A Bone Histomorphometric Analysis of Hypophosphatasia-related Osteoporosis after Teriparatide Treatment.

A 79-year-old man was admitted with a compression fracture of the first lumbar vertebra. His alkaline phosphatase (ALP) level was 35 IU/L, and his dual energy X-ray absorptiometry T score was -3.7 standard deviations, indicating osteoporosis. A genetic analysis showed a mutation of the alkaline phosphatase biomineralization-associated gene encoding tissue-nonspecific alkaline phosphatase. Hypophosphatasia-related osteoporosis was diagnosed. Alendronate, teriparatide, and minodronate were administered in that order. The ALP level increased during teriparatide use. A bone biopsy performed after three years of teriparatide treatment showed that cancellous bone was adynamic. In cortical bone, tetracycline double-labeling indicates enhanced bone formation. Teriparatide may thus be a viable treatment option even in patients with hypophosphatasia.

Cross-Talk Between NO Synthase Isoforms in Neuro-Inflammation: Possible Implications in HIV-Associated Neurocognitive Disorders.

Inducible nitric oxide synthase (iNOS) is expressed in several cell types, particularly in inflammatory cells, in response to diverse proinflammatory stimuli, including viral proteins as HIV Tat and gp120. This response is preceded by an early decline in basal nitric oxide (NO) levels, dependent on a signaling leading to inhibition of the constitutive isoform of NO synthase (cNOS). This process requires critical levels of arachidonic acid (AA), generated by Ca²⁺-dependent activation of cytosolic phospholipase A2, and is mediated by the downstream tyrosine kinase-dependent phosphorylation of cNOS. Lowering basal NO levels are necessary for the activation of nuclear factor-κB, and thus for the expression of a variety of genes regulated by this transcription factor, which include iNOS. Notably, NO and AA, two small lipid soluble molecules, can trigger the above responses also in distal cells. Thus, AA produced at the very early stages of the inflammatory response is a likely critical signal switching the regulation of the "NO tone" from physiological (i.e., mediated by cNOS) to pathological (i.e., mediated by iNOS). This later phase of the inflammatory response is often accompanied by the onset of deleterious effects in the tissue, in which a critical role is played by iNOS-derived NO (directly or indirectly, i.e., via formation of peroxynitrite) as well as by products of the AA cascade. In this review, the authors discuss the implications of the crosstalk between the NOS isoforms in HIV-associated neuro-pathogenesis highlighting the role of NO and AA as mediators of cytotoxicity.

Low insulin resistance after surgery predicts poor GH suppression one year after complete resection for acromegaly: a retrospective study.

Remission of acromegaly is defined as a nadir in GH <1.0 ng/mL during a 75-g oral glucose tolerance test (75gOGTT) and insulin-like growth factor-1 (IGF-1) normalization. Recently, a lower cut-off value for GH nadir (<0.4 ng/mL) has been proposed. We retrospectively evaluated the prevalence and clinical characteristics of postoperative cases with normalized IGF-1 levels and a GH nadir of 0.4-1.0 ng/mL one year after complete resection of GH-secreting pituitary adenoma (GHoma). We included 110 cases of acromegaly with complete adenoma resection, no preoperative treatment, preoperative glycosylated hemoglobin <6.5%, preoperative basal plasma glucose <126 mg/dL, GH nadir <1.0 ng/mL during a 75gOGTT, and normalized IGF-1 at the first postoperative year evaluation, whereupon patients were divided into two groups: control (GH nadir <0.4 ng/mL) and high GH (GH nadir >0.4 ng/mL). Clinical parameters, including measures of insulin secretion and resistance, were compared between groups. The high GH group included 10 patients (9.1%) and had a lesser level of insulin resistance immediately following surgery and at the first postoperative year evaluation. On single regression analysis, insulin resistance immediately following surgery was predictive of and correlated with the GH nadir at the first postoperative year evaluation. The GH nadir at the first postoperative year evaluation may be insufficient in patients with normalized IGF-1 with low insulin resistance immediately following complete resection of GHoma. Careful evaluation is needed to assess remission in such patients.

