Characterization of microvascular disease in pediatric sickle cell disease using nailfold capillaroscopy.

Sickle cell disease (SCD) is a disorder with repetitive vaso-occlusive crises resulting in microvascular obstruction and tissue ischemia that may lead to multi-organ ischemia and dysfunction. Nailfold videocapillaroscopy (NFC) is an imaging technique utilized in clinical rheumatology to visualize capillaries located near the fingertip. To characterize NFC abnormalities in the setting of pediatric SCD, we performed NFC using a video capillaroscope on 8 digits in 44 stable SCD patients and 65 age matched healthy controls. Mean capillary number was lower (6.4 ± 1.3 vs 7.5 ± 1.8, p = 0.001) in the SCD group compared to controls. The percentage of dilated capillaries was similar (7.1 ± 8.3 vs. 5.9 ± 8.2, p = 0.4). The large majority of capillaries visualized in the SCD and control groups were normal capillary types per the EULAR definition, with a similar percentage of normal, nonspecific capillary morphologies and abnormal types. Regarding normal capillary sub-types, the SCD group and controls exhibited similar percentages of stereotype hairpin shapes, and tortuous or once or twice crossing type capillaries. On multivariate analyses, mean capillary number was independently associated with SCD after adjusting for age, body mass index, systolic blood pressure and gender. In conclusion, pediatric SCD is associated with lower capillary number but similar percentage of dilated capillaries and morphology on NFC. In our SCD cohort, capillary number was unrelated to our available markers of disease severity, including history of sickle crises, previous hospitalization for crises or Hemoglobin F levels.

Pathology Report: Presacral Noncommunicating Enteric Duplication Cyst.

BACKGROUND: Gastrointestinal (GI) tract duplication cysts or enteric duplication cysts are rare congenital malformations sometimes found on the mesenteric aspect of segments of the alimentary tract. Enteric duplication cysts are lined by normal GI epithelium and may be classified as foregut, mid-gut, and hindgut cysts. Except in very rare cases of retroperitoneal enteric duplication cysts, these cysts communicate with the GI tract and share a common blood supply. Concurrent congenital malformations are not uncommon and malignant transformation within enteric duplication cysts has also been reported. METHODS: We describe a case of a noncommunicating enteric duplication cyst in a 52-year-old woman. RESULTS: The patient presented with a presacral cystic mass requiring frequent drainage procedures that was primarily believed to be of neural origin. Upon resection, the lesion contained heterotopic tissue, including ciliated bronchial epithelium, squamous and transitional epithelia, and pancreatic and gastric tissue. Focal, low-grade intestinal adenoma was present, but malignancy was not detected in this case. CONCLUSION: To our knowledge, this is the sixth reported case of a noncommunicating enteric duplication cyst in the English medical literature.

Unique Features of Prostate Cancer in African American and West Indian Patients Including Diagnosis of High Grade Cancers Using Only Elevated Serum Levels of Prostate Specific Antigen.

OBJECTIVE: We have studied the occurrence and nature of prostate cancer in 330 African American patients with respect to its frequency of occurrence, the prevalence of high grade cancers (Gleason score ≥7), distribution of prostate specific antigen (PSA) levels, whether serum PSA levels correlate with Gleason scores, and whether tumor grade correlates with tumor extension and/or metastasis. METHODS: We reviewed the medical charts of patients at the University Hospital of SUNY Downstate Medical Center for whom prostate biopsies or excisions were performed (2015-2019). We then computed the prevalence of prostate cancer and high grade tumors. To determine if there was a quantitative relationship between PSA and Gleason score, we used linear regression analysis. We further used the Fisher exact test to determine if there exists a serum PSA level beyond which the diagnosis of high-grade prostate cancer is definitive. RESULTS: The prevalence of prostate cancer was high at 75.8%; of these cancers, 70% were found to be high grade. Ninety two percent of PSA values were ≥ 4.0ng/mL; the sensitivity was 94%; the positive predictive value was 80%. There was a poor correlation between PSA and Gleason score (R2=0.1), but almost 30 percent of PSA values were >20 ng/mL, and almost all of these corresponded to high grade tumors (Fisher exact test, p<0.00001, α=0.05). Fifteen cancers extended beyond the capsule or metastasized; all were high grade tumors. CONCLUSIONS: These patients presented with a high frequency of high-grade prostate cancer and elevated PSA values, such that PSA> 20ng/mL are virtually diagnostic of high-grade prostate cancer. Since the average age, 65, of screening for biopsy in this population is the same as for other demographic groups, screening should be performed at younger ages in this population.

