A Pediatric Case of Reninoma Presenting with Paraneoplastic SIADH.

INTRODUCTION: A reninoma (juxtaglomerular cell tumour) is a rare cause of secondary hypertension that can present with headaches alongside the triad of severe hypertension, hypokalemia, and metabolic alkalosis. CASE PRESENTATION: We describe a case of a 15-year-old previously healthy girl who presented with headaches and hypertensive urgency who had severe hypokalemia, moderate hyponatremia and elevated aldosterone and renin levels. Abdominal ultrasound and MRI with contrast revealed a unilateral mass localized to the right kidney. Despite treatment of her hypertension, she had persistent hyponatremia with clinical euvolemia which was consistent with the paraneoplastic syndrome of inappropriate antidiuretic hormone secretion (SIADH). She underwent radical nephrectomy which normalized her blood pressure and aldosterone and renin values. The pathology findings were consistent with a reninoma with a mitotic rate of 1-2 mitoses per 10 high power fields. DISCUSSION/CONCLUSION: Hypertension in the pediatric age group requires work-up to rule out secondary causes. The classic triad of hypertension, hypokalemia, and metabolic alkalosis warrants assessment for aldosterone-mediated hypertension which can be a result of a renin-producing tumour. Curative approach requires surgical resection of the tumour. Reninomas may rarely manifest with a paraneoplastic phenomenon including SIADH, as seen in our case. Although reninomas are benign tumours, there are also a few reports of malignant transformation and metastases. Features uncommon in reninomas such as mitotic activity warrant long-term surveillance.

Medical Curriculum: How Do We Manage Incidental Findings in Educational Settings?

Medical curricula encompass two practical-based teaching categories with likelihood of identifying incidental findings (unexpected and previously undiagnosed findings with potential health implications) in live models for demonstration purposes. One relates to clinical skills involving peers and simulated or volunteer patients. The other involves laboratory sessions, with live models, for the purposes of demonstrating scientific principles. As educationalists, it is our professional and ethical duty to have guidance on how to manage incidental findings. In this commentary, we have outlined our best practice guidelines formalised as a written policy exploring consent, debriefing, and the teachers' role. Our aim was to develop an 'easy-to-follow' standardised mechanism.

Dietary intakes of children with nephrotic syndrome.

BACKGROUND: Our multidisciplinary clinical pathway for treatment of childhood nephrotic syndrome (NS) was established with the goal of standardizing local clinical practice. This descriptive study aimed to assess nutrient intakes of children with newly diagnosed NS compared with nutrition goals defined by our pathway. METHODS: Our pathway includes evidence-based recommendations that target daily intakes during corticosteroid induction therapy: energy (Estimated Energy Requirements (EER) × Sedentary Physical Activity (PA)), sodium (1 mg/kcal), calcium (Dietary Reference Intake (DRI) + 500 mg elemental calcium), and vitamin D (DRI +800-1000 IU). After dietitian-led education at initial diagnosis, 3-day food records were completed at 4 weeks post-diagnosis. Daily nutrient intakes were compared to pathway targets and DRIs. RESULTS: Thirty-six children (median age 4.8 years, 44% female) with newly diagnosed NS submitted food records. Mean energy and sodium intakes were 103±22% and 99±53% of pathway targets, respectively. Fourteen (39%) children exceeded pathway sodium recommendations, with four (11%) exceeding them by greater than 50%. Seven (19%) children met DRI for calcium, while six (17 %) met pathway targets for calcium. No children met DRI for vitamin D from diet alone; and only one met the target with supplementation. CONCLUSIONS: This is the first study to describe dietary intakes of children with newly diagnosed NS. Our clinical pathway targets for energy and sodium were achievable; however, calcium and vitamin D intakes fell short of pathway guidelines and DRIs. Prescription of supplemental calcium and vitamin D may be needed to achieve target intakes of calcium and vitamin D.

Nursery origin and population connectivity of swordfish Xiphias gladius in the North Pacific Ocean.