The USP8 mutational status may predict drug susceptibility in corticotroph adenomas of Cushing's disease.

CONTEXT: Somatic mutations in the ubiquitin-specific peptidase USP8 gene were recently detected in one- to two-third(s) of corticotroph adenomas of Cushing's disease (CD). These mutations may lead to the deubiquitination of EGFR, thereby increasing EGFR signaling, which has been implicated in ACTH hypersecretion. OBJECTIVE: Our objective was to determine the impact of USP8 mutations on the clinicopathological features of CD. SUBJECTS AND METHODS: USP8 mutations as well as clinicopathological characteristics were examined in 60 corticotroph adenomas including 15 Crooke's cell adenomas (CCAs), a rare histological variant presenting with generally aggressive behavior, using qRT-PCR and/or immunohistochemistry. RESULTS: USP8 mutations were exclusively detected in women, except for one case, with a prevalence of 42.2% in non-CCA and 13.3% in CCA (overall 35%). Clinically well-behaved presentations including microadenoma and curative resection were more common in mutated cases. The expression of EGFR was not associated with the mutation status. In contrast, mutated tumors expressed significantly higher levels of POMC, SSTR5, and MGMT. CONCLUSIONS: Microadenomas that strongly express POMC were common among mutated tumors, which may lead to the mechanisms by which very small adenomas secrete excess ACTH to present overt CD. While USP8 mutations were less likely to enhance tumorous ACTH hypersecretion via EGFR-mediated activation, the presence of USP8 mutations may predict favorable responses to the somatostatin analog pasireotide, which exhibits high affinity for SSTR5. In contrast, non-mutated aggressive tumors such as CCA may respond better to the alkylating agent temozolomide because of their significantly weak expression of MGMT.

A CASE OF AN AROMATASE-PRODUCING SERTOLI CELL TUMOR PRESENTING WITH GYNECOMASTIA.

A 64-year-old man had complained of a left scrotal mass and gynecomastia since June 2012. A left testicular tumor was suspected and the patient was referred to our department in December 2013. He presented with bilateral gynecomastia and a painless left scrotal mass that was firm, smooth surfaced, and the size of large hen's egg. Levels of markers of testicular germ cell tumors were all within normal range. Endocrinological examination revealed a marked elevation in serum estradiol (E2) level. The patient underwent high inguinal orchiectomy in December 2013.The pathological diagnosis was a Sertoli cell tumor of the left testis. Immunohistochemistry revealed the expression of aromatase synthesis; we speculated that this E2 production by the tumor caused the gynecomastia.Serum E2 level normalized after the orchiectomy. Owing to the diagnosis of malignancy, retroperitoneal lymph node dissection was performed in January 2014. No lymph node metastasis was found in the specimen. The gynecomastia improved gradually, and the patient has been free of disease since the surgery.

Therapeutic outcomes in patients undergoing surgery after diagnosis of Cushing's disease: A single-center study.

This study aimed to investigate early and late outcomes of patients who underwent neurosurgical procedures for the preoperative diagnosis of Cushing's disease (CD). Clinical, endocrine, imaging, and histologic data from 252 patients undergoing pituitary surgery at Toranomon Hospital through the end of 2012 were entered into a database and statistically analyzed. In 22 of these patients (8.7%; positive venous sampling in 15 and negative venous sampling in 7 patients), tumors were invisible on magnetic resonance imaging (MRI) and 42.9% of them achieved remission. In the remaining 230 patients, 93.5% of those with microadenomas (n=154) and 71.1% of those with macroadenomas (n=76) achieved early postoperative remission, with recurrence rates of 2.7% and 14.8%, respectively, during a 72.5-month median follow-up. In multivariate analyses, cavernous sinus invasion (CSI; odds ratio [OR], 13.0), type of surgery (OR, 4.0), and tumor size (OR, 2.7) were significant preoperative factors affecting early postoperative results, whereas peak cortisol levels ≥9.4 µg/dL in response to corticotropin-releasing hormone (CRH) and CSI were significant factors predicting recurrence. Tumor recurrence was more common in patients with non-densely granulated adenomas than in patients with densely granulated adenomas. We propose that the higher remission and lower recurrence rates in this series are due to our surgical strategies, including extracapsular tumor removal, aggressive resection of tumors with CSI, extended transsphenoidal surgery (TSS), or a combined approach for large/giant adenomas. Appropriate multimodal treatments, including radiotherapy, medication, and repeated surgery in patients with persistent or recurrent CD, could result in better overall outcomes than previously achieved.

