Artri King-induced Hypothalamic-pituitary-adrenal Axis Disruption: A Report of 3 Cases

We present a case series of 3 patients who developed iatrogenic hypothalamic-pituitary-adrenal axis disruption while taking Artri King, an over-the-counter supplement marketed for joint pain that is reported to contain dexamethasone not listed on the supplement's label. Patient 1, a 58-year-old woman, presented with persistent hyponatremia, weight gain, proximal muscle weakness, dorsocervical fat pad, and new, red striae on her breast and abdomen in the setting of Artri King use. Her dexamethasone level was elevated (Table 1), confirming the suspicion of dexamethasone content in this supplement. Patient 2, a 55-year old woman, had presented with cushingoid features and a low morning cortisol level (Table 1) in the setting of Artri King use. Patient 3, a 59-year-old man, presented with poorly controlled diabetes in the setting of Artri King use and an elevated serum dexamethasone level. Supplements containing hidden glucocorticoids can cause not only iatrogenic Cushing syndrome, but also adrenal suppression, providing a diagnostic challenge for providers.

Type 2 diabetes mellitus and cognitive function: understanding the connections

PURPOSE OF REVIEW

To review the connection between type 2 diabetes and cognitive dysfunction, including its epidemiology, potential mechanisms of pathophysiology, risk factors, possible prevention, and treatment considerations.

RECENT FINDINGS

Diabetes is a risk factor for mild cognitive decline, in addition to Alzheimer's disease and vascular dementia. Duration of diabetes, concomitant vascular or associated co-morbidities, hyper- and hypoglycemia may lead to worsening cognitive dysfunction. Unfortunately, there is a lack of evidence-based guidance on the prevention of cognitive dysfunction in the diabetes population. Studies of diabetes medications, including metformin, glucagon-like peptide-1 (GLP-1) receptor agonists, and sodium-glucose cotransporter-2 inhibitors (SGLT2) have shown some benefit with cardiovascular morbidity and may affect cognition. In the absence of clearly defined preventive tools, diabetes practice guidelines recommend annual cognitive screening as standard of care in adults with diabetes aged 65 years or older.

SUMMARY

People living with diabetes are at risk for significant decline in cognitive function. Epidemiology and risk factors are well defined. Prevention and treatment strategies are limited and require further study.

A Case of COVID-19-Associated Free-Floating Aortic Thrombus Successfully Treated with Thrombectomy

Patient: Male, 61-year-old

Final Diagnosis: Aortic thrombosis

Symptoms: Shortness of breath

Medication:—

Clinical Procedure: Thrombectomy

Specialty: Infectious Diseases • General and Internal Medicine • Surgery

SAT-495 Thyrotoxicosis Presenting as Right Sided Heart Failure: Two Case Reports, Two Differing Outcomes Illustrating the Importance of Early Aggressive Treatment to Reverse Cardiac Dysfunction

Background: Graves’ thyrotoxicosis can lead to life-threatening right heart failure requiring urgent treatment. We present two such cases to illustrate management challenges and the importance of early definitive treatment.

Clinical cases: The first case is a 41 year old female with Graves’ hyperthyroidism and severe right heart failure. Cardiac ECHO showed LVEF 76% with severe biatrial enlargement, TV regurgitation, and an enlarged RV. The liver was enlarged, transaminases were high, bilirubin was 24 mg/dl (0-1.4), and clotting was prolonged. Due to hepatic dysfunction, methimazole was held. She was not a candidate for I-131 as she had received iodinated contrast. Treatment with dexamethasone and SSKI normalized thyroid function over four days. She was discharged but presented two months later with worsened hyperthyroidism and right heart failure. She was a poor surgical candidate and I-131 was administered as definitive therapy. She developed PEA arrest the following day without recovery leading to withdrawal of care and death eight days later.

The second case is also a 41 year old female with an 18 year history of Graves’ disease, intermittently compliant with methimazole. She presented with hyperthyroidism and severe right heart failure. The liver was enlarged, transaminases were high, bilirubin was 5.1 mg/dl, and clotting was prolonged. Cardiac ECHO showed LVEF 66% with severe biatrial enlargement, TV and MV regurgitation, enlarged RV, and increased RA pressure. Due to hepatic dysfunction, methimazole was held. She was not a candidate for I-131 as she had received iodinated contrast. She was prepared for thyroidectomy with aggressive heart failure treatment, dexamethasone, SSKI, and cholestyramine. Thyroid function normalized over six days and she underwent total thyroidectomy eight days after admission without complications. Postoperative cardiac ECHO showed marked improvement of cardiac parameters.

