Osteopenia and rickets are common among extremely low birth weight infants  despite current practices of vitamin and mineral supplementation. Few data are available evaluating the usual course of markers of mineral status in this population. Our objectives in this study were to determine the relationship between birth weight (BW) and peak serum alkaline phosphatase activity (P-APA) in ELBW infants and evaluate our experience with the diagnosis of rickets in these infants.We evaluated all ELBW infants admitted to Texas Children's Hospital NICU in 2006 and 2007. Of 211 admissions, we excluded 98 patients who were admitted at >30 days of age or did not survive/stay for >6 weeks. Bone radiographs obtained in 32 infants were reviewed by a radiologist masked to laboratory values.In this cohort of 113 infants, P-APA was found to have a significant inverse relationship with BW, gestational age and serum phosphorus. In paired comparisons, P-APA of infants <600 g  and infants 600–800 g  were both significantly higher than P-APA of infants 800–1000 g , p < 0.01. Thirty-two patients had radiographic evaluation for evidence of rickets, based on P-APA greater than 800 IU/L, parenteral nutrition greater than 3 to 4 weeks, or clinical suspicion. Of these, 18 showed radiologic rickets and 14 showed osteopenia without rickets. Infants with BW <600 g were more likely to have radiologic rickets (10/20 infants) compared to those with BW 600–800 g (6/43 infants) and BW 800–1000 g (2/50 infants), p < 0.01 for each. P-APA was not significantly higher in infants with radiologic rickets (1078 ± 356 IU/L) compared to those without radiologic evidence of rickets .Elevation of P-APA >600 IU/L was very common in ELBW infants. BW was significantly inversely related to both P-APA and radiologic rickets. No single value of P-APA was related to radiological findings of rickets. Given the very high risk of osteopenia and rickets among ELBW infants, we recommend consideration of early screening and early mineral supplementation, especially among infants <600 g BW. Metabolic bone disease is a common problem encountered in premature infants. This entity, also known as osteopenia of prematurity, often leads to morbidity in the form of fractures, which have been described in 30% of infants <1500 g birth weight (BW) . In its Metabolic bone disease is characterized by decreased bone mineral density which occurs primarily as the result of decreased mineral stores in preterm infants which may be exacerbated by increased mineral demands in the neonatal period. Calcium (Ca) and phosphorus (P) are maximally acquired by the fetus during the third trimester of pregnancy, so premature infants are born with significantly lower mineral stores compared to term infants . AdditioSerum alkaline phosphatase activity (APA), serum P, and serum Ca have traditionally been used to screen for metabolic bone disease in preterm infants. Elevated APA and decreased serum P have been shown to correlate with increased risk of osteopenia and rickets in premature infants ,8. Koo eIn this study, we sought to determine usual peak serum alkaline phosphatase activity (P-APA) in ELBW infants and determine the frequency at which rickets is diagnosed in these infants.Using an existing database of neonatal intensive care unit (NICU) admissions, we identified all ELBW patients admitted to the Level 3 NICU at Texas Children's Hospital from January 2006 through December 2007. Their medical records were reviewed and data collected with approval from the Institution Review Board for Baylor College of Medicine and Affiliated Institutions. The following data were initially obtained: gestational age (GA), age at admission, and age at time of discharge or death. Infants excluded from further analysis were admitted to Texas Children's Hospital at age >30 days, were transferred to another institution prior to staying six weeks, or died prior to staying six weeks in the NICU.For the remaining patients in the study, the following laboratory values were obtained: P-APA, serum Ca and serum P at the time of P-APA, and maximum conjugated bilirubin.During this period, it was policy in our hospital to measure serum P and APA in all ELBW infants weekly until the infants were receiving full enteral feeds and had shown a clear pattern that the APA was no longer rising. Recommended practice in our hospital at that time was that a wrist or knee radiograph be obtained in infants who had a persistently high APA  or had long-term inadequate mineral intake. Long term inadequate mineral intake was defined as intake below 150 mg/kg/day of calcium or 75 mg/kg/day of phosphorous for at least 3 weeks. Inadequate mineral intake was most commonly seen in infants on long term TPN (>3–4 weeks). Infants with APA <800 IU/L receiving prolonged TPN (>3–4 weeks) or who were clinically suspected to have rickets also received radiographs. All patients' radiographic records were reviewed, and patients who had been evaluated radiographically for the presence of rickets were identified. Presence or absence of the diagnoses cholestasis (defined as conjugated bilirubin >2 mg/dL), bronchopulmonary dysplasia, necrotizing enterocolitis, and gastrointestinal perforation were determined and recorded.All radiographs of these patients which were performed for the purpose of evaluating for the presence of osteopenia and rickets were reviewed by an individual pediatric radiologist who was masked to the laboratory values associated with these patients. Radiographs obtained for these evaluations included images of the wrist(s) and/or knee(s). Patients were classified as normal, as having osteopenia , or as having rickets .SPSS  was used to analyze the data. General linear modeling was used to make group comparisons. Data are presented as the Mean ± Standard Deviation.A total of 211 infants were admitted to Texas Children's Hospital NICU with a BW <1000 g between January 2006 and December 2007. Of these, 39 patients were excluded from the study because they were admitted after 30 days of age. An additional 59 patients were excluded from the study because they either died before age six weeks or were discharged before hospital length of stay reached six weeks. The remaining cohort of 113 infants was the population for which all additional data were obtained and analyzed.In the cohort of 113 infants, the mean BW was 768 ± 153 g, and mean GA was 26 ± 2 weeks. Mean P-APA was 749 ± 326 IU/L. P-APA was found to have significant inverse relationships with BW, GA, and serum P  and infants 600–800 g  were both significantly higher than P-APA of infants 800–1000 g , p < 0.01  compared to those with BW 600–800 g (6/43 infants) and BW 800–1000 g (2/50 infants). Table P-APA was significantly higher in infants with radiologic diagnosis of rickets 1078 ± 357 IU/L) compared to infants who were not evaluated for rickets with radiographs , but not those whose radiographs did not demonstrate rickets . However, four infants with rickets did have P-APA <800 IU/L. Seventeen infants with P-APA >800 IU/L did not have radiographic evaluation for rickets. Mean serum P was slightly lower in infants with rickets (5.1 ± 0.2 mg/dL) compared to infants who were not evaluated for rickets , but not those whose radiographs did not demonstrate rickets . There was no close correlation between serum Ca and the diagnosis of rickets. The BW, P-APA, and serum P for the 32 patients in which radiographic rickets evaluation were obtained are shown in Table 57 IU/L cThe average maximum conjugated bilirubin of the 113 infants was 3.7 ± 5.3 mg/dL. Fifty-five of the infants had the diagnosis of cholestasis based on maximum conjugated bilirubin >2.0 mg/dL. Eighty-seven of the infants had a diagnosis of bronchopulmonary dysplasia. Twenty-five of the infants had a diagnosis of necrotizing enterocolitis, and 12 had a diagnosis of gastrointestinal perforation. Diagnoses of cholestasis, bronchopulmonary dysplasia, necrotizing enterocolitis, and gastrointestinal perforation were not significantly associated with the radiographic diagnosis of rickets. However, P-APA was higher in the 55 patients with cholestasis (867 ± 311 IU/L) compared to the 58 patients without cholestasis . A total of 28/55 subjects with cholestasis (51%) had a P-APA > 800 IU/L of which 13 were > 1000 IU/L. Only 12/58 subjects without cholestasis (21%) had a P-APA > 800 IU/L of which 6 were > 1000 IU/L.We found that, despite modern nutritional management, rickets is a common clinical problem in a large NICU setting. A total of 18 of 113 patients <1000 g BW were diagnosed with radiographic rickets over a 24 month time period in our NICU. Mean P-APA exceeded 600 IU/L in all subgroups and