Short-term preoperative octreotide treatment for TSH-secreting pituitary adenoma.

Preoperative control of hyperthyroidism in patients with TSH-secreting pituitary adenomas (TSHoma) may avoid perioperative thyroid storm. Perioperative administration of octreotide may control hyperthyroidism, as well as shrink tumor size. The effects of preoperative octreotide treatment were assessed in a large number of patients with TSHomas. Of 81 patients who underwent surgery for TSHoma at Toranomon Hospital between January 2001 and May 2013, 44 received preoperative short-term octreotide. After excluding one patient because of side effects, 19 received octreotide as a subcutaneous injection, and 24 as a long-acting release (LAR) injection. Median duration between initiation of octreotide treatment and surgery was 33.5 days. Octreotide normalized free T4 in 36 of 43 patients (84%) and shrank tumors in 23 of 38 (61%). Length of octreotide treatment did not differ significantly in patients with and without hormonal normalization (p=0.09) and with and without tumor shrinkage (p=0.84). Serum TSH and free T4 concentrations, duration of treatment, incidence of growth hormone (GH) co-secretion, results of octreotide loading tests, form of administration (subcutaneous injection or LAR), tumor volume, and tumor consistency did not differ significantly in patients with and without hormonal normalization and with and without tumor shrinkage. Short-term preoperative octreotide administration was highly effective for TSHoma shrinkage and normalization of excess hormone concentrations, with tolerable side effects.

Costunolide and Dehydrocostuslactone, two natural sesquiterpene lactones, ameliorate the inflammatory process associated to experimental pleurisy in mice.

The aim of this study was to investigate the effect of costunolide (CS) and dehydrocostuslactone (DCE) a well-known sesquiterpene lactones contained in many plants, in a model of lung injury induced by carrageenan administration in the mice. Injection of carrageenan into the pleural cavity of mice elicited an acute inflammatory response characterized by fluid accumulation in the pleural cavity which contained a large number of polymorphonuclear cells (PMNs) as well as an infiltration of PMNs in lung tissues and increased production of tumour necrosis factor α (TNF-α). All parameters of inflammation were attenuated by CS and DCE (15mg/kg 10% DMSO i.p.) administered 1h before carrageenan. Carrageenan induced an up regulation of the intracellular adhesion molecules-1 (ICAM-1) and P-selectin, as well as nitrotyrosine and poly (ADP-ribose) (PAR) as determined by immunohistochemical analysis of lung tissues. The degree of staining for the ICAM-1, P-selectin, nitrotyrosine and PAR was reduced by CS and DCE. Additionally we show that this inflammatory events were associated with NF-κB and STAT3 activation and these sesquiterpenes down-regulated it. Taken together, ours results clearly shown that CS and DCE may offer a novel therapeutic approach for the management of inflammatory diseases.

Direct interaction of natural and synthetic catechins with signal transducer activator of transcription 1 affects both its phosphorylation and activity.