Conclusion: Right heart failure is an uncommon and often overlooked complication that can arise in poorly managed or treatment-resistant Graves’ disease. It is life-threatening and requires aggressive normalization of thyroid function, treatment of heart failure, and timely definitive therapy with I-131 or thyroidectomy. Frequently complicated by liver abnormalities, the use of thionamides is questionable. Additionally, hospitalized patients have often been evaluated with iodinated contrast studies or treated with SSKI during the acute phase, which limit the use of I-131. Our cases show that dexamethasone, SSKI, and cholestyramine can rapidly normalize thyroid function. The first case ended in death, probably due to delay in definitive treatment, whereas the second patient had an early thyroidectomy with good outcome. We recommend aggressive treatment to normalize thyroid function and reverse cardiac dysfunction followed by early definitive therapy.

[Perinatal asphyxia and acute renal insufficiency in Ouagadougou]

AIM

This study aimed to analyze acute renal failure in perinatal asphyxia (PNA) of term newborns in a sub-Saharan urban health center.

PATIENTS AND METHODS

The study was prospective, conducted from 1st June to 30th November 2013 on term newborns hospitalized at the centre hospitalier universitaire pédiatrique Charles-de-Gaulle for PNA. Renal insufficiency (RI) was defined by a serum creatinine greater than or equal to 90 μmol/L.

RESULTS

Eighty-five PNA cases were included, or 19.8% of newborns hospitalized in the study period. The sex ratio was 2.1. Thirty-eight newborns (44.7%) had RI. Their creatinine averaged 153.8±96.6 μmol/L. Twenty-six of 38 (68.4%) had brain damage in Sarnat stage 2 and 12 (31.6%) stage 3. Twelve newborns with RI (31.6%) had seizures. Transfontanellar echography revealed an abnormality in 30 cases (78.9%) of RI. Of the 38 newborns with renal failure, albuminuria was found in 21 cases (65.2%) and leukocyturia in 28 cases (73.7%). Renal function improved in 86.1% of cases. Newborns with initially normal serum creatinine had no RI during hospitalization. Six newborns (7.1%) died.

CONCLUSION

This study showed that acute RI is common during PNA most particularly in newborns with severe neurological impairment. In our context, earlier support for women in labor could help prevent PNA and therefore newborn acute RI.

Use of independent component analysis to improve signal-to-noise ratio in multi-probe fluorescence microscopy

In conventional multi-probe fluorescence microscopy, narrow bandwidth filters on detectors are used to avoid bleed-through artefacts between probes. The limited bandwidth reduces the signal-to-noise ratio of the detection, often severely compromising one or more channels. Herein, we describe a process of using independent component analysis to discriminate the position of different probes using only a dichroic mirror to differentiate the signals directed to the detectors. Independent component analysis was particularly effective in samples where the spatial overlap between the probes is minimal, a very common case in cellular microscopy. This imaging scheme collects nearly all of the emitted light, significantly improving the image signal-to-noise ratio. In this study, we focused on the detection of two fluorescence probes used in vivo, NAD(P)H and ANEPPS. The optimal dichroic mirror cutoff frequency was determined with simulations using the probes spectral emissions. A quality factor, defined as the cross-channel contrast-to-noise ratio, was optimized to maximize signals while maintaining spatial discrimination between the probes after independent component analysis post-processing. Simulations indicate that a ∼3 fold increase in signal-to-noise ratio using the independent component analysis approach can be achieved over the conventional narrow-band filtering approach without loss of spatial discrimination. We confirmed this predicted performance from experimental imaging of NAD(P)H and ANEPPS in mouse skeletal muscle, in vivo. For many multi-probe studies, the increased sensitivity of this 'full bandwidth' approach will lead to improved image quality and/or reduced excitation power requirements.

