Phenotypic Expression and Outcomes in Patients with the p.Arg301Gln GLA Variant in Anderson-Fabry Disease

The p.Arg301Gln variant in the α -galactosidase A gene (GLA) has been poorly described in the literature. The few reports show controversial information, with both classical and nonclassical Anderson-Fabry Disease (AFD) presentation patterns. The aim of this study was to analyze the penetrance, clinical phenotype, and biochemical profile of an international cohort of patients carrying the p.Arg301Gln genetic variant in the GLA gene. This was an observational, international, and retrospective cohort case series study of patients carrying the p.Arg301Gln variant in the GLA gene associated with AFD disease. Forty-nine p.Arg301Gln GLA carriers, 41% male, were analyzed. The penetrance was 63% in the entire cohort and 1.5 times higher in men. The mean age of symptoms onset was 41 years; compared to women, men presented symptoms earlier and with a shorter delay to diagnosis. The typical clinical triad-cornea verticillate, neuropathic pain, and angiokeratomas-affected only 20% of the cohort, with no differences between genders. During follow-up, almost 20% of the patients presented some type of nonfatal cardiovascular and renal event (stroke, need for dialysis, heart failure, and arrhythmias requiring intracardiac devices), predominantly affecting men. Residual levels were the most common finding of α-GAL A enzyme activity, only a few women had a normal level; a small proportion of men had undetectable levels. The incidence of combined outcomes including all causes of death was 33%, and the cumulative incidence of all-cause mortality was 9% at the follow-up. Patients carrying the p.Arg301Gln GLA variant have a high penetrance, with predominantly cardiorenal involvement and clinical onset of the disease in middle age. Only a small proportion showed the classic clinical presentation of AFD. As in other X-linked diseases, males were more affected by severe cardiovascular and renal events. This genotype-phenotype correlation could be useful from a practical clinical point of view and for future decision making.

The magnitude of the plasma hepcidin response to oral iron supplements depends on the iron dosage

BACKGROUND

Iron deficiency without anaemia is a common health problem, especially in young menstruating women. The efficacy of the usually recommended oral iron supplementation is limited due to increased plasma hepcidin concentration, which reduces iron absorption and leads to side effects such as intestinal irritation. This observation raises the question of how low-dose iron therapy may affect plasma hepcidin levels and whether oral iron intake dose-dependently affects plasma hepcidin production.

METHODS

Fifteen non-anaemic women with iron deficiency (serum ferritin ≤30 ng/ml) received a single dose of 0, 6, 30, or 60 mg of elemental oral iron as ferrous sulfate on different days. Plasma hepcidin was measured before and seven hours after each dose.

RESULTS

Subjects had an average age of 23 (standard deviation = 3.0) years and serum ferritin of 24 ng/ml (interquartile range = 16-27). The highest mean change in plasma hepcidin levels was measured after ingesting 60 mg of iron, increasing from 2.1 ng/ml (interquartile range = 1.6-2.9) to 4.1 ng/ml (interquartile range = 2.5-6.9; p < 0.001). Iron had a significant dose-dependent effect on the absolute change in plasma hepcidin (p = 0.008), where lower iron dose supplementation resulted in lower plasma hepcidin levels. Serum ferritin levels were significantly correlated with fasting plasma hepcidin levels (R2 = 0.504, p = 0.003) and the change in plasma hepcidin concentration after iron intake (R2 = 0.529, p = 0.002).

CONCLUSION

We found a dose-dependent effect of iron supplementation on plasma hepcidin levels. Lower iron dosage results in a smaller increase in hepcidin and might thus lead to more efficient intestinal iron absorption and fewer side effects. The effectiveness and side effects of low-dose iron treatment in women with iron deficiency should be further investigated. This study was registered at the Swiss National Clinical Trials Portal (2021-00312) and ClinicalTrials.gov (NCT04735848).

Osteonecrosis of the jaw: surgical treatment results before and during the COVID-19 pandemic in one of the reference hospitals in Poland

OBJECTIVE

The COVID-19 pandemic has had a huge impact not only on everyday life but, above all, on the functioning of medical entities. During its duration, there were problems with access to health care, including maxillofacial surgery departments. The aim of the study is to analyze how the pandemic affected the surgical results of the treatment of osteonecrosis of the jaws at the Clinic of Maxillofacial Surgery in Poznań which delivers services in maxillofacial surgery for almost 4.5 million inhabitants in Poland.

PATIENTS AND METHODS

We conducted a retrospective analysis of patients' medical records before and during the pandemic restrictions. The data was obtained by entering the appropriate passwords and ICD-10 diagnoses (e.g., M87) in the hospital's IT system. The obtained information was subjected to statistical analysis.

RESULTS

The number of patients before and during the pandemic did not differ significantly. During the COVID-19 pandemic, the waiting time of patients after admission to the hospital for surgery and the total time of hospitalization were shortened. The number of complications was similar in both groups. However, the waiting time for a follow-up visit was longer during restriction time.

CONCLUSIONS

The COVID-19 pandemic had an impact on the course of surgical treatment in patients with osteonecrosis of the jaws. The outcomes of the medical procedure remained consistent with the ones observed before the implementation of restrictions. This is likely due to the urgency of the illness. Despite the pandemic, a critical condition called osteonecrosis of the jaw was treated promptly.

Fabry disease biomarkers in patients switched from enzyme-replacement therapy to migalastat oral chaperone therapy

Background: A biomarker profile was evaluated longitudinally in patients with Fabry disease switched from enzyme-replacement therapy (ERT) to migalastat. Methods: 16 Gb3 isoforms and eight lyso-Gb3 analogues were analyzed in plasma and urine by LC-MS/MS at baseline and at three different time points in naive participants and participants switching from either agalsidase α or β to migalastat. Results: 29 adult participants were recruited internationally (seven centers). The Mainz Severity Score Index and mean biomarker levels remained stable (p ≥ 0.05) over a minimum of 12 months compared with baseline following the treatment switch. Conclusion: In this cohort of patients with Fabry disease with amenable mutations, in the short term, a switch from ERT to migalastat did not have a marked effect on the average biomarker profile.

Head-to-head trial of pegunigalsidase alfa versus agalsidase beta in patients with Fabry disease and deteriorating renal function: results from the 2-year randomised phase III BALANCE study

BACKGROUND

Pegunigalsidase alfa is a PEGylated α-galactosidase A enzyme replacement therapy. BALANCE (NCT02795676) assessed non-inferiority of pegunigalsidase alfa versus agalsidase beta in adults with Fabry disease with an annualised estimated glomerular filtration rate (eGFR) slope more negative than -2 mL/min/1.73 m2/year who had received agalsidase beta for ≥1 year.

METHODS

Patients were randomly assigned 2:1 to receive 1 mg/kg pegunigalsidase alfa or agalsidase beta every 2 weeks for 2 years. The primary efficacy analysis assessed non-inferiority based on median annualised eGFR slope differences between treatment arms.

RESULTS

Seventy-seven patients received either pegunigalsidase alfa (n=52) or agalsidase beta (n=25). At baseline, mean (range) age was 44 (18-60) years, 47 (61%) patients were male, median eGFR was 74.5 mL/min/1.73 m2 and median (range) eGFR slope was -7.3 (-30.5, 6.3) mL/min/1.73 m2/year. At 2 years, the difference between median eGFR slopes was -0.36 mL/min/1.73 m2/year, meeting the prespecified non-inferiority margin. Minimal changes were observed in lyso-Gb3 concentrations in both treatment arms at 2 years. Proportions of patients experiencing treatment-related adverse events and mild or moderate infusion-related reactions were similar in both groups, yet exposure-adjusted rates were 3.6-fold and 7.8-fold higher, respectively, with agalsidase beta than pegunigalsidase alfa. At the end of the study, neutralising antibodies were detected in 7 out of 47 (15%) pegunigalsidase alfa-treated patients and 6 out of 23 (26%) agalsidase beta-treated patients. There were no deaths.

CONCLUSIONS

Based on rate of eGFR decline over 2 years, pegunigalsidase alfa was non-inferior to agalsidase beta. Pegunigalsidase alfa had lower rates of treatment-emergent adverse events and mild or moderate infusion-related reactions.

TRIAL REGISTRATION NUMBER

NCT02795676.

Screening for health-related quality of life and its determinants in Fabry disease: A cross-sectional multicenter study

BACKGROUND

Fabry disease (FD) is a rare X-linked lysosomal storage disorder caused by α-galactosidase A (α-Gal A) deficiency. The progressive accumulation of globotriaosylceramide results in life-threatening complications, including renal, cardiac, and cerebrovascular diseases. In order to improve health care of FD-patients, knowledge of its predictors is important. The aim of our study was to evaluate health-related quality of life (HrQol) in FD and to identify its independent determinants by exploring a wide range of demographic, social and clinical parameters.

RESULTS

In this cross-sectional multicenter study, 135 adult patients with FD were recruited at three specialized European centers in Germany and Switzerland. Demographics, social status and clinical parameters as well as data on HrQol (EQ5D, EQ VAS) and depression were collected by means of self-reporting questionnaires and confirmed by medical records. HrQol and its predictors were evaluated by univariate and multivariate regression analyses. The study population consisted of 78 female and 57 male FD patients (median age 48 yrs) of whom 80.7% (N = 109) were on enzyme replacement therapy (ERT) and 10.4% (N = 14) were on chaperone treatment. Univariate analysis revealed various factors reducing HrQol such as age > 40 years, classic phenotype, organ involvement (kidney and heart disease, stroke/transient ischemic attack (TIA), gastrointestinal disturbances), depression, and burning limb pain. However, only the following factors were identified as independent predictors of decreased HrQol: classic phenotype, kidney and heart disease, stroke/TIA, depression, and burning limb pain. ERT and chaperone therapy were independent determinants of increased HrQol.

CONCLUSIONS

Modifiable factors, such as burning limb pain and depression, identified as independent predictors of HrQol-deterioration should be addressed in programs aiming to improve HrQol in FD. A multidisciplinary approach is essential in FD-patients since diverse organ involvement prominently compromises HrQol in affected patients. Our findings showed that the classic phenotype is a strong predictor of worsening HrQol.

