Two Cases of Sporadic Amyotrophic Lateral Sclerosis With Contrasting Clinical Phenotypes: Genetic Insights.

Amyotrophic lateral sclerosis (ALS) is a fatal neuromuscular disease that affects individuals of diverse racial and ethnic backgrounds. There is currently no cure for ALS, and the number of efficient disease-modifying drugs for ALS is limited to a few, despite the large number of clinical trials conducted in recent years. The latter could be attributed to the significant heterogeneity of ALS clinical phenotypes even in their familial forms. To address this issue, we conducted postmortem genetic screening of two female patients with sporadic ALS (sALS) and contrasting clinical phenotypes. The results demonstrated that despite their contrasting clinical phenotypes, both patients had rare pathologic/deleterious mutations in five genes: ACSM5, BBS12, HLA-DQB1, MUC20, and OBSCN, with mutations in three of those genes being identical: BBS12, HLA-DQB1, and MUC20. Additional groups of mutated genes linked to ALS, other neurologic disorders, and ALS-related pathologies were also identified. These data are consistent with a hypothesis that an individual could be primed for ALS via mutations in a specific set of genes not directly linked to ALS. The disease could be initiated by a concerted action of several mutated genes linked to ALS and the disease's clinical phenotype will evolve further through accessory gene mutations associated with other neurological disorders and ALS-related pathologies.

Nutritional Strategies in the Rehabilitation of Musculoskeletal Injuries in Athletes: A Systematic Integrative Review.

It is estimated that three to five million sports injuries occur worldwide each year. The highest incidence is reported during competition periods with mainly affectation of the musculoskeletal tissue. For appropriate nutritional management and correct use of nutritional supplements, it is important to individualize based on clinical effects and know the adaptive response during the rehabilitation phase after a sports injury in athletes. Therefore, the aim of this PRISMA in Exercise, Rehabilitation, Sport Medicine and Sports Science PERSiST-based systematic integrative review was to perform an update on nutritional strategies during the rehabilitation phase of musculoskeletal injuries in elite athletes. After searching the following databases: PubMed/Medline, Scopus, PEDro, and Google Scholar, a total of 18 studies met the inclusion criteria (Price Index: 66.6%). The risk of bias assessment for randomized controlled trials was performed using the RoB 2.0 tool while review articles were evaluated using the AMSTAR 2.0 items. Based on the main findings of the selected studies, nutritional strategies that benefit the rehabilitation process in injured athletes include balanced energy intake, and a high-protein and carbohydrate-rich diet. Supportive supervision should be provided to avoid low energy availability. The potential of supplementation with collagen, creatine monohydrate, omega-3 (fish oils), and vitamin D requires further research although the effects are quite promising. It is worth noting the lack of clinical research in injured athletes and the higher number of reviews in the last 10 years. After analyzing the current quantitative and non-quantitative evidence, we encourage researchers to conduct further clinical research studies evaluating doses of the discussed nutrients during the rehabilitation process to confirm findings, but also follow international guidelines at the time to review scientific literature.

A diagnostic model for overweight and obesity from untargeted urine metabolomics of soldiers.

Soldiers in active military service need optimal physical fitness for successfully carrying out their operations. Therefore, their health status is regularly checked by army doctors. These inspections include physical parameters such as the body-mass index (BMI), functional tests, and biochemical studies. If a medical exam reveals an individual's excess weight, further examinations are made, and corrective actions for weight lowering are initiated. The collection of urine is non-invasive and therefore attractive for frequent metabolic screening. We compared the chemical profiles of urinary samples of 146 normal weight, excess weight, and obese soldiers of the Mexican Army, using untargeted metabolomics with liquid chromatography coupled to high-resolution mass spectrometry (LC-MS). In combination with data mining, statistical and metabolic pathway analyses suggest increased S-adenosyl-L-methionine (SAM) levels and changes of amino acid metabolites as important variables for overfeeding. We will use these potential biomarkers for the ongoing metabolic monitoring of soldiers in active service. In addition, after validation of our results, we will develop biochemical screening tests that are also suitable for civil applications.

