Infarct size, inflammatory burden and admission hyperglycemia in diabetic patients with acute myocardial infarction treated with SGLT2-inhibitors: a multicenter international registry

Background

Sodium-glucose co-transporter 2 inhibitors (SGLT2-I) currently receive intense clinical interest in patients with and without diabetes mellitus (DM) with pleiotropic beneficial effects. Nowadays, the inflammation response in the setting of acute myocardial infarction (AMI) has been proposed as a potential pharmacological intervention target. In this setting, we tested the hypothesis that the SGLT2-I displays anti-inflammatory effect along with glucose-lowering properties. We investigated the relationship between stress hyperglycemia, inflammation burden and infarct size in a cohort of type 2 diabetic AMI patients treated with SGLT2-I versus other oral anti-diabetic (OAD) agents alone.

Methods

In this multicenter international registry, all diabetic patients with AMI treated with percutaneous coronary intervention (PCI) between 2018 and 2021 were enrolled. Based on the admission anti-diabetic therapy, patients were divided into those receiving SGLT2-I versus other OAD agents alone. Patients on insulin therapy alone or combined with OAD agents were excluded from the study. The following inflammatory markers were evaluated at different time points: total white blood cell, neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and neutrophil-to-platelet ratio (NPR), C-reactive protein. Infarct size was assessed by peak troponin levels and echocardiographic parameters.

Results

The final study population consisted of 583 patients hospitalized for AMI (both STEMI and NSTEMI) classified as SGLT2-I users (n=98) versus other OAD agents alone (n=485). Admission hyperglycemia was more prevalent among the other OAD agents group. Reduced infarct size was detected in patients treated with SGLT2-I compared to those treated with other OAD agents alone. Both at admission, and after 24 hours, inflammatory indices were significantly higher in patients treated with other OAD agents alone, with a significant increase in neutrophils levels at 24 hours, compared to the SGLT2-I group. In multivariate analysis, SGLT2-I emerged as a significant predictor of reduced inflammatory response (OR 0.45, 95% CI 0.27–0.75, p=0.002), together with peak troponin values, independently of age, admission creatinine values and admission glycemia.

Conclusions

Type 2 Diabetic patients hospitalized for AMI and receiving SGLT2-I exhibited modest inflammatory response and myocardial damage/infarct size compared to other OAD agents alone, independently of glucose-metabolic control. Our findings pave the way for new pathophysiological and therapeutic insights regarding the cardioprotective effect of SGLT2-I in the setting of coronary artery disease.

Funding Acknowledgement

Type of funding sources: None.

Cumulative Effects of Strontium Ranelate and Impact Exercise on Bone Mass in Ovariectomized Rats

OBJECTIVE

To explore the effect of physical exercise (EXE), strontium ranelate (SR), or their combination on bone status in ovariectomized (OVX) rats.

DESIGN

Sixty female Wistar rats were randomized to one of five groups: sham (Sh), OVX (O), OVX+EXE (OE), OVX+SR (OSR), and OVX+EXE+SR (OESR). Animals in EXE groups were subjected to 10 drops per day (45 cm in height); rats in SR groups received 625 mg/kg/day of SR, 5 days/week for 8 weeks. Bone mineral density (BMD) and bone mineral content (BMC, dual-energy X-ray absorptiometry (DXA)), mechanical strength of the left femur (three-point bending test), and femur microarchitecture of (micro-computed tomography imaging, microCT) analyses were performed to characterize biomechanical and trabecular/cortical structure. Bone remodeling, osteocyte apoptosis, and lipid content were evaluated by ELISA and immunofluorescence tests.

RESULTS

In OVX rats, whole-body BMD, trabecular parameters, and osteocalcin (OCN) levels decreased, while weight, lean/fat mass, osteocyte apoptosis, and lipid content all increased. EXE after ovariectomy improved BMD and BMC, trabecular parameters, cross-sectional area (CSA), moment of inertia, and OCN levels while decreasing osteocyte apoptosis and lipid content. SR treatment increased BMD and BMC, trabecular parameters, CSA, stiffness, OCN, and alkaline phosphatase (ALP) levels. Furthermore, fat mass, N-telopeptide (NTX) level, osteocyte apoptosis, and lipid content significantly decreased. The combination of both EXE and SR improved bone parameters compared with EXE or SR alone.

CONCLUSION

EXE and SR had positive and synergistic effects on bone formation and resorption.

Emerging Natural-Product-Based Treatments for the Management of Osteoarthritis

Osteoarthritis (OA) is a complex degenerative disease in which joint homeostasis is disrupted, leading to synovial inflammation, cartilage degradation, subchondral bone remodeling, and resulting in pain and joint disability. Yet, the development of new treatment strategies to restore the equilibrium of the osteoarthritic joint remains a challenge. Numerous studies have revealed that dietary components and/or natural products have anti-inflammatory, antioxidant, anti-bone-resorption, and anabolic potential and have received much attention toward the development of new therapeutic strategies for OA treatment. In the present review, we provide an overview of current and emerging natural-product-based research treatments for OA management by drawing attention to experimental, pre-clinical, and clinical models. Herein, we review current and emerging natural-product-based research treatments for OA management.

Effect of body mass index on ischemic and bleeding events in patients presenting with acute coronary syndromes: insights from the START-ANTIPLATELET registry

Background

The protective effect of obesity on mortality in acute coronary syndromes (ACS) patients remains debated. We aimed at evaluating the impact of obesity on ischemic and bleeding events as possible explanations to the obesity paradox in ACS patients.

Methods

For the purpose of this sub-study, patients enrolled in the START-ANTIPLATELET registry were stratified according to Body Mass Index (BMI) into three groups: normal, BMI <25kg/m2; overweight, BMI: 25–29.9kg/m2; obese, BMI ≥30kg/m2. The primary endpoint was net adverse clinical endpoints (NACE), defined as a composite of all-cause death, myocardial infarction (MI), stroke, and major bleeding.

Results

Patients were classified as follows: 410 (33.9%) normal, 538 (44.5%) overweight, 261 (21.6%) obese. Compared to the normal weight group, obese and overweight patients had a higher prevalence of cardiovascular risk factors, but were younger, with a better left ventricular ejection fraction (LVEF) and lower PRECISE-DAPT score. At one-year follow-up NACE was more frequently observed in normal than in overweight and obese patients (15.1%,8.6%,and9.6%, respectively; p=0.004), driven by a significantly higher rate of all-cause death (6.3%,2.6%, and 3.8%, respectively; p=0.008), while no significant differences were noted in terms of MI, stroke, and major bleeding. When correcting for confounding variables, BMI loses its power in independently predicting outcomes, failing to confirm the obesity paradox in a real-world ACS population.