Systems analyses of the Fabry kidney transcriptome and its response to enzyme replacement therapy identified and cross-validated enzyme replacement therapy-resistant targets amenable to drug repurposing

Fabry disease is a rare disorder caused by variations in the alpha-galactosidase gene. To a degree, Fabry disease is manageable via enzyme replacement therapy (ERT). By understanding the molecular basis of Fabry nephropathy (FN) and ERT's long-term impact, here we aimed to provide a framework for selection of potential disease biomarkers and drug targets. We obtained biopsies from eight control individuals and two independent FN cohorts comprising 16 individuals taken prior to and after up to ten years of ERT, and performed RNAseq analysis. Combining pathway-centered analyses with network-science allowed computation of transcriptional landscapes from four nephron compartments and their integration with existing proteome and drug-target interactome data. Comparing these transcriptional landscapes revealed high inter-cohort heterogeneity. Kidney compartment transcriptional landscapes comprehensively reflected differences in FN cohort characteristics. With exception of a few aspects, in particular arteries, early ERT in patients with classical Fabry could lastingly revert FN gene expression patterns to closely match that of control individuals. Pathways nonetheless consistently altered in both FN cohorts pre-ERT were mostly in glomeruli and arteries and related to the same biological themes. While keratinization-related processes in glomeruli were sensitive to ERT, a majority of alterations, such as transporter activity and responses to stimuli, remained dysregulated or reemerged despite ERT. Inferring an ERT-resistant genetic module of expressed genes identified 69 drugs for potential repurposing matching the proteins encoded by 12 genes. Thus, we identified and cross-validated ERT-resistant gene product modules that, when leveraged with external data, allowed estimating their suitability as biomarkers to potentially track disease course or treatment efficacy and potential targets for adjunct pharmaceutical treatment.

An expert consensus on the recommendations for the use of biomarkers in Fabry disease

Fabry disease is an X-linked lysosomal storage disorder caused by the accumulation of glycosphingolipids in various tissues and body fluids, leading to progressive organ damage and life-threatening complications. Phenotypic classification is based on disease progression and severity and can be used to predict outcomes. Patients with a classic Fabry phenotype have little to no residual α-Gal A activity and have widespread organ involvement, whereas patients with a later-onset phenotype have residual α-Gal A activity and disease progression can be limited to a single organ, often the heart. Diagnosis and monitoring of patients with Fabry disease should therefore be individualized, and biomarkers are available to support with this. Disease-specific biomarkers are useful in the diagnosis of Fabry disease; non-disease-specific biomarkers may be useful to assess organ damage. For most biomarkers it can be challenging to prove they translate to differences in the risk of clinical events associated with Fabry disease. Therefore, careful monitoring of treatment outcomes and collection of prospective data in patients are needed. As we deepen our understanding of Fabry disease, it is important to regularly re-evaluate and appraise published evidence relating to biomarkers. In this article, we present the results of a literature review of evidence published between February 2017 and July 2020 on the impact of disease-specific treatment on biomarkers and provide an expert consensus on clinical recommendations for the use of those biomarkers.

Effectiveness of low-dose iron treatment in non-anaemic iron-deficient women: a prospective open-label single-arm trial

BACKGROUND

Iron deficiency without anaemia is highly prevalent and is particularly associated with fatigue, cognitive impairment, or poor physical endurance. Standard oral iron therapy often results in intestinal irritation with associated side effects and premature discontinuation of therapy, therefore, optimal oral iron therapy with sufficient iron absorption and minimal side effects is desirable.

METHODS

Thirty-six iron-deficient non-anaemic premenopausal women (serum ferritin ≤30 ng/ml, haemoglobin ≥117 g/l) with normal body mass index (BMI) and no hypermenorrhea received 6 mg of elemental oral iron (corresponding to 18.6 mg ferrous sulphate) twice daily for 8 weeks.

RESULTS

Participants treated with low-dose iron had an average age of 28 years and a BMI of 21 kg/m2. Their serum ferritin and haemoglobin increased significantly from 18 ng/ml to 33 ng/ml (p <0.001) and from 135 g/l to 138 g/l (p = 0.014), respectively. Systolic blood pressure increased from 114 mmHg to 120 mmHg (p = 0.003). Self-reported health status improved after 8 weeks (p <0.001) and only one woman reported gastrointestinal side effects (3%).

CONCLUSION

This prospective open-label single-arm trial shows that oral iron treatment of 6 mg of elemental iron twice daily over 8 weeks is effective in iron-deficient non-anaemic women. Due to the negligible side effects, low-dose iron treatment is a valuable therapeutic option for iron-deficient non-anaemic women with normal BMI and menstruation. Further placebo-controlled studies with a larger number of participants are needed to confirm these results.

CLINICALTRIALS

gov NCT04636060.

Long-Term Monitoring of Cardiac Involvement under Migalastat Treatment Using Magnetic Resonance Tomography in Fabry Disease

Background: Fabry cardiomyopathy is characterized by left ventricular hypertrophy, myocardial fibrosis, arrhythmia, and premature death. Treatment with migalastat, an oral pharmacological chaperone, was associated with a stabilization of cardiac biomarkers and a reduction in left ventricular mass index, as measured by echocardiography. A recent study, using cardiac magnetic resonance (CMR) as the gold standard, found a stable course of myocardial involvement after 18 months of treatment with migalastat. Our study aimed to provide long-term CMR data for the treatment with migalastat. Methods: A total of 11 females and four males with pathogenic amenable GLA mutations were treated with migalastat and underwent 1.5T CMR imaging for routine treatment effect monitoring. The main outcome was a long-term myocardial structural change, reflected by CMR. Results: After migalastat treatment initiation, left ventricular mass index, end diastolic volume, interventricular septal thickness, posterior wall thickness, estimated glomerular filtration rate, and plasma lyso-Gb3 remained stable during the median follow-up time of 34 months (min.: 25; max.: 47). The T1 relaxation times, reflecting glycosphingolipid accumulation and subsequent processes up to fibrosis, fluctuated over the time without a clear trend. No new onset of late gadolinium enhancement (LGE) areas, reflecting local fibrosis or scar formation of the myocardium, could be detected. However, patients with initially present LGE showed an increase in LGE as a percentage of left ventricular mass. The median α-galactosidase A enzymatic activity increased from 37.3% (IQR 5.88-89.3) to 105% (IQR 37.2-177) of the lower limit of the respective reference level (p = 0.005). Conclusion: Our study confirms an overall stable course of LVMi in patients with FD, treated with migalastat. However, individual patients may experience disease progression, especially those who present with fibrosis of the myocardium already at the time of therapy initiation. Thus, a regular treatment re-evaluation including CMR is needed to provide the optimal management for each patient.

Clinical and CMR characteristics associated with cardiac events in patients with Fabry disease

BACKGROUND

The assessment of late gadolinium enhancement (LGE) and left ventricular hypertrophy (LVH) by cardiac magnetic resonance (CMR) as diagnostic and prognostic maker in Fabry disease is advancing. We aimed to investigate the impact of clinical characteristics and CMR findings on cardiac outcome in patients with FD.

METHODS

In this study 55 patients with genetically confirmed FD and available CMR imaging were included. The primary endpoint was defined as a composite of cardiac events including cardiac death, new occurrence of atrial fibrillation, heart failure, ventricular tachycardia and bradycardia requiring device insertion.

RESULTS

During a median follow-up of 4.9 years (IQR 3.7-5.9), 9 patients (16.3%) reached the primary cardiac end point. The global amount of LGE was associated with an increased risk for primary endpoint in the univariate analysis (HR 1.4 per 10% increase in LGE, p = 0.002). However maximal wall thickness (MWT) was the sole independent predictor of the primary endpoint in a stepwise logistic regression model (HR 9.8 per mm increase in MWT, p < 0.0001). Kaplan-Meier analysis revealed significant difference in event free survival rate between patients with and without LVH (Long-rank p = 0.006) and in patients with and without LGE (Long-rank p < 0.001). Patients without LVH and LGE were free of adverse cardiac events.

CONCLUSION

LVH and LGE detected by CMR were associated with adverse cardiac events in FD. In particular maximal wall thickness can be useful in cardiac risk stratification of FD patients.

Relationship of Vessel Density to Vessel Length Density in Patients with Treated Fabry Disease

BACKGROUND

Fabry disease (FD) is a potentially lethal lysosomal disorder with systemic vascular changes. Previous studies demonstrated retinal vascular involvement using optical coherence tomography angiography (OCTA) in affected patients; Aim: To analyze and quantify the retinal vasculature measuring vessel density (VD), vessel length density (VLD), and the ratio of VD to VLD (VD/VLD) in superficial capillary plexuses (SCP) and deep capillary plexuses (DCP) using OCTA in patients with FD and to show whether they differ from healthy controls (HC); Patients and methods: Single-center, retrospective, consecutive cohort study of patients with genetically proven FD. Patients underwent an ophthalmological examination including OCTA. VD, VLD, foveal avascular zone (FAZ), and the VD/VLD were compared to an HC group using a linear mixed model; Results: A statistically significant difference in the VLD and VD/VLD of DCP was observed between the two groups (p < 0.001). Using ROC curves with AUC and Youden's Index, a cut-off value for differentiating both groups using VD/VLD in DCP FD with high specificity and high sensitivity was established; Conclusions: FD and HC groups seem to be separable using the VD/VLD ratio in DCP. This new biomarker might differentiate changes in the retinal microvasculature that are not detectable by VD or VLD alone.

Deep next-generation proteomics and network analysis reveal systemic and tissue-specific patterns in Fabry disease

Fabry disease (FD) is an X-linked lysosomal rare disease due to a deficiency of α-galactosidase A activity. The accumulation of glycosphingolipids mainly affects the kidney, heart, and central nervous system, considerably reducing life expectancy. Although the accumulation of undegraded substrate is considered the primary cause of FD, it is established that secondary dysfunctions at the cellular, tissue, and organ levels ultimately give rise to the clinical phenotype. To parse this biological complexity, a large-scale deep plasma targeted proteomic profiling has been performed. We analyzed the plasma protein profiles of FD deeply phenotyped patients (n = 55) compared to controls (n = 30) using next-generation plasma proteomics including 1463 proteins. Systems biology and machine learning approaches have been used. The analysis enabled the identification of proteomic profiles that unambiguously separated FD patients from controls (615 differentially expressed proteins, 476 upregulated, and 139 downregulated) and 365 proteins are newly reported. We observed functional remodeling of several processes, such as cytokine-mediated pathways, extracellular matrix, and vacuolar/lysosomal proteome. Using network strategies, we probed patient-specific tissue metabolic remodeling and described a robust predictive consensus protein signature including 17 proteins CD200, SPINT1, CD34, FGFR2, GRN, ERBB4, AXL, ADAM15, PTPRM, IL13RA1, NBL1, NOTCH1, VASN, ROR1, AMBP, CCN3, and HAVCR2. Our findings highlight the pro-inflammatory cytokines' involvement in FD pathogenesis along with extracellular matrix remodeling. The study shows a tissue-wide metabolic remodeling connection to plasma proteomics in FD. These results will facilitate further studies to understand the molecular mechanisms in FD to pave the way for better diagnostics and therapeutics.

