Serum biomarkers correlated with liver stiffness assessed in a multicenter study of pediatric cholestatic liver disease.

BACKGROUND AND AIMS: Detailed investigation of the biological pathways leading to hepatic fibrosis and identification of liver fibrosis biomarkers may facilitate early interventions for pediatric cholestasis. APPROACH AND RESULTS: A targeted enzyme-linked immunosorbent assay-based panel of nine biomarkers (lysyl oxidase, tissue inhibitor matrix metalloproteinase (MMP) 1, connective tissue growth factor [CTGF], IL-8, endoglin, periostin, Mac-2-binding protein, MMP-3, and MMP-7) was examined in children with biliary atresia (BA; n = 187), alpha-1 antitrypsin deficiency (A1AT; n = 78), and Alagille syndrome (ALGS; n = 65) and correlated with liver stiffness (LSM) and biochemical measures of liver disease. Median age and LSM were 9 years and 9.5 kPa. After adjusting for covariates, there were positive correlations among LSM and endoglin ( p = 0.04) and IL-8 ( p < 0.001) and MMP-7 ( p < 0.001) in participants with BA. The best prediction model for LSM in BA using clinical and lab measurements had an R2 = 0.437; adding IL-8 and MMP-7 improved R2 to 0.523 and 0.526 (both p < 0.0001). In participants with A1AT, CTGF and LSM were negatively correlated ( p = 0.004); adding CTGF to an LSM prediction model improved R2 from 0.524 to 0.577 ( p = 0.0033). Biomarkers did not correlate with LSM in ALGS. A significant number of biomarker/lab correlations were found in participants with BA but not those with A1AT or ALGS. CONCLUSIONS: Endoglin, IL-8, and MMP-7 significantly correlate with increased LSM in children with BA, whereas CTGF inversely correlates with LSM in participants with A1AT; these biomarkers appear to enhance prediction of LSM beyond clinical tests. Future disease-specific investigations of change in these biomarkers over time and as predictors of clinical outcomes will be important.

Utilization of p53 and p16 Immunohistochemistry in the Classification of Human Papillomavirus-Associated, p53 Wild-Type, and p53 Abnormal Oral Epithelial Dysplasia.

p53 immunohistochemistry (IHC) has recently been shown to be a clinically useful marker for predicting risk of progression to invasive squamous cell carcinoma in oral epithelial dysplasia (OED). The literature supports the use of p53 IHC as a marker to identify TP53 mutation in in situ and invasive vulvar lesions and as a surrogate marker for high-risk human papillomavirus (HPV) infection, but there is little documentation for similar use in OED. The purpose of this study was to determine whether p53 IHC is a reliable surrogate marker for detecting both TP53 mutation and high-risk HPV infection in OED. We studied 57 cases of OED (11 mild, 18 moderate, and 28 severe), and all were stained for p16 and p53 IHC. High-risk HPV RNA in situ hybridization (ISH) was performed in selected cases (all p16-positive cases and all OED showing abundant apoptotic cells and karyorrhectic cells; N = 27). Targeted next-generation sequencing (NGS) was performed in 33 p16-negative cases and all high-risk HPV RNA ISH-negative cases (N = 36). We identified 21 cases with p53 basal sparing patterns (mid-epithelial and markedly reduced [null-like]), 14 cases with p53 wild-type patterns (scattered basal and patchy basal/parabasal), and 22 cases with p53 abnormal patterns (18 overexpression, 3 null, and 1 novel cytoplasmic pattern). Among cases with p53 basal sparing patterns, 20 were positive for p16 (20/21, 95%), and all were positive for high-risk HPV RNA ISH (21/21, 100%). The 36 sequenced cases had IHC patterns concordant with TP53 mutation status in 92% (33/36) of lesions. This study demonstrates that p53 IHC expression patterns are sensitive and specific for detection of both high-risk HPV infection and TP53 mutation. Coupled with selective p16 IHC testing, this IHC panel can accurately subclassify OED into HPV-associated, p53 wild-type (conventional), and p53 abnormal OED.

