Third trimester physiological hypercortisolemia may protect from postpartum depression and stress

OBJECTIVE

This study was aimed to evaluate the impact of physiological alterations in cortisol milieu on mood changes during late pregnancy and postpartum.

PATIENTS AND METHODS

A total of 77 healthy pregnant subjects were prospectively evaluated after 36 weeks of gestation and at 3-4 weeks postpartum. Free cortisol (FC) was calculated using Coolen's equation and the free cortisol index (FCI) was defined as serum Total cortisol/Cortisol-binding globulin. Concurrently, status of depression, anxiety and stress were graded using Beck Depression Inventory, Beck Anxiety Inventory and Perceived Stress Scale. Statistical analysis was performed and p<0.05 was considered statistically significant.

RESULTS

Higher FC levels during late pregnancy were associated with lower scores on stress and depression early postpartum, albeit the latter was not statistically significant. Additionally, as FCI increased during late pregnancy both the scores on stress and depression decreased during early postpartum.

CONCLUSIONS

Increased cortisol levels during the latter periods of pregnancy may have long-lasting protective effects. They may enable the mother to cope with the changing and demanding conditions during postpartum.

Determinants of anti-PD-1 response and resistance in clear cell renal cell carcinoma

ADAPTeR is a prospective, phase II study of nivolumab (anti-PD-1) in 15 treatment-naive patients (115 multiregion tumor samples) with metastatic clear cell renal cell carcinoma (ccRCC) aiming to understand the mechanism underpinning therapeutic response. Genomic analyses show no correlation between tumor molecular features and response, whereas ccRCC-specific human endogenous retrovirus expression indirectly correlates with clinical response. T cell receptor (TCR) analysis reveals a significantly higher number of expanded TCR clones pre-treatment in responders suggesting pre-existing immunity. Maintenance of highly similar clusters of TCRs post-treatment predict response, suggesting ongoing antigen engagement and survival of families of T cells likely recognizing the same antigens. In responders, nivolumab-bound CD8+ T cells are expanded and express GZMK/B. Our data suggest nivolumab drives both maintenance and replacement of previously expanded T cell clones, but only maintenance correlates with response. We hypothesize that maintenance and boosting of a pre-existing response is a key element of anti-PD-1 mode of action.

Publisher Correction: Spatial heterogeneity of the T cell receptor repertoire reflects the mutational landscape in lung cancer

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Spatial heterogeneity of the T cell receptor repertoire reflects the mutational landscape in lung cancer

Somatic mutations together with immunoediting drive extensive heterogeneity within non-small-cell lung cancer (NSCLC). Herein we examine heterogeneity of the T cell antigen receptor (TCR) repertoire. The number of TCR sequences selectively expanded in tumors varies within and between tumors and correlates with the number of nonsynonymous mutations. Expanded TCRs can be subdivided into TCRs found in all tumor regions (ubiquitous) and those present in a subset of regions (regional). The number of ubiquitous and regional TCRs correlates with the number of ubiquitous and regional nonsynonymous mutations, respectively. Expanded TCRs form part of clusters of TCRs of similar sequence, suggestive of a spatially constrained antigen-driven process. CD8+ tumor-infiltrating lymphocytes harboring ubiquitous TCRs display a dysfunctional tissue-resident phenotype. Ubiquitous TCRs are preferentially detected in the blood at the time of tumor resection as compared to routine follow-up. These findings highlight a noninvasive method to identify and track relevant tumor-reactive TCRs for use in adoptive T cell immunotherapy.

Auditory changes in acromegaly

OBJECTIVE

The aim of this study is to determine the changes involving auditory system in cases with acromegaly.

MATERIALS AND METHODS

Otological examinations of 41 cases with acromegaly (uncontrolled n = 22, controlled n = 19) were compared with those of age and gender-matched 24 healthy subjects. Whereas the cases with acromegaly underwent examination with pure tone audiometry (PTA), speech audiometry for speech discrimination (SD), tympanometry, stapedius reflex evaluation and otoacoustic emission tests, the control group did only have otological examination and PTA. Additionally, previously performed paranasal sinus-computed tomography of all cases with acromegaly and control subjects were obtained to measure the length of internal acoustic canal (IAC).