Neuropathology of Pediatric SARS-CoV-2 Infection in the Forensic Setting: Novel Application of Ex Vivo Imaging in Analysis of Brain Microvasculature.

Two years into the COVID-19 pandemic, there are few published accounts of postmortem SARS-CoV-2 pathology in children. We report 8 such cases (4 infants aged 7-36 weeks, 4 children aged 5-15 years). Four underwent ex vivo magnetic resonance neuroimaging, to assist in identification of subtle lesions related to vascular compromise. All infants were found unresponsive (3 in unsafe sleeping conditions); all but 1 had recent rhinitis and/or influenza-like illness (ILI) in the family; 1 had history of sickle cell disease. Ex vivo neuroimaging in 1 case revealed white matter (WM) signal hyperintensity and diffuse exaggeration of perivascular spaces, corresponding microscopically to WM mineralization. Neurohistology in the remaining 3 infants variably encompassed WM gliosis and mineralization; brainstem gliosis; perivascular vacuolization; perivascular lymphocytes and brainstem microglia. One had ectopic hippocampal neurons (with pathogenic variant in DEPDC5). Among the children, 3 had underlying conditions (e.g., obesity, metabolic disease, autism) and all presented with ILI. Three had laboratory testing suggesting multisystem inflammatory syndrome (MIS-C). Two were hospitalized for critical care including mechanical ventilation and extracorporeal membrane oxygenation (ECMO); one (co-infected with adenovirus) developed right carotid stroke ipsilateral to the ECMO cannula and the other required surgery for an ingested foreign body. Autopsy findings included: acute lung injury in 3 (1 with microthrombi); and one each with diabetic ketoacidosis and cardiac hypertrophy; coronary and cerebral arteritis and aortitis, resembling Kawasaki disease; and neuronal storage and enlarged fatty liver. All 4 children had subtle meningoencephalitis, focally involving the brainstem. On ex vivo neuroimaging, 1 had focal pontine susceptibility with corresponding perivascular inflammation/expanded perivascular spaces on histopathology. Results suggest SARS-CoV-2 in infants may present as sudden unexpected infant death, while in older children, signs and symptoms point to severe disease. Underlying conditions may predispose to fatal outcomes. As in adults, the neuropathologic changes may be subtle, with vascular changes such as perivascular vacuolization and gliosis alongside sparse perivascular lymphocytes. Detection of subtle vascular pathology is enhanced by ex vivo neuroimaging. Additional analysis of the peripheral/autonomic nervous system and investigation of co-infection in children with COVID-19 is necessary to understand risk for cardiovascular collapse/sudden death.

Story of the solitary subependymal giant cell astrocytoma: A case report and literature review.

Subependymal giant cell astrocytoma (SEGA) is the characteristic benign, slow-growing brain tumor seen in tuberous sclerosis (TS). There are several case reports of a diagnosis of SEGA in patients with no clinical or radiological diagnosis of TS. However, there is limited literature describing the tumor genetics in such cases. We report a case of a 17-year-old girl who was diagnosed with SEGA bearing the TSC2 mutation, while testing negative for TSC mutations on germline testing. We also did a literature review of studies that reported the genetics behind solitary SEGAs. Genetic testing of both the tumor itself and germline genetic testing can provide valuable information with clinical implications, for example, the basis for the need of close surveillance in TS patients.

Hirschsprung Disease in an Infant with L1 syndrome: Report of a New Case and a novel L1CAM variant.

L1syndrome is an X-linked disorder manifesting with congenital hydrocephalus, adducted thumbs and spasticity. There are rare cases of L1 syndrome and coincident Hirschsprung disease, with mutations in the L1CAM gene thought to underlie both. We present a novel pathogenic L1CAM variant in someone with L1 syndrome and Hirschsprung disease.

Dissemination Patterns and Short-Term Management of Multifocal Rosette-Forming Glioneuronal Tumors.