Mycobacterium chimaera Encephalitis Following Cardiac Surgery: A New Syndrome.

We report the cases of 3 patients with fatal, disseminated Mycobacterium chimaera infections following cardiac surgeries. Progressive neurocognitive decline and death were explained by active granulomatous encephalitis, with widespread involvement of other organs. This syndrome is clinically elusive and, thus, may have caused deaths in prior reported series.

Investigation of the Rosenbaum Concussion Knowledge and Attitudes Survey in Collegiate Athletes.

OBJECTIVE: The purpose of this study is to determine whether the Rosenbaum Concussion Knowledge and Attitudes Survey (RoCKAS) is an appropriate outcome measure to assess knowledge and attitudes toward concussion in collegiate student-athletes as determined through validity and reliability testing. STUDY DESIGN: Convenience study. SETTING: The researcher recruited all athletic teams at a Division III National Collegiate Athletic Association institution. PARTICIPANTS: Four hundred thirty-three collegiate student-athletes, 18 years of age or older, from a variety of sports took part in this study. As the validity of RoCKAS has never been established for the target population, this study randomly split respondents into 2 studies. INTERVENTIONS: Participants in this study completed the RoCKAS during preseason meetings before concussion education. The primary researcher was not present during the completion of the survey to allow participants to answer honestly without concern of coercion. MAIN OUTCOME MEASURES: A paper-based Rosenbaum Concussion Knowledge and Attitudes Survey. RESULTS: The Concussion Knowledge Index (CKI) was distributed in 2 cluster constructs and identified variables of low and high difficulty. Multivariate statistical analysis of the Concussion Attitude Index (CAI) explains 68.79% of the total variance. The Confirmatory Factor Analysis did not confirm the hypothesis that similar constructs can be found between data sets ((Equation is included in full-text article.)= 207.902; consistent akaike information criterion = 391.550; root mean square error of approximation = 0.125, and goodness of fit index = 0.868). CONCLUSIONS: The CKI is a valid and reliable measure in collegiate student-athletes. However, the results of the Confirmatory Factor Analysis indicated a poor model fit and improper correlations between attitude items. Therefore, the CAI may not be a sound outcome measure of collegiate student-athlete's attitudes toward concussions.

Multiplexed color-coded probe-based gene expression assessment for clinical molecular diagnostics in formalin-fixed paraffin-embedded human renal allograft tissue.

Histopathologic diagnoses in transplantation can be improved with molecular testing. Preferably, molecular diagnostics should fit into standard-of-care workflows for transplant biopsies, that is, formalin-fixed paraffin-embedded (FFPE) processing. The NanoString(®) gene expression platform has recently been shown to work with FFPE samples. We aimed to evaluate its methodological robustness and feasibility for gene expression studies in human FFPE renal allograft samples. A literature-derived antibody-mediated rejection (ABMR) 34-gene set, comprised of endothelial, NK cell, and inflammation transcripts, was analyzed in different retrospective biopsy cohorts and showed potential to molecularly discriminate ABMR cases, including FFPE samples. NanoString(®) results were reproducible across a range of RNA input quantities (r = 0.998), with different operators (r = 0.998), and between different reagent lots (r = 0.983). There was moderate correlation between NanoString(®) with FFPE tissue and quantitative reverse transcription polymerase chain reaction (qRT-PCR) with corresponding dedicated fresh-stabilized tissue (r = 0.487). Better overall correlation with histology was observed with NanoString(®) (r = 0.354) than with qRT-PCR (r = 0.146). Our results demonstrate the feasibility of multiplexed gene expression quantification from FFPE renal allograft tissue. This represents a method for prospective and retrospective validation of molecular diagnostics and its adoption in clinical transplantation pathology.

Pyrroles as antioxidants: solvent effects and the nature of the attacking radical on antioxidant activities and mechanisms of pyrroles, dipyrrinones, and bile pigments.