Our previous studies showed that (-)-epigallocatechin-3-gallate (EGCG) inhibits signal transducer activator of transcription 1 (STAT1) activation. Since EGCG may be a promising lead compound for new anti-STAT1 drug design, 15 synthetic catechins, characterized by the (-)-gallocatechin-3-gallate stereochemistry, were studied in the human mammary MDA-MB-231 cell line to identify the minimal structural features that preserve the anti-STAT1 activity. We demonstrate that the presence of three hydroxyl groups of B ring and one hydroxyl group in D ring is essential to preserve their inhibitory action. Moreover, a possible molecular target of these compounds in the STAT1 pathway was investigated. Our results demonstrate a direct interaction between STAT1 protein and catechins displaying anti-STAT1 activity. In particular, surface plasmon resonance (SPR) analysis and molecular modeling indicate the presence of two putative binding sites (a and b) with different affinity. Based on docking data, site-directed mutagenesis was performed, and interaction of the most active catechins with STAT1 was studied with SPR to test whether Gln518 on site a and His568 on site b could be important for the catechin-STAT1 interaction. Data indicate that site b has higher affinity for catechins than site a as the highest affinity constant disappears in the H568A-STAT1 mutant. Furthermore, Janus kinase 2 (JAK2) kinase assay data suggest that the contemporary presence in vitro of STAT1 and catechins inhibits JAK2-elicited STAT1 phosphorylation. The very tight catechin-STAT1 interaction prevents STAT1 phosphorylation and represents a novel, specific and efficient molecular mechanism for the inhibition of STAT1 activation.

Efficacy and safety of advanced renal cell carcinoma patients treated with sorafenib: roles of cytokine pretreatment.

BACKGROUND: We conducted a retrospective, questionnaire-based analysis to assess the outcomes of advanced renal cell carcinoma (RCC) in Japanese patients treated with sorafenib in the daily clinical setting. PATIENTS AND METHODS: Patients (n = 110) were treated with sorafenib 400 mg twice daily at 12 centers. Overall survival (OS), progression-free survival (PFS), safety, and prognostic factors associated with PFS were assessed. RESULTS: The median OS was not reached within the study period, while the median PFS was 11.0 mo [95 % confidence interval (CI), 6.6 to 14.4 mo]. Univariate analysis showed that higher C-reactive protein (CRP) level, lower Na(+) level, and presence of liver metastasis were significant predictors of poorer PFS (p < 0.05, respectively). Among these variables, multivariate analysis identified higher CRP level (p = 0.004) and the presence of liver metastasis (p < 0.001) as being significantly associated with poorer PFS. The most common adverse event was skin toxicity (67 %), followed by gastrointestinal symptoms (26 %), hypertension (22 %), fatigue (19 %), hematological toxicity (10 %), and hemorrhage (6 %). The incidence of adverse events was comparable to that of previously reported clinical trials. CONCLUSIONS: Multivariate analysis indicated that CRP and liver metastasis were negatively associated with prognosis. Sorafenib therapy for Japanese patients with advanced RCC was effective and well tolerated.

[Updates on rickets and osteomalacia: etiology and pathophysiology of osteomalacia].

Impairment of bone mineralization causes rickets and osteomalacia. Rickets develops with impaired mineralization of bone prior to epiphyseal closure, and so does osteomalacia after the closure of epiphyses. Pain in lower extremities and back and bone pain are usually observed in patients with osteomalacia. Chronic hypophosphatemia and/or impairment of vitamin D action are involved in the development of osteomalacia. It is of great importance to suspect osteomalacia from clinical symptoms and laboratory data, such as hypophosphatemia and/or high serum alkaline phosphatase level.

Ketoacidosis as the initial clinical condition in nine patients with acromegaly: a review of 860 cases at a single institute.

OBJECTIVE: Excess GH causes insulin resistance and impaired glucose metabolism. The objective of this study was to clarify the prevalence of ketoacidosis as the initial presenting symptom of acromegaly. DESIGN AND METHODS: Data were collected from 860 patients with acromegaly who underwent pituitary surgery at Toranomon Hospital over the last 32 years, between 1980 and 2011. RESULTS: Nine cases had ketoacidosis before being diagnosed with acromegaly, including seven males and two females with a mean +/- S.D. age of 38.8 +/- 14.2 years. Serum GH and IGF1 levels were 155 +/- 203 ng/ml and 9.86 +/- 0.68 SDS before pituitary surgery and 3.6 +/- 1.7 ng/ml and 3.72 +/- 3.40 SDS after surgery respectively. The maximum tumor diameter was 28.2 +/- 11.6 mm (ranging from 15 to 47 mm, n=8). None of the patients were diagnosed with diabetes mellitus (DM) nor were they positive for antibodies related to type 1 DM. A possible precipitating factor for ketoacidosis in six cases was excessive ingestion of sugar-containing soft drinks. All the cases had invasive pituitary adenomas. After pituitary surgery, plasma glucose levels were under control without requiring insulin in all cases. Furthermore, six patients did not need oral hypoglycemic agents. CONCLUSIONS: Approximately 1% of patients with acromegaly presented with diabetic ketoacidosis as their first clinical condition.