RESULTS

PTA values were higher (p < 0.001 for right ears and p = 0.001 for left ears), and SD scores were (p = 0.002 for right ears and p = 0.002 for left ears) lower in acromegalic patients. IAC width in acromegaly group was narrower compared to that in control group (p = 0.03 for right ears and p = 0.02 for left ears). When only cases with acromegaly were taken into consideration, PTA values in left ears had positive correlation with growth hormone and insulin-like growth factor-1 levels (r = 0.4, p = 0.02 and r = 0.3, p = 0.03). Of all cases with acromegaly 13 (32%) had hearing loss in at least one ear, 7 (54%) had sensorineural type and 6 (46%) had conductive type hearing loss.

CONCLUSION

Acromegaly may cause certain changes in the auditory system in cases with acromegaly. The changes in the auditory system may be multifactorial causing both conductive and sensorioneural defects.

LONGER CECUM INSERTION TIME AND MORE INADEQUATE COLONIC PREPARATION IN PATIENTS WITH ACROMEGALY: IS A DIFFERENT COLONOSCOPY PREPARATION NEEDED?

Purpose

To investigate whether there is a difference between acromegalic and non-acromegalic cases in terms of bowel preparation and colonoscopic intervention.

Methods

Patients with controlled and uncontrolled acromegaly and as a control group (CG) patients without acromegaly between January 2010 and March 2014 were included. Groups were compared regarding adequacy of bowel preparation, cecal insertion time (CIT) and colonoscopy results.

Results

Fifty-nine patients with acromegaly (controlled n=30, uncontrolled n=29) and 73 age and gender matched volunteers without acromegaly were evaluated. CIT in cases with controlled, uncontrolled acromegaly cases and in CG was 5.33 [4.00-6.00], 7.00 [4.91-11.31], and 3.10 [2.35-4.65] minutes, respectively (p<0.001). Cases in CG had shorter CIT compared to controlled and uncontrolled acromegaly cases ( p=0.014 and p<0.001, respectively). There was no significant difference regarding CIT between controlled and uncontrolled acromegaly cases (p=0.247). Six (20%) of controlled acromegaly patients, 10 (35%) of uncontrolled acromegaly patients and three (4%) of CG had inadequate bowel cleansing (p<0.001). Although statistically insignificant, cases with inadequate bowel cleansing had tendency towards having prolonged CIT in comparison to cases with adequate bowel cleansing (6.00 [3.87-9.00] and 4.16 [2.95-5.70] minutes, respectively, p=0.07).

Conclusion

Inadequate bowel cleansing is one of the main problems encountered during colonoscopic investigation/surveillance in acromegalic patients. Therefore, a different protocol for colonoscopy preparation may be needed for these cases.

Pembrolizumab in the management of metastatic melanoma

Pembrolizumab is a humanized IgG4 anti-PD-1 antibody that plays a major role in the treatment of advanced melanoma. Through blockade of PD-1, it leads to an increase in effector T-cell activity in the tumor microenvironment. Clinical trial outcomes for pembrolizumab in addition to pharmacokinetics, pharmacodynamics and safety of the compound are discussed in this article. Phase I trials have demonstrated safety and efficacy of pembrolizumab in advanced, pretreated melanoma patients. When compared with chemotherapy in a Phase II trial of ipilimumab-refractory patients, those treated with pembrolizumab showed superior progression-free survival. In addition, in the pivotal Phase III trial pembrolizumab improved overall survival compared with ipilimumab in patients naive to immune checkpoint inhibition. Pembrolizumab is well tolerated and has a favorable safety profile. Common adverse events are fatigue, rash, itching and diarrhea. Less frequent immune-related adverse events include hypothyroidism, colitis, hepatitis and pneumonitis.