The absolute rate constants, k(inh), and stoichiometric factors, n, of pyrroles, 2-methyl-3-ethylcarboxy-4,5-di-p-methoxyphenylpyrrole, 6, 2,3,4,5-tetraphenylpyrrole, 7, and 2,3,4,5-tetra-p-methoxyphenylpyrrole, 8, compared to the phenolic antioxidant, di-tert-butylhydroxyanisole, DBHA, during inhibited oxidation of cumene initiated by AIBN at 30 degrees C gave the relative antioxidant activities (k(inh)) DBHA > 8 > 7 > 6 and n = 2, whereas in styrene, 8 > DBHA. These results are explained by hydrogen atom transfer, HAT, from the N-H of pyrroles to ROO(*) radicals. The k(inh) values in styrene of dimethyl esters of the bile pigments of bilirubin ester (BRDE), of biliverdin ester (BVDE), and of a model compound (dipyrrinone, 1) gave k(inh) in the order pentamethylhydroxychroman (PMHC) >> BRDE > 1 > BVDE. These antioxidant activities for BVDE and the model compound, 1, and PMHC dropped dramatically in the presence of methanol due to hydrogen bonding at the pyrrolic N-H group. In contrast the k(inh) of BRDE increased in methanol. We now show that pyrrolic compounds may react by HAT, proton-coupled electron transfer, PCET, or single electron transfer, SET, depending on their structure, the nature of the solvent, and the attacking radical. Compounds BVDE and 1 react by the HAT or PCET pathway (HAT/PCET) in styrene/chlorobenzene with ROO(*) and with the DPPH(*) radical in chlorobenzene according to N-H/N-D kH/kD of 1.6, whereas the DKIE with BRDE was only 1.2 with ROO(*). The antioxidant properties of polypyrroles of the BVDE class and model compounds (e.g., 1) are controlled by intramolecular H bonding which stabilizes an intermediate pyrrolic radical in HAT/PCET. According to kinetic polar solvent effects on the monopyrrole, 8, and BRDE, which gave increased rates in methanol, some pyrrolic structures are also susceptible to SET reactions. This conclusion is supported by some calculated ionization potentials. The antioxidant mechanism for BRDE with peroxyl radicals is described by the PCET reaction. Experiments using the 2,6-di-tert-butyl-4-(4'-methoxyphenyl)phenoxyl radical (DBMP(*)) showed this to be a better radical to monitor HAT activities in stopped-flow kinetics compared to the use of the more popular DPPH(*) radical.

Does positive youth development predict adolescent attitudes about sexuality?

The purpose of this study was to explore the relationships among individual factors, parental factors, involvement in activities, and adolescent attitudes regarding sex (the outcome variable). We suggest that Positive Youth Development (PYD) research and programming should include promoting healthy sexuality as an important developmental outcome for youth. PYD philosophy and theory, bioecological theory (Bronfenbrenner & Morris, 1998), and identity development theory (Erikson, 1983, 1968; Marcia, 1980, 1993) provided the foundation for this study and were used to make the connections between PYD, adolescent sexuality (including attitudes and behavior), and aspects of the parent-adolescent relationship. Both self-esteem and sexual experience were significant predictors of attitudes regarding sex, but overall, parents contributed the most influence on the outcome variable. (It should be noted, however, that parental influence was the only factor that was a significant predictor.) Only one of the two involvements in activities variables was a significant predictor of attitudes regarding sex.

Molecular Profiling of Hyalinizing Clear Cell Carcinomas Revealed a Subset of Tumors Harboring a Novel EWSR1-CREM Fusion: Report of 3 Cases.