exceeded 950 IU/L in those <600 g BW. Nonetheless, among those infants who received a radiograph to evaluate rickets, there was no significant difference in P-APA in those in whom rickets was diagnosed compared to those who had osteopenia without rickets.Although rickets is not a reportable condition in any age group in the United States, it is likely that the number of preterm infants with rickets exceeds the number of older children with rickets. Regardless, it remains clear that rickets is an important clinical event in the NICU population with substantial morbidity . In addiThe diagnosis of rickets generally remains dependent on clinical suspicion and on biochemical P-APA data with a radiograph verifying the findings. Physical examination may reveal signs of osteopenia or rickets, including pathologic fractures or bony prominences at the costochondral junctions . Dual enWe cannot identify the sensitivity as not all infants received radiographic evaluation for rickets, including seventeen infants with P-APA >800 IU/L, and therefore we cannot determine the true incidence of radiographic rickets in this population. However, we did determine that radiographic rickets developed in at least 50% of infants <600 g BW, at least 14% of infants 600–800 g BW, and at least 4% of infants 800–1000 g BW.in utero accretion rate for Ca peaks in the early 3rd trimester at about 100–120 mg/kg/d [in utero Ca retention among these infants. It is possible that there is a unique and extremely elevated short term demand for minerals in these smallest infants that is not met by any of the usual nutrient delivery systems. It is also possible that elevated APA levels in these infants are not specific for the presence of rickets, and other factors including cholestasis may complicate the interpretation of elevated APA. Extremely high mineral demands in ELBW infants have not been documented in the literature, except for a single case report. This case report describes an infant with persistent radiographic rickets and elevated APA. After receiving daily calcium and phosphorus doses of 600 mg/kg and 500 mg/kg, respectively, APA levels improved [The reason for a high rate of rickets in infants <1000 g BW and especially those <600 g BW is unknown. In the United States, preterm formulas, fortified human milk and TPN delivered via central access provide about 80–100 mg/kg/d of retained Ca and approximately half that amount of retained P when appropriate nutrition is successfully provided. However, clinical concerns such as lack of central access, fluid restriction, and/or feeding intolerance may limit nutrient delivery, leading to suboptimal delivery of Ca and P. The  mg/kg/d . The larimproved .in utero. This rapid bone growth has not been documented in the literature. We did not document the feeding or TPN course of the infants in the study. However, acute gastrointestinal events including necrotizing enterocolitis and gastrointestinal perforation were not increased in the infants with rickets. Such events generally require reduction in enteral feeds in conjunction with increased TPN delivery.Although overall growth rates are not excessive in ELBW infants, whether on TPN or enteral feeds, we suggest that very high APA and rickets may be caused by rapid bone growth in these infants which exceeds bone growth Clinically, the total APA is often used as a marker for nutritional intervention. APA was first suggested as a screening tool for neonatal rickets based on a study including 30 premature infants . BackstrOur data indicate that elevated APA level should not be the only factor prompting radiographic evaluation for rickets, as rickets occurred in infants even with APA <600 IU/L. Our study supports the existing data that P deficiency is important in the development of metabolic bone disease , but serWe propose the following guidelines for clinicians evaluating ELBW infants for rickets. In general, we recommend that a radiograph of the wrist and/or knee to evaluate for rickets be obtained in premature infants when multiple measurements of APA are >800 IU/L (two levels measured at least one week apart), and/or the APA approaches or exceeds 1000 IU/L. A prolonged need for TPN (>3–4 weeks), or suspicion of fracture, or abnormal bone findings on an incidental radiograph should also trigger a radiographic evaluation for rickets. An additional policy of screening all infants <600 g BW with a radiograph of the wrist or knee when on full feeds or at about six weeks of age would also be reasonable. Infants >600 g BW with APA less than about 1000 IU/L and no clinical evidence of rickets may be followed with weekly or bi-weekly APA measurements (until levels are <500 IU/L) without additional evaluation or intervention, especially if they are receiving adequate mineral intake Figure . We recoElevation of APA >600 IU/L was very common in ELBW infants. BW was significantly inversely related to both P-APA and rickets. No single value of APA was related to radiological findings of rickets. Given the very high risk of osteopenia and rickets among ELBW infants, we recommend consideration of early screening and early mineral supplementation, especially among infants <600 g BW or APA >800 IU/L.APA: alkaline phosphatase activity; BW: birth weight; Ca: calcium; ELBW: extremely low birth weight; GA: gestational age; NICU: neonatal intensive care unit; P: phosphorus; P-APA: peak alkaline phosphatase activity; TPN: total parenteral nutritionThe authors declare that they have no competing interests.SMM assisted in the design of the study, performed the data collection, and prepared the manuscript. SPR, PDH, and KMH participated in data collection. BRP reviewed all radiographs for osteopenia and rickets. SAA designed and coordinated the study, performed statistical analysis, and participated in preparation of the manuscript. All authors read and approved the manuscript prior to submission.The pre-publication history for this paper can be accessed here:


VHL) alteration, a common event in sporadic clear-cell renal-cell carcinoma (CCRCC), leads to highly vascularised tumours. Vascular endothelial growth factor (VEGF) is the major factor involved in angiogenesis, but the prognostic significance of both VHL inactivation and VEGF expression remain controversial. The aims of this study were to analyse the relationship between VHL genetic and epigenetic alterations, VHL expression and VEGF tumour or plasma expression, and to analyse their respective prognostic value in patients with CCRCC.The von Hippel–Lindau gene  and methylation-specific MLPA. Expression of pVHL and VEGF was determined by immunohistochemistry. Plasma VEGF was measured by enzyme-linked immunosorbent assay (ELISA).A total of 102 patients with CCRCC were prospectively analysed. Alterations in VHL mutation, deletion and promoter methylation were identified in 70, 76 and 14 cases, respectively. Overall, at least one VHL-gene alteration occurred in 91 cases (89.2%). Both VEGF tumour and plasma expression appeared to be decreased in case of VHL alteration. Median progression-free survival and CCRCC-specific survival were significantly reduced in patients with wild-type VHL or altered VHL and high VEGF expression, which, therefore, represent two markers of tumour aggressiveness in CCRCC.Stratifying CCRCCs according to VHL and VEGF status may help tailor therapeutic strategy. Renal-cell carcinoma (RCC) accounts for 3% of all solid tumours. Seventy-five to 85% of RCCs are clear-cell carcinomas ), which are highly vascularised tumours. As much as 30% of patients do have metastases at the time of diagnosis and an additional 30–40% will develop metastases during follow-up, although a radical surgery has been initially performed (VHL) tumour suppressor has been isolated in 1993 (VHL gene (pVHL) is the substrate recognition component of a ubiquitin ligase complex that targets a transcription factor, hypoxia-inducible factor (HIF), for proteolysis. A biallelic VHL inactivation leads to HIF-1α accumulation and subsequent overexpression of genes, which are critical for tumour angiogenesis, cell proliferation and migration  tumour expression, was associated to a particular aggressive CCRCC phenotype , tumour VEGF expression, plasma VEGF levels and usual prognostic parameters in CCRCC. We subsequently analysed the respective prognostic value of these different biological tumour characteristics.Although some studies have shown a positive relationship between genetic and epigenetic A total of 102 patients operated for a sporadic CCRCC at the Department of Urology at the Rennes University Hospital between 2003 and 2004 were analysed. In case of distant metastases, patients were treated