Rapid degradation of poly(ADP-ribose) after injection into the mouse bloodstream.

Extensive DNA damage leads to the activation of poly(ADP-ribose) polymerase and subsequently to the formation of poly(ADP-ribose). When the damage is severe or leads to cell death, poly(ADP-ribose) may leak into the blood circulation. The metabolism of poly(ADP-ribose) in the bloodstream is not well understood. Thus, in the present study, the metabolism of P-labeled poly(ADP-ribose) was followed in mice after injection of this labeled compound into the tail vein. The results showed that 5 min after injection more than half of the radioactivity was concentrated in acid-soluble fractions, namely in low molecular weight compounds in the blood, liver, and kidneys. Most of this radioactivity was in the form of inorganic phosphate, detected 5 min post-injection in the blood, kidneys, and urine. By contrast, the metabolites ADP-ribose and phosphoribosyl-AMP were not detected in any of the tissues nor in blood or urine. Taken together, these findings suggest that once poly(ADP-ribose) enters the bloodstream it is rapidly degraded, thereby preventing its accumulation in the blood.

A large functioning parathyroid cyst in a patient with multiple endocrine neoplasia type 1.

A 62-year-old woman presented with a mass on the left side of the neck. Biochemical testing revealed primary hyperparathyroidism. Further, a prolactinoma was detected, and the patient's son and daughter also had primary hyperparathyroidism, indicating that the patient had multiple endocrine neoplasia type 1 (MEN1). Neck ultrasonography revealed several cystic nodules (≤ 30 mm) that appeared to be adenomatous. After parathyroidectomy with autotransplantation, the largest cystic mass, in the left lower thyroid lobe, was pathologically diagnosed as a functioning parathyroid cyst, and all laboratory data returned to normal. On genetic analysis of blood, we found a novel single base insertion (duplication) in exon 10 codon 552 of the MEN1 gene (c1659dupT) that creates an early stop codon. This is the first case report of a parathyroid cyst resulting from parathyroid hyperplasia in a MEN1 patient.

Synthesis and biological evaluation of new N-alkylcarbazole derivatives as STAT3 inhibitors: preliminary study.

The signalling pathway of Janus tyrosine Kinases-Signal Transducers and Activators of Transcription (JAK-STAT) is activated by a number of cytokines, hormones (GH, erythropoietin and prolactin), and growth factors. JAK-STAT signalling is involved in regulation of cell proliferation, differentiation and apoptosis. These activities are due to different members of JAK-STAT family consisting of: JAK1, JAK2, JAK3, Tyk2 and STAT1, STAT2, STAT3, STAT4, STAT5a, STAT5b, STAT6. Recent studies suggest a key role for STAT family proteins, in particular for STAT3, in selectively inducing and maintaining a pro-carcinogenic inflammatory microenvironment, that promote tumour cells transformation. Moreover, a striking correlation between cancer development/progression and STAT3 persistent activation exists, probably due to STAT3 promoting of the pro-oncogenic inflammatory pathways, like NF-kB, IL-6 and JAK family kinases. Recent study demonstrated that carbazoles can inhibit STAT3 mediated transcription. From these evidences, STAT3 represents a therapeutic target, so we have synthesized a new set of N-alkylcarbazole derivatives substituted in positions 2, 4 and 6, to evaluate their activity on STAT3. Some of these compounds showed an interesting activity as STAT3 selective inhibitors; in particular, compounds 9a 9b and 9c revealed to inhibit the STAT3 activation for the 50%, 90% and 95%, respectively.