Conclusions

Our study conflicts the obesity paradox in real-world ACS population, and suggest that the reduced mortality rate may be explained by a lower bleeding risk in obese patients allowing a more aggressive medical treatment, and by a better LVEF translating into a higher survival rate.

Funding Acknowledgement

Type of funding source: None

Ticagrelor versus Clopidogrel in high bleeding risk patients presenting with Acute Coronary Syndromes: insights from the multicenter START-ANTIPLATELET registry

Background

Optimal dual antiplatelet therapy in high bleeding risk (HBR) patients with acute coronary syndromes (ACS) remains debated. Although current guidelines recommend the use of potent P2Y12 inhibitors in these patients (according to the labeled indications), clopidogrel is frequently used in clinical practice based on a perceived advantage in terms of safety in the HBR population.

Purpose

We sought to investigate the use of clopidogrel versus ticagrelor in consecutive HBR ACS patients and their impact on ischemic and bleeding events at 1 year.

Methods

ACS patients enrolled in the START-ANTIPLATELET registry with at least 1 HBR criterion were included in the present analysis and stratified according to DAPT type (clopidogrel versus ticagrelor). The primary endpoint was net adverse clinical endpoint (NACE), defined as a composite of all-cause death, myocardial infarction, stroke, and major bleeding. The secondary endpoints were major adverse cardiac and cerebral events (MACE), defined as a composite of all-cause death, myocardial infarction and stroke, each individual component of NACE and MACE, and target vessel revascularization.

Results

Among a total of 1,209 patients with 1-year follow-up in the registry, 383 patients were considered at HBR, of whom 174 (45.4%) were on clopidogrel and 209 (54.6%) on ticagrelor. Clopidogrel was more likely to be administered in patients at increased ischemic and bleeding risk, while ticagrelor in those undergoing percutaneous coronary intervention. Mean DAPT duration was longer in the ticagrelor group than in the clopidogrel group (10.40±4.29 versus 9.35±5.4; p-value=0.03). At 1-year follow-up, the risk of NACE and MACE events was significantly higher in the clopidogrel than in the ticagrelor group (NACE: HR 1.82; 95% CI 1.07–3.09; p-value=0.02; MACE: HR 1.83; 95% CI 1.04–3.24; p-value=0.03) (Figure). After multivariate adjustment for clinical and procedural characteristics, no difference in NACEs nor MACEs was observed between patients on clopidogrel versus ticagrelor (NACE: adjusted HR 1.27; 95% CI 0.71–2.27; p-value=0.42; MACE: adjusted HR 1.19; 95% CI 0.63–2.24; p-value=0.59) (Figure). Age, number of HBR criteria, and mean DAPT duration were independent predictors of NACEs.

Conclusions

In a real-world ACS registry, approximately 50% of patients are at HBR and frequently treated with clopidogrel. In HBR ACS patients, no difference was observed in ischemic and bleeding events between clopidogrel and ticagrelor after adjustment for potential confounders.

Kaplan-Meier curves at 1-year follow-up.

Funding Acknowledgement

Type of funding source: None

Ultrasonic processes for the advanced remediation of contaminated sediments

Sediments play a fundamental role in the aquatic environment, so that the presence of contaminants poses severe concern for the possible negative effects on both environmental and human health. Sediment remediation is thus necessary to reduce pollutant concentrations and several techniques have been studied so far. A novel approach for sediment remediation is the use of Advanced Oxidation Processes, which include ultrasound (US). This paper focuses on the study of the ultrasonic effects for the simultaneous reduction of both organic and inorganic contaminants from sediments. To this end, the US technology was investigated as a stand-alone treatment as well as in combination with an electro-kinetic (EK) process, known to be effective in the removal of heavy metals from soil and sediments. The US remediation resulted in higher organic compound degradation, with an average 88% removal, but promising desorption yields (47-84%) were achieved for heavy metals as well. The combined EK/US process was found to be particularly effective for lead. Experimental outcomes highlighted the potential of the ultrasonic technology for the remediation of contaminated sediments and addressed some considerations for the possible scale-up.

Enhanced myelopoiesis and aggravated arthritis in S100a8-deficient mice

Expressed strongly by myeloid cells, damage-associated molecular pattern (DAMP) proteins S100A8 and S100A9 are found in the serum of patients with infectious and autoimmune diseases. Compared to S100A9, the role of S100A8 is controversial. We investigated its biological activity in collagen-induced arthritis using the first known viable and fertile S100a8-deficient (S100a8^-/-) mouse. Although comparable to the wild type (WT) in terms of lymphocyte distribution in blood and in the primary and secondary lymphoid organs, S100a8^-/- mice had increased numbers of neutrophils, monocytes and dendritic cells in the blood and bone marrow, and these all expressed myeloid markers such as CD11b, Ly6G and CD86 more strongly. Granulocyte-macrophage common precursors were increased in S100a8^-/- bone marrow and yielded greater numbers of macrophages and dendritic cells in culture. The animals also developed more severe arthritic disease leading to aggravated osteoclast activity and bone destruction. These findings were correlated with increased inflammatory cell infiltration and cytokine secretion in the paws. This study suggests that S100A8 is an anti-inflammatory DAMP that regulates myeloid cell differentiation, thereby mitigating the development of experimental arthritis.

MAVS deficiency induces gut dysbiotic microbiota conferring a proallergic phenotype

Prominent changes in the gut microbiota (referred to as "dysbiosis") play a key role in the development of allergic disorders, but the underlying mechanisms remain unknown. Study of the delayed-type hypersensitivity (DTH) response in mice contributed to our knowledge of the pathophysiology of human allergic contact dermatitis. Here we report a negative regulatory role of the RIG-I-like receptor adaptor mitochondrial antiviral signaling (MAVS) on DTH by modulating gut bacterial ecology. Cohousing and fecal transplantation experiments revealed that the dysbiotic microbiota of Mavs-/- mice conferred a proallergic phenotype that is communicable to wild-type mice. DTH sensitization coincided with increased intestinal permeability and bacterial translocation within lymphoid organs that enhanced DTH severity. Collectively, we unveiled an unexpected impact of RIG-I-like signaling on the gut microbiota with consequences on allergic skin disease outcome. Primarily, these data indicate that manipulating the gut microbiota may help in the development of therapeutic strategies for the treatment of human allergic skin pathologies.