Targeting Membrane HDM-2 by PNC-27 Induces Necrosis in Leukemia Cells But Not in Normal Hematopoietic Cells.

BACKGROUND/AIM: Anticancer peptide PNC-27 binds to HDM-2 protein on cancer cell membranes inducing the formation of cytotoxic transmembrane pores. Herein, we investigated HDM-2 membrane expression and the effect of PNC-27 treatment on human non-stem cell acute myelogenous leukemia cell lines: U937, acute monocytic leukemia; OCI-AML3, acute myelomonocytic leukemia and HL60, acute promyelocytic leukemia. MATERIALS AND METHODS: We measured cell surface membrane expression of HDM-2 using flow cytometry. Cell viability was assessed using MTT assay while direct cytotoxicity was measured by lactate dehydrogenase (LDH) release and induction of apoptotic markers annexin V and caspase-3. RESULTS: HDM-2 is expressed at high levels in membranes of U937, OCI-AML3 and HL-60 cells. PNC-27 can bind to membrane HDM-2 to induce cell necrosis and LDH release within 4 h. CONCLUSION: Targeting membrane HDM-2 can be a potential strategy to treat leukemia. PNC-27 targeting membrane HDM-2 demonstrated significant anti-leukemia activity in a variety of leukemic cell lines.

EPB41L5 is Associated With the Metastatic Potential of Low-grade Pancreatic Neuroendocrine Tumors.

BACKGROUND/AIM: Low-grade pancreatic neuroendocrine tumors (LG-PNETs) behave unpredictably. The aim of the study was to identify biomarkers that predict PNET metastasis to improve treatment selection. PATIENTS AND METHODS: Five patients with primary non-metastatic LG-PNETs, six with primary LG-PNETs with synchronous or metachronous metastases (M-PNETs), and six metastatic to liver LG-PNETs (ML-PNETs) from the group of six M-PNET patients were selected. RNA data were normalized using iterative rank-order normalization. Student's t-test identified differentially-expressed genes in LG-PNETs versus M-PNETs. A 2-fold difference in expression was considered to be significant. Results were validated with an independent dataset of LG-PNETs and metastatic LG-PNETs. RESULTS: Overall, 195 genes had a >2-fold change (in either direction). A total of 29 genes were differentially overexpressed in M-PNETs. Erythrocyte membrane protein band 4.1-like 5 (EPB41L5) had a 2.07-fold change increase in M-PNETs and the smallest p-value. EPB41L5 was not statistically different between M-PNETs and ML-PNETs. EPB41L5 differential expression between primary and metastatic LG-PNETs was confirmed by immunohistochemistry. CONCLUSION: These results support further investigation into whether EPB41L5 is a biomarker of PNETs with high risk for metastases.

Cytology as a screening tool for anal squamous intraepithelial lesion for HIV positive men: 10-year experience in an inner city hospital.