Element:Ca ratios in the otolith cores of young-of-the-year (YOY) swordfish, Xiphias gladius, were used as natural tracers to predict the nursery origin of subadult and adult swordfish from three foraging grounds in the North Pacific Ocean (NPO). First, the chemistry of otolith cores (proxy for nursery origin) was used to develop nursery-specific elemental signatures in YOY swordfish. Sagittal otoliths of YOY swordfish were collected from four regional nurseries in the NPO between 2000 and 2005: (1) Central Equatorial North Pacific Ocean (CENPO), (2) Central North Pacific Ocean (CNPO), (3) Eastern Equatorial North Pacific Ocean (EENPO) and (4) Western North Pacific Ocean (WNPO). Calcium (43 Ca), magnesium (24 Mg), strontium (88 Sr) and barium (138 Ba) were quantified in the otolith cores of YOY swordfish using laser ablation inductively coupled plasma mass spectrometry. Univariate tests indicated that three element:Ca ratios (Mg:Ca, Sr:Ca and Ba:Ca) were significantly different among nurseries. Overall classification success of YOY swordfish to their nursery of collection was 72% based on quadratic discriminant analysis. Next, element:Ca ratios in the otolith cores of subadults and adults collected from three foraging grounds where targeted fisheries exist (Hawaii, California and Mexico) were examined to calculate nursery-specific contribution estimates. Mixed-stock analysis indicated that the CENPO nursery contributed the majority of individuals to all three foraging grounds (Hawaii 45.6 ± 13.2%, California 84.6 ± 10.8% and Mexico 64.5 ± 15.9%). The results from this study highlight the importance of the CENPO nursery and provide researchers and fisheries managers with new information on the connectivity of the swordfish population in the NPO.

Recruitment dynamics and fishery characteristics of juvenile goatfishes Mulloidichthys spp. in Hawai'i.

The most common goatfishes in Hawai'i, Mulloidichthys flavolineatus and M. vanicolensis, comprise a unique resource due to their cultural, ecological and biological significance. These species exhibit pulse-type recruitment to nearshore areas during the summer months. Such pulses of juvenile fishes provide prey for pelagic and nearshore fishes and support a popular directed fishery. However, limited scientific information exists on juvenile stages of these fishes, known locally as oama, despite their contribution to coastal ecology and the extensive nearshore fisheries. Here we resolve growth rates, habitat preferences, hatching dates, size and age structure, as well as fishing catch rates based on new recruits in 2014 and 2015. We sampled 257 M. flavolineatus and 204 M. vanicolensis to compare ecological and fisheries characteristics between species and years. Both show strong habitat segregation, with M. vanicolensis found almost exclusively on hard and M. flavolineatus on soft substrates. Oama recruited in anomalously high numbers in 2014, a trend reflected in a higher catch per unit effort. In contrast, 2015 recruits grew faster, were heavier on average and hatched later than during 2014. Both species have calculated hatch dates in March to July, with M. vanicolensis hatching earlier, recruiting earlier and being consistently larger than M. flavolineatus. This baseline information regarding recruitment and early life-history characteristics can enhance management for other data-limited species that comprise a substantial component of nearshore fisheries in Hawai'i.

Pregnancy outcomes among solid organ transplant recipients in British Columbia.

OBJECTIVE: Since 1954, over 14 000 women have given birth after having had an organ transplantation. Unfortunately, some women and physicians remain misinformed about the feasibility and outcomes of pregnancy post transplantation. Our primary objective was to assess their perceptions and difficulties with regard to becoming pregnant. Our secondary objectives were to determine the incidence of pregnancies among transplant recipients in British Columbia and any maternal, graft, or fetal complications. METHODS: From 1997 to 2007 in British Columbia, there were over 500 female recipients of solid organ transplants. We surveyed recipients in this group who were of child-bearing age. RESULTS: One hundred forty of 295 (47%) eligible recipients responded: 44 of these women had attempted pregnancy after transplant, and 31 women gave birth to 47 children. One half of the respondents planned to have children post transplant; 108 of 140 (77%) had no children before transplant. One quarter of the respondents were advised against pregnancy by their physician, and 33% of these women found a new physician to support their pregnancy. Rates of miscarriage (27%), rejection (21%), and prematurity (65%) were higher than expected. Infections were rare, and no birth defects or noteworthy health problems in the offspring were reported. CONCLUSIONS: Overall, pregnancy appears to be safe following solid organ transplantation, but careful monitoring and counselling are recommended.