BACKGROUND: Multifocal rosette-forming glioneuronal tumors (RGNTs) are challenging to manage. Gross total resection is often impossible, and data on adjunctive therapies are limited. We reviewed cases of multifocal RGNTs in the literature with special focus on dissemination patterns and management. METHODS: A literature review was conducted using PubMed and the key words "(multifocal OR multicentric OR satellite OR dissemination) AND glioneuronal." RESULTS: There were 21 cases of multifocal RGNTs identified. Follow-up was available in 18 cases at a median of 17 months. Progression-free survival and overall survival at 1 year were 84% and 94%, respectively. Of all cases, 43% had cerebrospinal fluid (CSF) dissemination, 48% had intraparenchymal spread, and 10% had both. The presence of CSF dissemination led to palliative care and/or death in 20% of cases (n = 2). None of the cases with intraparenchymal spread progressed. Radiotherapy was used in 50% of cases with CSF dissemination, chemotherapy was used in 20%, and CSF shunting was used in 36%. No tumors with intraparenchymal spread required adjunctive therapy or shunting. CONCLUSIONS: RGNTs with CSF dissemination are more likely to behave aggressively, and early adjunctive therapies should be discussed with patients. Tumors with intraparenchymal spread grow slowly, and maximal safe resection followed by observation is likely sufficient in the short term. Long-term behavior of multifocal RGNTs is still unclear.

Enhanced Efficacy and Increased Long-Term Toxicity of CNS-Directed, AAV-Based Combination Therapy for Krabbe Disease.

Infantile globoid cell leukodystrophy (GLD, Krabbe disease) is a demyelinating disease caused by the deficiency of the lysosomal enzyme galactosylceramidase (GALC) and the progressive accumulation of the toxic metabolite psychosine. We showed previously that central nervous system (CNS)-directed, adeno-associated virus (AAV)2/5-mediated gene therapy synergized with bone marrow transplantation and substrate reduction therapy (SRT) to greatly increase therapeutic efficacy in the murine model of Krabbe disease (Twitcher). However, motor deficits remained largely refractory to treatment. In the current study, we replaced AAV2/5 with an AAV2/9 vector. This single change significantly improved several endpoints primarily associated with motor function. However, nearly all (14/16) of the combination-treated Twitcher mice and all (19/19) of the combination-treated wild-type mice developed hepatocellular carcinoma (HCC). 10 out of 10 tumors analyzed had AAV integrations within the Rian locus. Several animals had additional integrations within or near genes that regulate cell growth or death, are known or potential tumor suppressors, or are associated with poor prognosis in human HCC. Finally, the substrate reduction drug L-cycloserine significantly decreased the level of the pro-apoptotic ceramide 18:0. These data demonstrate the value of AAV-based combination therapy for Krabbe disease. However, they also suggest that other therapies or co-morbidities must be taken into account before AAV-mediated gene therapy is considered for human therapeutic trials.

Narrowing down the Common Cytogenetic Deletion 14q to a 5.6-Mb Critical Region in 1p/19q Codeletion Oligodendroglioma-Relapsed Patients Points to Two Potential Relapse-Related Genes: SEL1L and STON2.

Based on a literature review and our database, we report on the smallest 14q deletion identified in a brain tumor characterized by 1p/19q codeletion low-grade oligodendroglioma. In 2013, array-comparative genomic hybridization of the brain tumor revealed 1p/19q codeletion as a sole abnormality. In 2019, the patient relapsed showing additional abnormalities including a 14q deletion of 16.5 Mb at 14q24.2q31.3. This region overlaps with 2 previously identified minimal regions, 14q21.2q24.3 and 14q31.3q32.1, based on 142 cases of glioma. The authors reported no correlation between these 2 regions and survival. By extracting these 2 regions from our patient's deletion and comparing it to 12 other cases of 1p/19q codeletion oligodendrogliomas reported in the literature, we narrowed down the 14q loss possible critical region to 5.6 Mb mapping at 14q31.1q31.2. This region contains 2 potential relapse-related genes: SEL1L and STON2.

Bacillus toyonensis COPE52 Modifies Lipid and Fatty Acid Composition, Exhibits Antifungal Activity, and Stimulates Growth of Tomato Plants Under Saline Conditions.