[Infectious Etiologies of the acute diarrheas of the child from 0 to 5 years at the Pediatric University hospital Charles de Gaulle (Ouagadougou, Burkina Faso)]

To identify the infectious agents responsible for acute diarrheas in children from 0 to 5 years, with the aim of improving care, we led a cross-sectional prospective study at the Pediatric University hospital Charles de Gaulle from January 1st - November 30th, 2009. A sample of 103 children's stools hospitalized for acute diarrhea was analyzed. The average age of the patients was of 9.5 months and the most affected age bracket was the one from 0 to 12 months. More than half of the cases of diarrheas (60.2%) had an infectious etiology of which 33% of viral origin, 21.4% bacterial, 9.7% parasitic and in 9.7% of the cases a co-infection. In the viral diarrheas, rotavirus was observed in 17.5% of the cases and serotypes adenoviruses 40, 41 in 15.5% of the cases. The isolated bacteria were essentially represented by enteropathogenic Escherichia coli (21 cases). This bacterium had a strong resistance to amoxicillin, cotrimoxazole (90%) as well as in the amoxicillin+Clavulanic acid (57%). The ascendancy of rotavirus in the etiology of the acute diarrheas of children from 0 to 5 years hints to a need for vaccination against this infectious agent. Aside from the ineffectiveness of group A penicillins and of the cotrimoxazole against most of the isolated bacteria calls to medical prescribers to reconsider antibiotic treatment in the diarrheas of the children.

Iron inhibits activation-induced cytidine deaminase enzymatic activity and modulates immunoglobulin class switch DNA recombination

Immunoglobulin (Ig) class switch DNA recombination (CSR) and somatic hypermutation (SHM) are critical for the maturation of the antibody response. Activation-induced cytidine deaminase (AID) initiates CSR and SHM by deaminating deoxycytidines (dCs) in switch (S) and V(D)J region DNA, respectively, to generate deoxyuracils (dUs). Processing of dUs by uracil DNA glycosylase (UNG) yields abasic sites, which are excised by apurinic/apyrimidinic endonucleases, eventually generating double strand DNA breaks, the obligatory intermediates of CSR. Here, we found that the bivalent iron ion (Fe(2+), ferrous) suppressed CSR, leading to decreased number of switched B cells, decreased postrecombination Iμ-C(H) transcripts, and reduced titers of secreted class-switched IgG1, IgG3, and IgA antibodies, without alterations in critical CSR factors, such as AID, 14-3-3γ, or PTIP, or in general germline I(H)-S-C(H) transcription. Fe(2+) did not affect B cell proliferation or plasmacytoid differentiation. Rather, it inhibited AID-mediated dC deamination in a dose-dependent fashion. The inhibition of intrinsic AID enzymatic activity by Fe(2+) was specific, as shown by lack of inhibition of AID-mediated dC deamination by other bivalent metal ions, such as Zn(2+), Mn(2+), Mg(2+), or Ni(2+), and the inability of Fe(2+) to inhibit UNG-mediated dU excision. Overall, our findings have outlined a novel role of iron in modulating a B cell differentiation process that is critical to the generation of effective antibody responses to microbial pathogens and tumoral cells. They also suggest a possible role of iron in dampening AID-dependent autoimmunity and neoplastic transformation.

[Tuberculosis in children infected with HIV followed at Charles de Gaulle pediatric university hospital of Ouagadougou (Burkina Faso)]

AIMS

To study the epidemiological aspects, diagnosis and outcome of tuberculosis in children infected with HIV at the University Hospital Pediatric Charles de Gaulle, Ouagadougou.

MATERIAL AND METHODS

We conducted a retrospective chart review of children under 15 years followed from 2002 to 2008 for HIV infection.

RESULTS

The incidence of tuberculosis was 5.5%. The average patient age was 5 years with a female predominance of 63.6%. Prolonged fever, chronic cough and weight loss were the main reasons for consultation. Pulmonary tuberculosis was the most frequent clinical form with 11 cases. The contribution of the direct smear was low: 13.6%. At the radiological images of miliary (36.4%) were the most frequently encountered followed by non-parenchymal opacities systematized (31.8%). The lethality of co-infection TB-HIV was 18.2%. The prognostic factors were younger age, severe immunosuppression and orphan status or total mother.

CONCLUSION

Early detection of HIV infection in children and the capacity of TB diagnosis should improve the management of co-infection in a pediatric setting.