Quantifying inflammation using interleukin-6 for improved phenotyping and risk stratification in acute heart failure

AIMS

Systemic inflammation may be central in the pathophysiology of acute heart failure (AHF). We aimed to assess the possible role of systemic inflammation in the pathophysiology, phenotyping, and risk stratification of patients with AHF.

METHODS AND RESULTS

Using a novel Interleukin-6 immunoassay with unprecedented sensitivity (limit of detection 0.01 ng/L), we quantified systemic inflammation in unselected patients presenting with acute dyspnoea to the emergency department in a multicentre study. One-year mortality was the primary prognostic endpoint. Among 2042 patients, 1026 (50.2%) had an adjudicated diagnosis of AHF, 83.7% of whom had elevated interleukin-6 concentrations (>4.45 ng/L). Interleukin-6 was significantly higher in AHF patients compared to patients with other causes of dyspnoea (11.2 [6.1-26.5] ng/L vs. 9.0 [3.2-32.3] ng/L, p < 0.0005). Elevated interleukin-6 concentrations were independently predicted by increasing N-terminal pro-B-type natriuretic peptide and high-sensitivity cardiac troponin T, as well as the clinical diagnosis of infection. Among the different AHF phenotypes, interleukin-6 concentrations were highest in patients with cardiogenic shock (25.7 [14.0-164.2] ng/L) and lowest in patients with hypertensive AHF (9.3 [4.8-21.6] ng/L, p = 0.001). Inflammation as quantified by interleukin-6 was a strong and independent predictor of 1-year mortality both in all AHF patients, as well as those without clinically overt infection at presentation (adjusted hazard ratio [95% confidence interval] 1.45 [1.15-1.83] vs. 1.48 [1.09-2.00]). The addition of interleukin-6 significantly improved the discrimination of the BIOSTAT-CHF risk score.

CONCLUSION

An unexpectedly high percentage of patients with AHF have subclinical systemic inflammation as quantified by interleukin-6, which seems to contribute to AHF phenotype and to the risk of death.

Corrigendum to 'Single-dose psilocybin-assisted therapy in major depressive disorder: a placebo-controlled, double-blind, randomised clinical trial'

[This corrects the article DOI: 10.1016/j.eclinm.2022.101809.].

Single-dose psilocybin-assisted therapy in major depressive disorder: A placebo-controlled, double-blind, randomised clinical trial

BACKGROUND

Psilocybin has been suggested as a novel, rapid-acting treatment for depression. Two consecutive doses have been shown to markedly decrease symptom severity in an open-label setting or when compared to a waiting list group. To date, to our knowledge, no other trial compared a single, moderate dose of psilocybin to a placebo condition.

METHODS

In this double-blind, randomised clinical trial, 52 participants diagnosed with major depressive disorder and no unstable somatic conditions were allocated to receive either a single, moderate dose (0.215 mg/kg body weight) of psilocybin or placebo in conjunction with psychological support. MADRS and BDI scores were assessed to estimate depression severity, while changes from baseline to 14 days after the intervention were defined as primary endpoints. The trial took place between April 11th, 2019 and October 12th, 2021 at the psychiatric university hospital in Zürich, Switzerland and was registered with clinicaltrials.gov (NCT03715127).

FINDINGS

The psilocybin condition showed an absolute decrease in symptom severity of -13.0 points compared to baseline and were significantly larger than those in the placebo condition (95% CI -15.0 to -1.3; Cohens' d = 0.97; P = 0.0011; MADRS) and -13.2 points (95% CI; -13.4 to -1.3; Cohens' d = 0.67; P = 0.019; BDI) 14 days after the intervention. 14/26 (54%) participants met the MADRS remission criteria in the psilocybin condition.

INTERPRETATION

These results suggest that a single, moderate dose of psilocybin significantly reduces depressive symptoms compared to a placebo condition for at least two weeks. No serious adverse events were recorded. Larger, multi-centric trials with longer follow-up periods are needed to inform further optimisation of this novel treatment paradigm.

FUNDING

The study was funded by the Swiss National Science Foundation, Crowdfunding, the Swiss Neuromatrix Foundation, and the Heffter Research Institute.

Thrombosis-related miR-16-5p predicts the disease severity in patients hospitalised for COVID-19

Introduction

SARS-CoV-2 tropism for the ACE2 receptor, along with the multifaceted inflammatory reaction, is likely to drive the generalized hypercoagulable state seen in patients with COVID-19.

Methodology

Using the original bioinformatic workflow and network medicine approaches we reanalyzed four coronavirus-related expression datasets and performed co-expression analysis focused on thrombosis and ACE2 related genes. We identified microRNAs (miRNAs) which play role in ACE2-related thrombosis in coronavirus infection and further, we validated the expressions of those miRNAs in 79 hospitalized COVID-19 patients and 32 healthy volunteers by PCR and monitored miRNAs patterns during the acute phase of COVID-19, as well as the prognostic potential of these miRNAs as biomarkers.

Results

We identified EGFR, HSP90AA1, APP, TP53, PTEN, UBC, FN1, ELAVL1 and CALM1 as regulatory genes which could play a pivotal role in COVID-19 related thrombosis. We also found miR-16-5p, miR-27a-3p, Let-7b-5p and miR-155-5p as regulators in coagulation and thrombosis process. We observed in separate cohort of COVID-19 patients and healthy controls that (i) expression of miR-16-5p, miR-27a-3p and miR-155-5p increased during observation, compared to the baseline measurement; (ii) a low baseline miR-16-5p expression presents predictive utility in assessment of the hospital length of stay or death in follow-up as a composite endpoint (AUC: 0.810, 95% CI, 0.71–0.91, p<0.0001); (iii) low baseline expression of miR-16-5p and diabetes mellitus are independent predictors of increased length of stay or death according to a multivariate analysis (OR: 9.417; 95% CI, 2.647–33.506; p=0.0005 and OR: 6.257; 95% CI, 1.049–37.316; p=0.044, respectively).

Conclusion

This study enabled us to better characterize changes in gene expression and signaling pathways related to COVID-19 thrombosis. In this study we identified, characterized and validated miRNAs which could serve as novel, thrombosis-related biomarkers of the COVID-19, can be used for early stratification of patients and prediction of severity of infection development in an individual.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Medical University of Warsaw

Diagnostic ability of miR-19a and Let-7f along with platelet and leukocyte extracellular vesicles in acute ischemic stroke patients

Background

Ischemic stroke (IS) is one of the most frequent causes of death. Since miRNAs have been illustrated to play an important role in various processes through regulation of multiple genes, and platelet function, their utility as novel biomarkers should be determined.

Purpose

We aimed to analyze the circulating platelet-derived miR-19a-3p, miR-186-5p, Let-7f, platelet-extracellular vesicles (EVs), leukocyte-EVs, and endothelial-EVs levels 24-h and 7-days after IS as novel diagnostic and prognostic/predictive biomarkers in 28 acute IS and 35 control patients.

Methods

Blood samples of 28 patients diagnosed with acute IS with hyper platelet reactivity were collected 24-h and 7-days after stroke and 35 age- and gender-matched individuals free of stroke with multiple risk factors for cardiovascular disease. Platelet reactivity was assessed by AA-, TRAP-, ADP-induced platelet aggregometry. PlasmaRNA was extracted; quality RNA was assessed: fluorometric assay; RT-PCR for miRNAs expression measurement and flow-cytometry for EVs determination p&lt;0.05.

Results

Patients with IS on day-1 had significantly higher platelet reactivity assessed by AA-induced platelet aggregometry compared to controls (p=0.001). Patients with normal platelet activation had significantly higher miR-186-5p expression levels compared to patients with HPR at day-1 acute-stroke (p=0.034). Seven days after acute stroke, expression levels of miR-186-5p significantly decreased in the same patients with normal platelet reactivity (p=0.036). Patients with HPR had significantly elevated platelet-EVs (CD62) concentration compared to patients with normal platelet reactivity at the day of 1 acute-stroke (p=0.012). Similarly, patients with HPR had significantly higher leukocyte-EVs (CD45) concentration compared to patients with normal platelet function at day-1 acute-stroke (p=0.002). Diagnostic values of baseline miRNAs and EVs were evaluated with receiver operating characteristic curve analysis. ROC curve showed that pooling the miR-19a-3p expressions, platelet-EVs, and leukocyte-EVs concentration yielded a higher AUC than the value of each individual biomarker as AUC was 0.893 (95% CI, 0.79–0.99). Patients with moderate stroke had significantly elevated miR-19a-3p expression levels compared with patients with minor stroke at the day of acute IS. AUC in ROC curve analysis was 0.867, (95% CI, 0.74–0.10) p=0.001.

Conclusions

Our analysis showed alteration of circulating miRNAs and EVs after IS. Combination of miR-19a-3p, Let-7f, platelet-EVs and leukocyte-EVs might have a diagnostic value for acute stroke and miR-19a-3p can predict the severity of stroke in IS patients.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Science Centre - Narodowe Centrum Nauki

Circulating miRNAs as independent predictors of cardiovascular mortality in patients with type 2 diabetes mellitus

Background

MicroRNAs (miRNAs, miR) are essential gene expression regulators involved in numerous biological processes and diseases including type 2 diabetes (DM).

Purpose

We aimed to determine the predictive value of selected circulating miRNAs for cardiovascular and all-cause mortality and their potential usefulness as biomarkers in DM patients.

Method

Two hundred fifty-two patients with diabetes were enrolled in the study. Among the patients included, 26 (10.3%) patients died during a median follow-up of 71 months (5.9 years). Plasma miR-191 and miR-16 expressions were assessed by quantitative real-time PCR and compared between the patients who survived and those who died.