Different Buffers for Hemodiafiltration: A Controlled Study

Hemodiafiltration (HDF) is usually performed using a dialytic solution (D) containing acetate (A) or bicarbonate (B) and a replacement fluid (RF) containing lactate (L).

To clarify the role of buffers in HDF, 11 patients underwent different study periods, each three months long: bicarbonate hemodialysis (BHD = Baseline period); HDF with (A) in D and (L) in RF (first period of HDF); HDF with (A) in D and (B) in RF (second HDF); HDF with (B) in D and (L) in RF (third HDF); HDF with (B) in D and (B) in RF (fourth HDF = BHDF).

HDF achieved: 1) an increase in dialytic efficiency (kt/V, 1.28), reducing the time-session (197 min); 2) an improvement in acid-base status (pre-dialytic values in BHDF: pH 7.36; pCO2 39.8 mmHg; HCO−3 21.8 mM/L); 3) better “dry weight” gain (reached in 92.8% of HDF and in 81% of BHD sessions); 4) a significant decrease, in dialytic side-effects (mainly during the third and fourth periods).

On the whole, BHDF (HDF done using only bicarbonate buffer) represents an easy and safe technique, leading to better cardiovascular stability than BHD and HDF without bicarbonate buffer.

Prevalence and Correlates of Anemia and Uncontrolled Anemia in Chronic Hemodialysis Patients – The Campania Dialysis Registry

Background

This study investigated prevalence and correlates of anemia and uncontrolled anemia in chronic hemodialysis patients.

Methods

A cross-sectional analysis was performed on registry data for 2,746 chronic (<6 months) hemodialysis patients aged 25–84. Data collection included years of dialysis, hours of dialysis/wk, disease causing hemodialysis, body mass index (BMI), erythropoietin (EPO) treatment, hemoglobin, markers of viral hepatitis, serum albumin, calcium, and phosphorus.

Results

Prevalence was 88.7% for anemia (hemoglobin <11 g/100 mL and EPO treatment at any Hb level), 39.4% for uncontrolled anemia (hemoglobin<11 g/100 mL). Gender, years of dialysis, hereditary cystic kidney disease (HCKD), and low BMI (<24 kg/m2) were independent correlates of anemia (P<0.001). Gender, HCKD, low BMI, serum albumin and calcium were independent correlates of uncontrolled anemia (P<0.05). An interaction was found between age (not correlated with anemia and uncontrolled anemia) and the association of gender with uncontrolled anemia (P<0.05). EPO doses were higher in patients with high prevalence of uncontrolled anemia than in patients with low prevalence (i.e., women vs men, other diseases vs HCKD, low vs not-low BMI, P<0.01). Gender, years of dialysis, HCKD, BMI, serum albumin, and calcium were independent correlates of the hemoglobin/EPO dose ratio in patients on EPO treatment (P<0.05).

Conclusion

Anemia and uncontrolled anemia are more frequent in hemodialysis patients with short-term dialysis, diseases other than HCKD, low BMI, and female gender. Gender effect was lower in elderly patients. Uncontrolled anemia was also associated with low serum albumin and calcium, suggesting that these parameters are indices of EPO resistance.

Progenitor Cells from Cartilage: Grade Specific Differences in Stem Cell Marker Expression

Recent research has confirmed the presence of Mesenchymal stem cell (MSC)-like progenitors (MPC) in both normal and osteoarthritic cartilage. However, there is only limited information concerning how MPC markers are expressed with osteoarthritis (OA) progression. The purpose of this study was to compare the prevalence of various MPC markers in different OA grades. Human osteoarthritic tibial plateaus were obtained from ten patients undergoing total knee replacement. Each sample had been classified into a mild or severe group according to OARSI scoring. Tissue was taken from each specimen and mRNA expression levels of CD105, CD166, Notch 1, Sox9, Acan and Col II A1 were measured at day 0 and day 14 (2 weeks in vitro). Furthermore, MSC markers: Nucleostemin, CD90, CD73, CD166, CD105 and Notch 1 were studied by immunofluorescence. mRNA levels of MSC markers did not differ between mild and severe OA at day 0. At day 14, protein analysis showed that proliferated cells from both sources expressed all 6 MSC markers. Only cells from the mild OA subjects resulted in a significant increase of mRNA CD105 and CD166 after in vitro expansion. Moreover, cells from the mild OA subjects showed significantly higher levels of CD105, Sox9 and Acan compared with those from severe OA specimens. Results confirmed the presence of MSC markers in mild and severe OA tissue at both mRNA and protein levels. We found significant differences between cells obtained from mild compared to severe OA specimens suggests that mild OA derived cells may have a greater MSC potential.

Abstract OT3-03-03: Challenges faced across borders to open European academic multicentre projects: The ET-FES program part of the ERA-Net TRANSCAN JTC 2011

Background

The activation of international non-profit clinical trials funded by the European Commission (EC) is challenging given the cross-borders regulations and the need to follow specific timelines according to EC rules. We report here the logistic procedures and challenges faced by 4 academic centres from 4 different countries from the European Union (EU) for the activation of such program in metastatic breast cancer (MBC).

Materials and Methods

The primary objective of the ET-FES program is to validate the use of a new radiotracer 18F Fluoroestradiol (FES), targeting estrogen receptors, as a tool to better predict endocrine responsiveness in MBC, with PET/CT. The trial is sponsored by EO Galliera (Genoa, Italy) and brings together Italy, Spain, France and Germany. In 10/2012, ET-FES was approved for funding from EC under the Seventh Framework Programme after the first ERA-NET TRANSCAN Joint Transnational Call (JTC) for Proposals (2011) on validation of new biomarkers for personalized cancer medicine.