following surgery according to the standard of care of the period, which was immunotherapy. Surveillance following surgery included repeated clinical assessments, blood biochemistry tests, chest and abdominal CT scans. No patient was lost to follow-up. The study protocol was approved by the institutional ethics committee and informed consent for participating in this study was obtained in each case. The clinicopathological data of the patients are summarised in Formalin-fixed paraffin sections were stained with hematoxylin and eosin–safran for light microscopy. The slides were reviewed by one pathologist (N Rioux-Leclercq). Only conventional CCRCCs were considered for analysis. Macroscopic and histological parameters, which were analysed included tumour size, tumour necrosis and nuclear Fuhrman grade .121 and VEGF165 free isoforms) in plasma. All samples were assessed in duplicate. The value of plasma VEGF (pVEGF) was expressed in pg/ml. The detection limit of the test was 9 pg−1ml and the upper limits of normal value used for VEGF in plasma was 62.5 pg ml−1  and heated in a 600 W microwave four times for 2 min. The slides were then left to cool down for 30 min and rinsed in a phosphate-buffered saline solution. Slides were incubated at room temperature for 1 h with the polyclonal anti-VEGF antibody . A biotin–streptavidin detection system  was then used with diaminobenzidine as the chromogen . Negative controls were performed by omitting the primary antibody and by incubating primary antibody with immunising VEGF peptide prior to slide treatment. VEGF immunoreactivity was expressed as the percentage of the VEGF-positive cells by scoring at least 1000 tumour cells at × 400 magnification. The immunohistochemical signals in the CCRCCs were evaluated as membranous and/or cytoplasmic. For prognostic analysis, a 30% cut-off was used according to previous reports . Primer pairs and PCR-sequencing conditions are described elsewhere (We amplified two overlapping fragments for exon 1 (1A and 1B) and one fragment for each of exons 2 and 3, covering part of the VHL gene  was used. The kit contains eight probes to the VHL gene , additional probes to other genes on 3p and control probes to regions telomeric and centromeric from VHL. Detailed information on probe sequences, gene loci and chromosome locations can be found at www.mlpa.com.Multiplex Ligation-dependent Probe Amplification (MLPA) analysis was used to detect deletions or duplications in the μl containing 10 μl of the ligation reaction mixture using the PTC 200 thermal cycler . Aliquots of 1.5 μl of the PCR reaction were combined with 0.3 μl ROX-labelled internal size standard  and 9 μl deionised formamide. Fragments were separated by electrophoresis on an Applied 3130XL capillary sequencer and quantified using the GeneMarker version 1.6 software (SoftGenetics). For copy-number detection, normal control DNA samples were included in each set of MLPA experiments. Interpretation was based on the comparison of peak heights between the control DNA and the tumour sample. Cut-off levels for loss of relative copy number were set at 0.75.Genomic DNA (50–200 ng) was denatured and the probes were allowed to hybridise (16 h at 60°C). PCR was performed on the samples in a volume of 50 HhaI). The SALSA MS-MLPA kit ME001B Tumour suppressor-1 allows to detect aberrant methylation of CpG islands located in the promoter region of the VHL gene. DNA (50–200 ng) was denatured and the probes were allowed to hybridise (16 h at 60°C). The VHL probes used in this study for methylation quantification analysis contained one HhaI restriction site in the target recognition sequence. Following hybridisation, the samples were divided into two and one half of the samples was ligated, whereas for the other part of the sample ligation was combined with HhaI digestion enzyme. This digestion resulted in ligation of only the methylated sequences. PCR was performed on both parts of the samples and analysed by electrophoresis as described above. Reference unmethylated DNAs, isolated from blood from healthy volunteers, were included in each set of MLPA experiments. The unmethylated DNA will not generate a signal, and a normal probe signal will be detected if the site is methylated.Methylation-Specific-MLPA (MS-MLPA) was used to detect CpG island methylation , which was defined as death from RCC .All analyses were conducted with the SPSS 10.1 software, and P-value significance was fixed at 0.05.Sixty-eight (66.7%) and 51 patients (50%) had good performance status and no symptoms at diagnosis, respectively. Tumours were organ-confined (pT1-2) and low-grade (G1-2) in 58 (56.9%) and 37 cases (36.3%), respectively . In 12 cVHL gene mutation was found in 70 cases (68.6%). Mutations occurred in exon 1–3 in 30 (42.8%), 26 (37.2%) and 14 cases (20%), respectively. Stop, frameshift, missense, splice site and other mutation types were found in 10 (14.3%), 31 (45.7%), 19 (27.1%), six (8.6%) and four cases (4.3%), respectively . Mutation type and site of mutation did not impact either on PFS or on RCC-SS.A ectively . AlthougVHL deletion and promoter methylation occurred in 76 (74.5%) and 14 cases (13.7%), respectively . When considering patients with no VHL mutation, deletion or hyper-methylation , it appeared that their outcome was significantly worse both for PFS and RCC-SS than patients having at least one VHL alteration  and Fuhrman grades (P=0.03).ectively . OverallVHL gene, potentially leading to biallelic alteration, were found in 68 tumours (66.7%), whereas no or a single alteration of the VHL gene was found in 34 patients (33.3%). Comparison of these two groups yielded borderline prognostic significance for PFS  but not for RCC-SS . There was no relation with tumour size (P=0.6), T stage (P=0.2), N stage (P=0.4) or M stage (P=0.7).At least two alterations of the P=0.02), M stages (P=0.01), Fuhrman grades . Finally, absence of pVHL expression was associated with a more favourable outcome measured both by PFS (P=0.02) and RCC-SS . The absence of pVHL expression was associated with lower N stages  and comparing this former group to tumours expressing pVHL , the first group exhibited better outcome both in terms of PFS  and in terms of RCC-SS  expressed pVHL and did not present any VHL alteration. This group had a median PFS of 7 months compared with 58 months for the rest of the population . The median RCC-SS time was 18 months for this particular group with no VHL abnormality, whereas it was not reached for the rest of the population , M stage (P=0.03), Fuhrman grade  or ECOG performance status (P=0.4) (data not shown).Positive staining for VEGF was defined as a membranous and/or cytoplasmic staining pattern of tumour cells. Weak staining was observed in podocytes and endothelial cells in non-tumoral kidney tissue. Median VEGF tumour expression was 49% (0–100). In 60 cases (58.8%) VEGF tumour expression was ⩾30%. The expression of VEGF in tumour was associated with T stage , which is superior to what is reported for healthy donors (P=0.001), Fuhrman grade , but not with N stage (P=0.07) or M stage . Tumour and plasma VEGF were both predictors for PFS  and RCC-SS . Similarly, tumours presenting biallelic inactivation of the VHL gene were associated with decreased VEGF tumour expression (P=0.0001) and plasma VEGF levels  and VEGF plasma levels (P=0.002) compared with tumours expressing pVHL. Finally, the group not harbouring any VHL abnormality  was also characterised by increased mean VEGF plasma  and mean VEGF tumour expression  compared with tumours with either mutation, deletion or methylation of the VHL gene .A strong relationship was observed between VEGF tumour expression, VEGF plasma level and pVHL detection . HoweverP=0.005; . ConsistVHL alteration, it appeared that both VEGF tumour expression (cut-off 30%) and VEGF plasma level  were able to stratify two population subsets with distinct outcomes. Based on these finding, our total CCRCC population was, therefore, stratified into three distinct groups: Group 1, at least one VHL alteration and low VEGF expression; Group 2, at least one VHL alteration and high VEGF expression and Group 3, no VHL alteration regardless of VEGF expression. When stratifying with plasma VEGF level, the median PFS times for the three groups were 58, 27 and 17 months, respectively , whereas median RCC-SS time was not reached for the first two groups and was 36 months for the third group . In the latest setting, median RCC-SS time was not reached for the first two groups and was 36 months for the third group  VEGF instead of being overexpressed in VHL-inactivated tumours seems to be relatively low and (3) a small cohort of CCRCC with no