Results

Patients who died from cardiovascular-related death had significantly higher expression of miR-191 and miR-16 as compared with patients who survived (p=0.003, p=0.001, respectively). The study population was divided into two subgroups by using ROC curve analysis for each miRNA, i.e., low or high value of single miRNAs. Kaplan Meier and Cox regression were performed for survival analysis. High expression levels of miRNAs were associated with cardiovascular mortality, when the models included one single miRNA and other covariates: miR-191 (HR = 4.793, 95% CI: 1.48–15.579; p=0.009) and miR-16 (HR = 4.66, 95% CI: 1.48–14.75; p=0.009). Furthermore, miRNAs expression between clopidogrel and the whole acetylsalicylic acid groups (i.e., 75 mg +150 mg), miR-191 expressions was significantly higher in the clopidogrel subgroup (p=0.010), whereas miR-16 did not differ (p=0.127).

Conclusion

To conclude, miR-191 and miR-16 expression are strong and independent predictors of cardiovascular and all-cause mortality in patients with T2DM. Moreover, miR-191 and miR-16 present significant interactions with antiplatelet treatment regimens and clinical outcomes.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Medical University of Warsaw

Prevalence, patient characteristics and outcome of hyponatremia in acute heart failure

Background

Hyponatremia is the most common electrolyte disturbance found in hospitalized patients. Previous studies have shown that low serum sodium levels at presentation are associated with increased mortality and morbidity in patients hospitalized with acute heart failure (AHF). However, given the complicated multifactorial origin of hyponatremia, the role of serum sodium level in risk stratification in patients with AHF is still largely unknown.

Purpose

To evaluate the prevalence and prognostic value of hyponatremia in patients presenting with AHF to the emergency department (ED).

Methods

Basics in Acute Shortness of Breath EvaLuation (BASEL V) was a prospective, multicenter, diagnostic study recruiting dyspneic patients at the ED. The final diagnosis of AHF was adjudicated by 2 independent physicians. Hyponatremia was defined as a serum sodium level of &lt;135 mmol/l. The prognostic accuracy of hyponatremia in predicting all-cause mortality and a composite outcome of death and heart failure (HF) rehospitalization was quantified using multivariable adjusted Cox regression. Adjustments were made for the following variables: age, sex, history of ischemic heart disease, previous HF, infection as a trigger of AHF, systolic blood pressure, glomerular filtration rate and log-transformed N-terminal pro-B-type natriuretic peptide (NT-proBNP) at presentation. The incremental value of hyponatremia to the MEESSI-Score, a validated AHF risk score, was quantified using area under the curve (AUC) analyses.

Results

Among 1572 patients with AHF, 1499 patients were eligible for the main analysis, of whom 215 (14.3%) had hyponatremia, 1249 (83.3%) normonatremia and 35 (2.3%) hypernatremia at presentation. Of those with hyponatremia, 21 (9.8%) and 54 (25.1%) patients died, 27 (12.6%) and 79 (36.7%) patients experienced the composite outcome within 30 and 180 days, respectively. Multivariable adjusted hazard ratios (aHR) were 0.97 (95%-CI 0.94–1.01) and 0.97 (95%-CI 0.95–0.99) for mortality, 0.97 (95%-CI 0.94–1.00) and 0.98 (95%-CI 0.95–0.99) for the composite outcome within 30 and 180 days, respectively. The risk for mortality and a composite of all-cause mortality and HF rehospitalization within 180 days after presenting to the ED with AHF rose significantly with a lower sodium level at presentation. Each 1-unit decrease in sodium level [mmol/L] was associated with a 3% and 2.7% increase in the hazard rate of mortality (aHR 0.97, p=0.01) and the composite outcome (aHR 0.98, p=0.01), respectively. While in the 30-day analyses after multivariable adjustment sodium had no significant prognostic value. The already excellent predictive ability of the MEESSI-Score for 30-day mortality was not enhanced by sodium level (AUC 0.80 versus 0.80, p=0.834).

Conclusion

Hyponatremia at presentation is associated with a higher risk of 180-day mortality in patients with AHF. However, its role as an independent prognostic marker in risk stratification remains unclear.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Swiss National Science FoundationSchweizerische Herzstiftung

Clinical effect of obesity on N-terminal pro-B-type natriuretic peptide cut-off concentrations for the diagnosis of acute heart failure

AIMS

Obese patients have lower natriuretic peptide concentrations. We hypothesized that adjusting the concentration of N-terminal pro-B-type natriuretic peptide (NT-proBNP) for obesity could further increase its clinical utility in the early diagnosis of acute heart failure (AHF).

METHODS AND RESULTS

This hypothesis was tested in a prospective diagnostic study enrolling unselected patients presenting to the emergency department with acute dyspnoea. Two independent cardiologists/internists centrally adjudicated the final diagnosis using all individual patient information including cardiac imaging. NT-proBNP plasma concentrations were applied: first, using currently recommended cut-offs; second, using cut-offs lowered by 33% with body mass index (BMI) of 30-34.9 kg/m² and by 50% with BMI ≥ 35 kg/m² . Among 2038 patients, 509 (25%) were obese, of which 271 (53%) had AHF. The diagnostic accuracy of NT-proBNP as quantified by the area under the receiver-operating characteristic curve was lower in obese versus non-obese patients (0.890 vs. 0.938). For rapid AHF rule-out in obese patients, the currently recommended cut-off of 300 pg/ml achieved a sensitivity of 96.7% (95% confidence interval [CI] 93.8-98.2%), ruling out 29% of patients and missing 9 AHF patients. For rapid AHF rule-in, the age-dependent cut-off concentrations (age <50 years: 450 pg/ml; age 50-75 years: 900 pg/ml; age >75 years: 1800 pg/ml) achieved a specificity of 84.9% (95% CI 79.8-88.9%). Proportionally lowering the currently recommended cut-offs by BMI increased sensitivity to 98.2% (95% CI 95.8-99.2%), missing 5 AHF patients; reduced the proportion of AHF patients remaining in the 'gray zone' (48% vs. 26%; p = 0.002), achieving a specificity of 76.5% (95% CI 70.7-81.4%).

CONCLUSIONS

Adjusting NT-proBNP concentrations for obesity seems to further increase its clinical utility in the early diagnosis of AHF.

Agalsidase-β should be proposed as first line therapy in classic male Fabry patients with undetectable α-galactosidase A activity

BACKGROUND

Fabry disease (FD) is a rare X-linked lysosomal storage disease caused by mutations in the α-galactosidase A (GLA) gene leading to deficiency of α-galactosidase A (α-gal A). This results in progressive multisystemic glycosphingolipid accumulation, especially globotriaosylceramide (Gb3) and globotriaosylsphingosine (Lyso-Gb3). Enzyme replacement therapy with two recombinant enzymes, agalsidase-α and -β is approved for two different dosages. However, little is known about which enzyme is more effective in decreasing the metabolite load in male and female patients with the classic form of the disease.

METHODS

In this prospective observational study, 14 consecutive adult Fabry patients (10 males) with a classic GLA-mutation, were switched from agalsidase-α to agalsidase-β at the respective licensed doses. Lyso-Gb3 levels were measured before the switch and for a period of 12 months after the switch in dried blood spots by tandem mass spectrometry.

RESULTS

Mean age at start of the switch was 36.7 ± 14 years. Plasma Lyso-Gb3 levels decreased from 27.2 ± 17.9 ng/mL before the switch to 16.8 ± 10.5 ng/mL after the switch (mean reduction of 30.1%; p = 0.004). The decrease was maximal in the subgroup of 7 male patients with no or very low residual enzyme activity (mean reduction of 40.4%). However, two females with high residual enzyme activity also showed a reduction >30% after the switch. In male patients, the reduction of plasma Lyso-Gb3 correlated negatively with the residual α-gal A activity: r = -0.803; p = 0.009.

CONCLUSION

Agalsidase-β at licensed dose is significantly more effective than agalsidase-α to reduce Lyso-Gb3 levels in classic Fabry patients, and should be used as first line therapy in classic males with no residual enzyme activity.

COVID-19 in Fabry disease: a reference center prospective study

Background

During the coronavirus disease-19 (COVID-19) pandemic, vulnerable populations must be identified to prevent increased mortality. Fabry disease (FD) is a rare X-linked lysosomal storage disorder leading to chronic kidney disease (CKD), cardiomyopathy, pneumonopathy and premature strokes. Little is known whether SARS-CoV-2 infection bears a particular risk for FD patients.

Methods

During pandemic (02.2020–03.2021) we have regularly followed 104 unvaccinated FD patients. In 61/104, titre of serum antibodies against SARS-CoV-2 were measured and SARS-CoV-2 PCR test was performed in symptomatic patients or in case of positivity of other family members. The symptoms and duration of COVID-19 were reported by the patients or the treating physician.

Results

No deaths or intensive care unit hospitalizations occurred. 13/104 (12.5%) were diagnosed with SARS-CoV-2 infection (16.7% (4/24) men 12.2% (6/49) women of classic phenotype, 25% (3/12) of the men and 0% (0/8) of the women of later- onset phenotype). Of those, 2/13 (15.4%) patients—both kidney transplant recipients—developed severe COVID-19, were hospitalized, and required a high-flow oxygen mask. The rest either developed mild COVID-19 manifestations (8/13, 61.5%) or were asymptomatic (3/13, 23.1%). 2/13 (15.4%) of the patients experienced Fabry pain crisis and 3/13 (23.1%) long COVID-19 like symptoms.

Conclusions

Similar to the general population, in FD patients the risk for severe COVID-19 seems to be driven by the immune system rather than by FD itself. Immunosuppression in kidney transplant recipients represented the highest risk in this population.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13023-022-02386-7.

Diurnal Variations in Natriuretic Peptide Levels: Clinical Implications for the Diagnosis of Acute Heart Failure

BACKGROUND

Current guidelines recommend interpreting concentrations of NPs (natriuretic peptides) irrespective of the time of presentation to the emergency department. We hypothesized that diurnal variations in NP concentration may affect their diagnostic accuracy for acute heart failure.