Results

The official start of the program was set up on 06/2013 by the Italian Ministry of Health. Time to institutional review board and to competent authority (CA) approvals were 1.5 and 11, 2 and 5, 3 and 16, and 13 and 14+ months in Italy, France, Spain and Germany respectively. Overall, no blocking comment was raised by the ethical committees; only minor clinical and methodological issues were raised in Germany and Spain. Issues from CA were raised in all countries except France (12, 21 and 23 queries in Italy, Spain and Germany respectively), on quality aspects of 18F-FES investigational medicinal product dossier. At the sponsor level, time to final agreement signature with Advanced Accelerator Applications, the 18F-FES manufacturing company, required 13 months. First patient could be enrolled in Italy 14 and 22 months after ethical committee approval and after the official start of the ET-FES project respectively.

Conclusions

As of May 2016, of 310 patients expected, only 28 have been enrolled from Italy. From a regulatory viewpoint and acknowledging that 18F-FES does not have yet any marketing approval in the EU, the ET-FES program approval process was timely completed at the ethical committee level in Italy, France and Spain. Time to CA approval varied across countries and was timely achieved only in France, due to requirements varying from CA to CA, stressing the serious lack of harmonized procedures although intended by the 2001/20/EC directive. Regarding sponsor's responsibilities (i.e. Italy), the administrative procedures needed to activate this type of EU projects remain critical, appealing for more tolerant time span in order to satisfy all the legal aspects on contracts by public bodies, according to national rules and laws. One needs to be very conscious of these timelines when applying to EU/EC calls, especially when the time allowed for the conduction of research is limited (3 years here), unless jeopardizing the entire multicentre and multinational effort.

Citation Format: Brain E, Corradengo D, Oriana N, Piccardo A, Matteucci F, Cortes J, Harbeck N, Würstlein R, Piris A, Alberini J-L, Merlo DF, Degenhardt T, Turbiez I, Madar O, Monti M, Cesaro A, Rivitti E, Rollandi GA, Iacozzi M, Campazzi E, Campora S, Camporese D, Gennari A. Challenges faced across borders to open European academic multicentre projects: The ET-FES program part of the ERA-Net TRANSCAN JTC 2011 [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr OT3-03-03.

Regulation of TLR3 Activation by S100A9

Recognition of viral dsRNA by endosomal TLR3 activates innate immune response during virus infection. Trafficking of TLR3 to the endolysosomal compartment arising from fusion of late endosome (LE) with lysosome is required for recognition and detection of pathogen associated molecular patterns, which results in activation of the TLR3-dependent signaling cascade. Existing knowledge about the mechanism(s) and cellular factor(s) governing TLR3 trafficking is limited. In the current study, we identified intracellular S100A9 protein as a critical regulator of TLR3 trafficking. S100A9 was required for maturation of TLR3 containing early endosome (EE) into LE, the compartment that fuses with lysosome to form the endolysosomal compartment. A drastic reduction in cytokine production was observed in S100A9-knockout (KO) primary macrophages following RNA virus infection and treatment of cells with polyinosinic-polycytidylic acid (polyIC; a dsRNA mimetic that acts as a TLR3 agonist). Mechanistic studies revealed colocalization and interaction of S100A9 with TLR3 following polyIC treatment. S100A9-TLR3 interaction was critical for maturation of TLR3 containing EE into LE because TLR3 could not be detected in the LE of polyIC-treated S100A9-KO macrophages. Subsequently, TLR3 failed to colocalize with its agonist (i.e., biotin-labeled polyIC) in S100A9-deficient macrophages. The in vivo physiological role of S100A9 was evident from loss of cytokine production in polyIC-treated S100A9-KO mice. Thus, we identified intracellular S100A9 as a regulator of TLR3 signaling and demonstrated that S100A9 functions during pre-TLR3 activation stages by facilitating maturation of TLR3 containing EE into LE.

Decoding norovirus infection in Crohn's disease

Although a causing viral infectious agent remains untraceable in Crohn's disease, most recent genome-wide association studies have linked the FUT2 W143X mutation (resulting in asymptomatic norovirus infection) with the pathogenesis of Crohn's ileitis and with vitamin B12 deficiency (i.e., a known risk factor for Crohn's disease with ileal involvement). In line with these findings, host variations in additional genes involved in host response to norovirus infection (such as ATG16L1 and NOD2) predispose humans to Crohn's ileitis. One may therefore presume that asymptomatic norovirus infection may contribute to disruption of the stability of the gut microbiota leading to Crohn's ileitis. These paradigms highlight not only the need to revisit the potential transmissibility of Crohn's disease, but also potential safety issues of forthcoming clinical trials on human probiotic infusions in Crohn's ileitis by rigorous donors screening program.

DAMP molecule S100A9 acts as a molecular pattern to enhance inflammation during influenza A virus infection: role of DDX21-TRIF-TLR4-MyD88 pathway

Pathogen-associated molecular patterns (PAMPs) trigger host immune response by activating pattern recognition receptors like toll-like receptors (TLRs). However, the mechanism whereby several pathogens, including viruses, activate TLRs via a non-PAMP mechanism is unclear. Endogenous “inflammatory mediators” called damage-associated molecular patterns (DAMPs) have been implicated in regulating immune response and inflammation. However, the role of DAMPs in inflammation/immunity during virus infection has not been studied. We have identified a DAMP molecule, S100A9 (also known as Calgranulin B or MRP-14), as an endogenous non-PAMP activator of TLR signaling during influenza A virus (IAV) infection. S100A9 was released from undamaged IAV-infected cells and extracellular S100A9 acted as a critical host-derived molecular pattern to regulate inflammatory response outcome and disease during infection by exaggerating pro-inflammatory response, cell-death and virus pathogenesis. Genetic studies showed that the DDX21-TRIF signaling pathway is required for S100A9 gene expression/production during infection. Furthermore, the inflammatory activity of extracellular S100A9 was mediated by activation of the TLR4-MyD88 pathway. Our studies have thus, underscored the role of a DAMP molecule (i.e. extracellular S100A9) in regulating virus-associated inflammation and uncovered a previously unknown function of the DDX21-TRIF-S100A9-TLR4-MyD88 signaling network in regulating inflammation during infection.

The lung disease severity following influenza A virus (IAV) infection is dependent on the extent of inflammation in the respiratory tract. Severe inflammation in the lung manifests in development of pneumonia. Therefore, it is very critical to identify cellular factors and dissect the molecular/cellular mechanism controlling inflammation in the respiratory tract during IAV infection. Knowledge derived from these studies will be instrumental in development of therapeutics to combat the lung disease associated with IAV infection. Towards that end, in the current study we have identified a cellular factor S100A9 which is responsible for enhanced inflammation during IAV infection. In addition, we have characterized a signal transduction pathway involving various cellular receptors and signaling adaptors that are involved in mediating S100A9-dependent inflammatory response. Thus, our studies have illuminated a cellular/molecular mechanism that can be intervened by therapeutics to reduce and control IAV-associated lung inflammatory disease like pneumonia.