INTRODUCTION: Human papillomavirus (HPV) and anal carcinoma are prevalent in high-risk patients including human immunodeficiency virus (HIV)-positive patients. There are currently no clear guidelines for screening, however. We assessed anal cytology specimens and HPV testing at an inner-city hospital by correlating anal cytology with anal biopsy (bx), and evaluated if results differed with traditional proctoscopy (TP) or high-resolution anoscopy (HRA). MATERIALS AND METHODS: 209 anal cytology and subsequent biopsies taken during the period 2003-2014 from 152 male patients were reviewed. Demographic data for age, sex, HIV, HPV, cytology, histology, and the method of biopsy were analyzed. RESULTS: All specimens were followed by a biopsy within a period of 6 months. Ninety-seven percent of patients were HIV-positive and 43% had AIDS. Lesions most diagnosed on cytology were low-grade squamous intraepithelial lesion (LSIL) (52%) and atypical squamous cells of undetermined significance (ASC-US) (21.5%). Lesions most diagnosed on bx were anal intraepithelial neoplasia (AIN) grade 2-3 (52%) and AIN grade 1 (37%). Almost all ASC-US cases tested for HPV were positive (97%). There was cytology histology correlation in 48% of LSIL and 83% of high-grade squamous intraepithelial lesions. Anal cytology had 97% sensitivity in detecting AIN and carcinoma and a positive predictive value of 96%. There was no difference in rate of detection of AIN 1and AIN 2-3 on bx using TP versus HRA. CONCLUSION: Screening in high-risk patients detected almost all high- and low-grade squamous intraepithelial lesions, however, anal cytology alone could not predict the degree of dysplasia. It may be prudent to perform anal bx in all atypical anal cytology. Clear guidelines are needed for screening of a high risk population.

Atypical Findings on Cervicovaginal Smears Correlate with Cervical Involvement by Malignant Mixed Müllerian Tumors of the Uterus.

OBJECTIVE: A malignant mixed müllerian tumor (MMMT) is a high-grade neoplasm commonly arising from the uterus. Patients present with bleeding and a mass protruding from the cervix. This study was designed to correlate Papanicolaou (Pap) smear findings with histological findings in women diagnosed with MMMT. STUDY DESIGN: Women diagnosed with MMMT were identified. Preoperative Pap tests were correlated with histological findings. Statistical analysis was performed to assess associations between abnormal Pap tests and histological findings. RESULTS: Forty patients with MMMT were included in the study. Age ranged from 37-85 years and tumor size ranged from 1.2 to 21 cm. In presurgical Pap tests (4 conventional and 36 liquid based), 11 smears (27.5%) were diagnosed as negative, 5 (12.5%) as atypical squamous cells of undetermined significance, 6 (15%) as atypical glandular cells, 16 (40%) as malignant and 2 (5%) as high-grade squamous intraepithelial lesion. Malignant cells detected on Pap smears showed a strong correlation with endocervical involvement by MMMT (p = 0.002). Larger tumors were more likely to involve the cervix (p = 0.0115). CONCLUSIONS: The Pap test can predict cervical involvement by MMMT. On Pap smears, MMMT cells showed no correlation with other adverse histological features (lymphovascular invasion, myoinvasion or adnexal involvement).

GATA3 expression in metastatic urothelial carcinoma in fine needle aspiration cell blocks: a review of 25 cases.

GATA binding protein 3 is a zinc finger transcription factor with high affinity for urothelial tissue and is a promising immunohistochemical marker in detection of urothelial carcinomas (UC). We studied its usefulness in metastatic high-grade UC. This study was performed on cell blocks (CB) of fine needle aspirates from 25 cases of metastatic high-grade UC in patients with previously resected high-grade UC. Immunohistochemical staining for GATA3, thrombomodulin, uroplakin, cytokeratin 7, and cytokeratin 20 was performed. Twenty-three of 25 cases of metastatic UC expressed GATA3 (92%); positive staining for cytokeratin 7 was present in 23 of 25 cases (92%), 20 of 25 (80%) stained for thrombomodulin, and 13 of 25 (52%) stained for cytokeratin 20. No case expressed uroplakin. Five hundred forty-seven non-urothelial carcinomas, including breast ductal carcinoma (77), hepatocellular carcinoma (100), colonic adenocarcinoma (81), pancreatic adenocarcinoma (28), gastric adenocarcinoma (31), endometrial carcinoma (27), ovarian serous carcinoma (27), lung adenocarcinoma (27), lung squamous cell carcinoma (26), malignant melanoma (27), renal cell carcinoma (48), and prostatic adenocarcinoma (48) in tissue microarrays were also analyzed and were GATA3 negative except for 35 of 77 (45.5%) of GATA3 positive breast ductal carcinoma. GATA3 has high sensitivity and specificity for detection of metastatic UC and thus may play an important role in diagnosing metastatic UC in CB samples.