Processing effects on lycopene content and antioxidant activity of tomatoes

Consumption of tomato products has been associated with decreased risk of some cancer types, and the tomato antioxidant, lycopene, is thought to play an important role in the observed health effects. In this study, four carotenoids, trans-lycopene, phytofluene, phytoene, and zeta-carotene, were quantified in tomato products. Samples of raw tomatoes, tomato juice after hot break scalder, and final paste were obtained from two different processing plants over two years. Comparison of carotenoid levels throughout processing indicated that lycopene losses during processing of tomatoes into final paste (25-30 degrees Brix) ranged from 9 to 28%. The initial Brix level of the raw tomatoes appeared to influence the amount of lycopene loss that occurred, possibly due to the differences in processing time required to achieve the final desired Brix level of the paste. In general, no consistent changes in the other carotenoids were observed as a function of processing. The antioxidant activity of fresh tomatoes, tomato paste, and three fractions obtained from these products (i.e., aqueous, methanol, and hexane fractions) was also determined. In both a free radical quenching assay and a singlet oxygen quenching assay, significant antioxidant activity was found in both the hexane fraction (containing lycopene) and the methanol fraction, which contained the phenolic antioxidants caffeic and chlorogenic acid. The results suggest that in addition to lycopene, polyphenols in tomatoes may also be important in conferring protective antioxidative effects.

Identification of benzethonium chloride in commercial grapefruit seed extracts

Commercial grapefruit seed extracts (GSE) were extracted with chloroform. The solvent was evaporated, and the resulting solid was subsequently analyzed by high-performance liquid chromatography, electrospray ionization mass spectrometry, nuclear magnetic resonance (NMR) spectroscopy, and elemental analysis (by proton-induced X-ray emission [PIXE] analysis). The main constituent was identified as benzethonium chloride, a synthetic antimicrobial agent commonly used in cosmetics and other topical applications. This compound comprised 8.03% (n = 2) of the liquid GSE sample. Higher amounts of benzethonium chloride were found in powder GSE samples.

Diazepam induces FGF-2 mRNA in the hippocampus and striatum

starting by 6 h following diazepam injection and returning to approximately control values by 24 h. In situ hybridization showed elevated FGF-2 mRNA labeling in the hippocampal formation, mostly in the pyramidal layer of the CA1 and CA2 subfields and in the dentate gyrus hilar region. These results indicate that diazepam treatment up-regulates FGF-2 expression in select regions of the brain and suggest that GABA may promote neuroplasticity in concert with FGF-2.

Identification of three triterpenoids in almond hulls

Three triterpenoids, betulinic acid, oleanolic acid, and ursolic acid, were isolated as their methyl esters (treatment with diazomethane) from diethyl ether extracts of almond hulls (Nonpareil variety) using flash chromatography and preparative high-performance liquid chromatography. The triterpenoids, which comprised approximately 1% of the hulls, were characterized using chromatographic and spectroscopic methods. These studies demonstrate that almond hulls are a rich source of these triterpenoids, which have reported anti-inflammatory, anti-HIV, and anti-cancer activities.

[Pleuropulmonary staphylococcal infection in infants, in a hospital environment in Ouagadougou (Burkina Faso)]

We observed 36 cases of pleuropulmonary staphylococcal infection (PPS) in infants aged 0 to 30 months, during a prospective study carried out between April 1st 1995 and March 31 1996 at the Pediatrics Department of Ouagadougou University Hospital. PPS accounted for 0.5% of all hospital admissions and 11.6% of all acute basal respiratory infections in children aged less than 30 months. Slightly more boys than girls were affected, with a sex ratio of 1.2. We identified the classic triad of symptoms: cough-fever-polypnea, associated with abdominal ballooning and a change in general condition. On X rays, the typical images showing parenchymatous bubbles were the second most frequent observation (27.8%) after parenchymatous opacities (69.5%). The most frequently used antibiotics were oxacillin (Bristopen), gentamycin (Gentallin) and cefuroxime-axetil (Zinnat). The prognosis of PPS is poor, with a high mortality rate (27.8%) and a risk of pleural recurrence. Being very young, late hospitalization, malnutrition and leukopenia were identified as factors indicating a poor prognosis. Recygling of health care personnel for the management of acute respiratory infections, a decrease in malnutrition and an improvement in vaccination cover are essential if the mortality and morbidity of acute respiratory infections, and PPS in particular, are to be reduced.