We describe a novel gene fusion, EWSR1-CREM, identified in 3 cases of clear cell carcinoma (CCC) using anchored multiplex polymerase chain reaction, a next-generation sequencing-based technique. CCC is a low-grade salivary tumor recently characterized to have EWSR1-ATF1 fusions in the majority of cases. Three cases of malignant tumor presenting in the base of tongue, lung, and nasopharynx were studied. All cases shared a clear cell morphology with hyalinized stroma, presence of mucin and p63 positivity and were initially diagnosed as mucoepidermoid carcinoma but were negative for evidence of any of the expected gene fusions. Anchored multiplex polymerase chain reaction demonstrated a EWSR1-CREM fusion in all 3 cases to confirm a diagnosis of CCC. This finding is biologically justified as CREM and ATF1 both belong to the CREB family of transcription factors. EWSR1-CREM fusions have not been previously reported in CCC and have only rarely been reported in other tumors. We show that the ability to discover novel gene variants with next-generation sequencing-based assays has clinical utility in the pathologic classification of fusion gene-associated tumors.

Personalized oncogenomic analysis of metastatic adenoid cystic carcinoma: using whole-genome sequencing to inform clinical decision-making.

Metastatic adenoid cystic carcinomas (ACCs) can cause significant morbidity and mortality. Because of their slow growth and relative rarity, there is limited evidence for systemic therapy regimens. Recently, molecular profiling studies have begun to reveal the genetic landscape of these poorly understood cancers, and new treatment possibilities are beginning to emerge. The objective is to use whole-genome and transcriptome sequencing and analysis to better understand the genetic alterations underlying the pathology of metastatic and rare ACCs and determine potentially actionable therapeutic targets. We report five cases of metastatic ACC, not originating in the salivary glands, in patients enrolled in the Personalized Oncogenomics (POG) Program at the BC Cancer Agency. Genomic workup included whole-genome and transcriptome sequencing, detailed analysis of tumor alterations, and integration with existing knowledge of drug-target combinations to identify potential therapeutic targets. Analysis reveals low mutational burden in these five ACC cases, and mutation signatures that are commonly observed in multiple cancer types. Notably, the only recurrent structural aberration identified was the well-described MYB-NFIB fusion that was present in four of five cases, and one case exhibited a closely related MYBL1-NFIB fusion. Recurrent mutations were also identified in BAP1 and BCOR, with additional mutations in individual samples affecting NOTCH1 and the epigenetic regulators ARID2, SMARCA2, and SMARCB1. Copy changes were rare, and they included amplification of MYC and homozygous loss of CDKN2A in individual samples. Genomic analysis revealed therapeutic targets in all five cases and served to inform a therapeutic choice in three of the cases to date.

A CLINICAL GUIDE TO THE ASSESSMENT AND TREATMENT OF BREATHING PATTERN DISORDERS IN THE PHYSICALLY ACTIVE: PART 1.

BACKGROUND: Appropriate assessment and interventions for breathing patterns prior to assessment of the patient's musculoskeletal complaint may be beneficial. Breathing pattern disorders (BPDs) are remediable and influenced by biochemical, biomechanical, psychological, and/or unknown factors. The purpose of this clinical commentary is to demonstrate the integratration of a BPD assessment into a standard clinical musculoskeletal orthopedic examination. CLINICAL ASSESSMENT: The observation of a patient's breathing pattern begins when they enter the clinic, is followed by palpation and orthopedic tests, which allows for proper classification of BPDs. OUTCOMES: Disease-oriented measures guide the assessment and classification of BPD, while patient-oriented measures describe clinically important differences among patient values. CLASSIFICATION: There are many possible variations of classifications of BPD, however, six primary dysfunctions found in the literature have become the foundation of the BPD assessment. DISCUSSION AND CONCLUSION: Restoring proper breathing mechanics and neuromuscular motor control patterns during breathing may result in a decrease in pain, improved patient outcomes, and overall patient well being associated with their primary musculoskeletal complaint. A comprehensive evaluation of breathing patterns, as a part of an orthopedic examination, may guide a clinician in providing effective and appropriate treatments to decrease pain and improve function. LEVEL OF EVIDENCE: 5.

A CLINICAL GUIDE TO THE ASSESSMENT AND TREATMENT OF BREATHING PATTERN DISORDERS IN THE PHYSICALLY ACTIVE: PART 2, A CASE SERIES.