The problem of unrecognized acromegaly: surgeries patients undergo prior to diagnosis of acromegaly

PURPOSE

To reveal the variety of symptoms experienced by patients before acromegaly diagnosis and to emphasize unneeded surgeries that patients undergo related to acromegaly prior to diagnosis of the disease.

METHODS

In total, 490 consecutive adult patients with acromegaly who were treated at our institution between 1998 and 2014 were included in this cross-sectional study, of which 313 could be contacted. Participants were questioned about their complaints at initial consultation and at the time of diagnosis, the first medical professional who they consulted, interval between onset and diagnosis, and surgeries they had undergone.

RESULTS

This study included 313 participants, of whom 181 were women. The mean age was 48.8 ± 12.0 years. Patients most frequently presented with acral growth of hands and feet (32.6%) and headache (26.2%). Internists were the medical specialists who were most frequently first consulted (29.4%) then neurosurgeons (11.8%). Acromegaly was generally diagnosed by endocrinologists (55%), followed by neurosurgeons (23%). The median elapsed period prior to diagnosis was 24 months, interquartile range 6.0-48.0 months. Some 45.7% had undergone surgery; 35.2% were related to acromegaly symptoms: head and throat surgery (12.8%), nose surgery (9.3%), thyroidectomy (6.4%), carpal tunnel surgery (4.8%). The delay period for patients who had an operation prior to acromegaly diagnosis was significantly longer than for those who had no operations (p < 0.001).

CONCLUSIONS

Acromegaly patients mostly present to internal medicine professionals. Surgeries related to acromegaly complications and symptoms before diagnosis cause a long delay period before diagnosis. Medical staff must be more aware of the clinical aspects of acromegaly.

Evaluation of cognitive functions in gestational diabetes mellitus

OBJECTIVE

To evaluate the association between cognitive functions and metabolic status in cases with gestational diabetes mellitus (GDM).

METHODS

In this study 44 patients with GDM and 45 normal pregnant were included. Depression was evaluated with Beck's depression inventory (BDI). Cognitive functions were evaluated with Montreal cognitive assessment (MOCA), paced auditory serial addition test (PASAT), spatial recall test (SRT), symbol digit modalities (SDMT), and word list generation (WLG).

RESULTS

The mean gestational age, educational level and account of previous birth of the subjects in the study were not statistically different between the groups. The mean scores of BDI of the 2 groups were not statistically different. MOCA score and SDMT was significantly decreased in GDM in comparison to NP (p=0.005, p=0.04 respectively). Also, SDMT score was inversely correlated with number of pregnancies, postprandial blood glucose and HbA1c.The scores of PASAT, SRT, SPART and WLG were statistically similar between the groups.

CONCLUSIONS

Our findings may be a clue for early onset of impairment in cognitive functions in cases with new onset diabetes during pregnancy.

Catheter-based renal denervation for treatment of resistant hypertension

Hypertension is a common disease associated with important cardiovascular complications. Persistent blood pressure of 140/90 or higher despite combined use of a reninangiotensin system blocker, calcium channel blocker and a diuretic at highest tolerated doses constitutes resistant hypertension. Excess sympathetic activity plays an important pathogenic role in resistant hypertension in addition to contributing to the development of metabolic problems, in particular diabetes. Reduction of renal sympathetic activity by percutaneous catheter-based radiofrequency ablation via the renal arteries has been shown in several studies to decrease blood pressure in patients with resistant hypertension, and importantly is largely free of significant complications. However, longer term follow-up is required to confirm both long-term safety and efficacy.