METHODS

In a secondary analysis of a multicenter diagnostic study enrolling patients presenting with acute dyspnea to the emergency department and using central adjudication of the final diagnosis by 2 independent cardiologists, the diagnostic accuracy for acute heart failure of BNP (B-type NP), NT-proBNP (N-terminal pro-B-type NP), and MR-proANP (midregional pro-atrial NP) was compared among 1577 daytime presenters versus 908 evening/nighttime presenters. In a validation study, the presence of a diurnal rhythm in BNP and NT-proBNP concentrations was examined by hourly measurements in 44 stable individuals.

RESULTS

Among patients adjudicated to have acute heart failure, BNP, NT-proBNP, and MR-proANP concentrations were comparable among daytime versus evening/nighttime presenters (all P=nonsignificant). Contrastingly, among patients adjudicated to have other causes of dyspnea, evening/nighttime presenters had lower BNP (median, 44 [18-110] versus 74 [27-168] ng/L; P<0.01) and NT-proBNP (median, 212 [72-581] versus 297 [102-902] ng/L; P<0.01) concentrations versus daytime presenters. This resulted in higher diagnostic accuracy as quantified by the area under the curve of BNP and NT-proBNP among evening/nighttime presenters (0.97 [95% CI, 0.95-0.98] and 0.95 [95% CI, 0.93-0.96] versus 0.94 [95% CI, 0.92-0.95] and 0.91 [95% CI, 0.90-0.93]) among daytime presenters (both P<0.01). These differences were not observed for MR-proANP. Diurnal variation of BNP and NT-proBNP with lower evening/nighttime concentration was confirmed in 44 stable individuals (P<0.01).

CONCLUSIONS

BNP and NT-proBNP, but not MR-proANP, exhibit a diurnal rhythm that results in even higher diagnostic accuracy among evening/nighttime presenters versus daytime presenters.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifiers: NCT01831115, NCT02091427, and NCT02210897.

Endocrine disorders in patients with Fabry disease: insights from a reference centre prospective study

CONTEXT

Fabry Disease (FD) is a rare X-linked storage disease characterised by a-galactosidase A deficiency and diffuse organ accumulation of glycosphingolipids. Enzyme replacement and chaperone therapies are only partially effective. It remains unclear if FD-related endocrine disorders contribute to the observed morbidity.

OBJECTIVE

To investigate the function of the endocrine system in patients with FD.

DESIGN

We conducted an observational prospective study from 2017 to 2020.

SETTING AND PATIENTS

We included 77 patients with genetically confirmed FD (27 men, 20/27 Classic, 7/26 Late Onset phenotype, 50 women, 41/50 and 9/50 respectively), who are systematically followed by our reference centre.

RESULTS

36/77 (46.8%) patients had VitD deficiency (25(0H)VitD <20 μg/L) despite the fact that 19/36 (52.8%) were substituted with cholecalciferol. Only 21/77 (27.3%) patients had normal VitD levels without VitD substitution. 11/77 (14.3%) had significant hypophosphatemia (p < 0.80 mmol/L). Three new cases (3.9%) of subclinical, two (2.6%) of overt and six (7.8%) of known hypothyroidism were identified. Of note, men had significantly higher renin levels than women [61.4 (26.1-219.6) vs.25.4 (10.9-48.0) mU/L, p = 0.003]. There were no major abnormalities in adrenal, growth and sex-hormone axes. Patients of Classic phenotype had significantly higher High-Density Lipoprotein Cholesterol (HDL-C) levels (p = 0.002) and in men those levels were positively correlated with globotriaosylsphingosin (Lyso-Gb3) values. 10/77 (13%) of the patients were underweight.

CONCLUSIONS

VitD supplementation should be considered for all patients with FD. Thyroid screening should be routinely performed. Malnutrition should be prevented or treated, particularly in Classic phenotype patients. Overall, our data suggest that FD specialists should actively seek and diagnose endocrine disorders in their patients.

Do clinical guidelines facilitate or impede drivers of treatment in Fabry disease?

Background

Variable disease progression confounds accurate prognosis in Fabry disease. Evidence supports the long-term benefit of early intervention with disease-specific therapy, but current guidelines recommend treatment initiation based on signs that may present too late to avoid irreversible organ damage. Findings from the ‘PRoposing Early Disease Indicators for Clinical Tracking in Fabry Disease’ (PREDICT-FD) initiative included expert consensus on 27 early indicators of disease progression in Fabry disease and on drivers of and barriers to treatment initiation in Fabry disease. Here, we compared the PREDICT-FD indicators with guidance from the European Fabry Working Group and various national guidelines to identify differences in signs supporting treatment initiation and how guidelines themselves might affect initiation. Finally, anonymized patient histories were reviewed by PREDICT-FD experts to determine whether PREDICT-FD indicators supported earlier treatment than existing guidance.

Results

Current guidelines generally aligned with PREDICT-FD on indicators of renal involvement, but most lacked specificity regarding cardiac indicators. The prognostic significance of neurological indicators such as white matter lesions (excluded by PREDICT-FD) was questioned in some guidelines and excluded from most. Some PREDICT-FD patient-reported signs (e.g., febrile crises) did not feature elsewhere. Key drivers of treatment initiation in PREDICT-FD were: (A) male sex, young age, and clinical findings (e.g., severe pain, organ involvement), (B) improving clinical outcomes and preventing disease progression, and (C) a family history of Fabry disease (especially if outcomes were severe). All guidelines aligned with (A) and several advocated therapy for asymptomatic male patients. There was scant evidence of (B) in current guidance: for example, no countries mandated ancillary symptomatic therapy, and no guidance advocated familial screening with (C) when diagnosis was confirmed. Barriers were misdiagnosis and a lack of biomarkers to inform timing of treatment. Review of patient histories generally found equal or greater support for treatment initiation with PREDICT-FD indicators than with other guidelines and revealed that the same case and guideline criteria often yielded different treatment recommendations.

Conclusions

Wider adoption of PREDICT-FD indicators at a national level could promote earlier treatment in Fabry disease. Clearer, more concise guidance is needed to harmonize treatment initiation in Fabry disease internationally.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13023-022-02181-4.

Neuropsychiatric Symptoms and Their Association With Sex, Age, and Enzyme Replacement Therapy in Fabry Disease: A Systematic Review

Patients suffering from Fabry disease (FD) have an increased risk of developing neuropsychiatric symptoms (NPS), mostly impairment in cognitive performance and depression. Single cases of psychosis have been reported, however, their association with FD can be coincidental. Furthermore, deficits in social functioning and adaptation as well as specific coping styles in FD patients were observed. Recent studies focused on a longitudinal course of the disease and identified risk factors associated with specific NPS. Since 2001, enzyme replacement therapy (ERT) has been available and in preliminary studies seems to improve cognitive impairment and adaptive skills. In this systematic review, we analyze the available literature on the NPS in FD and investigate if there are any differences in their distribution between males and females, children/adolescents and adults, and individuals treated with ERT and untreated. We discuss the role of the psychological, environmental, and molecular alterations and their correlation to psychiatric manifestations in FD. Finally, we would like to increase awareness of the spectrum of NPS in FD.

Comorbidities Associated with Worse Outcomes Among Inpatients Admitted for Acute Gastrointestinal Bleeding

BACKGROUND

Multimorbidity increases healthcare resource utilization. Little is known on specific comorbidity combinations.

AIMS

To identify comorbidities associated with increased resource utilization among inpatients admitted for gastrointestinal bleeding (GIB).

METHODS

This retrospective cross-sectional study, 1/2010-5/2018 at the University Hospital Zurich, Switzerland, analyzed electronic health records of patients with upper (UGIB) and lower (LGIB) GIB, focusing on length of stay (LOS) and 30-day readmissions for resource use and clinical outcomes, investigated by multivariable regression adjusted for antithrombotics.

RESULTS

Of 1101 patients, 791 had UGIB and 310 LGIB, most often melena and bleeding diverticula, respectively. In UGIB, thromboembolic events showed a trend toward 27% increased LOS (1.27; 95% confidence interval [CI] 1.00-1.61), antithrombotics independently associated with 46% increased LOS (1.46; 95% CI 1.32-1.62). Cancer (odds ratio [OR] 2.86; 95% CI 1.68-4.88) independently associated with 30-day readmissions, anemia showed a trend (OR 1.68; 95% CI 1.00-2.84). In LGIB, none of the investigated comorbidities associated with increased LOS, but antithrombotics independently associated with 25% increased LOS (1.25; 95% CI 1.07-1.46). Atrial fibrillation/flutter (OR 2.69; 95% CI 1.06-6.82) and cancer (OR 4.76; 95% CI 1.40-16.20) associated strongly with 30-day readmissions.

CONCLUSIONS

In both groups, cancer associated with 30-day readmissions, antithrombotics with increased LOS. Thromboembolic events and anemia showed clinically important trends in UGIB. Atrial fibrillation/flutter associated with 30-day readmissions in LGIB. Prospective studies are needed to investigate these complex multimorbid populations and establish appropriate guidelines.

CA 125 in the diagnosis and risk stratification of acute heart failure

Background

Recent evidence confirms the elevation of CA 125 in non-tumor processes such as acute heart failure (AHF). However, the utility of this novel biomarker for diagnosis, prognosis, and therapy guidance in AHF remains unclear.

Purpose

To investigate the potential of CA 125 for diagnosis, prognosis and therapy guidance in unselected AHF patients presenting with acute dyspnea to the emergency department (ED).

Methods

We quantified CA 125 in a blinded fashion among patients presenting with acute dyspnea to the ED in a multicenter diagnostic study. Final diagnosis of AHF including AHF-phenotype was centrally adjudicated by two independent cardiologists. To further characterize CA 125's potential in AHF correlations with established biochemical and imaging markers were assessed. Diagnostic accuracy for AHF was quantified by the area under the receiver operating characteristic curve (AUC). All-cause mortality within 360 days was the prognostic endpoint.