VHL alteration exhibit a very unfavourable outcome.The importance of tumour angiogenesis in CCRCC development and spreading has been recently strongly validated by the proven efficacy of antiangiogenic drugs that target mainly the VHL/VEGF pathway  exhibited low VEGF tumour expression, and out of the 34 remaining tumours, 25 (73.5%) had high VEGF tissue expression. It clearly suggests that VHL-independent mechanisms are involved in VEGF upregulation in advanced CCRCC. Conversely, unexpected low VEGF levels were found in tumours with VHL alterations, indicating that VHL alteration does not necessarily trigger tumour progression.In this series, we could confirm that plasma or tumour VEGF were elevated in the majority of patients and that both high plasma and tissue VEGF were associated with increased risk of dying from CCRCC. Unexpectedly, mean VEGF tumour expression and mean VEGF plasma levels were significantly increased in tumours with no VHL mutational rate along with 74.5 and 13.7% deletion and promoter methylation rates, respectively, which is consistent with what is generally reported in the literature . These tumours are generally good prognostic tumours that are likely to be cured by surgery or that could be potentially good candidates for immunotherapy in case of metastases. Carbonic Anhydrase IX is generally overexpressed in such tumours and CAIX has been proven to be a good selection criteria for response to interleukin-2-based immunotherapy  probably reflect additional molecular events following initial VHL alteration. These tumours with VEGF-driven aggressiveness would be good candidates for receiving tyrosine kinase inhibitors (TKIs) that target VEGF-R and PDGF-R. It is probably in this particular group that VEGF should be evaluated in the future as a predictive factor for response to TKIs. Two different studies suggested that tumours with loss of function of VHL were more likely to be sensitive to anti-VEGF drugs, thus suggesting that both VHL and VEGF status are potentially important for predicting response to TKIs  classification is increased by using mTOR inhibitors that do not target specifically the VHL/VEGF pathway (VHL-mutated, seem to be less sensitive to VEGF targeting drugs than their clear-cell counterpart, and that by contrast non-clear-cell RCCs seem to be sensitive to mTOR inhibitors (The third group with no VHL alteration would be needed to validate further our hypotheses through prospective clinical trials, and non-VHL molecular pathways that are involved in CCRCC should be better characterised.In conclusion, classifying CCRCC according to VHL/VEGF status could potentially help physicians to choose the appropriate therapeutic strategy according to the molecular stage of the disease: surgery/immunotherapy, surgery/TKIs and mTOR inhibitors. We investigated a relatively small series of 102 patients with CCRCC. Consequently, subgroups are limited in size. A larger number of tumours with no


Background. Management of multiple-endocrine neoplasia type 1- (MEN1-) associated hyperparathyroidism is associated with high recurrence rates and high surgical morbidity due to multiple neck explorations. Cinacalcet, a calcimimetic agent licensed for the treatment of secondary hyperparathyroidism and parathyroid carcinoma, may provide a medical alternative for the management of these complex patients. Methods. A prospective audit was performed of eight patients; three males and five females, aged 20–38 at diagnosis. Two patients commenced cinacalcet as primary treatment and six had previous surgery. Six patients had complications of hyperparathyroidism: renal calculi, renal dysfunction, and reduced bone mineral density. All were commenced on cinacalcet 30 mg bd for MEN1 associated hyperparathyroidism; doses were subsequently reduced to 30 mg od in four patients. Results. Significant reductions were observed in serum calcium and PTH measurements. Serum calcium reduced by a median of 0.35 mmol/L (P = .012 Wilcoxon Signed Rank). Serum PTH levels decreased by a median of 5.05 pmol/L (P = .012). There was no change in urine calcium. Duration ranged from 10–35 months with maintenance of control. Cinacalcet was well tolerated by six patients; one experienced nausea and one experienced diarrhoea. Conclusion. Cinacalcet is an effective and well-tolerated medical treatment for the management of complex primary hyperparathyroidism. Primary hyperparathyroidism (PHPT) in Multiple Endocrine Neoplasia Type I MEN1) has a penetrance rate of nearly 100% by the age of 50 years  has a pe. EffectiCinacalcet is a potential medical alternative; by allosterically modulating the calcium sensing receptor on the PTH cell, it increases sensitivity to extracellular calcium and down-regulates PTH secretion. It is licensed for the management of secondary hyperparathyroidism and parathyroid carcinoma , 5. In pWe reviewed the clinical data of nine patients treated with cinacalcet for MEN-1 PHPT with institutional board approval. The cohort consisted of three males, five females, aged 20–38 years at diagnosis . All hadPretreatment serum calcium levels ranged 2.62–2.91 mmol/L, median 2.76 mmol/L (reference range 2.15–2.65 mmol/L), and PTH levels ranged 4.8–36.5 pmol/L, median 15.9 pmol/L (reference range 1.3–6.8 pmol/L). All patients deficient in 25-hydroxy vitamin D were commenced on supplements and achieved levels within the laboratory reference range prior to commencement of cinacalcet. Six out of eight patients exhibited complications of PHPT: reduced BMD in five patients, (T score of less than −2.5), renal calculi in four patients, and renal dysfunction in four patients (>25% reduction in creatinine clearance). Two patients had no complications of hyperparathyroidism but were under the age of 50; all patients therefore fulfilled criteria for treatment as determined by the Consensus on the management of asymptomatic primary hyperparathyroidism 2002 [Cinacalcet was generously provided by Amgen on a compassionate-use basis to the hospital for no charge. After a product license was obtained in the UK for use in renal failure-related hyperparathyroidism, it was prescribed on an off label basis at 30 mg twice daily. The dose was subsequently reduced in four patients: two due to clinical response and two due to side effects. Due to the pharmacokinetics of cinacalcet, all serum calcium and PTH measurements were taken predose according to a defined protocol. As steady state drug levels are achieved after 7 days, results of the first clinical assessment (three months postcommencement) were used for comparison.P value <.05. All variables studied were normally distributed. The nonparametric Wilcoxon Signed Ranks Test was performed for the comparison of the variables between the studied groups because of the small sample size.Statistical significance was accepted at a Analysis was performed using SPSS  for W indows XP (Microsoft Corp).P = .012) (P = .012) (P = .018). A significant increase was noted in serum phosphate (P = .012) but no change was found in 24-hour urinary calcium measurements  . Serum P = .012) . Analyseurements .P = .345).A comparison was made between pre- and 2 hours post cinacalcet PTH measurements for the 5 individuals in whom results were available; no significant difference was detected  compared to studies of cinacalcet use in sporadic PHPT (mean reduction 7.6%) [Previously published data highlighted the theoretical concern of increased urinary calcium excretion with cinacalcet use, due to the direct action at the calcium sensing receptors in the kidney. The overall reduction in serum calcium appears to counteract this effect and significant changes in urinary calcium excretion have not been demonstrated in primary hyperparathyroidism . In viewEffective control of serum calcium and PTH levels in MEN1 PHPT is an appropriate therapeutic strategy to reduce the early onset of associated complications. Where surgery has been noncurative or is not possible, cinacalcet may provide a medical alternative; this is supported by our study and a recent case report of a 30-year-old woman who maintained biochemical control after 1 year of cinacalcet for management of MEN1 hyperparathyroidism . Longer-


