Prevalence of advanced liver fibrosis and steatosis in type-2 diabetics with normal transaminases: A prospective cohort study

BACKGROUND Nonalcoholic fatty liver disease(NAFLD)and type-2 diabetes mellitus(T2DM)have an intricate bidirectional relationship.Individuals with T2DM,not only have a higher prevalence of non-alcoholic steatosis,but also carry a higher risk of progression to nonalcoholic steatohepatitis.Experts still differ in their recommendations of screening for NAFLD among patients with T2DM.AIM To study the prevalence of NAFLD and advanced fibrosis among our patient population with T2DM.METHODS During the study period(November 2018 to January 2020),59 adult patients with T2DM and 26 non-diabetic control group individuals were recruited prospectively.Patients with known significant liver disease and alcohol use were excluded.Demographic data and lab parameters were recorded.Liver elastography was performed in all patients.RESULTS In the study group comprised of patients with T2DM and normal alanine aminotransferase levels(mean 17.8±7 U/L),81%had hepatic steatosis as diagnosed by elastography.Advanced hepatic fibrosis(stage F3 or F4)was present in 12%of patients with T2DM as compared to none in the control group.Patients with T2DM also had higher number of individuals with grade 3 steatosis[45.8%vs 11.5%,(P<0.00001)and metabolic syndrome(84.7%vs 11.5%,P<0.00001)].CONCLUSION A significant number of patients with T2DM,despite having normal transaminase levels,have NAFLD,grade 3 steatosis and advanced hepatic fibrosis as measured by liver elastography.     

Deletion of MCL-1 causes lethal cardiac failure and mitochondrial dysfunction

MCL-1 is an essential BCL-2 family member that promotes the survival of multiple cellular lineages, but its role in cardiac muscle has remained unclear. Here, we report that cardiac-specific ablation of Mcl-1 results in a rapidly fatal, dilated cardiomyopathy manifested by a loss of cardiac contractility, abnormal mitochondria ultrastructure, and defective mitochondrial respiration. Strikingly, genetic ablation of both proapoptotic effectors (Bax and Bak) could largely rescue the lethality and impaired cardiac function induced by Mcl-1 deletion. However, while the overt consequences of Mcl-1 loss were obviated by combining with the loss of Bax and Bak, mitochondria from the Mcl-1-, Bax-, and Bak-deficient hearts still revealed mitochondrial ultrastructural abnormalities and displayed deficient mitochondrial respiration. Together, these data indicate that merely blocking cell death is insufficient to completely overcome the need for MCL-1 function in cardiomyocytes and suggest that in cardiac muscle, MCL-1 also facilitates normal mitochondrial function. These findings are important, as specific MCL-1-inhibiting therapeutics are being proposed to treat cancer cells and may result in unexpected cardiac toxicity.     

Analysis of LMNB1 Duplications in Autosomal Dominant Leukodystrophy Provides Insights into Duplication Mechanisms and Allele‐Specific Expression

Autosomal dominant leukodystrophy (ADLD) is an adult onset demyelinating disorder that is caused by duplications of the lamin B1 (LMNB1) gene. However, as only a few cases have been analyzed in detail, the mechanisms underlying LMNB1 duplications are unclear. We report the detailed molecular analysis of the largest collection of ADLD families studied, to date. We have identified the minimal duplicated region necessary for the disease, defined all the duplication junctions at the nucleotide level and identified the first inverted LMNB1 duplication. We have demonstrated that the duplications are not recurrent; patients with identical duplications share the same haplotype, likely inherited from a common founder and that the duplications originated from intrachromosomal events. The duplication junction sequences indicated that nonhomologous end joining or replication‐based mechanisms such fork stalling and template switching or microhomology‐mediated break induced repair are likely to be involved. LMNB1 expression was increased in patients’ fibroblasts both at mRNA and protein levels and the three LMNB1 alleles in ADLD patients show equal expression, suggesting that regulatory regions are maintained within the rearranged segment. These results have allowed us to elucidate duplication mechanisms and provide insights into allele‐specific LMNB1 expression levels.     

Intrapericardial Immature Teratoma with Successful Treatment in a Neonate

Intra-pericardial teratoma, most often a benign tumor, is an extremely rare condition in a newborn. It can be a diagnostic and therapeutic challenge if it presents with massive pericardial effusion. Complete surgical excision of the tumor is necessary because of its association with tissues of malignant potential. A 16-d-old newborn was diagnosed with intra pericardial immature teratoma (IT) and managed successfully with multidisciplinary team approach by prompt referral for complete surgical resection followed by adjuvant chemotherapy with carboplatin, etoposide and bleomycin (JEB) to prevent recurrence. The infant is now on close follow up with monitoring of serum alpha fetoprotein (AFP) levels and imaging studies for early diagnosis of recurrence of tumor and chemotherapy related complications.     