The relationship between vitamin D status and HIV-related complications in HIV-infected children and young adults.

BACKGROUND: In HIV-infected adults, we and others have shown that vitamin D deficiency is independently associated with increased carotid intima-media thickness (cIMT), a surrogate marker for cardiovascular disease (CVD). This study explored for the first time the relationship between vitamin D and CVD risk in HIV-infected youth. METHODS: This is a cross-sectional assessment of cIMT, inflammation, metabolic markers and vitamin D status in HIV-infected youth and healthy controls. We measured serum 25-hydroxyvitamin D (25(OH)D), fasting lipids, insulin, glucose, inflammatory markers and cIMT. RESULTS: Thirty HIV-infected subjects and 31 controls were included. Among HIV-infected subjects, median age was 11 years (37% males; 73% black; similar to controls). HIV-infected subjects' mean (standard deviation) serum 25(OH)D was 24 (35) ng/mL; 70% had 25(OH)D<20 ng/mL (deficient), 23% between 20-30 ng/mL (insufficient) and 7%>30 ng/mL (sufficient); proportions were similar to controls (P=0.17). After adjusting for season, sex and race, there was no difference in serum 25(OH)D between groups (P=0.11). Serum 25(OH)D was not significantly correlated with cIMT, inflammatory markers or lipids. Serum 25(OH)D was negatively correlated with body mass index, insulin resistance, HIV duration, and cumulative use of antiretroviral therapy, non- and nucleoside reverse transcriptase inhibitors. CONCLUSIONS: Most HIV-infected youth have vitamin D deficiency or insufficiency. Despite no direct association between serum 25(OH)D and cIMT, there were notable associations with some CVD risk factors, particularly inverse correlation with insulin resistance. Studies are needed to determine whether CVD risk, including insulin resistance, could be improved with vitamin D supplementation.

Comparative efficacy of vertebroplasty, kyphoplasty, and medical therapy for vertebral fractures on survival and prevention of recurrent fractures.

OBJECTIVE: To evaluate the efficacy of surgical and medical therapies on recurrent vertebral fracture and mortality rates. METHODS: A retrospective review of medical records was performed of patients seen at Emory University Spine Center and Hospital (Atlanta, Georgia) for vertebral fracture between 1998 and 2007. Patients with vertebral fracture or who underwent vertebroplasty or kyphoplasty were identified by use of the International Classification of Diseases, Ninth Revision and Current Procedural Terminology codes, respectively. Outcome measures included site and date of recurrent vertebral fractures and mortality. RESULTS: We identified 250 patients with vertebral fractures and classified them into 4 groups: surgical therapy only, surgical plus medical treatment, medical therapy only, and no treatment. There was no significant difference in the cumulative survival rates among the 4 study groups nor between the treatment groups. There was, however, a significant difference in the cumulative refracture-free rates among the 4 study groups (P<.0001). Recurrent fracture-free rates were highest in the group that received no treatment. The 2-year cumulative refracture-free rates were 95.9%, 84.8%, 81.7%, and 68.5%, respectively, for the no treatment, medical therapy only, surgical treatment only, and medical plus surgical therapy groups. Recurrent fracture-free rates were significantly different for patients who received surgical or medical or surgical plus medical therapy (P=.0007), with patients in the medical plus surgical group having the shortest time to refracture, although these patients may have been sicker and more frail than the other groups. CONCLUSION: We found that surgical treatment with vertebroplasty or kyphoplasty did not decrease recurrent vertebral fractures in patients presenting with an initial vertebral fracture. Medical and surgical therapies together may shorten the time to refracture, but the observed elevated risk may be due to other confounding factors. We found no difference in survival in patients undergoing kyphoplasty or vertebroplasty in comparison with medical or no treatment groups. The relationship between surgical and medical therapy and vertebral refracture rates should be further evaluated with use of a prospective cohort design.