α2β1 integrin regulates Th17 cell activity and its neutralization decreases the severity of collagen-induced arthritis

Th17 cells play a critical role in the pathogenesis of rheumatoid arthritis (RA), but the mechanisms by which these cells regulate the development of RA are not fully understood. We have recently shown that α2β1 integrin, the receptor of type I collagen, is the major collagen-binding integrin expressed by human Th17 cells. In this study, we examined the role of α2β1 integrin in Th17-mediated destructive arthritis in the murine model of collagen-induced arthritis (CIA). We found that α2β1 integrin is expressed on synovial Th17 cells from CIA mice and its neutralization with a specific mAb significantly reduced inflammation and cartilage degradation, and protected the mice from bone erosion. Blockade of α2β1 integrin led to a decrease in the number of Th17 cells in the joints and to a reduction of IL-17 levels in CIA mice. This was associated with an inhibition of receptor activator of NF-κB ligand levels and osteoclast numbers, and reduction of bone loss. We further show that α2β1 integrin is expressed on synovial Th17 cells from RA patients, and that its ligation with collagen costimulated the production of IL-17 by polarized human Th17 cells by enhancing the expression of retinoic acid receptor-related orphan receptor C through ERK and PI3K/AKT. Our findings provide the first evidence, to our knowledge, that α2β1 integrin is an important pathway in Th17 cell activation in the pathogenesis of CIA, suggesting that its blockade can be beneficial for the treatment of RA and other Th17-associated autoimmune diseases.

Impact of neutrophil-secreted myeloid related proteins 8 and 14 (MRP 8/14) on leishmaniasis progression

The myeloid-related proteins (MRPs) 8/14 are small proteins mainly produced by neutrophils, which have been reported to induce NO production in macrophages. On the other hand, Leishmania survives and multiplies within phagocytes by inactivating several of their microbicidal functions. Whereas MRPs are rapidly released during the innate immune response, their role in the regulation of Leishmaniasis is still unknown. In vitro experiments revealed that Leishmania infection alters MRP-induced signaling, leading to inhibition of macrophage functions (NO, TNF-α). In contrast, MRP-primed cells showed normal signaling activation and NO production in response to Leishmania infection. Using a murine air-pouch model, we observed that infection with L. major induced leukocyte recruitment and MRP secretion comparable to LPS-treated mice. Depletion of MRPs significantly reduced these inflammatory events and augmented both parasite load and footpad swelling during the first 8 weeks post-infection, as also observed in MRP KO mice. On the contrary, mouse treatment with recombinant MRPs (rMRPs) had the opposite effect. Collectively, our results suggest that rapid secretion of MRPs by neutrophils at the site of infection may protect uninfected macrophages and favor a more efficient innate inflammatory response against Leishmania infection. In summary, our study reveals the critical role played by MRPs in the regulation of Leishmania infection and how this pathogen can subvert its action.

Parasites of the Leishmania genus have developed multiple mechanisms to subvert the immune response. Among these mechanisms are the activation of host phosphatases and inactivation of cell signaling pathways, which in turn activate the immune response. On the other hand, it has been observed that the Myeloid Related Proteins (MRPs) 8 and 14 are potent activators of some components of the immune response. In this study, we evaluated the effect of MRPs 8 and 14 on the progression of cutaneous Leishmaniasis. To do so, we used immortalized macrophages and stimulated them with MRPs before or after infection with L. major. We observed that stimulating macrophages with MRPs prior to infection induced NO and TNF-α production, as well as phosphorylation of MAPKs and nuclear translocation of transcription factors NF-κB and AP-1. However, when MRP stimulation was performed after infection, these effects where subverted. Moreover, using a murine model of cutaneous infection, we observed that depletion of MRPs caused increased parasite burden and bigger lesions. On the contrary, injection of recombinant MRPs directly into the lesion, considerably reduced lesion size and parasite burden. Our study suggests that MRPs could have a potential therapeutic use in the control of Leishmania infection.

S100A8 and S100A9 induce cytokine expression and regulate the NLRP3 inflammasome via ROS-dependent activation of NF-κB(1.)

S100A8 and S100A9 are cytoplasmic proteins expressed by phagocytes. High concentrations of these proteins have been correlated with various inflammatory conditions, including autoimmune diseases such as rheumatoid arthritis and Crohn's disease, as well as autoinflammatory diseases. In the present study, we examined the effects of S100A8 and S100A9 on the secretion of cytokines and chemokines from PBMCs. S100A8 and S100A9 induced the secretion of cytokines such as IL-6, IL-8, and IL-1β. This secretion was associated with the activation and translocation of the transcription factor NF-κB. Inhibition studies using antisense RNA and the pharmacological agent BAY-117082 confirmed the involvement of NF-κB in IL-6, IL-8, and IL-1β secretion. S100A8- and S100A9-mediated activation of NF-κB, the NLR family, pyrin domain-containing 3 (NLRP3) protein, and pro-IL-1β expression was dependent on the generation of reactive oxygen species. This effect was synergistically enhanced by ATP, a known inflammasome activator. These results suggest that S100A8 and S100A9 enhance the inflammatory response by inducing cytokine secretion of PBMCs.

An inflammation loop orchestrated by S100A9 and calprotectin is critical for development of arthritis

OBJECTIVE

The S100A9 and S100A8 proteins are highly expressed by neutrophils and monocytes and are part of a group of damage-associated molecular pattern molecules that trigger inflammatory responses. Sera and synovial fluids of patients with rheumatoid arthritis (RA) contain high concentrations of S100A8/A9 that correlate with disease activity.

METHODS

In this study, we investigated the importance of S100A9 in RA by using neutralizing antibodies in a murine lipopolysaccharide-synchronized collagen-induced arthritis model. We also used an in vitro model of stimulation of human immune cells to decipher the role played by S100A9 in leukocyte migration and pro-inflammatory cytokine secretion.

