Loss of stress sensor GADD45A promotes stem cell activity and ferroptosis resistance in LGR4/HOXA9-dependent AML

The overall prognosis of acute myeloid leukemia (AML) remains dismal, largely due to the inability of current therapies to kill leukemia stem cells (LSCs) with intrinsic resistance. Loss of the stress sensor GADD45A is implicated in poor clinical outcomes but its role in LSCs and AML pathogenesis is unknown. Here we define GADD45A as a key downstream target of LGR4 oncogenic signaling and discover a regulatory role for GADD45A loss in promoting leukemia-initiating activity and oxidative resistance in LGR4/HOXA9-dependent AML, a poor prognosis subset of leukemia. Knockout of GADD45A enhances AML progression in murine and patient-derived xenograft (PDX) mouse models. Deletion of GADD45A induces substantial mutations, increases LSC self-renewal and stemness in vivo and reduces levels of reactive oxygen species (ROS), accompanied by decreased response to ROS-associated genotoxic agents (e.g., ferroptosis inducer RSL3) and acquisition of an increasingly aggressive phenotype upon serial transplantation in mice. Our single-cell CITE-seq analysis on patient-derived LSCs in PDX mice and subsequent functional studies in murine LSCs and primary AML patient cells show that loss of GADD45A is associated with resistance to ferroptosis (an iron-dependent oxidative cell death caused by ROS accumulation) through aberrant activation of antioxidant pathways related to iron and ROS detoxification such as FTH1 and PRDX1, upregulation of which correlates with unfavorable outcomes in AML patients. These results reveal a therapy resistance mechanism contributing to poor prognosis and support a role for GADD45A loss as a critical step for leukemia-initiating activity and as a target to overcome resistance in aggressive leukemia.

Predominance of MGMT promoter methylation among Pakistani glioblastoma patients

BACKGROUND

Glioblastoma multiforme (GBM), the most prevalent subgroup of neuroepithelial tumors, is characterized by dismal overall survival (OS). Several studies have linked O6-methylguanine-DNA-methyltransferase (MGMT) promoter methylation to OS in GBM patients. However, MGMT methylation frequencies vary geographically and across ethnicities, with limited data for South Asian populations, including Pakistan. This study aimed to analyze MGMT promoter methylation in Pakistani GBM patients.

METHODS

Consecutive primary GBM patients diagnosed ≥ 18 years-of-age, with no prior chemotherapy or radiotherapy history, were retrospectively selected. DNA was isolated from formalin-fixed-paraffin-embedded tissues. MGMT promoter methylation was analyzed using methylation-specific PCR. Clinical, pathological, and treatment data were assessed using Fisher's exact/Chi-squared tests. OS was calculated using Kaplan-Meier analysis in SPSS 27.0.1.

RESULTS

The study included 48 GBM patients, comprising 38 (79.2%) males and 10 (20.8%) females. The median diagnosis age was 49.5 years (range 18-70). MGMT methylation was observed in 87.5% (42/48) of all cases. Patients with MGMT methylation undergoing radiotherapy or radiotherapy plus chemotherapy exhibited significantly improved median OS of 7.2 months (95% CI, 3.7-10.7; P < 0.001) and 16.9 months (95% CI, 15.9-17.9; P < 0.001), respectively, compared to those undergoing surgical resection only (OS: 2.2 months, 95% CI, 0.8-3.6).

CONCLUSION

This is the first comprehensive study highlighting a predominance of MGMT methylation in Pakistani GBM patients. Furthermore, our findings underscore the association of MGMT methylation with improved OS across diverse treatment modalities. Larger studies are imperative to validate our findings for better management of Pakistani GBM patients.

Sinoatrial nodal artery fistula to bronchial arteries originating from the right coronary artery in the setting of chronic bronchiectasis and coronary artery disease

We present a 67-year-old male with past medical history of hyperlipidemia, hypertension, and emphysema, and who was a former smoker, with dyspnea on exertion and chest pain.