Impact of mutations within the putative Ca2+-binding lumenal interhelical a-b loop of the photosystem II D1 protein on the kinetics of photoactivation and H2O-oxidation in Synechocystis sp. PCC6803

Mutations D1-D59N and D1-D61E in the putative Ca2+-binding lumenal interhelical a-b loop of the photosystem II (PSII) D1 protein [Chu, H. A., Nguyen, A. P., and Debus (1995), Biochemistry 34, 5839-5858] were further characterized in terms of S-state cycling and photoactivation. Bare platinum electrode measurements of centrifugally deposited O2-evolving membranes isolated from the a-b loop mutants demonstrated a retarded appearance of O2 following single turnover flashes, although not to the extent of retardation seen in the Deltapsb0 mutant, which lacks the extrinsic manganese-stabilizing protein (MSP). Double flash measurements indicate that retarded O2 release in mutants coincides with a decrease in overall PSII turnover during the S3-[S4]-S0 transition. S2 and S3 decay measurements in the isolated membranes indicate that D1-D59N and D1-D61E have faster decays of these higher S-states in contrast to slowed decays in the Deltapsb0 mutant. Measurements of the flash interval dependence of photoactivation indicate that intermediates of photoactivation [light-dependent assembly of the (Mn)4 complex] are highly destabilized in the a-b loop mutants compared to both DeltapsbO and the wild-type: flash intervals of greater than 2 s result in the nearly complete decay of unstable photointermediate(s) in the D1-D59N and D1-D61E samples, whereas a similar loss does not occur until intervals even greater than 10 s in the DeltapsbO and wild-type samples. These results are consistent with a role for the residues D1-D59 and D1-D61 in modulating the redox properties of the higher S-states and, also, possibly in the binding the calcium ion involved in photoactivation.

Diazepam induces FGF-2 and its mRNA in the spinal cord

We have explored the possibility that the GABA system can influence the expression of FGF-2 in the spinal cord. The GABA agonist diazepam was systemically injected in adult rats, and the expression of FGF-2 was examined in the cervical spinal cord region between 6 h and 7 days post-injection. Results of nuclease protection assays showed increases in FGF-2 mRNA, starting by 6 h and returning to approximately control values by 3 days. There was an increase in the density of FGF-2 immunostained astrocyte-like cells between 6 h and 3 days. Results showing that diazepam up-regulates FGF-2 expression in the spinal cord suggest that GABA may promote neuroplasticity in concert with FGF-2.

In vitro cellular response to polypyrrole-coated woven polyester fabrics: potential benefits of electrical conductivity

Electrically conducting polypyrrole-treated films have recently been shown to influence the morphology and function of mammalian cells in vitro. This type of polymer represents a possible alternative biomaterial for use in vascular implantation. The present study compared the in vitro biocompatibility of the five different polyester woven fabrics having increasing levels of electrical conductivity ranging from 4.5 x 10(4) to 123 omega/square with that of low density polyethylene and polydimethylsiloxane primary reference materials. Biocompatibility was measured in terms of four different types of in vitro cellular response, including (a) an indirect and (b) a direct control organotypic culture assay using endothelial cells, (c) a polymorphonuclear (PMN) cell activation study using flow-cytometric measurements of CD11/CD18 integrin molecule expression, and (d) a semiquantification of interleukin (IL)-6 mRNA expression on monocytes/macrophages using reverse-transcriptase polymerase chain reaction. The organotypic culture study revealed that the fabrics with high levels of conductivity exhibited lower cell migration, proliferation, and viability. The PMN activation study of blood from 10 healthy adult donors demonstrated that the two most conductive fabrics were able to identify the more reactive donors. The levels of IL-6 mRNA expression by monocytes/macrophages decreased as the conductivity level of the fabrics increased. The results of the present study therefore indicate that high levels of conductivity (< 200 omega/square) on polyester fabrics are detrimental to the growth, migration, and viability of endothelial cells; induce elevated PMN activation; and affect the intracellular metabolism of monocytes. They also point to a specific range of conductivity (10(3) < 10(4) omega/square) which is associated with an optimum in vitro cellular response.

Physical exercise induces FGF-2 and its mRNA in the hippocampus

Clinical and experimental evidence indicate that physical activity has a positive impact on brain function; however, the molecular bases for how exercise affects the structure and function of the brain are largely unknown. We have investigated the influences of variable periods of voluntary wheel-running on the expression of basic fibroblast growth factor and its mRNA in various brain regions. Nuclease protection assays revealed that the hippocampus was the only region examined exhibiting changes in FGF-2 mRNA as a result of exercise. FGF-2 mRNA increased to reach a peak by the 4th night of wheel-running. FGF-2 immunoreactivity, normally located in the perinuclear area of astrocytes, following exercise became stronger and appeared to spread to the cytoplasm and processes of astrocytes. Quantification of the FGF-2-immunoreactive astrocytes showed an increase in density between 2 and 4 nights of running in discrete regions of the hippocampus. These results demonstrate that exercise regulates FGF-2 expression and suggest that growth factors are likely mediators of the positive effects of exercise on the brain.