RESULTS

Treatment with anti-S100A9 antibodies improved the clinical score by 50%, diminished immune cell infiltration, reduced inflammatory cytokines, both in serum and in the joints, and preserved bone/collagen integrity. Stimulation of neutrophils with S100A9 protein led to the enhancement of neutrophil transendothelial migration. S100A9 protein also induced the secretion by monocytes of proinflammatory cytokines like TNFα, IL-1β and IL-6, and of chemokines like MIP-1α and MCP-1.

CONCLUSION

The effects of anti-S100A9 treatment are likely direct consequences of inhibiting the S100A9-mediated promotion of neutrophil transmigration and secretion of pro-inflammatory cytokines from monocytes. Collectively, our results show that treatment with anti-S100A9 may inhibit amplification of the immune response and help preserve tissue integrity. Therefore, S100A9 is a promising potential therapeutic target for inflammatory diseases like rheumatoid arthritis for which alternative therapeutic strategies are needed.

Amplification loop of the inflammatory process is induced by P2X7R activation in intestinal epithelial cells in response to neutrophil transepithelial migration

Inflammatory bowel diseases (IBD) are characterized during their active phase by polymorphonuclear leukocyte (PMNL) transepithelial migration. The efflux of PMNL into the mucosa is associated with the production of proinflammatory cytokines and the release of ATP from damaged and necrotic cells. The expression and function of purinergic P2X(7) receptor (P2X(7)R) in intestinal epithelial cells (IEC) and its potential role in the "cross talk" between IEC and PMNL have not been explored. The aims of the present study were 1) to examine P2X(7)R expression in IEC (T84 cells) and in human intestinal biopsies; 2) to detect any changes in P2X(7)R expression in T84 cells during PMNL transepithelial migration, and during the active and quiescent phases of IBD; and 3) to test whether P2X(7)R stimulation in T84 monolayers can induce caspase-1 activation and IL-1beta release by IEC. We found that a functional ATP-sensitive P2X(7)R is constitutively expressed at the apical surface of IEC T84 cells. PMNL transmigration regulates dynamically P2X(7)R expression and alters its distribution from the apical to basolateral surface of IEC during the early phase of PMNL transepithelial migration in vitro. P2X(7)R expression was weak in intestinal biopsies obtained during the active phase of IBD. We show that activation of epithelial P2X(7)R is mandatory for PMNL-induced caspase-1 activation and IL-1beta release by IEC. Overall, these changes in P2X(7)R function may serve to tailor the intensity of the inflammatory response and to prevent IL-1beta overproduction and inflammatory disease.

Autophagy and Crohn's disease: at the crossroads of infection, inflammation, immunity, and cancer

Inflammatory bowel diseases (IBD) are common inflammatory disorders of the gastrointestinal tract that include ulcerative colitis (UC) and Crohn's disease (CD). The incidences of IBD are high in North America and Europe, affecting as many as one in 500 people. These diseases are associated with high morbidity and mortality. Colorectal cancer risk is also increased in IBD, correlating with inflammation severity and duration. IBD are now recognized as complex multigenetic disorders involving at least 32 different risk loci. In 2007, two different autophagy-related genes, ATG16L1 (autophagy-related gene 16-like 1) and IRGM (immunity-related GTPase M) were shown to be specifically involved in CD susceptibility by three independent genome-wide association studies. Soon afterwards, more than forty studies confirmed the involvement of ATG16L1 and IRGM variants in CD susceptibility and gave new information on the importance of macroautophagy (hereafter referred to as autophagy) in the control of infection, inflammation, immunity and cancer. In this review, we discuss how such findings have undoubtedly changed our understanding of CD pathogenesis. A unifying autophagy model then emerges that may help in understanding the development of CD from bacterial infection, to inflammation and finally cancer. The Pandora's box is now open, releasing a wave of hope for new therapeutic strategies in treating Crohn's disease.

Differential expression and regulation of ADAM17 and TIMP3 in acute inflamed intestinal epithelia

The acute phase of Crohn's disease (CD) is characterized by a large afflux of polymorphonuclear leukocytes (PMNL) into the mucosa and by the release of TNF-alpha. Conversion of inactive TNF-alpha into an active form requires the cleavage of a transmembrane TNF-alpha precursor by the TNF-alpha-converting enzyme (ADAM17), a protease mainly regulated by the tissue inhibitor of metalloproteinase 3 (TIMP3). The aim of the present study was to investigate in an in vitro model of PMNL transepithelial migration and in the intestinal mucosa of patients with CD the expression and regulation of ADAM17 and TIMP3 in intestinal epithelial cells (IEC). ADAM17 and TIMP3 expression was analyzed by Western blotting, RT-PCR, confocal microscopy, and immunohistochemistry by using the T84 model and digestive biopsies. ADAM17 expression in IEC was increased at a posttranscriptional level during the early phase (from 2 to 4 h) of PMNL transepithelial migration whereas TIMP3 was only increased 24 h later. TNF-alpha induced an early upregulation of ADAM17 in T84 cells, whereas PMNL adhesion, H(2)O(2), or epithelial tight junction opening alone did not affect the amount of ADAM17. Immunohistochemistry of intestinal biopsies revealed that strong expression of ADAM17 was associated with a high activity of CD. In contrast, TIMP3 was very poorly expressed in these biopsies. ADAM17 and TIMP3 profiling did not correlated with the NOD2/CARD15 status. The ADAM17 activity was higher both in the early phase of PMNL transepithelial migration and in active CD. These results showed early posttranscriptional upregulation of ADAM17 in IEC linked to PMNL transepithelial migration and a high activity of CD.

Low selection of topoisomerase mutants from strains of Escherichia coli harbouring plasmid-borne qnr genes

OBJECTIVES

To investigate mutations in the type II topoisomerase genes in quinolone-resistant mutants selected from bacteria harbouring plasmid-borne qnr genes.

METHODS

Mutants were selected by nalidixic acid, ciprofloxacin and moxifloxacin from two Escherichia coli reference strains and corresponding transconjugants harbouring qnrA1, qnrA3, qnrB2 or qnrS1 genes.