Single cell assessment of allergen-specific T cell responses with MHC class II peptide tetramers: methodological aspects.

BACKGROUND: We report herein critical methodological principles for assessing, at a single cell level, allergen-specific T cell responses using MHC class II peptide tetramers. METHODS: We developed MHC class II peptide tetramers to monitor T cell responses against the immunodominant Bet v 1(141-155) peptide in individuals with either an HLA-DRB1*0101, DRB1*0401 or DRB1*1501 background. In vitro stimulation was performed with serially truncated versions of the Bet v 1(141-155) epitope chemically conjugated to the Ii-Key peptide. RESULTS: Identification of Bet v 1(141-155) as a high-affinity epitope for multiple HLA-DRB1 allotypes led to the development of corresponding tetramers detecting Bet v 1(141-155)-specific T cells with a high specificity and sensitivity. Stimulation with Bet v 1(141-155) Ii-Key conjugate peptides is the most efficient procedure to expand Bet v 1(141-155)-specific CD4+ T cells, allowing to detect such cells in both allergic and healthy individuals. MHC class II Bet v 1(141-155) tetramer-positive T cells produce IFN-gamma and IL-10 in healthy individuals, and IL-5 in allergic patients. Frequencies of Bet v 1-specific CD4+ T cells circulating in the blood of allergic or nonallergic individuals range from approximately 10(-5) to 10(-3) CD4+ T cells, outside or within the pollen season, respectively. CONCLUSIONS: MHC class II peptide tetramers are valuable tools to assess allergen-specific T cell responses, both qualitatively and quantitatively. Selection of a high-affinity T cell epitope, as well as optimization of in vitro stimulation conditions to expand rare T cell progenitors are critical success factors in those analyses.

Ii-Key/HER-2/neu(776-790) hybrid peptides induce more effective immunological responses over the native peptide in lymphocyte cultures from patients with HER-2/neu+ tumors.

We have demonstrated that coupling an immunoregulatory segment of the MHC class II-associated invariant chain (Ii), the Ii-Key peptide, to a promiscuous MHC class II epitope significantly enhances its presentation to CD4+ T cells. Here, a series of homologous Ii-Key/HER-2/neu(776-790) hybrid peptides, varying systematically in the length of the epitope(s)-containing segment, are significantly more potent than the native peptide in assays using T cells from patients with various types of tumors overexpressing HER-2/neu. In particular, priming normal donor and patient PBMCs with Ii-Key hybrid peptides enhances recognition of the native peptide either pulsed onto autologous dendritic cells (DCs) or naturally presented by IFN-gamma-treated autologous tumor cells. Moreover, patient-derived CD4+ T cells primed with the hybrid peptides provide a significantly stronger helper effect to autologous CD8+ T cells specific for the HER-2/neu(435-443) CTL epitope, as illustrated by either IFN-gamma ELISPOT assays or specific autologous tumor cell lysis. Hybrid peptide-specific CD4+ T cells strongly enhanced the antitumor efficacy of HER-2/neu(435-443) peptide-specific CTL in the therapy of xenografted SCID mice inoculated with HER-2/neu overexpressing human tumor cell lines. Our data indicate that the promiscuously presented vaccine peptide HER-2/neu(776-790) is amenable to Ii-Key-enhancing effects and supports the therapeutic potential of vaccinating patients with HER-2/neu+ tumors with such Ii-Key/HER-2/neu(776-790) hybrid peptides.

Suppression of major histocompatibility complex class II-associated invariant chain enhances the potency of an HIV gp120 DNA vaccine.

Summary One function of the major histocompatibility complex (MHC) class II-associated invariant chain (Ii) is to prevent MHC class II molecules from binding endogenously generated antigenic epitopes. Ii inhibition leads to MHC class II presentation of endogenous antigens by APC without interrupting MHC class I presentation. We present data that in vivo immunization of BALB/c mice with HIV gp120 cDNA plus an Ii suppressive construct significantly enhances the activation of both gp120-specific T helper (Th) cells and cytotoxic T lymphocytes (CTL). Our results support the concept that MHC class II-positive/Ii-negative (class II(+)/Ii(-)) antigen-presenting cells (APC) present endogenously synthesized vaccine antigens simultaneously by MHC class II and class I molecules, activating both CD4(+) and CD8(+) T cells. Activated CD4(+) T cells locally strengthen the response of CD8(+) CTL, thus enhancing the potency of a DNA vaccine.