A Multireader Multicase (MRMC) Receiver Operating Characteristic (ROC) Study Evaluating Noninferiority of Quantitative Transmission (QT) Ultrasound to Digital Breast Tomosynthesis (DBT) on Detection and Recall of Breast Lesions

RATIONALE AND OBJECTIVES

Quantitative transmission (QT) imaging is an emerging volumetric ultrasound modality for women too young for mammography. QT images tissue without overlap seen in mammography, thereby can potentially improve breast mass detection and characterization and noncancer recall. We compared radiologists' interpretation of QT vs digital breast tomosynthesis (DBT) with a multireader multicase observer performance study.

MATERIALS AND METHODS

Study subjects received screening DBT and QT scans in HIPAA-compliant, institutional review board-approved prospective case-collection studies at four clinical sites. Twenty-four Mammography Quality Standards Act-qualified radiologists interpreted 177 cases (66 with cancer, atypia, or solid mass and 111 normal or with nonsolid benign abnormality), first QT, then 2 weeks later DBT synthesized 2D-views. Readers reported up to three findings per case and for each finding a recall or no recall decision and confidence of that decision. The study hypothesis was area under receiver operating characteristic curve (AUC) of QT was noninferior to DBT. Sensitivity and specificity were also compared.

RESULTS

AUC of QT (0.746 ± 0.028, mean ± SD) was noninferior to DBT (0.700 ± 0.028) for AUC difference margin of -0.05 (P < .05). AUC difference was 0.046 ± 0.028 (95% CI: [-0.008, 0.101]). Sensitivity was 70.6 ± 7.2% for QT and 85.2 ± 6.4% for DBT, specificity was 60.1 ± 12.3% vs 37.2 ± 11.0%, and both differences were statistically significant. Of a total of 21 cases of cysts, readers recommended recall, on average, in 1.1 ± 1.4 cases with QT, but not with DBT, and 10.6 ± 2.2 cases with DBT, but not with QT.

CONCLUSION

QT can be a potential alternative to mammography for breast cancer screening of women too young to undergo mammography.

Successful treatment of early bioprosthetic mitral valve fusion in a patient on VA ECMO with balloon valvuloplasty via direct cannulation of pulmonary vein

We present a case of a 57-year-old male who underwent bioprosthetic mitral valve replacement (MVR) and developed postoperative cardiogenic shock requiring venoarterial extracorporeal membrane oxygenation (VA ECMO) and Impella 5.5 (Abiomed) hemodynamic support.

Whole-Body Imaging Using Low Frequency Transmission Ultrasound

RATIONALE AND OBJECTIVES

To indicate that 3D low-frequency ultrasound tomography with 3D data acquisition (volography) is a safe, low-cost, high-resolution, whole-body meso-scale medical imaging modality that gives high-resolution quantitatively accurate clinically relevant images.

MATERIALS AND METHODS

We compare the speed of sound accuracy in various organs in situ. We validate our 3D ultrasound tomography images using MRI and gross section anatomy as ground truth in 10-day old piglets. Data acquisition is accomplished with the QT Scanner at ∼1 MHz center frequency, and array transceivers for reflection data @3.6 MHz. Images are generated with unique model-based 3D ultrasound tomography algorithms. In reflection, we use 3D refraction-corrected ray tracing to allow 360° compounding with sub-mm resolution. Four 10-12 day old pigs were anesthetized and whole-body images were acquired via low-frequency transmitted ultrasound and 3T MRI.

RESULTS

Tissue values were within an average of 1.07% (0.5%) of the literature values. We also show the detailed correlation of our images with MRI images in axial, coronal, and sagittal views. Volography images of a piglet show high resolution and quantitative accuracy, showing more contrast &resolution than 3T MRI, including the kidney showing medulla, cortex and fibrous cover, and small intestines with ileal lumen detail visible.

CONCLUSION

We establish that 3D ultrasound tomography (volography), yields high-resolution quantitatively accurate images whole-body images in presence of bone and air which are potentially clinically useful but have not appeared in the literature.