RESULTS

The proportion of resistant mutants selected by the three quinolones was, respectively, in the same range for qnr-positive transconjugants and reference strains. Only 20% (65/329) of the mutants selected from the transconjugants showed a gyrase mutation, whereas 79% (94/119) of those from the reference strains without a qnr gene did (P < 0.0001). At four times the MIC of the selector quinolone, gyrA mutants represented 49% and 95% of the mutants selected with nalidixic acid, 4% and 94% with ciprofloxacin and 0% and 54% with moxifloxacin for qnr-positive transconjugants and reference strains, respectively. Mutations within gyrA were distributed at codon 87 (D87G, H, N or Y) and at codon 83 (S83L) with three novel mutations (gyrA Ser83stop, gyrA Asp82Asn and gyrB insertion of Glu at 465) and three rare mutations (gyrA Gly81Asp, gyrA Asp82Gly and gyrA Ser431Pro), mainly obtained from reference strains after moxifloxacin selection. Strikingly, none of the mutants selected by moxifloxacin from qnr-positive transconjugants harboured a mutation in the topoisomerase genes.

CONCLUSIONS

Topoisomerase mutants are rarely selected by ciprofloxacin and moxifloxacin from strains harbouring qnr. This suggests that the quinolone resistance-determining region domains are protected from quinolones by the Qnr protein and consequently other mechanisms are developed to acquire a further step of fluoroquinolone resistance.

Upper airway obstructive disease in mucopolysaccharidoses: polysomnography, computed tomography and nasal endoscopy findings

In mucopolysaccharidoses, upper airway obstruction has multiple causative factors and progressive respiratory disease may severely affect morbidity and mortality. In a cross-sectional study over 2 years we evaluated upper airway obstructive disease through overnight polysomnography, upper airway computed tomography and nasal endoscopy in 5 children and 6 adults with mucopolysaccharidoses of various types. Measurements of apnoea and apnoea-hypopnoea index, arousal index, and sleep efficiency were obtained through polysomnography. Retropalatal and retroglossal spaces were calculated through computed tomography, and the degree of adenoid hypertrophy was assessed through endoscopy. Apnoea index and apnoea-hypopnoea index were significantly higher in children than in adults with mucopolysaccharidoses (p = 0.03 and p = 0.03, respectively). Compared to healthy controls, retropalatal and retroglossal spaces were significantly smaller in children (p = 0.03 and p = 0.004, respectively) or adults with mucopolysaccharidoses (p = 0.004 and p = 0.004, respectively). All subjects had adenoid hypertrophy causing first-degree (36%) or second-degree (64%) obstruction at endoscopy. Overnight polysomnography, upper airway computed tomography and nasal endoscopy are useful tools for diagnosing obstructive sleep apnoea syndrome in mucopolysaccharidoses, and identifying the site and severity of airway obstruction.

Inhibition of p38 mitogen activated protein kinase controls airway inflammation in cystic fibrosis

BACKGROUND

Cystic fibrosis (CF) airways are characterised by chronic inflammation, increased interleukin (IL)-8 secretion, and neutrophil activation which are considered the principal factors of morbidity and mortality in CF patients. Optimising management of this chronic inflammatory response is therefore a key issue of basic and clinical CF research. Several reports have addressed ways to manage CF airways inflammation, and an attractive therapeutic strategy may be the inhibition of the p38-mitogen activated protein kinase (p38-MAP-k) pathway.

METHODS

A new ex vivo model was used to study the mucosal inflammatory response to environmental airways stimuli. Nasal biopsy tissues from CF patients and controls were cultured ex vivo for 20 minutes, 4 hours, and 24 hours in the presence of lipopolysaccharide (LPS) from Pseudomonas aeruginosa (PA) with and without the p38-MAP-k inhibitor SB203580. Quantitative mRNA assessment, immunohistochemistry, and Western blots were used to detect the expression and modulation of inflammatory markers.

RESULTS

PA-LPS challenge induced a time dependent mucosal inflammation indicated by rapid epithelial activation, IL-8 release, COX-2 upregulation, and neutrophil migration to the upper mucosal layers. Some of these LPS induced changes (IL-8 release and neutrophil migration) were specific to CF tissues. SB203580 significantly controlled all LPS induced mucosal changes in CF tissues.

CONCLUSION

These findings provide a rationale and proof of principle for the potential use of p38-MAP-k inhibitors to control inflammation in patients with CF.

[Effects of atorvastatin on ischemic acute renal failure in aging rats]

BACKGROUND

Aging (O) rats have a greater susceptibility to renal ischemia than young (Y) rats due to an endothelial dysfunction partially reversed by exogenous administration of L-Arginine. Since statins are able to increase nitric oxide (NO) production, aim of the study was to evaluate whether pre-treatment with atorvastatin (ATO, 10 mg/kg/day for 12 days), had positive effects on ischemic acute renal failure (ARF) of aging rats.

METHODS

Renal clearance studies (inulin) were performed 24 hours after ischemia in 6 Groups (n=6 in each Group) of both Y- and O-rats: control rats (CON), untreated rats with ARF (Groups IRA), and rats with ARF but pretreated with ATO (Groups ATO+IRA).

RESULTS

Renal ischemia determined a sharper decrease in GFR of Group O-IRA than Y-IRA (-80% and -63% vs respective CON, both p<0.001). In both Groups the fall in GFR was secondary to renal vasoconstriction and the consequent reduction in renal plasma flow. Pre-treatment with ATO did not modify GFR in Group Y-ATO+IRA, but was able to determine a marked rise in GFR of rats of O-ATO+IRA Group (+100% vs O-IRA), through a reduction in renal vascular resistances. Induction of ARF greatly enhanced nitrate excretion in Group Y-IRA, but slightly affected Group O-ARF. Administration of ATO did not modify nitrite excretion in Y rats, whereas it was able to increase nitrate excretion in O-ATO+ARF rats (+111% vs O-IRA).

CONCLUSIONS

Pre-treatment with ATO is able to improve the renal response to ischemia in aging rats, through a mechanism which likely is NO-dependent.

[Progression of chronic renal failure in remnant rats: role of arginase inhibition]

BACKGROUND

Oral administration of arginine to remnant (REM) rats (5/6 nx) slows the progression of chronic renal failure through a nitric-oxide(NO)-dependent mechanism. We have recently shown that inhibition of arginase, the main metabolic pathway of arginine, was able to induce similar results on renal dynamics (GIN: 2001, 18:285-290). Aim of the present study was to test whether these changes were mediated by increased availability of arginine-derived NO. Methods. Three Groups of REM rats were studied for 8 weeks after surgery: 1) untreated REM (Group REM); 2) REM rats treated with arginine (1%) in tap water (Group ARG); 3) REM rats administered a Mn++-free diet, to induce partial inhibition of arginase (Group MNF). Normal unmanipulated rats were used as controls (Group NOR).