Salinity is one of the most important factors that limit the productivity of agricultural soils. Certain plant growth-promoting bacteria (PGPB) have the ability to stimulate the growth of crop plants even under salt stress. In the present study, we analysed the potential of PGPB Bacillus toyonensis COPE52 to improve the growth of tomato plants and its capacity to modify its membrane lipid and fatty acid composition under salt stress. Thus, strain COPE52 increased the relative amount of branched chain fatty acids (15:0i and 16:1∆9) and accumulation of an unknown membrane lipid, while phosphatidylethanolamine (PE) levels decreased during growth with 100 and 200 mM NaCl. Importantly, direct and indirect plant growth-promoting (PGP) mechanisms of B. toyonensis COPE52, such as indole-3-acetic acid (IAA), protease activity, biofilm formation, and antifungal activity against Botrytis cinerea, remained unchanged in the presence of NaCl in vitro, compared to controls without salt. In a greenhouse experiment, tomato plants (Lycopersicon esculentum 'Saladette') showed increased shoot and root length, higher dry biomass, and chlorophyll content when inoculated with B. toyonensis COPE52 at 0 and 100 mM NaCl. In summary, these results indicate that Bacillus toyonensis COPE52 can modify cell membrane lipid components as a potential protecting mechanism to maintain PGP traits under saline-soil conditions.

Subependymal Giant-cell Astrocytoma Masquerading as Restrictive Eating Disorder and Depression in an Adolescent.

Recent studies have shown that psychiatric symptoms might be the only primary manifestation of central nervous system malignancy. As a result, clinicians might overlook a brain tumor diagnosis due to overlying psychiatric symptoms. We herein describe an adolescent female patient without tuberous sclerosis clinical features whose primary presentation for a subependymal giant-cell astrocytoma was restrictive eating disorder, urinary incontinence, and depression. The behavioral symptoms improved significantly following tumor resection. This case illustrates that compression of the frontal lobes and hypothalamus can manifest as primary psychiatric symptoms of subacutely manifested anhedonia, appetite loss, low energy, flat affect, and depressive mood. An absence of tuberous sclerosis clinical features should not preclude a diagnosis of subependymal giant-cell astrocytoma. Clinicians should maintain an index of suspicion for a brain tumor in patients with sudden-onset restrictive eating disorder and depression.

A 26-Year-Old Woman With Diplopia and Nystagmus.

A 26-year-old woman presented for a routine contact lens evaluation but was found to have a subtle right sixth nerve paresis and adducting nystagmus of the left eye. She reported horizontal diplopia on far right gaze as well as subjective right-sided weakness and poor balance for 1 year. Brain and spinal MRI revealed multiple cystic lesions with variable enhancement throughout the posterior fossa and cervical spinal cord. These MRI findings were highly suspicious for an infectious central nervous system process, such as neurocysticercosis; however, primary or metastatic tumors were also important considerations. Tumor location and imaging characteristics were most helpful in differentiating among these etiologies. A brain biopsy ultimately established the diagnosis of a rosette-forming glioneuronal tumor.

Oral immunotherapy tolerizes mice to enzyme replacement therapy for Morquio A syndrome.

Immune response to therapeutic enzymes poses a detriment to patient safety and treatment outcome. Enzyme replacement therapy (ERT) is a standard therapeutic option for some types of mucopolysaccharidoses, including Morquio A syndrome caused by N-acetylgalactosamine-6-sulfate sulfatase (GALNS) deficiency. Current protocols tolerize patients using cytotoxic immunosuppressives, which can cause adverse effects. Here we show development of tolerance in Morquio A mice via oral delivery of peptide or GALNS for 10 days prior to ERT. Our results show that using an immunodominant peptide (I10) or the complete GALNS enzyme to orally induce tolerance to GALNS prior to ERT resulted in several improvements to ERT in mice: (a) decreased splenocyte proliferation after in vitro GALNS stimulation, (b) modulation of the cytokine secretion profile, (c) decrease in GALNS-specific IgG or IgE in plasma, (d) decreased GAG storage in liver, and (e) fewer circulating immune complexes in plasma. This model could be extrapolated to other lysosomal storage disorders in which immune response hinders ERT.

Three Novel Aberrations Involving PLAG1 Leading to Lipoblastoma in Three Different Patients: High Amplification, Partial Deletion, and a Unique Complex Rearrangement.