Results

Among 470 patients eligible for this analysis, 268 (57.0%) had adjudicated AHF. CA 125 concentrations at presentation were significantly higher among AHF patients vs. patients with other final diagnoses (45.8 U/ml [interquartile range (IQR), 18.5–110.3] vs. 16.2 U/ml [IQR, 9.6–31.6], p&lt;.001). Patients with worsening heart failure had significant higher CA 125 levels compared to other heart failure phenotypes (p=.018). There was a significant positive correlation of CA 125 and high-sensitivity cardiac troponin T and NTproBNP and a significant negative correlation of CA 125 and left ventricular ejection fraction (correlation coefficients 0.204, 0.220, −0.331, respectively; all ps&lt;.001). CA 125's AUC for AHF was significantly lower compared to NTproBNP's in the overall population (0.72, 95% confidence interval (CI) 0.67–0.76 vs. 0.93, 95% CI 0.90–0.95, p&lt;.001, Figure 1) and in predefined subgroups according to age, gender and renal function. Among 268 AHF patients, 84 (31.3%) died within 360 days of follow-up. CA 125 plasma concentrations above the median indicated increased risk of all-cause mortality (hazard ratio 2.06, 95% CI 1.31–3.24; p=.002, Figure 2). CA 125's prognostic accuracy for 360-days mortality was comparable with NT-proBNP's and high-sensitivity cardiac troponin T's. CA 125 did not independently predict all-cause mortality at 360 days when used in validated multivariable regression models and had no interactions with medical therapies at discharge.

Conclusion

CA 125 may aid physicians in the risk stratification and rapid triage of patients with suspected AHF.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Swiss National Science FoundationSwiss Heart Foundation Figure 1. ROC curve comparisonFigure 2. Kaplan-Meier curve 360 days mortality

Increased symmetric dimethyl-arginine is a predictor factor of decreased platelet reactivity and increased bleeding risk in patients with acute coronary syndrome

Background

One of the promising biomarkers in CVD are asymmetric dimethylarginine (ADMA) and symmetric dimethylarginine (SDMA), which are products of L-arginine methylation and are both involved in endothelial dysfunction. ADMA, SDMA and L-homoarginine, have emerged as biomarkers linked to cardiovascular outcomes [1].

Purpose

To investigate the association of SDMA with platelet reactivity and bleeding risk in patients with acute coronary syndrome (ACS) treated with potent P2Y12 inhibitors prasugrel and ticagrelor.

Methods

Our prospective observational study enrolled 292 patients with ACS undergoing percuteneus coronary intervention [2]. Plasma concentrations of SDMA were measured during the hospitalization for ACS. Impedance aggregometry was used. The primary study endpoint was the concentration of metabolites and platelet reactivity. The primary clinical outcome endpoint was the incidence of Thrombolysis in Myocardial Infarction (TIMI) bleeding events (major, minor and minimal). The efficacy endpoint was the composite of major adverse cardiac events (MACE: stent thrombosis, myocardial infarction, stroke and cardiac death).

Results

There was an inverse correlation between SDMA serum levels and platelet reactivity (r=−0.25; p&lt;0.000). The ADP+PGE1-induced platelet reactivity was 33% lower among patients with the highest SDMA quartile (4th) as compared to those with the 1–3rd SDMA quartile (8 [0–29] vs 12 [0–126] U; p&lt;0.001). The AA-induced platelet reactivity was 56% lower among patients with the highest SDMA quartile (4th) as compared to those with the 1–3rd SDMA quartile (4 [0–48] vs 9 [0–133]; p&lt;0.001). In a multivariate model, the highest SDMA (4th) quartile was found to be an independent predictor of the lowest ADP+PGE1 and AA induced platelet aggregation (OR: 2.666, 95% CI [1.184–5.999], p=0.018).

Conclusions

Our study shows that high plasma concentration of SDMA, but not ADMA, is independently associated with low platelet reactivity to ADP and AA and is associated with major and minor bleeding events in patients with ACS on potent antiplatelet therapies. Therefore, SDMA might have a potential to be further evaluated as a blood biomarker for individualization of duration and potency of antiplatelet therapies in an ACS population at high risk of bleeding complications.

Acknowledgment

I-COMET research team

Funding Acknowledgement

Type of funding sources: None. Figure 1Table 1

MicroRNAs as disease specific diagnostic biomarkers for neoplastic aetiology-related and inflammatory-related pericardial fluid effusion

Background and aim

Malignant involvement of the pericardium is seen in 1 to 20 percent of autopsies in patients with cancer. The most common metastatic tumor involving the pericardium is lung cancer [1]. We aimed to distinguish the origin of the pericardial fluid effusion (i.e. pericarditis vs cancer) based on miRNAs expression in peripheral blood plasma.

Method

8 patients hospitalized for collection of pericardial fluid with pericardial effusion of neoplastic aetiology (lung cancer). Control group includes 8 patients with effusion of inflammatory aetiology. Plasma RNA was extracted by mirVANAPARISKit and quality of RNA was assessed by fluorometric assay. GEP analysis was performed using the Clariom D pico chips, analysed on the Affymetrix platform. Statistical analysis by TAC software. Additional analyses were performed in and R using Signal information obtained from the TAC output. We performed the following tests using log2 transformed data and all comparison groups (A-F). Additional FDR correction, logistic regression, Mann-whitney t-test was used depending of the variables. We calculated Area under the curve using ROCp R package. Scores were ranging from 0 to 1. Co-expression analysis to identify genes authentically expressed was performed using Spearman correlation (cutoff = 0.9, Rpval = 0.05). In order to identify the targets of DE miRNAs we used our wizbionet R package and previously developed pipelines [2,3]. We performed target screening using multimiR package, selecting top 20% predictions from all available databases.

Results

We analyzed targets for all mature versions, and if DE miR was identified as pre-miR we generated -3p and -5p version for it. We also screened DisgeNet database for genes associated with cancer and pericarditis, we identified 2823 and 157 such genes. After identification of the targets of DE miRNAs we performed data aggregation, summarization and obtained information how many targets overall and targets associated with IS are regulated by each DE miRNA. Additionally we identified top targets regulated by the top miRNAs. MiR-5695, miR-4446-5p, miR-572, miR-3131 and miR-4784 were found the most significantly differentially expressed miRNAs in blood plasma for patients with malignancy compared to pericarditis. MiR-22-3p, miR-642a, miR-6771, miR-140-3p, and miR660-5p were found the most significantly differentially expressed miRNAs in pericardial fluid plasma for patients with malignancy compared to pericarditis. Importantly, miR-500b, miR-5188, miR-490, miR-24-3p, miR-383-3p were found the most promising differentially diagnostic biomarkers for malignancy and inflammatory-related pericardial fluid effusion.

Conclusions

For the first time our results indicate the differentially diagnostic power of miRNAs based on comparison of circulating in peripheral blood and pericardial fluid in patients having excessive pericardial fluid effusion due to different etiologies.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

High concentrations of plasma trimethylamine-n-oxide is associated with long-term cardiovascular mortality in patients with acute coronary syndrome

Background

Acute coronary syndrome (ACS) remains a leading cause of mortality worldwide [1]. Patients who experienced ACS are at high risk of future cardiovascular events and death [2–4]. Identification of reliable predictive tools could potentially improve the risk stratification [5]. Numerous studies revealed that intestinal microbial organisms (microbiota) and its metabolites, as TMAO (trimethylamine-N-oxide) may play a pathogenic role in a cardiovascular disease (CVD) and ACS [6]. Elevated concentration of circulating TMAO has been associated with increased risk of CVD and major adverse cardiac events (MACE), including myocardial infarction (MI), stroke, major bleeding and all-cause mortality [7].

Purpose

To investigate the association of liver metabolite TMAO with cardiovascular disease (CV)-related and all-cause mortality in patients with acute coronary syndrome (ACS) who underwent percutaneous coronary intervention.

Methods

Our prospective observational study enrolled 292 patients with ACS. Plasma concentrations of TMAO were measured during the hospitalization for ACS. Observation period lasted 7 years in the median. Adjusted Cox-regression analysis was used for prediction of mortality.

Results

ROC curve analysis revealed that increasing concentrations of TMAO levels assessed at the time point of ACS significantly predicted the risk of CV mortality (c-index=0.78, p&lt;0.001). The cut-off value of &gt;4 μmol/L, labeled as high TMAO level (23% of study population), provided the greatest sum of sensitivity (85%) and specificity (80%) for the prediction of CV mortality and was associated with a positive predictive value of 16% and a negative predictive value of 99%. A multivariate Cox regression model revealed that high TMAO level was a strong and independent predictor of CV death (HR=11.62, 95% CI: 2.26–59.67; p=0.003). High TMAO levels as compared with low TMAO levels were associated with the highest risk of CV death in a subpopulation of patients with diabetes mellitus (27.3% vs 2.6%; p=0.004). Although increasing TMAO levels were also significantly associated with all-cause mortality, their estimates for diagnostic accuracy were low.

Conclusions

High TMAO level is a strong and independent predictor of long-term CV mortality among patients presenting with ACS. TMAO concentration of 4 μmol/L may be a cut-off value for prognosis of ACS patients.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Kaplan-Meier curvesTable 1

Fingerprint of novel circulating microRNAs identify patients with stroke-embolic stroke of undetermined source

Background

Stroke is the second-most common cause of death worldwide. Circulating levels of selected microRNAs (miRNAs) were found to be modulated both in animal experimental models and in patients with stroke, opening up new avenues for the identification of more effective and specific biomarkers to identify and risk-stratify stroke patients. Aim of the present study is to identify all circulating miRNAs that are modulated in patients with stroke, to select specific miRNAs to be used as disease biomarkers to improve prognosis.

Methods

48 patients with stroke- ESUS were involved in the study. We have divided the patient groups based on patients who had a second stroke or TIA and did not have (safety vs safety control). Total RNA was extracted from plasma samples quality of extracted material was assessed using a fluorometric electrophoretic assay. MiRNA profiling was performed using the Affymetrix platform using. Statistical analysis was performed in TAC software. Additional analyses were performed in and R using Signal information obtained from the TAC output. We performed the following tests using log2 transformed data and all comparison groups (A-F). We performed additional FDR correction, logistic regression, Mann-whitney test t-test depending if variances were equal or differing. We calculated Area under the curve using ROCp R package. Scores were ranging from 0–1. Co-expression analysis to identify genes authentically expressed was performed using Spearman correlation (cutoff=0.9, Rpval=0.05). In order to identify the targets of DE miRNAs we used our wizbionet R package and previously developed pipelines [1,2]. We performed target screening using multimiR package, selecting top 20% predictions from all available databases.