Ii-Key/MHC class II epitope peptides as helper T cell vaccines for cancer and infectious disease.

Potent MHC class II antigenic peptide vaccines are created by covalently linking the N-terminus of a MHC class II epitope through a polymethylene bridge to the C-terminus of the Ii-Key segment of the Ii protein. Such hybrids enhance potency of presentation in vitro of the MHC class II epitope about 200 times relative to the epitope-only peptide. In vivo, as measured by IFN-gamma ELISPOT assays, the helper T cell response to vaccination is enhanced up to 8 times. The design of such hybrid vaccine peptides comes from insight into the mechanism of action of the Ii-Key motif within the Ii protein, in regulating antigenic peptide binding into the antigenic peptide binding groove of MHC class II molecules. Here we present the logic and experimental history of the development of these vaccine peptides, with particular attention to the hypothesized mechanism of action. Methods for the design and testing of these peptides are presented. Experience in developing peptide vaccines for immunotherapy of cancer is reviewed, focusing on the clinical potential of Ii-Key/MHC class II epitope hybrids.

Ii-Key/MHC class II epitope hybrids: a strategy that enhances MHC class II epitope loading to create more potent peptide vaccines.

Life-threatening diseases, such as cancer and pandemic influenza, demand new efforts towards effective vaccine design. Peptides represent a simple, safe and adaptable basis for vaccine development; however, the potency of peptide vaccines is insufficient in most cases for significant therapeutic efficacy. Several methods, such as Ligand Epitope Antigen Presentation System and ISCOMATRIX, have been developed to enhance the potency of peptide vaccines. One way of increasing the loading of MHC class II peptides occurs through the use of Ii-Key technology. Ii-Key (LRMK), a portion of the MHC class II-associated invariant chain (Ii), facilitates the direct loading of epitopes to the MHC class II molecule groove. Linking the Ii-Key moiety via a simple polymethylene bridge to an MHC class II epitope, to generate an Ii-Key/MHC class II epitope hybrid, greatly enhances the vaccine potency of the tethered epitope. The combination of such Ii-Key/MHC class II epitope hybrids with MHC class I epitope-containing peptides might generate a potent peptide vaccine for malignancies and infectious diseases. The Ii-Key hybrid technology is compared with other methods that enhance the potency of a peptide vaccine.

Enhanced CD4+ T-cell response in DR4-transgenic mice to a hybrid peptide linking the Ii-Key segment of the invariant chain to the melanoma gp100(48-58) MHC class II epitope.

Linking the Ii-Key functional group LRMK, through a simple polymethylene linker, to the melanoma gp100(48-58) MHC class II epitope significantly enhances the vaccine response to that epitope in DR4-IE transgenic mice. A homologous series of Ii-Key/gp100(46-58) hybrids was synthesized to test the influence of spacer length (between Ii-Key and the gp100(48-58) epitope) on in vivo enhancement of gp100(48-58)-specific CD4+ T-lymphocyte responses. As measured by IFN-gamma and IL-4 ELISPOT cytokine assays, the most effective vaccine hybrid was the one with a shorter linker between Ii-Key and the epitope. Mechanistic reasons for this observation are considered. This structure-activity relationship was seen with bulk and CD4+ purified T cells, and both primary and secondary in vitro restimulation assays. CFA augmented the IFN-gamma response and to a lesser extent the IL-4 response. CpG enhanced a strong IFN-gamma response, with a negligible IL-4 response. The 3- to 5-times enhancement of the total ELISPOT responses (number of spots x mean spot area) observed after vaccination with peptides consisting of an MHC class II epitope engineered into an Ii-Key hybrid indicates a potent vaccine effect. Such constructs can be applied to many diagnostic and therapeutic uses.

Linkage of Ii-Key segment to gp100(46-58) epitope enhances the production of epitope-specific antibodies.