Lipoblastoma is a rare benign neoplasm with overlapping histology with other lipomatous tumors. Genetic aberrations including translocations of 8q and splitting of the PLAG1 probe leading to "promoter swapping" and gains of chromosome 8 or PLAG1 foci have been described in lipoblastoma. Here, we report 3 lipoblastomas revealing novel genetic aberrations involving PLAG1: a high level of PLAG1 amplification up to 50 copies in a 4-year-old girl with recurrence of a right flank mass, a partial deletion of PLAG1 with the flanking junction breakpoints involving the 3'PLAG1 and 5'HAS2 genes in a 17-month-old boy with a retroperitoneal mass, and an insertion of 2q31 into 8q11.2 and translocation of 8q to 2q with the latter translocated onto 12q leading to separation of the PLAG1 FISH probe in a 5-year-old girl with a left back mass. Our novel cytogenetic findings further expand the mechanisms of PLAG1 transcriptional upregulation in lipoblastoma pathogenesis.

Genetic ablation of acid ceramidase in Krabbe disease confirms the psychosine hypothesis and identifies a new therapeutic target.

Infantile globoid cell leukodystrophy (GLD, Krabbe disease) is a fatal demyelinating disorder caused by a deficiency in the lysosomal enzyme galactosylceramidase (GALC). GALC deficiency leads to the accumulation of the cytotoxic glycolipid, galactosylsphingosine (psychosine). Complementary evidence suggested that psychosine is synthesized via an anabolic pathway. Here, we show instead that psychosine is generated catabolically through the deacylation of galactosylceramide by acid ceramidase (ACDase). This reaction uncouples GALC deficiency from psychosine accumulation, allowing us to test the long-standing "psychosine hypothesis." We demonstrate that genetic loss of ACDase activity (Farber disease) in the GALC-deficient mouse model of human GLD (twitcher) eliminates psychosine accumulation and cures GLD. These data suggest that ACDase could be a target for substrate reduction therapy (SRT) in Krabbe patients. We show that pharmacological inhibition of ACDase activity with carmofur significantly decreases psychosine accumulation in cells from a Krabbe patient and prolongs the life span of the twitcher (Twi) mouse. Previous SRT experiments in the Twi mouse utilized l-cycloserine, which inhibits an enzyme several steps upstream of psychosine synthesis, thus altering the balance of other important lipids. Drugs that directly inhibit ACDase may have a more acceptable safety profile due to their mechanistic proximity to psychosine biogenesis. In total, these data clarify our understanding of psychosine synthesis, confirm the long-held psychosine hypothesis, and provide the impetus to discover safe and effective inhibitors of ACDase to treat Krabbe disease.

Shear wave elastography correlates with liver fibrosis scores in pediatric patients with liver disease.

BACKGROUND: While liver biopsy remains the gold standard, given the procedure risks and sampling errors, there is a need for reliable noninvasive biomarkers of hepatic fibrosis. OBJECTIVE: Determine the accuracy of two-dimensional shear wave elastography (2-D SWE) in predicting the histological severity of liver fibrosis in pediatric patients with known or suspected liver disease. MATERIALS AND METHODS: Subjects 0-18 years old with known or suspected liver disease and liver biopsy within 30 days (n=70) were included. Comparisons by 2-D SWE were made to a control group (n=79). Two-dimensional SWE was performed using the GE LOGIQ E9 system. Liver biopsy specimens were scored according to METAVIR and Ishak scoring systems using Spearman's Rho correlation. Receiver operator characteristic (ROC) analysis, Kruskal-Wallis and Mann-Whitney U tests were conducted. RESULTS: Control group median 2-D SWE measurements were lower than in subjects with any degree of liver fibrosis (P<0.001). Those with METAVIR F0 and Ishak 0 scores had significantly lower median 2-D SWE measurements (1.35 m/s; 1.36 m/s) than those with more advanced liver disease (F1-F3: 1.49-1.62 m/s; 1-4: 1.45-1.63 m/s) (P<0.05 for all), whereas the 2-D SWE in the higher scores were similar. Results did not differ between METAVIR and Ishak scores for any degree of fibrosis. Fibrosis scores moderately correlated with median 2-D SWE measurements (rs=0.43). The area under the curve for F1 compared to combined control/F0 was 0.89 (95% confidence interval [CI] 0.83-0.95; P<0.001) with sensitivity of 94.6% and specificity of 78.6%. Results for Ishak score 1 were similar. The ideal cutoff value for identifying fibrosis was determined to be 1.29 m/s. CONCLUSION: The liver 2-D SWE measurements correlated with the histological liver fibrosis scores, regardless of the histopathological scoring system, although 2-D SWE was better at identifying patients with early fibrosis, not at distinguishing among the individual fibrosis levels. Two-dimensional SWE using the GE LOGIQ US system is useful for identifying pediatric patients at risk for liver fibrosis.