INTRODUCTION: Breathing pattern disorders (BPDs) are characterized by persistent, suboptimal breathing strategies that may result in additional musculoskeletal pain and/or dysfunction. The purpose of this case series was to examine the effects of Primal Reflex Release Technique (PRRT) and breathing exercise interventions in physically active individuals that presented with a primary complaint of musculoskeletal pain, a BPD, and startle reflexes. SUBJECTS: The assessment techniques described in Part 1 of this series were used to identify three student athletes (aged 16-22) who presented with musculoskeletal pain of the low back, mid back, and knee, BPDs, and startle reflexes. The subjects were unable to identify an apparent source of their pain. INTERVENTION: The clinician's classification of the subject's breathing patterns guided intervention(s). Each subject was treated once with PRRT and/or a breathing reflex triggering exercise. RESULTS: Each of the three subjects demonstrated clinically important improvements on the numerical pain rating scale specific to their tender areas and/or with their primary musculoskeletal complaint. DISCUSSION: These findings suggest that it may be useful to assess for a BPD and startle reflexes along with a standard orthopedic evaluation in the physically active athlete. Treatment of BPD's may positively impact musculoskeletal pain and/or dysfunction. Further research is needed to understand the effects of treatment of BPD's and how these effects relate to musculoskeletal dysfunction. SUMMARY: The prevalence of BPD with startle reflexes is unknown and implications regarding the assessment for and treatment of BPD has limited research; however, positive results were demonstrated for the three subjects after normalizing breathing patterns. LEVEL OF EVIDENCE: 4.

Pulmonary hyalinizing granuloma with associated elevation in serum and tissue IgG4 occurring in a patient with a history of sarcoidosis.

Pulmonary hyalinizing granulomas (PHGs) are unusual fibrosclerotic inflammatory lung lesions. The organ-based manifestations of the recently defined IgG4-related sclerosing disease typically show dense fibrosis and heavy lymphoplasmacytic infiltrates. IgG4-related sclerosing disease is also defined by increased serum IgG4 levels and increased tissue levels of IgG4-positive plasma cells. The morphologic features of PHG overlap with those seen in IgG4-related sclerosing disease, and this suggests that PHG may be a form of IgG4-related sclerosing disease. We present a case of a 51-year-old man with a history of sarcoidosis who presented with slowly enlarging pulmonary nodules. Histologic evaluation of one of the nodules yielded a diagnosis of PHG. Further investigation demonstrated both elevated serum IgG4 and elevated tissue IgG4-positive plasma cells in the PHG. In previous reports, lesions that are now considered part of IgG4-related sclerosing disease were documented in patients also diagnosed with PHG, although these reports date from before the description of IgG4 sclerosing disease. This case provides the first definitive evidence that PHG is part of the spectrum of IgG4-related sclerosing disease.

Pulmonary alveolar proteinosis as a reaction to fentanyl patch smoke.

We report a patient who developed shortness of breath and systemic symptoms after starting to smoke fentanyl patches. CT scan showed ground glass centrilobular nodules, and biopsy demonstrated alveolar proteinosis. Her symptoms disappeared and her chest imaging changes largely resolved when she stopped smoking the patches. Alveolar proteinosis is an uncommon drug reaction and in this case presented in a very unusual fashion as an inhalation injury.

A 15 year old boy with a posterior fossa tumor.

A 15 year old male presented with hydrocephalus from a tectal mass obstructing the cerebral aqueduct and upper fourth ventricle. The solid-cystic partly enhancing mass proved to be a pigmented pleomorphic xanthoastrocytoma, the third such example reported. The lesion revealed typical features of a PXA with the unusual addition of intracytoplasmic melanin in select lesional cells. Melanin pigment production is uncommon in glial tumors and of uncertain significance. The present case is recurrence-free one year post-operatively.

Synthesis and reactivity of a dipyrrinatolithium complex.

The synthesis and characterization of the first dipyrrinato-alkali-metal complex is reported herein. The novel reactivity of this lithium complex is demonstrated in the preparation, isolation, and characterization of a heteroleptic zinc(II) complex in high yield.