Linkage of the Ii-Key segment of the Ii protein to MHC class II epitope gp100(46-58) using a polymethylene linker significantly enhances the production of epitope-specific antibodies in HLA-DR4-IE transgenic mice. This enhancement is not restricted by the spacer length in between the Ii-Key and epitope. The use of either IFA or CFA induced only epitope-specific IgG1. In contrast, CpG adjuvant induced both IgG1 and IgG2a isotypes. These results indicate that the Ii-Key hybrid technology is a novel and potent method to increase the immunogenicity of a MHC class II epitope. It can also be used to more efficiently generate epitope-specific antibodies.

Immunotherapy of cancer by antisense inhibition of Ii protein, an immunoregulator of antigen selection by MHC class II molecules.

Ii protein suppression is a promising antisense drug-based therapy that dramatically enhances the immunogenicity of tumor cell major histocompatibility complex class II-presented antigenic epitopes. The strength of this approach is that the antisense only needs to be transiently effective in a fraction of the tumor cells. The systemic antitumor immune response generated subsequently eradicates both directly treated cells and distant tumor deposits. The drugs and mechanisms of this therapy are considered, in addition to practical developmental questions.

Turning tumor cells in situ into T-helper cell-stimulating, MHC class II tumor epitope-presenters: immuno-curing and immuno-consolidation.

Immunological control or cure of tumors depends on initiating a robust T helper cell response to MHC class II epitopes of tumor-associated antigens. T helper cells regulate the potency of cytotoxic T lymphocyte and antibody responses. We have developed a novel approach to stimulate T helper cells by converting tumor cells into MHC class II molecule-positive, antigen presenting cells. Furthermore, using antisense methods, we suppress expression of the Ii protein, that normally blocks the antigenic peptide binding site of MHC class II molecules during synthesis in the endoplasmic reticulum. In such gene-engineered tumor cells, the MHC class II molecules pick up antigenic peptides, which have been transported into the endoplasmic reticulum for binding to MHC class I molecules. All nucleated cells create such "surveys of self" to detect viral or malignant transformation. Our method extends that survey of self to MHC class II endogenous tumor-associated antigens. Simultaneous presentation of tumor antigens by both MHC class I and II generates a robust and long-lasting antitumor immune response. Injecting murine tumors with genes, which induce MHC class II molecules and suppress Ii protein, cures a significant number of animals with renal and prostate tumors. We have developed analogous human gene vectors that are suitable for most patients and cancers, because they are monomorphic and active in all HLA-DR alleles. We review our findings, and analyze remaining issues for preclinical study and the design of clinical trials.

Ii-Key/HER-2/neu MHC class-II antigenic epitope vaccine peptide for breast cancer.

PURPOSE: Cytotoxic T lymphocytes (CTL)- and T-helper cell-specific, and major histocompatibility complex (MHC) class-I and class-II peptides, respectively, of the HER-2/ neu protein, induce immune responses in patients. A major challenge in developing cancer peptide vaccines is breaking tolerance to tumor-associated antigens which are functionally self-proteins. An adequate CD4+ T-helper response is required for effective and lasting responses. METHODS: Stimulating anti-cancer CD4+ T cell responses by MHC class-II epitope peptides has been limited by their weak potency, at least compared with tight-binding MHC class-I epitope peptides. Previously, a potent T-cell response to a MHC class-II epitope was engineered by coupling the N-terminus of the pigeon cytochrome C [PGCC(95-104)] MHC class-II epitope to the C-terminus of an immunoregulatory segment of the Ii protein (hIi77-81, the Ii-Key peptide) through a polymethylene spacer. RESULTS: In vitro presentation of the MHC class-II epitope to a T hybridoma was enhanced greatly (>250 times). Now, an Ii-Key/HER-2/neu (777-789) MHC class-II epitope hybrid peptide stimulated lymphocytes from both a healthy donor and a patient with metastatic breast carcinoma. The in vitro primary stimulation with the hybrid peptide strongly activated IFN-gamma release, whereas the epitope-only peptide was weakly active. In fact, the hybrid stimulated IFN-gamma release as well as the wild-type peptide when augmented with IL-12; however, the hybrid was comparable to free peptide in stimulating IL-4 release. This pattern is consistent with preferential activation along a non-tolerogenic Th1 pathway. CONCLUSION: Such Ii-Key/MHC class-II epitope hybrid peptides have both diagnostic and therapeutic applications.