Familial Adenomatous Polyposis Syndrome: An Update and Review of Extraintestinal Manifestations.

CONTEXT.­: Familial adenomatous polyposis (FAP) is a rare genetic disorder with autosomal dominant inheritance, defined by numerous adenomatous polyps, which inevitably progress to colorectal carcinoma unless detected and managed early. Greater than 70% of patients with this syndrome also develop extraintestinal manifestations, such as multiple osteomas, dental abnormalities, and a variety of other lesions located throughout the body. These manifestations have historically been subcategorized as Gardner syndrome, Turcot syndrome, or gastric adenocarcinoma and proximal polyposis of the stomach. Recent studies, however, correlate the severity of gastrointestinal disease and the prominence of extraintestinal findings to specific mutations within the adenomatous polyposis coli gene (APC), supporting a spectrum of disease as opposed to subcategorization. Advances in immunohistochemical and molecular techniques shed new light on the origin, classification, and progression risk of different entities associated with FAP. OBJECTIVE.­: To provide a comprehensive clinicopathologic review of neoplastic and nonneoplastic entities associated with FAP syndrome, with emphasis on recent developments in immunohistochemical and molecular profiles of extraintestinal manifestations in the thyroid, skin, soft tissue, bone, central nervous system, liver, and pancreas, and the subsequent changes in classification schemes and risk stratification. DATA SOURCES.­: This review will be based on peer-reviewed literature and the authors' experiences. CONCLUSIONS.­: In this review we will provide an update on the clinicopathologic manifestations, immunohistochemical profiles, molecular features, and prognosis of entities seen in FAP, with a focus on routine recognition and appropriate workup of extraintestinal manifestations.

Diseño, validación y aplicación de un instrumento de evaluación de las competencias profesionales para realizar las funciones esenciales de la salud pública / Design, validation and application of an instrument for the evaluation of the professional competences for making the essential functions of public health

Introducción: Las funciones esenciales de la salud pública se han definido como las condiciones que permiten un mejor desempeño de su práctica. Competencia profesional es un conjunto de conocimientos, habilidades y actitudes necesarias para que un profesional de la salud pública desarrolle adecuadamente las funciones y actividades que le son propias. Objetivo: Diseñar, validar y aplicar un instrumento para evaluar las competencias profesionales necesarias para realizar las funciones esenciales de la salud pública que poseen los graduados de los cursos de posgrado en salud pública de la Escuela Militar de Graduados de Sanidad. Sujetos y métodos: Se realizó un estudio observacional, analítico y transversal, y se analizó estadísticamente. Resultados: Se diseñó un instrumento con excelente validez de contenido (IVC = 0,94) y fiabilidad elevada (alfa de Cronbach = 0,94). El 81,59% de los graduados de la Maestría en Salud Pública tenía las 56 competencias profesionales necesarias para realizar las funciones esenciales de la salud pública. Por otro lado, el 53,21% de graduados del Curso Técnico Especializado en Salud Pública las tenía. Conclusiones: Se diseñó un instrumento válido y fiable para evaluar las competencias profesionales para realizar las funciones esenciales de la salud pública, y se evaluaron dichas competencias en los graduados de los cursos de posgrado en salud pública. Este instrumento, adaptado a circunstancias particulares, puede aplicarse a otros cursos de posgrado en salud pública