Vitamin D supplementation and endothelial function in vitamin D deficient HIV-infected patients: a randomized placebo-controlled trial.

BACKGROUND: Studies suggest that vitamin D deficiency is a risk factor for cardiovascular disease and diabetes. Vitamin D deficiency is prevalent in HIV patients but the effect of vitamin D supplementation on cardiovascular risk in this population is unknown. METHODS: We conducted a randomized, double-blind, placebo-controlled trial among 45 HIV-infected adults in Cleveland (OH, USA) on stable antiretroviral therapy with durable virological suppression and a baseline serum 25-hydroxyvitamin D level of ≤20 ng/ml. Participants were randomized 2:1 to vitamin D3 4,000 IU daily or placebo for 12 weeks. The primary outcome was a change in flow-mediated brachial artery dilation (FMD). RESULTS: Baseline demographics were similar except for age (vitamin D versus placebo, mean ±sd 47 ±8 versus 40 ±10 years; P=0.009). Both groups had reduced FMD at baseline (median values 2.9% [IQR 1.6-4.8] for vitamin D versus 2.5% [IQR 1.7-6.4] for placebo; P=0.819). Despite an increase in the concentration of serum 25-hydroxyvitamin D from baseline to 12 weeks (5.0 ng/ml [IQR -0.9-7.4] versus -1.9 ng/ml [IQR -4.0-0.1] for vitamin D versus placebo, respectively; P=0.003), there was no difference in FMD change (0.55% [IQR -1.05-2.13] versus 0.29% [IQR -1.61-1.77]; P=0.748). Vitamin D supplementation was associated with a decrease in total and non-high-density lipoprotein cholesterol, and an increase in indices of insulin resistance. CONCLUSIONS: Among HIV-infected individuals with vitamin D deficiency, supplementation with 4,000 IU vitamin D3 daily for 12 weeks modestly improved vitamin D status and cholesterol but worsened insulin resistance without change in endothelial function. The mechanisms of resistance to standard doses of vitamin D and the complex role of vitamin D in glucose metabolism in this population require further investigation.

Pilot study of vitamin D supplementation in adults with cystic fibrosis pulmonary exacerbation: A randomized, controlled trial.

UNLABELLED: BACKGROUND: Vitamin D insufficiency is common in cystic fibrosis (CF) and vitamin D repletion may have an important role in improving clinical outcomes in CF. This randomized, placebo-controlled, pilot study examined the feasibility and impact of a single, large dose of cholecalciferol on vitamin D status and clinical outcomes in subjects with CF. METHODS: Thirty adults with were randomized in a double-blinded, pilot study to receive 250,000 IU cholecalciferol or placebo within 48 h of hospital admission for a pulmonary exacerbation. Concentrations of 25-hydroxyvitamin D (25(OH)D), clinical outcomes and potential adverse events were assessed up to one year after randomization. Mixed effects linear regression models were used to evaluate the difference in mean serum concentrations and log-rank analyses were used to evaluate survival. RESULTS: Data from all subjects was analyzed. Serum 25(OH)D concentrations increased from a mean of 30.6 ± 3.2 ng/mL to 58.1 ± 3.5 ng/mL (p < 0.001) at one week and 36.7 ± 2.6 ng/mL by 12 weeks (p = 0.06) in the vitamin D group; in contrast, serum 25(OH)D concentrations remained unchanged in the placebo group. Unadjusted, one-year survival and hospital-free days were increased in the vitamin D group (p = 0.029, p = 0.036; respectively). There was also a trend toward increased IV antibiotic therapy-free days in the vitamin D group (p = 0.073). There were no signs of hypervitaminosis D or adverse events. Serum PTH and calcium concentrations were similar across both groups. CONCLUSIONS: In this pilot study, a single, oral bolus of cholecalciferol increased serum 25(OH)D concentrations and was associated with a trend toward improved clinical outcomes in CF subjects hospitalized for a pulmonary exacerbation. Further investigation is needed into the clinical impact of improved vitamin D status in patients with CF.