Procalcitonin can be used as a marker of premature atherosclerosis in acromegaly

The objective of the study was to evaluate arterial morphologic changes of early atherosclerosis and changes in procalcitonin (PCT) levels in patients with acromegaly according to disease activity. Thirty-three active and 20 inactive acromegaly patients followed at Endocrinology-Metabolism out-patient clinic of Cerrahpasa Medical Faculty between 2004 and 2008 were included in the study. Twenty gender and age matched healthy subjects were included as the control group. Intima-media thickness (IMT) of the carotid arteries was measured by ultrasonography. Blood was drawn for biochemical tests and the serum concentrations of C-reactive protein (CRP) and PCT. Intergroup analysis revealed no significant differences between Growth hormone (GH), insulin like growth factor-1 (IGF-1), and IMT (P = 0.42, P = 0.47 respectively). No significant differences were found in the fibrinogen, CRP and PCT levels of the acromegaly patients and the subjects in the control group (P = 0.57, P = 0.84, P = 0.68 respectively). In the patients with IMT ≥ 1 mm, PCT (0.4 [IQR: 0.4-0.55]) levels were significantly different from the patients without atherosclerosis (0.06 [IQR: 0.05-0.12], P < 0.001). The correlation between IMT and PCT (P = 0.001, r = 0.47) was more significant than the correlation between IMT and CRP (P = 0.01, r = 0.28). There was a positive correlation between IMT and atherosclerotic risk factors such as age (P = 0.01, r = 0.27) and body mass index (BMI; P = 0.005, r = 0.32). Our results showed that PCT increases before CRP and it can be useful for the assessment of premature atherosclerosis in acromegaly as well.

Renal cyst formation in Fh1-deficient mice is independent of the Hif/Phd pathway: roles for fumarate in KEAP1 succination and Nrf2 signaling

The Krebs cycle enzyme fumarate hydratase (FH) is a human tumor suppressor whose inactivation is associated with the development of leiomyomata, renal cysts, and tumors. It has been proposed that activation of hypoxia inducible factor (HIF) by fumarate-mediated inhibition of HIF prolyl hydroxylases drives oncogenesis. Using a mouse model, we provide genetic evidence that Fh1-associated cyst formation is Hif independent, as is striking upregulation of antioxidant signaling pathways revealed by gene expression profiling. Mechanistic analysis revealed that fumarate modifies cysteine residues within the Kelch-like ECH-associated protein 1 (KEAP1), abrogating its ability to repress the Nuclear factor (erythroid-derived 2)-like 2 (Nrf2)-mediated antioxidant response pathway, suggesting a role for Nrf2 dysregulation in FH-associated cysts and tumors.

Expression profiling in progressive stages of fumarate-hydratase deficiency: the contribution of metabolic changes to tumorigenesis

Hereditary leiomyomatosis and renal cell carcinoma (HLRCC) is caused by mutations in the Krebs cycle enzyme fumarate hydratase (FH). It has been proposed that "pseudohypoxic" stabilization of hypoxia-inducible factor-α (HIF-α) by fumarate accumulation contributes to tumorigenesis in HLRCC. We hypothesized that an additional direct consequence of FH deficiency is the establishment of a biosynthetic milieu. To investigate this hypothesis, we isolated primary mouse embryonic fibroblast (MEF) lines from Fh1-deficient mice. As predicted, these MEFs upregulated Hif-1α and HIF target genes directly as a result of FH deficiency. In addition, detailed metabolic assessment of these MEFs confirmed their dependence on glycolysis, and an elevated rate of lactate efflux, associated with the upregulation of glycolytic enzymes known to be associated with tumorigenesis. Correspondingly, Fh1-deficient benign murine renal cysts and an advanced human HLRCC-related renal cell carcinoma manifested a prominent and progressive increase in the expression of HIF-α target genes and in genes known to be relevant to tumorigenesis and metastasis. In accord with our hypothesis, in a variety of different FH-deficient tissues, including a novel murine model of Fh1-deficient smooth muscle, we show a striking and progressive upregulation of a tumorigenic metabolic profile, as manifested by increased PKM2 and LDHA protein. Based on the models assessed herein, we infer that that FH deficiency compels cells to adopt an early, reversible, and progressive protumorigenic metabolic milieu that is reminiscent of that driving the Warburg effect. Targets identified in these novel and diverse FH-deficient models represent excellent potential candidates for further mechanistic investigation and therapeutic metabolic manipulation in tumors.