Results

MiR-4786, miR-1205, miR-548ar-3p and miR-518e-3p were found the most differentially expressed miRNAs between the groups. So far, miR-4786 was studied only in patients with acute leukemia [3]. Several studies showed the importance of miR-1205 in cell carcinoma and ovarian cancer progression [4]. Moreover, so far only one study showed the regulation of miR-548ar-3p in breast cancer [5]. Finally only one study showed the alteration of miR-518e-3p in Parkinsons disease patients [6]. Besides, our enrichment analysis showed Interleukin-2 signaling pathway, Lipid and lipoprotein metabolism, BDNF signaling pathway, MAPK signaling pathway, Intellectual Disability, Alzheimer's Disease are significantly related to ESUS- patients.

Conclusions

Any of those miRNAs were never studied in stroke before, our results identified several novel circulating prognostic biomarkers miRNAs that are down- of up-regulated in ESUS-stroke patients (who had only one vs multiple stroke). Among those several miRNAs were identified that are known to play a role in the pathophysiology of neurovascular diseases, paving the way to a new class of smart pathophysiology-based biomarkers in stroke.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Polish National Science Center OPUS Figure 1Figure 2

Increased Let-7e expression is associated with long-term all-cause mortality and antiplatelet treatment in patients with type 2 diabetes mellitus

Background

In the light of growing prevalence of type 2 diabetes mellitus (T2DM), efforts are made to discover novel biomarkers. MicroRNAs (miRNAs-miR) are non-coding RNAs used in various processes involved in regulating gene expression which play a role in platelet function.

Purpose

To analyze the ability of platelet-derived miRNAs in prediction of mortality and response to antiplatelet treatment among T2DM-patients.

Methods

252 diabetic subjects were enrolled and were receiving either acetylsalicylic acid (ASA) 75mg (65%) or 150 mg (15%) or clopidogrel (19%). Plasma miR-126, miR-223, miR-125a-3p and Let-7e expressions were assessed by qRT-PCR and compared between the patients who survived and those who died. Median observation time was 5.9 years. Adjusted Cox-regression analysis was used for prediction of mortality. Differential miRNAs expression due to different antiplatelet treatment was analyzed.

Results

ROC curve analysis revealed increasing concentrations of miR-126, Let-7e and miR-125a-3p levels had a diagnostic ability for prediction of long-term all-cause mortality (c-index=0.75, p&lt;0.001; 0.72, p&lt;0.001; 0.72, p=0.001, respectively). Multivariate Cox regression model revealed high miR-126 and Let-7e expressions which were strong and independent predictors of all-cause long-term mortality (HR=5.08, 95% CI: 1.92–13.43; p=0.001; HR=5.94, 95% CI: 1.98–17.79; p=0.001,respectively). After including all miRNAs into one multivariate Cox regression model, only Let-7e was predictive of future occurrence of long-term all-cause death (HR=7.83, 95% CI: 1.2–51.1; p=0.032). MiR-126, Let-7e and miR-223 expressions in the clopidogrel group were significantly higher than in the ASA group (p=0.014; p=0.013; p=0.028, respectively).

Conclusions

Let-7e expression is a strong and independent predictor of long-term all-cause mortality among patients with T2DM. MiR-223, miR-126 and Let-7e present significant interactions with antiplatelet treatment and clinical outcomes.

Funding Acknowledgement

Type of funding sources: None. Figure 1Table 1

Prognostic value of self-reported subjective exercise capacity in patients with acute dyspnea

Background

Quantitative assessment of self-reported exercise capacity as provided by the Duke Activity Status Index (DASI) is a validated measure of exercise capacity in stable ambulatory patients.

Objectives

This study aimedto test whether the quantification of self-reported exercise capacityusing the DASI may aid physicians in the risk stratification of patients presenting with acute dyspnea to the emergency department (ED).

Methods

Basics in Acute Shortness of Breath EvaLuation (BASEL V) was a prospective cohort study recruiting dyspneic patients at the ED. The prognostic value and accuracy of theDASI assessed shortly after presentation were quantified using Cox regression analyses and the Area under the curve (AUC).

Results

Among 1019 patients eligible for this analysis 529 (51.9%) had an adjudicated final diagnosis of acute heart failure, 75 (7.4%) and 297 (29.1%) patients died within 90 and 720 days after presentation. Unadjusted hazard ratios (HR) and multivariable adjusted hazard ratios (aHR) for 90-day and 720-day mortality increased continuously from the fourth (best self-reported exercise capacity) to the first DASI-quartile (worst self-reported exercise capacity). For 720-day mortality in the first quartile theHR was 9.1 (95%-CI 5.5–14.9) (aHR 6.1 [95%-CI 3.7–10.1]), in the second quartile 6.4 (95%-CI 3.9–10.6) (aHR 4.4 [95%-CI 2.6–7.3]), while in the third quartile the HR was 3.2 (95%-CI 1.9–5.5) (aHR 2.4 [95%-CI 1.4–4.0]). The prognostic accuracy of the DASI was moderate-to-high and higher than that of B-type natriuretic peptide (BNP) and NT-proBNP (N-terminal pro-BNP) concentrations, e.g. for 720-day mortality prediction AUC 0.70 versus 0.64, p=0.020; 0.72 versus 0.68, p=0.074.

Conclusions

Quantification of self-reported subjective exercise capacityusing the DASI provides moderate-to-high prognostic accuracy in patients presenting with acute dyspnea to the ED and may aid physicians in further risk stratification.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Union, the Swiss National Science Foundation. Duke Activity Status Index

MicroRNA-223 might be a predictive biomarker for major adverse cardiovascular events prognosis in patients undergoing transcatheter aortic valve implantation procedure

Background

Transcatheter aortic valve implantation (TAVI) is an emerging invasive therapeutic strategy for patients with severe aortic stenosis (AS) significantly enhancing not only quality-of-life measures but also improving short-and long-term survival rates.

Purpose

For these purposes we aimed to analyze correlation between expression levels of platelet-derived microRNAs in patients with heart failure (HF) due to AS who underwent TAVI procedure and assess their association with primary major adverse cardiac events (MACE) defined by all cause mortality and secondary MACE defined as cardiovascular mortality, ischemic stroke, and non-fatal myocardial infarction.

Methods

61 patients before and after the TAVI procedure were included. PlasmaRNA was extracted by mirVANA PARIS Kit and quality of RNA was assessed by fluorometric assay. GEP analysis was performed using the Clariom D pico chips, analyzed on the Affymetrix platform. RT-PCR was performed in order to validate the miRNAs in 61 patients by using the Taqman advanced protocol. MiRNA related to platelet function/antiplatelet treatment were chosen among those with the most relevant modulation between the groups. Wilcoxon test was performed for miRNAs comparison before and after TAVI. Calculations were performed using SPSS version 22.0, p&lt;0.05 (IBM Corporation, Chicago, USA).

Results

We have found that miR-223, miR-125b and miR-125a were significantly increased in patients after the TAVI procedure. ROC analysis showed that increased miR-223 expression after the TAVI procedure might slightly have protective value against MACE outcome.

Conclusions

Our analysis showed alteration of circulating miRNAs after the TAVI procedure and miR-223 might have a predictive value for MACE prognosis in patients with HF due to AS who underwent TAVI procedure.

Acknowledgment

I-COMET research team

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Does maternal age or related factors influence the appearance of psychopathology in children?

Introduction

Maternal age and related factors, such as social vulnerability, are associated with neurodevelopmental and behavioral disorders in offspring.

Objectives

To examine the influence of maternal age and its related factors on the appearance of autism spectrum disorder (ASD), attention deficit hyperactivity disorder (ADHD), alterations in executive functions and behavioral syndromes of the offspring.

Methods

A prospective study was conducted, consisting of 131 healthy pregnant women aged 20 to 41 years, recruited at 38 weeks’ gestation. Their offspring were followed up to 2 years after birth, when psychopatology was assessed. Maternal age and possible related factors were considered predictors. Bayesian ordinal regression models were performed for each outcome variable.

Results

Symptoms of ASD in children were associated with an older maternal age (OR = 0.188; 95% CI[1.062, 1.401]) and a lower educational level of the parents (OR = -0.879; 95% CI[0.202, 0.832]), meanwhile poor social support predicted most ADHD symptoms OR = -0.086; 95% CI[0.838, 1]) and executive dysfunctions OR = -0.661; 95% CI[0.313, 0.845]. Lower parental education predicted both externalizing and internalizing behavior.

Conclusions

Maternal age-related factors were the main predictors of neurodevelopmental disorders in offspring, rather than maternal age. The performance of prenatal interventions in pregnant women with advanced age and anxious depressive symptoms or adverse social situation, is crucial to reduce the risk of neurodevelopmental disorders in the offspring. Likewise, being able to carry out an early detection of childhood psychopathology would allow the implementation of resources that improve their long-term prognosis.

Disclosure

No significant relationships.

Standardising clinical outcomes measures for adult clinical trials in Fabry disease: A global Delphi consensus

BACKGROUND

Recent years have witnessed a considerable increase in clinical trials of new investigational agents for Fabry disease (FD). Several trials investigating different agents are currently in progress; however, lack of standardisation results in challenges to interpretation and comparison. To facilitate the standardisation of investigational programs, we have developed a common framework for future clinical trials in FD.

METHODS AND FINDINGS

A broad consensus regarding clinical outcomes and ways to measure them was obtained via the Delphi methodology. 35 FD clinical experts from 4 continents, representing 3389 FD patients, participated in 3 rounds of Delphi procedure. The aim was to reach a consensus regarding clinical trial design, best treatment comparator, clinical outcomes, measurement of those clinical outcomes and inclusion and exclusion criteria. Consensus results of this initiative included: the selection of the adaptative clinical trial as the ideal study design and agalsidase beta as ideal comparator treatment due to its longstanding use in FD. Renal and cardiac outcomes, such as glomerular filtration rate, proteinuria and left ventricular mass index, were prioritised, whereas neurological outcomes including cerebrovascular and white matter lesions were dismissed as a primary or secondary outcome measure. Besides, there was a consensus regarding the importance of patient-related outcomes such as general quality of life, pain, and gastrointestinal symptoms. Also, unity about lysoGb3 and Gb3 tissue deposits as useful surrogate markers of the disease was obtained. The group recognised that cardiac T1 mapping still has potential but requires further development before its widespread introduction in clinical trials. Finally, patients with end-stage renal disease or renal transplant should be excluded unless a particular group for them is created inside the clinical trial.

CONCLUSION

This consensus will help to shape the future of clinical trials in FD. We note that the FDA has, coincidentally, recently published draft guidelines on clinical trials in FD and welcome this contribution.

