulsions include their use as pump-priming fluids for cardiopulmonary bypass, lung ventilation fluids, anti-cancer agents, organ perfusates and cell culture media supplements, diagnostic imaging agents and ophthalmologic tools. Novel applications for perfluorochemicals as immunomodulating agents are also being explored.

Vasculopathic changes of CADASIL can be focal in skin biopsies.

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is a newly described cause of vascular dementia. Pathologic examination shows multiple small infarcts in the deep cerebral white matter together with a nonatherosclerotic, nonamyloid angiopathy involving the media of small cerebral arteries. Ultrastructurally, characteristic granular material is present in the basal lamina of vascular smooth muscle cells in cerebral and extracerebral blood vessels. The ultrastructural changes have also been demonstrated in skin biopsies of affected patients; consequently, some investigators have recently recommended skin biopsies for the diagnosis of CADASIL. This study describes a 54-year-old male with a family history for strokes who had clinical and radiological features suggestive of CADASIL. A skin biopsy was performed to confirm the diagnosis. Initially, the characteristic vasculopathic changes of CADASIL were not identified within small blood vessel walls. However, multiple deeper sections in other areas showed electron-dense material associated with vascular smooth muscle cells, characteristic of CADASIL. Subsequent genetic testing demonstrated a single nucleotide substitution at position 659 on chromosome 19p13.1 causing an amino-acid change (Cys --> Phe), a finding indicative of CADASIL. The involvement of blood vessels within the dermis makes skin biopsy a useful adjunct in the diagnosis of CADASIL. However, as illustrated by this case, the findings may be focal, requiring a thorough evaluation of the entire biopsy specimen.

Ischemic preconditioning reduces neutrophil accumulation and myocardial apoptosis.

BACKGROUND: This study tested the hypothesis that ischemic preconditioning (IP) inhibits myocardial apoptosis after a short period of ischemia and reperfusion. METHODS: In 9 anesthetized dogs, the left anterior descending (LAD) coronary artery was occluded for 30 min and reperfused for 3 h (control), while in 9 others, LAD occlusion was preceded by 5 min of occlusion and 5 min of reperfusion (IP). DNA from frozen myocardial tissue samples was extracted, and apoptosis were identified as "ladders" by agarose gel electrophoresis or confirmed histologically using the terminal transferase UTP nick end-labeling (TUNEL) assay. Neutrophil accumulation was detected by measuring cardiac myeloperoxidase activity. RESULTS: Thirty minutes of LAD occlusion caused a significant decrease in blood flow (colored microspheres), which was comparable between groups. In the control group, DNA ladders occurred in the area at risk (AAR) in six out nine experiments. In contrast, DNA laddering in the AAR was not observed in any of the IP group. AAR in the control group showed a greater percentage of apoptotic cells than IP (6.7 +/- 0.9% vs 1.2 +/- 0.2%; p < 0.01). Cardiac myeloperoxidase activity (U/g tissue) was significantly reduced from 0.07 +/- 0.004 in control to 0.04 +/- 0.01 in IP group (p < 0.05). CONCLUSIONS: We conclude that ischemic preconditioning attenuates apoptosis and neutrophil accumulation in the AAR in a model of nonlethal acute ischemia and reperfusion.

An unusual cervical carcinoma showing exception to epitheliotropism of human papillomavirus.

Human papillomaviruses (HPV) infect epithelial tissues but have not been previously detected within mesenchymal cells. During a systematic investigation of FIGO stage Ib cervical cancers with colorimetric in situ hybridization, we detected HPV 16 DNA within the stromal compartment of an unusual undifferentiated carcinoma. The mesenchymal nature of the HPV-containing cells was confirmed by immunohistochemistry and electron microscopy. No viral particles were identified. Sequencing the majority of the HPV 16 genome identified few changes from the revised reference clone; all previously reported in other HPV 16 variants. These viral changes are unlikely to explain the exceptional mesenchymal localization of the HPV 16 DNA in this case.

A transitional variant of Castleman's disease presenting as a chylous pleural effusion.

Castleman's disease is an uncommon clinicopathologic entity that results in unregulated growth of lymphoid tissue. It may present as benign involvement of one lymph node group or as multicentric disease with serious systemic symptoms. Pleural effusions are an uncommon manifestation of Castleman's disease. We present a patient with Castleman's disease who initially presented with a chylous pleural effusion.

Rapid progression to end-stage renal disease in young hypertensive African Americans with proteinuria.

Hypertensive nephrosclerosis (HN) remains the most common cause of end-stage renal disease (ESRD) in blacks. This study examined whether renal histology corresponds with clinical hypertension in proteinuric blacks. Nondiabetic hypertensive blacks who satisfied inclusion criteria were enrolled in this study. Four male patients, each with a family history of hypertension and mean age 41 years, consented to kidney biopsy. Their mean arterial pressure was 116.5 mm Hg, mean urine protein excretion was 7.7 +/- 3.5 g/day. All patients progressed to ESRD within a mean duration of 14 months; the mean rate of decline in glomerular filtration rate was 53 mL/min/y, with an ESRD incidence of 80%/y. The histologic findings were consistent with previously described features of HN. Prominent glomerulosclerosis involved 30% to 75% of the glomeruli and extensive arteriolosclerosis/arteriosclerosis, tubular atrophy, and interstitial fibrosis. There was no evidence of immune complex disease by either immunofluorescence, electron microscopy, or serologic studies. The mean arterial pressure showed a strong but nonsignificant correlation with progression to ESRD (r = 0.8) and arteriosclerosis/arteriolosclerosis (r = 0.8). Glomerular sclerosis correlated with the reciprocal of serum creatinine (r = 0.6), interstitial fibrosis (r = 0.8), and arteriosclerosis/arteriolosclerosis (r = 0.3). Urine protein excretion correlated weakly with progression to ESRD (r = 0.4). These results indicate a poor correlation between clinical findings and histologic features on renal biopsy in young hypertensive African Americans. Hypertension remains a major cause of ESRD among African Americans, and progression to ESRD may be rapid in patients with marked proteinuria. Early and aggressive intervention is warranted.