Secondary Transobturator Tape Procedure after Combined Pelvic Organ Prolapse Repair.

A 66-year-old female who underwent a partial urethrectomy complained of severe incontinence due to intrinsic sphincter deficiency. Bone anchor surgical technique was performed, but in 3 years, serious pelvic organ prolapse had occurred. Consequently, anterior and posterior tension-free vaginal mesh operation was planned. Preoperative urodynamic examination predicted postoperative stress incontinence, and concurrent transobturator tape (TOT) surgery was performed. After 3 months, stress incontinence reoccurred, and secondary TOT was performed. Relapse was probably caused by dislocation of the first TOT towards the bladder neck. Thus, the secondary TOT was placed distal to the initial tape towards the external urethral meatus, and proper tension was applied. After the operation, stress incontinence was cured. Thus, a second TOT procedure, with proper positioning and tensioning, can effectively cure stress incontinence that occurs after an initial TOT procedure.

α-bisabolol is an effective proapoptotic agent against BCR-ABL(+) cells in synergism with Imatinib and Nilotinib.

We showed that α-bisabolol is active against primary acute leukemia cells, including BCR-ABL(+) acute lymphoblastic leukemias (ALL). Here we studied the activity of α-bisabolol against BCR-ABL(+) cells using 3 cell lines (K562, LAMA-84, CML-T1) and 10 primary BCR-ABL(+) ALL samples. We found that: (a) α-bisabolol was effective in reducing BCR-ABL(+) cell viabilty at concentrations ranging from 53 to 73 µM; (b) α-bisabolol concentrations in BCR-ABL(+) cellular compartments were 4- to 12-fold higher than in normal cells, thus indicating a preferential intake in neoplastic cells; (c) α-bisabolol displayed a slight to strong synergism with the Tyrosine Kinase Inhibitors (TKI) imatinib and nilotinib: the combination of α-bisabolol+imatinib allowed a dose reduction of each compound up to 7.2 and 9.4-fold respectively, while the combination of α-bisabolol+nilotinib up to 6.7 and 5-fold respectively; (d) α-bisabolol-induced apoptosis was associated with loss of plasma membrane integrity, irreversible opening of mitochondrial transition pore, disruption of mitochondrial potential, inhibition of oxygen consumption and increase of intracellular reactive oxygen species. These data indicate α-bisabolol as a candidate for treatment of BCR-ABL(+) leukemias to overcome resistance to TKI alone and to target leukemic cells through BCR-ABL-independent pathways.

[Combination or sequential treatment using PTH and anti-resorption therapies].

PTH increases bone formation and has an anabolic effect on bone. Antiresorptive drugs such as bishopshonateand selective estrogen receptor modulator (SERM) inhibit bone resorption and increase bone mineral density (BMD) . Efficacy of combinationtreatment with PTH and antiresorption drugshas been investigated. It has been reported that single intravenous infusion of zoledronic acid along with daily subcutaneous injection of PTH (1-34) (teriparatide) increases both spine and hip BMD. On the other hand, daily oral alendronate and daily PTH (1-84) showed no additive effects. Patients who had been treated with antiresorption drugs showed somewhat blunt but significant positive response to teriparatide. It warrants sequential therapy with teriparatide following antiresorption drugs that is common in daily practice of osteoporosis. Since a period of PTH administration is limited up to 24 months and bone mineral density starts to decreases shortly after discontinuation of PTH, sequential treatment with antiresorptive agents following PTH is highly recommended.

Videourodyanamic Examination and Tension-free Vaginal Mesh/Transobturator Tape Surgery.

Most pelvic organ prolapse (POP) patients have lower urinary tract symptoms (LUTS) before and after POP surgery. LUTS of POP patients consist of various storage and voiding symptoms from anatomical causes. Videourodynamic examination for POP patients provides accurate information about morphological findings of the bladder and urethra, and lower urinary tract (LUT) function. The leak point pressure (LPP) measurement at cough maneuver in the standing position is important to detect urodynamic stress urinary incontinences (UDS SUI). Prolapse reduction procedure is not perfect for the detection of SUI.