Introduction: The essential functions of public health have been defined as the conditions that allow a better performance of the practice of public health. Professional competence is a set of knowledge, skills and attitudes necessary for a public health professional to adequately develop the functions and activities that are his own. Aim: To design, validate and apply an instrument to evaluate the professional competences necessary to perform the essential functions of public health, possessed by graduates of postgraduate courses in public health of the Military School of Graduates of Health. Subjects and methods: An observational, analytical and transversal study was carried out. It was analyzed statistically. Results: An instrument with excellent content validity (IVC = 0.94) and high reliability (Cronbach’s alpha = 0.94) was designed. 81.59% of the graduates of the master’s degree in public health had the 56 professional competences necessary to carry out the essential functions of public health. On the other hand, 53.21% of graduates of the technical course specialized in public health had them. Conclusions: A valid and reliable instrument was designed to evaluate the professional competences to carry out the essential functions of public health and those competences were evaluated in the graduates of the postgraduate courses in public health. This instrument, adapted to particular circumstances, can be applied to other postgraduate courses in public health

Peritoneal Nodules in a Pediatric Patient with Benign Teratoma. A Case Report and Review of Literature.

BACKGROUND: Mature ovarian teratomas are common in children. These well differentiated tumors are typically confined to the ovary. In rare cases, they can rupture leading to granulomatous peritonitis that mimics carcinomatosis. Ovarian tumors with peritoneal/omental implants suggest malignant pathology with a different prognosis. CASE: A 15-year-old girl presented with 5 months of abdominal pain, and weight loss. Computed tomography (CT) imaging of the abdomen revealed a large mass filling the abdomen. Slightly elevated lactate dehydrogenase (LDH) and carcinoma antigen 125 (CA125). On laparotomy an ovarian tumor with peritoneal and omental implants was identified. Left salpingo-oophorectomy, omentectomy, and peritoneal washing were performed. Pathology revealed a benign cystic teratoma. SUMMARY AND CONCLUSION: Although ovarian teratomas are typically benign, they might mimic carcinomatosis. In patients with unexpected finding of peritoneal implants, histologic diagnosis is recommended before proceeding with a full oncologic ovarian resection.

No Gut No Gain! Enteral Bile Acid Treatment Preserves Gut Growth but Not Parenteral Nutrition-Associated Liver Injury in a Novel Extensive Short Bowel Animal Model.

BACKGROUND: Parenteral nutrition (PN) provides nutrition intravenously; however, this life-saving therapy is associated with significant liver disease. Recent evidence indicates improvement in PN-associated injury in animals with intact gut treated with enteral bile acid (BA), chenodeoxycholic acid (CDCA), and a gut farnesoid X receptor (FXR) agonist, which drives the gut-liver cross talk (GLCT). We hypothesized that similar improvement could be translated in animals with short bowel syndrome (SBS). METHODS: Using piglets, we developed a novel 90% gut-resected SBS model. Fifteen SBS piglets receiving PN were given CDCA or control (vehicle control) for 2 weeks. Tissue and serum were analyzed posteuthanasia. RESULTS: CDCA increased gut FXR (quantitative polymerase chain reaction; P = .008), but not downstream FXR targets. No difference in gut fibroblast growth factor 19 (FGF19; P = .28) or hepatic FXR (P = .75), FGF19 (P = .86), FGFR4 (P = .53), or Cholesterol 7 α-hydroxylase (P = .61) was noted. PN resulted in cholestasis; however, no improvement was noted with CDCA. Hepatic fibrosis or immunostaining for Ki67, CD3, or Cytokeratin 7 was not different with CDCA. PN resulted in gut atrophy. CDCA preserved (P = .04 vs control) gut mass and villous/crypt ratio. The median (interquartile range) for gut mass for control was 0.28 (0.17-0.34) and for CDCA was 0.33 (0.26-0.46). CONCLUSIONS: We note that, unlike in animals with intact gut, in an SBS animal model there is inadequate CDCA-induced activation of gut-derived signaling to cause liver improvement. Thus, it appears that activation of GLCT is critically dependent on the presence of adequate gut. This is clinically relevant because it suggests that BA therapy may not be as effective for patients with SBS.