Waist circumference (WC) adjusted for body mass index (BMI) is positively associated with mortality, but the association with changes in WC is less clear. We investigated the association between changes in WC and mortality in middle-aged men and women, and evaluated the influence from concurrent changes in BMI.Data on 26,625 healthy men and women from the Danish Diet, Cancer and Health study was analyzed. WC and BMI were assessed in 1993–97 and in 1999–02. Information on mortality was obtained by linkage to the Danish central Person Register. Hazard ratios (HR) were estimated with Cox regression models. During 6.7 years of follow-up, 568 and 361 deaths occurred among men and women, respectively. Changes in WC were positively associated with mortality (HR per 5 cm for the sexes combined  = 1.09 (1.02∶1.16) with adjustment for covariates, baseline WC, BMI and changes in BMI), whereas changes in BMI were inversely associated with mortality  with adjustment for covariates, baseline WC, BMI and changes in WC). Associations between changes in WC and mortality were not notably different in sub-groups stratified according to changes in BMI, baseline WC or when smokers or deaths occurring within the first years of follow-up were excluded.Changes in WC were positively associated with mortality in healthy middle-aged men and women throughout the range of concurrent changes in BMI. These findings suggest a need for development of prevention and treatment strategies targeted against redistribution of fat mass towards the abdominal region. Obesity and weight gain increases the risk of premature morbidity and mortality Individuals also differ in their regional distribution of body fat, which have implications for their morbidity and mortality. Anthropometric measures of abdominal fatness (e.g. waist circumference (WC)) appears to be more strongly associated with the risk of type 2 diabetes, cardiovascular disease and mortality than anthropometric measures of general fatness (e.g. body mass index (BMI)) The association between mortality and changes in the localization of body fat is, however, not clear In 1993–97, a random sample of 160,725 individuals aged 50–64 years were invited to the Danish prospective study ‘Diet, Cancer and Health’. A total of 57,053 accepted the invitation . Participants filled in questionnaires and were clinically examined. In 1999–2002, repeated information was collected with questionnaires. The Danish Data protection Agency and the regional Ethical Committee approved the study, which was in accordance with the Helsinki Declaration II. Participants signed a written consent before participating. Details of the study are described elsewhere In 1993–97, technicians measured the individuals' height (nearest 0.5 cm without shoes) and weight . The WC was measured (nearest 0.5 cm) with a measuring tape at the smallest horizontal circumference between the ribs and iliac crest , or, in case of an indeterminable WC narrowing, halfway between the lower rib and the iliac crest. In 1999–02, individuals received a self-administrated questionnaire and reported their weight (kg) and WC (cm) measured at the level of the umbilicus using an enclosed paper measuring tape. BMI (kg/m2) was calculated as weight per height squared. Change in WC (DWC) (cm) and change in BMI (DBMI) (kg/m2) was calculated as the value in 1993–97 subtracted from the value in 1999–02.The validity of the self-reported WC was assessed in study carried out in 408 men and women from the cohort smoking habits , sports activity (0 versus >0 hours/wk) total energy intake  (KJ/day) Mediterranean diet scoredrinking pattern , educational level (length of education: <8 years (basic school), 8–10 years , >10 years ) menopausal status .Covariates, assessed with the 1999–02 questionnaire, were used: Information on all-cause mortality was obtained by linkage to the Danish Central Person Register using information about emigration, date of disappearance and vital status. The validity of all-cause mortality in the Danish Central Person Register is generally considered high Chronic disease may induce changes in anthropometry and increase the risk of early mortality Men and women with extreme values on the anthropometric variables  were also excluded due to potential measurement errors.Analyses were conducted for each sex separately and sexes were combined when appropriate Hazard ratios (HR) of mortality were calculated from Cox proportional hazard models with years since the examination in 1999–02 as time axis, so that individuals were considered at risk from 1999–02 until time at death, emigration/disappearance or April 27 2008, whichever came first.Analyzing continuous exposures in epidemiology has been widely debated To explore if the association between DWC and mortality was equal throughout the range of the DBMI, the association between DWC and mortality were investigated in groups with loss (DBMI< = 0) and gain in BMI (DBMI>0). The association between DWC and mortality may also depend on the initial fatness level Smoking and undiagnosed diseases may induce changes in anthropometry and increase the risk of mortality www.stata.com). Statistically significant differences were defined as differences with p<0.05.Analyses were conducted in STATA version 9.2  per 5 cm for in participants with concurrent loss of BMI and 1.02  per 5 cm in participants with concurrent gain in BMI after adjusting for covariates baseline BMI, WC and DBMI (p for interaction  = 0.06).The DWC was also positively associated with mortality in the two strata of baseline WC. The HR was 1.07  per 5 cm for in participants with low baseline WC and 1.11  per 5 cm in participants with high baseline WC after adjusting for covariates baseline BMI, WC and DBMI (p for interaction  = 0.31).Exclusion of current smokers and ex-smokers or deaths occurring within the first years of follow-up had no major influence on the associations between DWC, DBMI and mortality .This prospective study of healthy middle-aged men and women showed that changes in WC were positively associated with mortality, whereas changes in BMI were inversely associated with mortality. The positive association with changes in WC was stronger after adjustment for concurrent changes in BMI, and the inverse association with changes in BMI was stronger after adjustment for concurrent changes in WC.The strengths of the study are the large-scale, well-characterized study population with anthropometry and covariates assessed at two subsequent time points and the complete follow-up (99.5%). Despite this large study population, there were relatively few deaths, especially among those with loss of WC.In total, 57,053 (36%) of the invited individuals participated at baseline Chronic disease may induce changes in anthropometry Covariates that could have confounding or modifying effects  were included in the study, but had no notable effects on the direction and strength of the associations. Some residual confounding from these or unmeasured covariates could, however, still be present. It has been argued that a distinction between intentional and unintentional weight loss is important to handle the influence from underlying diseases in population based studies of changes in anthropometry Different measurement methods of WC and BMI were employed in 1993–97 and 1999–02. A validation study within the cohort Long-term population-based studies have shown increased mortality in healthy individuals who loose weight Recent studies, including studies within the current population In conclusion, changes in WC are positively associated with all-cause mortality in healthy middle-aged men and women throughout the range of concurrent changes in BMI. These findings suggest a need for development of prevention and treatment strategies targeted against redistribution of fat mass towards the abdominal region.Figure S1Hazard ratios and 95% confidence intervals of mortality according to body mass index (BMI) in 1993–97 with adjustment for waist circumference (WC) in men. Lines are the hazard ratios  derived from Cox's proportional hazard models where BMI was included as restricted cubic splines (3 knots). Reference points are the respective means of BMI. Years since the examination in 1999–02 was used as underlying time axis. Adjusted for: years between examinations, age in 1999–02, BMI in 1993–97, smoking habits, Mediterranean diet score, energy intake, education, drinking pattern and sports activity. Test of linearity p = 0.3059 (linear association). Test of effect p = 0.3048.(0.01 MB TIF)Click here for additional data file.Figure S2Hazard ratios and 95% confidence intervals of mortality according to body mass index (BMI) in 1993–97 with adjustment for waist circumference (WC) in women. Lines are the hazard ratios  derived from Cox's proportional hazard models where BMI was included as restricted cubic splines (3 knots). Reference points are the respective means of BMI. Years since the examination in 1999–02 was used as underlying time axis. Adjusted for: years between examinations, age in 1999–02, BMI in 1993–97, smoking habits, Mediterranean diet score, energy intake, education, drinking pattern, sports activity and menopausal status. Test of linearity p = 0.4510 (linear association). Test of effect p = 0.6572.