Copper mediated one-pot synthesis of quinazolinones and exploration of piperazine linked quinazoline derivatives as anti-mycobacterial agents

A facile method was developed for the synthesis of quinazolinone derivatives in a one-pot condensation reaction via in situ amine generation using ammonia as the amine source and with the formation of four new C–N bonds in good to excellent yields. With the optimised method, we synthesized a library of piperazine linked quinazoline derivatives and the synthesized compounds were evaluated for their inhibitory activity against Mycobacterium tuberculosis. The compounds 8b, 8e, 8f, 8m, 8n and 8v showed potent anti-mycobacterial activity with MIC values of 2–16 μg mL⁻¹. All the synthesized compounds follow Lipinski''s rules for drug likeness.

A facile method was developed for the synthesis of quinazolinone derivatives in a one-pot condensation reaction via in situ amine generation using ammonia as the amine source and with the formation of four new C–N bonds in good to excellent yields.     

MVP™ Micro Vascular Plug Systems for the Treatment of Pulmonary Arteriovenous Malformations

CardioVascular and Interventional Radiology - To describe our institutional experience with MVP™ micro vascular plug systems for the treatment of pulmonary arteriovenous malformations...     

The enhanced recovery after surgery (ERAS) protocol to promote recovery following esophageal cancer resection

Surgery Today - Esophageal cancer surgery, comprising esophagectomy with radical lymphadenectomy, is a complex procedure associated with considerable morbidity and mortality. The enhanced recovery...     

Single lead ST-segment recovery: a simple, reliable measure of successful fibrinolysis after acute myocardial infarction

Background

Successful reperfusion after acute ST-elevation myocardial infarction improves prognosis. Among the different electrocardiographic markers of reperfusion, sum ST resolution is considered the hallmark of reperfusion, but is cumbersome to use.

Methods

To assess the usefulness of a single lead ST resolution at 90 minutes after fibrinolysis compared with the sum ST resolution in predicting Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow, we used prospectively collected data from the Limitation of Myocardial Injury Following Thrombolysis in Acute Myocardial Infarction (LIMIT-AMI) study. All patients had electrocardiograms recorded at presentation and 90 minutes and a coronary angiogram 90 minutes after fibrinolysis.

Results

Infarction artery patency was assessed in 238 patients with 4 different ST resolution criteria: single lead ST resolution ≥50% and ≥70% and sum ST resolution ≥50% and ≥70%. The most sensitive criteria for TIMI grade 3 flow was single lead ST resolution ≥50% (sensitivity rate, 70%; specificity rate, 54%), whereas sum ST resolution ≥70% was most the specific criteria (sensitivity rate, 45%; specificity rate, 79%). The proportion of patients with TIMI grade 3 flow was similar in all 4 ST resolution groups (P = .84). Pre-discharge infarction size and ejection fraction were also similar. No single lead or sum lead measure of ST resolution was significantly associated with an increased risk of death, heart failure, or reinfarction.

Conclusion

We propose that single lead ST-resolution ≥50% as an optimal electrocardiographic indicator for successful reperfusion 90 minutes after fibrinolysis. This simple electrocardiographic measure should be combined with bedside clinical and hemodynamic assessment to optimize decision making after fibrinolysis.     

Catastrophic ATP loss underlies a metabolic combination therapy tailored for MYCN-amplified neuroblastoma

MYCN-amplified neuroblastoma is a lethal subset of pediatric cancer. MYCN drives numerous effects in the cell, including metabolic changes that are critical for oncogenesis. The understanding that both compensatory pathways and intrinsic redundancy in cell systems exists implies that the use of combination therapies for effective and durable responses is necessary. Additionally, the most effective targeted therapies exploit an “Achilles’ heel” and are tailored to the genetics of the cancer under study. We performed an unbiased screen on select metabolic targeted therapy combinations and correlated sensitivity with over 20 subsets of cancer. We found that MYCN-amplified neuroblastoma is hypersensitive to the combination of an inhibitor of the lactate transporter MCT1, AZD3965, and complex I of the mitochondrion, phenformin. Our data demonstrate that MCT4 is highly correlated with resistance to the combination in the screen and lowly expressed in MYCN-amplified neuroblastoma. Low MCT4 combines with high expression of the MCT2 and MCT1 chaperone CD147 in MYCN-amplified neuroblastoma, altogether conferring sensitivity to the AZD3965 and phenformin combination. The result is simultaneous disruption of glycolysis and oxidative phosphorylation, resulting in dramatic disruption of adenosine triphosphate (ATP) production, endoplasmic reticulum stress, and cell death. In mouse models of MYCN-amplified neuroblastoma, the combination was tolerable at concentrations where it shrank tumors and did not increase white-blood-cell toxicity compared to single drugs. Therefore, we demonstrate that a metabolic combination screen can identify vulnerabilities in subsets of cancer and put forth a metabolic combination therapy tailored for MYCN-amplified neuroblastoma that demonstrates efficacy and tolerability in vivo.