Forcing tumor cells to present their own tumor antigens to the immune system: a necessary design for an efficient tumor immunotherapy.

The general principle for tumor cells to escape from immune surveillance is to prevent tumor antigens from being recognized by the immune system. Many methods have been developed to increase the immunogenecity of the tumor cells. The most efficient methods are able to force tumor cells to present their own tumor antigens to the immune system. Stimulating Th cells by converting tumor cells into MHC class II+/Ii- antigen presenting cells is one of the most efficient technologies. Using antisense methods, we suppress the expression of the Ii protein that normally co-expresses with MHC class II molecules and blocks the antigenic peptide binding site of MHC class II molecules during synthesis in the endoplasmic reticulum. In such tumor cells, the "unprotected" MHC class II molecules pick up endogenous tumor antigenic peptides, which have been transported into the ER for binding to MHC class I molecules. Simultaneous presentation of tumor antigens by both MHC class I and II molecules generates a robust and long-lasting anti-tumor immune response. MHC class II+/Ii- tumor cells are potent tumor cell vaccines and also cure a significant number of animals with renal and prostate tumors. We have developed analogous human gene vectors that are suitable for most patients and cancers.

Ii-Key/MHC class II epitope hybrid peptide vaccines for HIV.

The Ii-Key/MHC class II epitope hybrid acts on MHC class II molecules to facilitate replacement of antigenic peptides with the epitope tethered to the Ii-Key motif. Hybrid peptides linking an immunoregulatory segment of the Ii protein (Ii-Key peptide) through a polymethylene bridge to MHC class II epitopes of HIV gp160 or gag are potent vaccines to elicit CD4(+) T cell responses. More potent responses to two MHC class II epitopes, HIV gp160(843-852) or HIV gag(279-292), occurred in mice immunized with Ii-Key hybrid peptides than with epitope-only peptides, as measured in IL-4 and IFN-gamma ELISPOT assays of splenic lymphocytes stimulated in vitro by epitope-only peptides. Both the number of responding cells and cytokine output per cell were increased. The Ii-Key/MHC class II epitope hybrid acts on MHC class II molecules to facilitate replacement of antigenic peptides with the epitope tethered to the Ii-Key motif. Such antigenic peptide constructs create opportunities to enhance greatly Th1 or Th2 responses to MHC class II epitopes for therapeutic purposes.

Tumor immunotherapy by converting tumor cells to MHC class II-positive, Ii protein-negative phenotype.

A potent antitumor CD4(+) T-helper cell immune response is created by inducing tumor cells in vivo to a MHC class II(+)/Ii(- )phenotype. MHC class II and Ii molecules were induced in tumor cells in situ following tumor injection of a plasmid containing the gene for the MHC class II transactivator (CIITA). Ii protein was suppressed by the antisense effect of an Ii-reverse gene construct (Ii-RGC) in the same or another co-injected plasmid. The MHC class II(+)/Ii(- )phenotype of the tumor cells was confirmed by FACS analysis of cells transfected in vitro and by immunostaining of tumor nodules transfected by injections in vivo. Subcutaneous Renca tumors in BALB/c mice were treated by intratumoral injection with CIITA and Ii-RGC, in combination with a subtherapeutic dose of IL-2, to up-regulate the activation of T cells. Significant tumor shrinkage and decrease in rates of progression of established Renca tumors were seen in the groups injected with Ii-RGC, compared with groups in which only IL-2 plus empty plasmid controls were injected. Our method provides an effective immunotherapy warranting further development for human cancers.

Identification of T helper cell-recognized epitopes in the chitinase of the filarial nematode Onchocerca volvulus.

T helper cell-recognized epitopes were determined in chitinase of Onchocerca volvulus, a vaccine candidate protein. The proliferation of splenic T cells of mice immunized with recombinant protein was tested with a library of chitinase-peptides of 16 amino acids with termini overlapping by 12 amino acids, and a library of "designer peptides", i.e. sequences identified with three epitope-predicting algorithms. Fourteen epitope-bearing stretches were identified with the peptides of the overlapping library. Testing of the designer peptides partially confirmed these data and revealed additional epitopes. Five clusters of epitopes were identified for the creation of peptide or minigene DNA vaccines with good potency and potential range of MHC allele presentation.