(0.01 MB TIF)Click here for additional data file.Figure S3Hazard ratios and 95% confidence intervals of mortality according to waist circumference (WC) in 1993–97 with adjustment for body mass index (BMI) in men. Lines are the hazard ratios  derived from Cox's proportional hazard models where WC was included as restricted cubic splines (3 knots). Reference points are the respective means of WC. Years since the examination in 1999–02 was used as underlying time axis. Lines are adjusted for: years between examinations, age in 1999–02, BMI in 1993–97, smoking habits, Mediterranean diet score, energy intake, education, drinking pattern and sports activity. Test of linearity p = 0.0603 (linear association). Test of effect p = 0.0041.(0.01 MB TIF)Click here for additional data file.Figure S4Hazard ratios and 95% confidence intervals of mortality according to waist circumference (WC) in 1993–97 with adjustment for body mass index (BMI) in women. Lines are the hazard ratios  derived from Cox's proportional hazard models where WC was included as restricted cubic splines (3 knots). Reference points are the respective means of WC. Years since the examination in 1999–02 was used as underlying time axis. Lines are adjusted for: years between examinations, age in 1999–02, BMI in 1993–97, smoking habits, Mediterranean diet score, energy intake, education, drinking pattern, sports activity and menopausal status. Test of linearity p = 0.8246 (linear association). Test of effect p = 0.4041.(0.01 MB TIF)Click here for additional data file.Figure S5Hazard ratios and 95% confidence intervals of mortality according to changes in body mass index (DBMI) with adjustment for changes in waist circumference (DWC) in men. Lines are the hazard ratio  derived from Cox's proportional hazard models where DBMI was included as restricted cubic splines (3 knots). Reference points are the respective means of DBMI. Years since the examination in 1999–02 is the underlying time axis. Adjusted for: years between examinations, age in 1999–02, baseline BMI, baseline WC, DWC, smoking habits, Mediterranean diet score, energy intake, education, drinking pattern and sports activity. Test of linearity p = 0.2261 (linear association). Test of effect p = 0.0041.(0.01 MB TIF)Click here for additional data file.Figure S6Hazard ratios and 95% confidence intervals of mortality according to changes in body mass index (DBMI) with adjustment for changes in waist circumference (DWC) in women. Lines are the hazard ratio  derived from Cox's proportional hazard models where DBMI was included as restricted cubic splines (3 knots). Reference points are the respective means of DBMI. Years since the examination in 1999–02 is the underlying time axis. Adjusted for: years between examinations, age in 1999–02, baseline BMI, baseline WC, DWC, smoking habits, Mediterranean diet score, energy intake, education, drinking pattern, sports activity and menopausal status. Test of linearity p = 0.7999 (linear association). Test of effect p = 0.5332.(0.01 MB TIF)Click here for additional data file.Figure S7Hazard ratios and 95% confidence intervals of mortality according to changes in waist circumference (DWC) with adjustment for changes in body mass index (DBMI) in men. Lines are the hazard ratio  derived from Cox's proportional hazard models where DWC was included as restricted cubic splines (3 knots). Reference points are the respective means of DWC. Years since the examination in 1999–02 is the underlying time axis. Adjusted for: years between examinations, age in 1999–02, baseline BMI, baseline WC, DBMI, smoking habits, Mediterranean diet score, energy intake, education, drinking pattern and sports activity. Test of linearity p = 0.5820 (linear association). Test of effect p = 0.2808.(0.01 MB TIF)Click here for additional data file.Figure S8Hazard ratios and 95% confidence intervals of mortality according to changes in waist circumference (DWC) with adjustment for changes in body mass index (DBMI) in women. Lines are the hazard ratio  derived from Cox's proportional-hazard models where DWC was included as restricted cubic splines (3 knots). Reference points are the respective means of DWC. Years since the examination in 1999–02 is the underlying time axis. Adjusted for: years between examinations, age in 1999–02, baseline BMI, baseline WC, DBMI, smoking habits, Mediterranean diet score, energy intake, education, drinking pattern, sports activity and menopausal status. Test of linearity p = 0.5374 (linear association). Test of effect p = 0.1131.(0.01 MB TIF)Click here for additional data file.Table S1Distribution of participants  and excluded  according to baseline characteristics.(0.03 MB DOC)Click here for additional data file.


Ksheerabala is an ayurvedic drug which is used to treat central nervous system disorders, arthritis, and insomnia. The aim of our study was to evaluate the effect of Ksheerabala on quinolinic acid-induced toxicity in rat brain. The optimal dose of Ksheerabala was found from a dose escalation study, wherein it was found that Ksheerabala showed maximum protection against quinolinic acid-induced neurotoxicity at a dose of 15 µL/100 g body weight/day, which was selected for further experiments. Four groups of female albino rats were maintained for 21 days as follows: 1. Control group, 2. Quinolinic acid (55 µg/100 g body weight), 3. Ksheerabala (15 µL/100 g body weight), 4. Ksheerabala (15 µL/100 g body weight) + Quinolinic acid (55 µg/100 g body weight). At the end of the experimental period, levels of lipid peroxidation products, protein carbonyls, and activities of scavenging enzymes were analyzed. The results revealed that quinolinic acid intake caused enhanced lipid and protein peroxidation as evidenced by increased levels of peroxidation products such as malondialdehyde, hydroperoxide, conjugated dienes, and protein carbonyls. On the other hand, the activities of scavenging enzymes such as catalase, superoxide dismutase (SOD), glutathione peroxidase, and glutathione reductase as well as the concentration of glutathione were reduced. On coadminstration of Ksheerabala along with quinolinic acid, the levels of all the biochemical parameters were restored to near-normal levels, indicating the protective effect of the drug. These results were reinforced by histopathological studies.One of the mechanisms of neurotoxicity is the induction of oxidative stress. There is hardly any cure for neurotoxicity in modern medicine, whereas many drugs in Ayurveda possess neuroprotective effects; however, there is no scientific validation for these drugs.  Sustained adverse interactions between neurotoxins arising from the environment, dietary and lipolytic factors, or from normal metabolism influenced by genetic factors could cause neurotoxicity. One of the common mechanisms for the induction of neurotoxicity is the overproduction of free radicals. Currently, neurorestorative treatment is not available in modern systems of medicine, whereas there are several ayurvedic drugs which have neuroprotective effects. Howerer, there is no scientific validation for these drugs.Ksheerabala is an ayurvedic drug used to treat arthritis, central nervous system disorders, and insomnia. The main contents of Ksheerabala are Bala (Sida cordifolia Linn.), Ksheera (cow's milk), and Thilathaila (Sesamum oil). The textual reference of Ksheerabala is found in Ashtangahridaya.[ahridaya.Sida cordifolia is a herb from the Malvaceae family that is used widely in ayurvedic medicine. Studies conducted by Auddy et al.[Sida cordifolia had more potent antioxidant activity than the other herbs. Studies conducted by Dhalwal et al.[Sida cordifolia is a potential source of natural antioxidants.dy et al. on the aal et al. also shoet al.[There are also reports that milk caseins possess significant antioxidant activity. Studies et al. have shoSesamum indicum[et al.[Sesame oil is derived from the plant species, m indicum and contm indicum includinm indicum tocopherm indicum and sesam indicum Sesame om indicum Other inm indicum Sesame om indicum Suja et um[et al. conducteN-methyl-D-aspartate receptor overactivation and oxidative stress.