Effects of sunlight and diet on vitamin D status of pulmonary tuberculosis patients in Tbilisi, Georgia.

OBJECTIVE: Vitamin D deficiency is common in tuberculosis (TB) and this may modulate immune responses. This study investigated vitamin D status in patients with TB and examined the sources of vitamin D in Tbilisi, Georgia. METHODS: We measured plasma 25-hydroxyvitamin D (25[OH]D) and dietary vitamin D intake in patients with pulmonary TB (n = 85) in Tbilisi, Georgia. To determine the impact of season on vitamin D status, we tested the in vitro conversion of 7-dehydrocholesterol (7-DHC) to previtamin D(3) after sunlight exposure. RESULTS: In subjects with TB, mean plasma 25(OH)D concentrations were 14.4 ± 7.0 ng/mL, and vitamin D insufficiency (25[OH]D <30 ng/mL) occurred in 97% of subjects. The dietary sources of vitamin D were mainly fish, eggs, and butter. The daily intake was well below recommended daily intakes in subjects with TB (172 ± 196 IU). The conversion of 7-DHC to previtamin D(3) was undetectable from October to March and highest in June and July from 11:00 to 14:00 h. CONCLUSION: An insufficient vitamin D dietary intake and a limited production of vitamin D from sunlight for most of the year may explain the high prevalence of vitamin D insufficiency in patients with TB in Tbilisi.

Risk factors for vitamin D deficiency and relationship with cardiac biomarkers, inflammation and immune restoration in HIV-infected youth.

BACKGROUND: Vitamin D deficiency is common in HIV-infected individuals. In adults, traditional and HIV-related factors play a role in vitamin D status, and deficiency appears to impair immune restoration and exacerbate HIV complications, like cardiovascular disease (CVD). This study sought to determine factors contributing to vitamin D status in HIV-infected youth and investigate the relationship with CVD risk, inflammation and immune restoration. METHODS: HIV-infected subjects (1-25 years old) were enrolled prospectively along with healthy controls that were group-matched by age, sex and race. HIV data were collected for the HIV-infected group, while traditional risk factors, including vitamin D intake, sun exposure, skin pigmentation, physical activity level and body mass index (BMI) were collected for both groups. Fasting lipids, plasma 25-hydroxyvitamin D (25[OH]D), and inflammation markers were measured. RESULTS: In total, 200 HIV-infected subjects and 50 controls were enrolled. HIV group had 53% male, 95% Black and a mean age of 17.2 ±4.6 years. There was no difference in 25(OH)D between groups; 77% of HIV+ and 74% of controls had 25(OH)D<20 ng/ml. Only Fitzpatrick skin type was independently associated with 25(OH)D. No HIV variables were associated with 25(OH)D, even when HIV sub-populations were examined. Inflammation, CVD risk factors and immune restoration were not independently associated with 25(OH)D. CONCLUSIONS: Vitamin D deficiency is common among HIV-infected youth. However, HIV factors, CVD risk, inflammation and immune restoration do not appear to have the same relationship with vitamin D as has been shown in adults. Supplementation trials are needed to determine if increasing 25(OH)D concentrations could better elucidate these relationships.