Despite their relative rarity compared to blood cancers, solid-tumor pediatric cancers are now the leading cause of pediatric cancer-related deaths. Among the most deadly is high-risk neuroblastoma (NB): amplification of MYCN confers high risk and is the clear driver of NB in these cancers (1). As such, MYCN remains the most important drug target in NB and one of the most important in pediatric cancer. Unfortunately, direct chemical targeting of MYCN has not yet been successful, and despite advancements in anti-GD2 immunotherapy (2), alternate ways of targeting MYCN-amplified NB may be needed to successfully treat this cancer.One approach is to find tumor-specific vulnerabilities, which are exploitable pharmacologically. Many efforts, including ours (3), have exhaustively looked for kinase inhibitors with particular efficacy in MYCN-amplified NBs. However, the emerging picture is a lack of kinase inhibitor efficacy in MYCN-amplified NB. Other vulnerabilities may be classified under the broad category of drugs targeting epigenetic modifiers. For example, using a CRISPR/Cas9 screen, Stegmaier and colleagues demonstrated that MYCN-amplified NB may be susceptible to targeting the H3K27me methylase EZH2 (4); in a different study, they demonstrated the susceptibility of MYCN-amplified NB to the combination of BRD4 inhibitors with CDK7 inhibitors (5). In addition, Thiele and colleagues (6) demonstrated high-risk NBs were susceptible to inhibition of the lysine methyltransferase SETD8. As promising as these data are, it remains unknown whether tolerability and/or clinical activity in MYCN-amplified NB will occur and SETD8, BRD4, and CDK7 inhibitors so far are not in the pediatric clinic. Cell death inducers constitute a third category. To this point, we recently uncovered a susceptibility of MYCN-amplified NB to the BCL-2 inhibitor venetoclax (3), confirmed by others (7). There, MYCN-driven NOXA expression sensitizes cells to venetoclax (3). Venetoclax is now in early phase trials in pediatric patients including those with NB ({"type":"clinical-trial","attrs":{"text":"NCT03236857","term_id":"NCT03236857"}}NCT03236857). It remains to be seen whether or not it will elicit responses in NB patients as a single agent.A fourth distinct category of therapeutic strategies to indirectly target oncogenes is through metabolism targeting, involving the growing coterie of drugs targeting the pathways fulfilling the high-energy demands of cancer cells. A major energy currency in cells is adenosine triphosphate (ATP). The Warburg effect describes the propensity of cancer cells (and highly proliferating normal cells) to produce ATP in the presence of oxygen with the less efficient, extramitochondrial glycolysis, as opposed to the more efficient mitochondria-based oxidative phosphorylation occurring in most noncancerous cells (8). The mechanistic explanation of the Warburg effect and how it might benefit cancer cells has been revised dramatically over the years. It was originally proposed that mitochondria from cancer cells were defective and lacked oxidative phosphorylation capabilities (9); on the contrary, emerging data show that many cancers rely on oxidative phosphorylation to facilitate the generation of ATP (8, 10). Interestingly, while amplified MYCN directly regulates the expression of many of the key glycolytic enzymes and as such contributes to the Warburg effect (11, 12), a study utilizing a Seahorse respirator demonstrated that a MYCN-amplified NB cell line favored oxidative phosphorylation over glycolysis for the metabolic needs, while the reverse was true for a MYCN wild-type NB cell line (13). In an independent study, MYCN was associated with higher glycolytic flux and oxidative phosphorylation and conferred sensitivity to fatty acid oxidation disruption (12). Overall, since c-MYC, which shares ∼40% binding homology to DNA-binding sites throughout the genome with MYCN, has been extensively characterized as a metabolic master regulator (14, 15), it is likely there are other MYCN-driven metabolic processes that may represent significant drug targets.Monocarboxylate transporters (MCTs) consist of four members (MCT1–4) in mammalian cells. Among their most critical substrates are lactate and pyruvate; MCT1 and MCT4 are responsible for lactate export across the plasma membrane to the extracellular space (16). AZD3965 (17) (AstraZeneca) is the first in-class–specific MCT1/2 dual inhibitor and is currently in early phase trials for diverse cancers; however, other inhibitors from different companies have recently been developed as well (18). Of note, AZD3965 has demonstrated good tolerability in diverse patients (clinical trial number {"type":"clinical-trial","attrs":{"text":"NCT01791595","term_id":"NCT01791595"}}NCT01791595). Although rare (65 cases/100,000 person-years), lactic acidosis led to the market retrieval of phenformin in America (19), yet phenformin remains in use as a type II antidiabetic drug in Europe, functioning centrally as a mitochondrial complex I electron transport chain (ETC) inhibitor. Phenformin reduces both glycolytic intermediates and pyruvate, increases shunting of glucose-derived carbon (increasing total lactate production), and markedly reduces tricarboxylic acid cycle intermediates (20). Indeed, there has been a recent resurgence in interest in the use of phenformin to treat cancer. For example, in BRAF mutant melanoma, phenformin sensitized cells to BRAF inhibitor through cooperative suppression of the metabolic sensor pathway mTORC1 (21). These preclinical data have led to a clinical trial of phenformin in combination with BRAF inhibitor in BRAF mutant melanoma ({"type":"clinical-trial","attrs":{"text":"NCT03026517","term_id":"NCT03026517"}}NCT03026517). Overall, while targeting individual metabolic pathways has demonstrated some preclinical success in different cancer models, it is limited with significant redundancy in pathways to generate ATP and regenerate NAD+ (22). We therefore assessed potential combination therapies involving metabolic targeting drugs to identify a strategy for MYCN-amplified NB.