[2+ concentration, ATP exhaustion, neuronal oxidative stress, and cell death,[Quinolinic acid is an endogenous neurotoxin that is involved in various neurological disorders. It is used to produce a pharmacological model of Huntington's disease in rats and primates, and has been shown to evoke e stress. Quinolinll death,–18 Quinoll death,Ksheerabala have antioxidant properties. One of the mechanisms for the induction of neurotoxicity is through the generation of free radicals. In this study, we have taken quinolinic acid- induced oxidative stress in rat brain as a model system to validate the action of this drug and study its mechanism of action.A review of literature shows that ingredients of ad libitum. Quinolinic acid dissolved in phosphate-buffered saline (pH.7.4) was administered intraperitoneally, and Ksheerabala dissolved in milk was given orally by gastric intubation; control rats received only the vehicle. The duration of the experiment was 21 days and the dose of quinolinic acid was selected on the basis of previous reports.[Female albino rats (Sprague Dawley strain) weighing between 100 and 140 g were divided into four groups of six rats each. Animals were housed in polypropylene cages which were kept in a room that was maintained between 28 and 32°C. The light cycle was composed of 12 h light and 12 h dark. Animals were handled using the Laboratory Animal Welfare Guidelines. Rats werKsheerabala (101) was procured from Kottakkal Arya Vaidyasala, Kottakkal, Kerala, India.Acid Value: Not more than 70; Iodine value: 30-50; Saponification value: 210-230.Loss on Drying: Not more than 1%.tailam heated with 30 mL methanol for 20 min, then kept at –20°C for 12 h. The nonsolidified methanol fraction is filtered, concentrated to 10 mL and used for HPTLC. These data were obtained from the Quality Control Department of Kottakkal Arya Vaidya Sala, Kotttakkal, Kerala.High Performance Thin Layer Chromatography (HPTLC): Distinct major peaks at Rf: 0.2-0.28, 0.55-065, 0.78-0.85, and around three minor peaks. A unique peak is seen at Rf: 0.45- 0.50. Scanning wavelength: 280 nm, Mobile phase: Benzene Ethyl acetate (6:4), Formic acid: 0.3 mL. Extraction: 20 mL Thirty rats were divided into five groups of six rats each:Ksheerabala (5 µL/100 g body weight/day) + Quinolinic acid (55 µg/100 g body weight/day); Group IV: Ksheerabala (15 µL/100 g body weight/day) + Quinolinic acid (55 µg/100 g body weight/day); Group V: Ksheerabala (25 µL/100 g body weight/day) + Quinolinic acid(55 µg/100 g body weight/day)Group I: Control rats; Group II: Quinolinic acid (55 µg/100 g body weight/day); Group III: Ksheerabala are usually prescribed for an adult patient. After 21 days, the rats were sacrificed and the concentrations of lipid peroxidation products, such as MDA, were determined in the brain.This dose range was selected based on the fact that 8-10 drops of Ksheerabala (15 µL/100 g body weight/day); Group IV: Ksheerabala (15 µL/100 g body weight/day) + Quinolinic acid (55 µg/100 g body weight/day)Group 1: Control rats; Group II: Quinolinic acid (55 µg/100 g body weight/day); Group III: At the end of the experimental period, rats were fasted overnight and sacrificed. The brain tissue was collected for the estimation of various parameters such as the activities of scavenging enzymes, concentrations of lipid peroxidation products and free fatty acids, and the activity of acetyl choline esterase.et al.[et al.[et al.[et al.[Tissues were extracted according to the procedure of Folch et al. and maloet al. Hydroperet al. and the et al. Tissue pl.[et al. Superoxil.[et al. and catal.[et al. The actil.[et al. whereas l.[et al. modifiedl.[et al. Glutathil.[et al. and freel.[et al. Acetylchl.[et al. and the l.[et al. For the post-hoc multiple comparison tests of significant differences among groups were determined, P < 0.05 was considered to be significant.The results were analyzed using a statistical program SPSS/PC+, Version 5.0 . A one-way ANOVA was employed for comparison among the six groups. Duncan's Ksheerabala along with quinolinic acid was seen to reduce MDA levels with maximum reduction being observed in the group administered 15 µL Ksheerabala.Quinolinic acid administration increased MDA  content Ksheerabala. There was a decrease in the glutathione content [The concentrations of MDA, HP, CD, and protein carbonyls  were fou content  in the qKsheerabala, the activities of all these enzymes were found to increase when compared to the quinolinic acid-treated group.The activities of catalase, SOD, glutathione peroxidase, and glutathione reductase  were sigKsheerabala plus quinolinic acid groups showed a significant decrease in the levels of these free fatty acids.The concentrations of free fatty acids  were fouKsheerabala plus quinolinic acid groups.The activity of the enzyme, acetylcholine esterase,  was founKsheerabala-treated groups showed normal neurons. Increased vacuolization and degenerated neurons could be observed in the quinolinic acid group whereas the neurons were almost normal in the brains of the Ksheerabala plus quinolinic acid groups.Histopathological studies of the brains of the control and Ksheerabala have not been documented in experimental animal models. In vivo studies in rats help us to elucidate the mechanism of action and validate the drug. Hence, we have used an animal model with quinolinic acid- induced neurotoxicity to validate the drug, Ksheerabala, and also to study its mechanism of action. As quinolinic acid is an endogenous neurotoxin, all the parameters were measured in the brain tissue.Scientific studies using Ksheerabala as the optimum dose and although 25 µL/100 g body weight Ksheerabala produced higher MDA levels, this difference was not statistically significant. Quinolinic acid has been reported to induce oxidative stress[Ksheerabala and quinolinic acid. Free fatty acids are the substrates for lipid peroxidation so that the observed increase in lipid peroxidation product levels may actually be due to the increase in the levels of the free fatty acids themselves. These increased levels of free fatty acids may lead to a change in the membrane architecture.Quinolinic acid-induced neurotoxicity is partially mediated by free radical formation and oxidative stress, and resuve stress and we tet al.[et al.[Ksheerabala.Studies conducted by Rodriguez-Martinez et al. and Cruzl.[et al. showed tet al.[Ksheerabala is also observed in the histopathological studies. The main ingredients of Ksheerabala: Sida cordifolia,[The activity of the membrane-bound enzyme, acetylcholine esterase, showed decreased activity in the quinolinic acid- treated group. This is in agreement with reports by Boegman et al. that an rdifolia, 3 milk,[rdifolia, 5 and serdifolia,–14 have Ksheerabala reduces the oxidative stress induced by quinolinic acid when administered together by affecting the membrane fluidity and architecture of the brain.Thus, it can be concluded from both biochemical and histopathological studies that the


The presentation of Hodgkin Lymphoma in a thymic cyst is rare. We describe a case in a 9 year-old boy, with a long follow-up course, complicated by two secondary neoplasms and a post bone marrow transplant lymphoproliferative disorder. We also review the literature on such presentations and second malignant neoplasms in childhood. Mediastinal disease in the context of Hodgkin lymphoma is a frequent finding. However, the association of a Hodgkin lymphoma with a thymic cyst is rarely reported . Here, wA 9-year-old boy presented in 1993 with a one-week history of cough and fever. He had a WBC 16 000 K/cu mm, Hgb 12.7 g/dL. Chest X-ray (CXR) revealed a consolidated right middle lobe. Suspecting pneumonia, he received a course of antibiotics. His symptoms improved slightly but his CXR remained unchanged after the course of antibiotics. CT scan demonstrated mediastinal lymphadenopathy and a 13 cm anterior mediastinal mass . A needlThe patient was staged at IIAE and started on chemotherapy with the following regimen: Nitrogen mustard, Prednisone, Vincristine, and Procarbazine (MOPP). He received six cycles of chemotherapy. Chest and mediastinal radiotherapy was initiated given his bulky disease. He received 2 340 cGy to an AP/PA mantle field in 13 fractions with 6 MV photons. At the age of 18 years (in the year 2002) he developed a left scapular pain and was clinically presumed to be caused by bursitis. Having the pain persisted for four months, an MRI was ordered disclosing a 10 cm soft tissue mass surrounding the left scapula, which had multiple calcifications and had eroded into the scapula. Chest X-ray showed a single small nodule within the right lower lobe of the lung. Biopsy of the periscapular mass demonstrated a chondroblastic osteosarcoma . The ostAt the age of 22 (in 2006) he presented with fever, cough, night sweats, fatigue, decreased appetite, and a weight loss of 25 pounds. A peripheral blood count showed white blood cells: 6.8 K/cu mm, red blood cells: 2.78 M/cu mm, Hgb: 9.5 g/dL, and platelet: 172,000 K/cu mm. Peripheral blood differential count showed: 3% myelocytes, 2% metamyelocytes, 22% bands, 