RESULTS

Liver arginase activity was significantly depressed only in MNF-rats (-35% vs. REM, p < 0.01). Blood pressure was significantly lower in Group MNF vs. ARG and REM after 6 weeks (p < 0.05). Proteinuria was significantly decreased in Group ARG (-42%, p < 0.05 vs. REM) and even more in Group MNF (-57%, p < 0.01). ARG plasma levels, decreased in REM rats (-41% vs. Group CON), were normalized in Group ARG (p < 0.01 vs. Group REM); arginase inhibition was able to increase such levels in Group MNF (+38% vs. REM) and this resulted in a proportional rise in urinary nitrite excretion (+33% vs. REM), grossly depressed in REM rats. Renal arginase activity was lower in all the Groups of remnant rats vs. Group NOR, but intrarenal concentrations of ARG were significantly lower only in rats of Group MNF (p < 0.05 vs. all the other Groups). Histological examination showed that MNF-rats had a glomerular sclerosis index lower than in the other Groups (p < 0.05 vs. Group REM and ARG).

CONCLUSIONS

In conclusion, inhibition of arginase in remnant rats slows the progression of CRF and preserves renal histology through a direct and/or indirect NO-dependent mechanism.

Cardiac performance in Turner's syndrome patients on growth hormone therapy

OBJECTIVES

To investigate possible cardiac morphofunctional alterations observed in 26 Turner's syndrome (TS) patients on prolonged high-dose growth hormone (GH) therapy.

STUDY DESIGN

We examined 26 TS subjects treated with rhGH (1 U/kg/week) for a mean period of 4.9 years (range 1-7.8) and 37 age-, weight- and height-matched healthy girls. Left ventricular volume, mass, systolic function, cardiac index, systemic vascular resistance and diastolic function were evaluated by two-dimensional and Doppler echocardiography.

RESULTS

Heart rate and systolic blood pressure (BP) were higher in TS patients than in controls, while diastolic BP was lower. Left ventricular volumes, ejection fraction, mass index, M/V ratio and cardiac index did not differ significantly; systemic vascular resistance was slightly decreased. Left ventricular fractional shortening and mean velocity of circumferential shortening were slightly increased while end-systolic meridional stress was decreased in TS. Contractile state was normal in TS. Diastolic function assessment showed a shortening of isovolumetric relaxation and diastolic filling times with an increased atrial contribution and a normal pulmonary venous flow.

CONCLUSION

Cardiac morphology in TS patients on GH therapy is similar to controls. The observed changes in left ventricular systolic and diastolic function should be interpreted as an adaptation to the higher heart rate and reduced peripheral vascular resistance induced by GH therapy.

[Clinical evaluation of 2 years of hemodiafiltration using bicarbonate]

At the end of a previous study concerning the use of different buffers for hemodiafiltration (BHDF) in both the re-infusate (40 mM/L) and dialysate (26 mM/L). Retrospective data analysis and showed BHDF to permit good acid/base balance, good clinical tolerability and satisfactory and persistent sense of well-being. From the point of view of kinetics, it is essential to evaluate carefully the acute and/or chronic effect of an alkaline blood pH during or after dial lysis, especially since the volume distribution of bicarbonate is not known.

Cardiovascular stability during the haemodialysis session: relationship between modelling and impedance parameters

The percentage of body water, if calculated from impedance, was found to be significantly different from the classic 58%. This supports the view that the evaluation of the dialytic efficiency should be, in the near future, carried out on the basis of a 'two-pool' model instead of the old 'one-pool'. The serial collection of data during a dialytic session supported the hypothesis that, 90 min after the start or, in general, after a body-water loss of about 5%-6%, some fundamental changes in measured indexes (phase angle, systolic pressure, body volumes, correlation matrix) usually appear. Large-scale research, based on an RS 232 interface connected to a computerised program, will probably help in clarifying whether some major intra-dialytic phenomena could in the near future be easily and automatically predicted.

[Occupational arsine poisoning: description of a case]

A case of occupational arsine poisoning is described that occurred in a small family workshop during blackening operations on zinc/aluminium alloy manufactured parts with acid solutions. This report shows that occupational poisonings wrongly believed to have disappeared can still occur, especially in small and often unsafe working environments.

Different buffers for hemodiafiltration: a controlled study

Hemodiafiltration (HDF) is usually performed using a dialytic solution (D) containing acetate (A) or bicarbonate (B) and a replacement fluid (RF) containing lactate (L). To clarify the role of buffers in HDF, 11 patients underwent different study periods, each three months long: bicarbonate hemodialysis (BHD = Baseline period); HDF with (A) in D and (L) in RF (first period of HDF); HDF with (A) in D and (B) in RF (second HDF); HDF with (B) in D and (L) in RF (third HDF); HDF with (B) in D and (B) in RF (fourth HDF = BHDF). HDF achieved: 1) an increase in dialytic efficiency (kt/V, 1.28), reducing the time-session (197 min); 2) an improvement in acid-base status (pre-dialytic values in BHDF: pH 7.36; pCO2 39.8 mmHg; HCO3- 21.8 mM/L); 3) better "dry weight" gain (reached in 92.8% of HDF and in 81% of BHD sessions); 4) a significant decrease, in dialytic side-effects (mainly during the third and fourth periods). On the whole, BHDF (HDF done using only bicarbonate buffer) represents an easy and safe technique, leading to better cardiovascular stability than BHD and HDF without bicarbonate buffer.

Chronobiological variations of prolactin (PRL) in chronic renal failure (CRF)

During a 24-hour period, the serum levels of prolactin (PRL) were determined in 89 subjects, including 24 controls and 65 with chronic renal failure (CRF), divided into groups according to sex, age and serum creatinine. In mild CRF, both in males and females, PRL level proved to be higher than controls while its circadian rhythm of secretion disappeared. The MANOVA analysis (multivariate analysis of variance) showed that all 3 considered factors (sex, age, creatinine) have a systematic effect on PRL values, that of creatinine being the most prominent. With the progression of renal failure, the physiological PRL oscillations tended to diminish. In general, increasing creatinine levels progressively shifted the acrophase (that is the time-distance between a given hour and the maximum peak of the function) to the morning, with hemodialysis patients showing acrophases between 12 p.m. and 1 a.m. It is possible that in CRF the PRL feedback system could no longer function.