Globotrioasylsphingosine Levels and Optical Coherence Tomography Angiography in Fabry Disease Patients

Background: To date, there are no studies associating the dried blood spot (DBS) levels of globotrioasylsphingosine (lysoGb3) with quantitative optical coherence tomography angiography (OCTA) parameters in Fabry disease (FD) patients. Here, we aimed to investigate the association between OCTA vessel density (VD), vessel length density (VLD) with DBS lysoGb3. Methods: A retrospective, single center analysis of all consecutive FD patients enrolled at the Department of Ophthalmology of the University Hospital of Zurich from 1 December 2017 to 9 September 2020. An association between VD and VLD detected by OCTA and lysoGb3 was investigated using a linear mixed model. Results: A total of 57 FD patients (23 male, 34 female; 109 eyes) were included. Forty-one patients suffered from the classic phenotype and 16 from the later-onset phenotype. LysoGb3 inversely correlated with VD and VLD in both the superficial (VD: p = 0.034; VLD: p = 0.02) and deep capillary plexus (VD: p = 0.017; VLD: p = 0.018) in the overall FD cohort. Conclusions: Our study shows an association between lysoGb3 and OCTA VD and VLD. This supports the hypothesis that quantitative OCTA parameters might be useful as diagnostic biomarkers for evaluating systemic involvement in FD, and possibly other diseases.

Sexual function in women with androgen excess disorders: classic forms of congenital adrenal hyperplasia and polycystic ovary syndrome

PURPOSE

We compared the sexual function in women with classic forms of congenital adrenal hyperplasia (CAH) and polycystic ovary syndrome (PCOS) to find if the cause of androgen excess determines sexual functioning.

METHODS

Hundred and four women (21 with CAH, 63 with PCOS and 20 healthy controls) aged 18-40 years were included into the study. All participants completed a questionnaire regarding their sociodemographic background and underwent anthropometric and basic biochemical measurements. Plasma levels of total testosterone, androstenedione, and 17-hydroxyprogesterone were measured with immunoassay. To assess the sexual functions, the Female Sexual Function Index (FSFI) questionnaire was applied.

RESULTS

Apart from the higher physical activity in PCOS patients (P = 0.017), we found no significant sociodemographic differences between the studied groups. In clinical assessment, women with CAH had a lower incidence of acne (P = 0.006). Their plasma levels of 17OHP (P = 0.005) and insulin resistance index (P = 0.0248) were higher, while total testosterone (P = 0.0495) and glucose (P = 0.0061) was lower compared to the PCOS group. Significantly more women with CAH were homosexual (P = 0.003) and bisexual (P = 0.006). CAH group showed a lower total FSFI score (P = 0.0043) and lower scores in three domains: lubrication (P = 0.0131), sexual satisfaction (P = 0.0006), and dyspareunia (P < 0.0001). Higher physical activity was associated in all women with higher total FSFI score (P = 0.009) and scores in the domain of desire (P = 0.034) and sexual satisfaction (P = 0.01), while in CAH women apart from the total score (P = 0.03) and sexual satisfaction (P = 0.002) also in the domains of orgasm (P = 0.005), and pain (P = 0.03).

CONCLUSIONS

CAH women present more often homosexual and bisexual orientation, while their sexual functions are impaired compared to PCOS patients.

Cardiac myosin-binding protein C in the diagnosis and risk stratification of acute heart failure

AIMS

Cardiac myosin-binding protein C (cMyC) seems to be even more sensitive in the quantification of cardiomyocyte injury vs. high-sensitivity cardiac troponin, and may therefore have diagnostic and prognostic utility.

METHODS AND RESULTS

In a prospective multicentre diagnostic study, cMyC, high-sensitivity cardiac troponin T (hs-cTnT), and N-terminal pro-B-type natriuretic peptide (NT-proBNP) plasma concentrations were measured in blinded fashion in patients presenting to the emergency department with acute dyspnoea. Two independent cardiologists centrally adjudicated the final diagnosis. Diagnostic accuracy for acute heart failure (AHF) was quantified by the area under the receiver operating characteristic curve (AUC). All-cause mortality within 360 days was the prognostic endpoint. Among 1083 patients eligible for diagnostic analysis, 51% had AHF. cMyC concentrations at presentation were higher among AHF patients vs. patients with other final diagnoses [72 (interquartile range, IQR 39-156) vs. 22 ng/L (IQR 12-42), P < 0.001)]. cMyC's AUC was high [0.81, 95% confidence interval (CI) 0.78-0.83], higher than hs-cTnT's (0.79, 95% CI 0.76-0.82, P = 0.081) and lower than NT-proBNP's (0.91, 95% CI 0.89-0.93, P < 0.001). Among 794 AHF patients eligible for prognostic analysis, 28% died within 360 days; cMyC plasma concentrations above the median indicated increased risk of death (hazard ratio 2.19, 95% CI 1.66-2.89; P < 0.001). cMyC's prognostic accuracy was comparable with NT-proBNP's and hs-cTnT's. cMyC did not independently predict all-cause mortality when used in validated multivariable regression models. In novel multivariable regression models including medication, age, left ventricular ejection fraction, and discharge creatinine, cMyC remained an independent predictor of death and had no interactions with medical therapies at discharge.

CONCLUSION

Cardiac myosin-binding protein C may aid physicians in the rapid triage of patients with suspected AHF.

Circular RNA-based biomarkers in blood of patients with Fabry disease and related phenotypes

BACKGROUND

Fabry disease is a rare X-linked lysosomal storage disease caused by mutations in the galactosidase α gene. Deficient activity of α-galactosidase A leads to glycosphingolipid accumulations in multiple organs. Circular RNAs represent strong regulators of gene expression. Their circular structure ensures high stability in blood. We hypothesised that blood-based circular RNA profiles improve phenotypic assignment and therapeutic monitoring of Fabry disease.

METHODS

A genome-wide circular RNA expression analysis was performed in blood of genetically diagnosed patients with Fabry disease (n=58), age-matched and sex-matched healthy volunteers (n=14) and disease control patients with acute kidney injury (n=109). Most highly dysregulated circular RNAs were validated by quantitative real-time PCR. Circular RNA biomarker sensitivity, specificity, predictive values and area under the curve (AUC) were determined. Linear regression analyses were conducted for validated circular RNA biomarkers and clinical patient characteristics.

RESULTS

A distinct circular RNA transcriptome signature identified patients with Fabry disease. Level of circular RNAs hsa_circ_0006853 (AUC=0.73), hsa_circ_0083766 (AUC=0.8) and hsa_circ_0002397 (AUC=0.8) distinguished patients with Fabry disease from both healthy controls and patients with acute kidney injury. Hsa_circ_0002397 was, furthermore, female-specifically expressed. Circular RNA level were significantly related to galactosidase α gene mutations, early symptoms, phenotypes, disease severities, specific therapies and long-term complications of Fabry disease.

CONCLUSION

The discovery of circular RNA-based and Fabry disease-specific biomarkers may advance future diagnosis of Fabry disease and help to distinguish related phenotypes.

Lyso-Gb3 associates with adverse long-term outcome in patients with Fabry disease

Background

Fabry disease (FD) is a rare X-linked lysosomal storage disease caused by mutations in the α-galactosidase A gene (GLA) leading to deficiency of α-galactosidase A and ultimately in progressive glycosphingolipid accumulation, especially globotriaosylceramide (Gb3) and its deacylated derivative globotriaosylsphingosine (Lyso-Gb3). The aim of the study was to assess plasma Lyso-Gb3 levels as a possible factor associated with adverse outcomes in FD.

Methods

In a cohort of 66 patients with genetically confirmed FD (26 males and 40 females), we analysed serum Lyso-Gb3 as a factor associated with adverse clinical outcomes in a long-term study. The main outcome was a composite endpoint of incident kidney replacement therapy, atrial fibrillation, pacemaker and/or implantable cardioverter defibrillator, cerebrovascular events or death, whichever occurred first.

Results

During the median follow-up time of 68 (40–80) months, events occurred in 19 (29%) of the patients. In a Cox multivariate regression analysis, Lyso-Gb3 levels (HR 4.62 (1.55 to 13.81); p=0.006) and the pretreatment exposure to Lyso-Gb3 (HR 3.41 (1.11 to 10.49); p=0.03) (both per SD increase) were significantly associated with adverse outcomes. If pretreatment Lyso-Gb3 exposure was added to multivariable logistic regression models containing age, sex, phenotype and enzyme replacement therapy as other covariates with the composite outcome as dependent variable, the area under the curve for the composite outcome significantly improved from 0.72 to 0.86 (p comparison=0.04).

Conclusion

Lyso-Gb3 is a significant risk factor associated with important clinical events. Whether treatment-related amelioration of Lyso-Gb3 levels will be associated with improved long-term outcome needs to be established in prospective intervention trials.

46 Use of time-lapse imaging technology to assess relationships of morphological and phototextural attributes of presumptive ovine zygotes and early embryos with their developmental competence invitro

The assessment of morphology and digital image opacity may provide valuable information on embryo viability because such traits are linked to embryonic gene expression, metabolism and ultrastructure. Time-lapse imaging has been used in research to monitor the dynamic nature of the developing pre-implantation embryo, which includes capturing alterations in various morphological parameters over time. The present study examined the effectiveness of time-lapse technology in assessing several morphometric and phototextural parameters for predicting the developmental potential of ovine embryos. The development of 37 long wool sheep embryos from IVF to the blastocyst stage was monitored and evaluated using Primo Vision time-lapse imaging technology. Image-Pro Plus software was then used to measure zona pellucida thickness, embryo diameter, cellular grey-scale pixel intensity and heterogeneity, and total area of the perivitelline space. A one-way analysis of variance (ANOVA) was done using SigmaPlot® 11.0 for all attributes at various time points during embryo development [i.e. presumptive zygote stage, t(0); first cleavage, t(2) or t(3); second cleavage, t(4) or t(6); and third cleavage, t(7) or t(8)]. Our results indicate that most parameters analysed did not differ among embryos varying in their developmental fate, with the exception of the perivitelline space area, which was greater (P&lt;0.05) for non-dividing embryos than for future blastocysts at the presumptive zygote stage (4040±4137 vs. 857±642µm2, respectively; mean±s.d.). Consequently, the measurement of perivitelline space at t(0) could be used to predict developmental potential of invitro-produced ovine embryos, but further investigation is required.