9% segmented neutrophils, 24% lymphocytes, 38% monocytes, and 2% eosinophils. A bone marrow aspirate smear showed increased cellular elements with blasts, constituting 82% of marrow cells. These blasts were medium-to-large sized with scanty-to-moderate cytoplasm, mostly fine red cytoplasmic granules, round to lobulated or bean-shaped nuclei, and variably conspicuous nucleoli . No AuerThe patient was put on an acute myelogenous leukemia protocol and underwent bone marrow transplantation afterwards. His course was complicated by an EBV-associated lymphoproliferative disease and graft-versus-host disease. His status deteriorated and he developed fever of unknown origin with an altered mental status and tachypnea and he passed away within days of onset of the fever at the age of 23 years.Mediastinal enlargement in patients with Hodgkin lymphoma (HL) can be attributable to mediastinal lymphadenopathy, thymic involvement by HL, or rarely the presence of thymic cysts . In 1983In 1987, a review of literature reported 11 cases ranging in age between 17 and 40 years. In this series, 60% of the cases were of nodular sclerosis subtype and 40% were of mixed cellularity subtype [The pathogenesis of cyst formation in the thymus in conjunction of HL is unclear. Possible explanations include a secondary treatment effect or thymic tissue infiltration by neoplastic cells . Thymic cysts can be microscopic or macroscopic and can reach sizes of 9–12 cm. They contain clear straw color or hemorrhagic fluid. Microscopically, thymic cysts are lined by thymic epithelial cells with intervening thymic tissue . In caseThe presence of a thymic cyst in patients with Hodgkin lymphoma does not necessitate any specific additional treatment. However, awareness of this association is of importance in raising the differential of a coexisting Hodgkin lymphoma in patients who present with thymic cysts. It also carries implications of posttreatment residual disease. The persistence of the thymic cysts after treatment can confound a completely resolved HL and give the impression of a residual disease . Some auThe majority of secondary AML (sAML) occurs in the first year after treatment of the primary malignancy . The risIn a review of cancer registries in a number of countries from 1970 to 2001, Schonfeld et al. noted that the incidence of acute myelogenous leukemia in patient with HL has declined. They propose that this change is probably related to change in chemotherapy . EarlierThe National institute of Cancer Childhood Cancer Survivors Study (CCSS) looked at the incidence of secondary malignancies in childhood cancer survivors treated by radiotherapy between 1970 and 1986 . The stuIn conclusion, we presented a case of thymic Hodgkin lymphoma in a 9-year-old boy who developed multiple secondary malignancies over a course of 14 years of follow-up. Modifications in therapeutic agents and avoiding radiation therapy may reduce the risks of such complications in the future.


Systemic sclerosis is a multi-systemic autoimmune disorder. Cardiac involvement by the disease, although not included in the diagnostic criteria, may be seen either clinically, histologically or may be revealed by various investigative modalities.To see the profile of cardiac involvement in patients of systemic sclerosis.Forty-seven patients of systemic sclerosis were included in the study. After taking a complete history and doing a detailed physical examination, the patients were submitted to electrocardiogram ECG , echocardiography and x-ray chest. Furst's organ indices scoring system for cardiac involvement was followed.Forty-seven patients of systemic sclerosis were included in the study. Five females gave a history of palpitations. A loud pulmonic heart sound was heard in 1. Arrhythmias were observed in 5 patients. Significantly, echocardiography revealed valvular involvement in 5 patients. Left ventricular hypertrophy was seen in 2 patients.In our patients, cardiac involvement was rare. In contrast to other studies, valvular involvement was a prominent feature.Complete evaluation for arrhythmias with 24-h Holter monitor was not used The criteria to be fulfilled for labeling a patient as a case of systemic sclerosis (established by the Sub-committee for Scleroderma Criteria of the American Rheumatology Association) includes one major criteria, i.e., sclerosis of skin proximal to the digits including the face, limbs, neck or trunk and/or two or more minor criteria, i.e., 1) Sclerodactyly 2) Digital pitted scarring and (3) Bilateral Lower zone  pulmonary fibrosis. Scleroda Digital Forty-seven patients of systemic sclerosis admitted in the in-patient wing of the Department of Dermatology, STD and Leprosy SMHS Hospital  during 1998–2005 were included in the study. The diagnosis of systemic sclerosis was made on the basis of the ARA criteria. A complete history was taken, especially regarding the presence of chest pain, dyspnea and palpitations. A detailed physical examination was done, including recording the weight, pulse, blood pressure, examination of chest, cardiovascular system  and abdomen. This was followed by a meticulous cutaneous examination and Furst's skin scoring. The patients were submitted to a battery of investigations, including electrocardiogram ECG  to examine the rate, rhythm, axis, PR interval, P- and T- wave changes, echocardiography to examine the valvular involvement including vegetations if any, atrial and ventricular involvement, coronary reserve and radiograph of Chest for observing the cardiac size.Furst's organ indices scoring for complete cardiological assessment was done with the following parameters:Cardiomegaly on x-ray chest or moderate-to-large pericardial effusion on echocardiogram – absent: 0; present: 1.5S ymptomatic congestive heart failure – absent: 0; present: 2Symptoms of arrhythmias  – absent: 0; present: 1.5Echocardiographic score (1 point for right ventricular dilatation or hypertrophy and 1 point for left ventricular dilatation or hypertrophy) 0–2Points:Accentuated second pulmonic sound on physical examination – absent: 0; present: 2Right ventricular hypertrophy right axis deviation or right atrial enlargement on ECG – absent: 0; present: 2Right bundle branch block on ECG – absent: 0; present: 2Maximum right heart score = 6Left ventricular hypertrophy, left axis deviation or left atrial enlargement on ECG – absent: 0; present: 2Left bundle branch block on ECG – absent: 0; present: 2Intraventricular conduction delay on EKG – absent: 0; present: 2M yocardial infarction by history or on ECG – absent: 0; Present: 2Maximum left heart score = 8Forty-seven patients of systemic sclerosis were included in the study. They included 45 females and 2 males (F:M ratio of 23:1). The age range of patients was 18–60 years (average age of presentation: 40 years). The duration of disease prior to presentation ranged from 1 month to 25 years. Amongst the associated medical conditions were diabetes (in 1 patient) and hypertension (in 2). Of these 47 patients, none showed cardiomegaly on chest x-ray. None had pericardial involvement. No patient was symptomatic for congestive cardiac failure. Five females gave a history of palpitations. Left ventricular hypertrophy was observed in 2 patients and right ventricular dilatation in 3. Evidence of Pulmonary Arterial Hypertension – loud second pulmonic sound on auscultation and right atrial enlargement  on ECG was observed in 5 patients. Myocardial infarction was not observed in any patient.Arrhythmias including ventricular premature contractions and evidence of bradycardia and left anterior or posterior hemiblock or left bundle branch block on ECG were observed in 5 patients. None of the patients had paroxysmal atrial tachycardia, atrial flutter or fibrillation. Significantly, echocardiography revealed valvular abnormalities in the form of mitral regurgitation (2 patients), mitral stenosis (2 patients), aortic regurgitation (2 patients), and Patent ductus arteriosus (1 patient).Cardiac involvement31The resting ECG is abnormal in 50% of the cases.6In our patients, cardiac involvement was rare. In contrast to other studies, valvular involvement was the prominent feature with mitral stenosis, mitral regurgitation, patent ductus arteriosus and aortic regurgitation seen, and no case of mitral valve prolapse detected. Significantly, one of our patients – a young female with severe vascular involvement in the form of Raynaud's recalcitrant to vasodilators – also complained of chest pain, and she died at home during harsh winter season, thereby leading one to conjecture an adverse cardiac event as a cause of death. (Cold-induced change in cardiac activity is known to occur.