Asymmetry of the alpha subunit of the chloroplast ATP synthase as probed by the binding of Lucifer Yellow vinyl sulfone.

The catalytic portion of the chloroplast ATP synthase (CF1) is structurally asymmetric. Asymmetry of the otherwise symmetrical alpha3beta3 heterohexamer is induced by the presence of tightly bound nucleotides and interactions with the single-copy, smaller subunits. Lucifer Yellow vinyl sulfone (4-amino-N-[3-(vinylsulfonyl)phenyl]naphthalimide-3,6-disulfonic acid) rapidly and covalently binds to lysine 378 on one alpha subunit [Nalin, C. M., Snyder, B., and McCarty, R. E., (1985) Biochemistry 24, 2318-2324] [Shapiro, A. B. (1991) Ph.D. Thesis, Cornell University, Ithaca, NY). The asymmetrical binding of Lucifer Yellow to CF1 provides a method to investigate the cause of asymmetry in the alpha subunits. The reaction of CF1 with Lucifer Yellow was monitored by total fluorescence of bound Lucifer Yellow as well as by quantitative determination of Lucifer Yellow bound to the tryptic peptide that contains lysine 378 of the alpha subunit. The total binding of Lucifer Yellow to CF1 was not affected by the presence of tightly bound nucleotides or nucleotide in the medium. Neither the total binding of Lucifer Yellow to CF1 nor the reaction of alpha-lysine 378 with Lucifer Yellow was changed by the removal of the epsilon subunit, the delta subunit, or both subunits. The extent of incorporation of Lucifer Yellow into lysine 378 of the alpha subunit in (alphabeta)n was about three times that of Lucifer Yellow incorporation into CF1. Reconstitution of (alphabeta)n with gamma restored the binding of one Lucifer Yellow per alpha3beta3gamma. Therefore, the interactions between gamma and the alphabeta heterohexamer are important in conferring asymmetry to the alpha subunits of CF1.

Effects of the co-polymer surfactant, Pluronic F-68, on platelet aggregation in human whole blood.

The effects have been studied of Pluronic F-68 on platelet aggregation in human whole blood. The median spontaneous platelet aggregation in normal blood (n = 15) was 18.4% [interquartile range (IQ) = 10.5-24.2%]. Commercial grade Pluronic F-68 significantly (P < 0.05) reduced platelet aggregation at 7.3 microM (median = 8.4%, IQ = 3.9-13.4; n = 12) and almost eliminated aggregation at concentrations of > 58 microM (median = 2.0%, IQ = 0.0-3.5). Similar results were obtained with a silica gelpurified Pluronic F-68 fraction (n = 3). Pluronic F-68 also accelerated the rate of platelet dis-aggregation in blood treated with 0.3, 1.0 or 3.0 mM adenosine di-phosphate. These results suggest that the therapeutic effects of Pluronic F-68 in ischaemic injury may be due, in part, to inhibition of platelet aggregation in the microcirculation. The beneficial effects of tissue perfusion with oxygen-carrying perfluorochemical emulsions, containing Pluronic F-68, may also involve direct effects of the surfactant on platelets.

Coinfection with Giardia lamblia and Enterocytozoon bieneusi in a patient with acquired immunodeficiency syndrome and chronic diarrhea.

Diarrhea is an important clinical problem in immunosuppressed patients with acquired immunodeficiency syndrome (AIDS). There are numerous classical as well as emerging enteric pathogens that can produce diarrhea; however, these agents can be missed when only one method, such as microbiological examination of stool, is used for diagnosis. The endoscopic biopsy is a sensitive method for diagnosis of many viral, fungal, and parasitic infections of the gastrointestinal tract. Although only one agent is often identified in mucosal biopsies from these immunosuppressed patients, coinfection with multiple microbial agents is being increasingly recognized. Giardia infection is not as prevalent as other pathogens in patients with AIDS, but it remains an important diarrheal agent that is potentially curable. However, there have been only rare reports of coinfections with giardiasis and other infectious agents. This report describes a patient with AIDS and chronic diarrhea who had repeated negative stool examinations for ova and parasites. Light and electron microscopic examination of subsequent endoscopically obtained small intestinal biopsies revealed coinfection with two parasites, Enterocytozoon bieneusi and Giardia lamblia. Following treatment with metronidazole for giardiasis, the diarrhea persisted, but was less severe. This report also describes the diagnostic features of Giardia and Enterocytozoon infections in biopsy tissues and emphasizes the importance of identifying enteric coinfections in patients with AIDS to ensure timely and specific modes of therapy.

Granulomatous interstitial nephritis and uveitis presenting as salt-losing nephropathy.

Salt-wasting nephropathy is a rare syndrome in which renal insufficiency is associated with extracellular volume depletion from marked natriuresis in the absence of adrenal insufficiency or diuretics. We report the clinical course of a 23-year-old woman with renal insufficiency, in association with orthostatic hypotension and salt wasting. A combination of daily infusion of saline, a high-salt diet and oral fludrocortisone did not compensate for her salt loses. Renal biopsy showed noncaseating granulomas and marked interstitial inflammation. Renal function and salt loss improved with prednisone therapy and 6 months after withdrawal of steroids, her renal function remains stable.