Deep Ensembles Are Robust to Occasional Catastrophic Failures of Individual DNNs for Organs Segmentations in CT Images

Deep neural networks (DNNs) have recently showed remarkable performance in various computer vision tasks, including classification and segmentation of medical images. Deep ensembles (an aggregated prediction of multiple DNNs) were shown to improve a DNN's performance in various classification tasks. Here we explore how deep ensembles perform in the image segmentation task, in particular, organ segmentations in CT (Computed Tomography) images. Ensembles of V-Nets were trained to segment multiple organs using several in-house and publicly available clinical studies. The ensembles segmentations were tested on images from a different set of studies, and the effects of ensemble size as well as other ensemble parameters were explored for various organs. Compared to single models, Deep Ensembles significantly improved the average segmentation accuracy, especially for those organs where the accuracy was lower. More importantly, Deep Ensembles strongly reduced occasional "catastrophic" segmentation failures characteristic of single models and variability of the segmentation accuracy from image to image. To quantify this we defined the "high risk images": images for which at least one model produced an outlier metric (performed in the lower 5% percentile). These images comprised about 12% of the test images across all organs. Ensembles performed without outliers for 68%-100% of the "high risk images" depending on the performance metric used.

COPI-regulated mitochondria-ER contact site formation maintains axonal integrity

Coat protein complex I (COPI) is best known for its role in Golgi-endoplasmic reticulum (ER) trafficking, responsible for the retrograde transport of ER-resident proteins. The ER is crucial to neuronal function, regulating Ca2+ homeostasis and the distribution and function of other organelles such as endosomes, peroxisomes, and mitochondria via functional contact sites. Here we demonstrate that disruption of COPI results in mitochondrial dysfunction in Drosophila axons and human cells. The ER network is also disrupted, and the neurons undergo rapid degeneration. We demonstrate that mitochondria-ER contact sites (MERCS) are decreased in COPI-deficient axons, leading to Ca2+ dysregulation, heightened mitophagy, and a decrease in respiratory capacity. Reintroducing MERCS is sufficient to rescue not only mitochondrial distribution and Ca2+ uptake but also ER morphology, dramatically delaying neurodegeneration. This work demonstrates an important role for COPI-mediated trafficking in MERC formation, which is an essential process for maintaining axonal integrity.

Low frequency 3D transmission ultrasound tomography: technical details and clinical implications

A novel 3D ultrasound tomographic (3D UT) method (called volography) that creates a speed of sound (SOS) map and a reflection modality that is co-registered are reviewed and shown to be artifact free even in the presence of high contrast and thus shown to be applicable for breast, orthopedic and pediatric clinical use cases. The 3D UT images are almost isotropic with mm resolution and the reflection image is compounded over 360 degrees to create sub-mm resolution in plane.

METHODS

The physics of ultrasound scattering requires 3D modeling and the concomitant high computational cost is ameliorated with a bespoke algorithm (paraxial approximation - discussed here) and Nvidia GPUs. The resulting reconstruction times are tabulated for clinical relevance. The resulting SOS map is used to create a refraction corrected reflection image at ∼3.6 MHz center frequency. The transmission data are highly redundant, collected over 360 degrees and at 2 mm levels by true matrix receiver arrays yielding 3D data. The high resolution SOS and attenuation maps and reflection images are used in a segmentation algorithm that optimally utilizes this information to segment out glandular, ductal, connective tissue, fat and skin. These volumes are used to estimate breast density, an important correlate to cancer.

RESULTS

Multiple SOS images of breast, knee and segmentations of breast glandular and ductal tissue are shown. Spearman rho is calculated between our volumetric breast density estimates and Volpara™ from mammograms, as 0.9332. Multiple timing results are shown and indicate the variability of the reconstruction times with breast size and type but are ∼30 minutes for average size breast. The timing results with the 3D algorithm indicate ∼60 minute reconstruction times for pediatrics with two Nvidia GPUs. Characteristic variations of the glandular and ductal volumes over time are shown. The SOS from QT images are compared with literature values. The results of a multi-reader multi-case (MRMC) study are shown that compares the 3D UT with full field digital mammography and resulted in an average increase in ROC AUC of 10%. Orthopedic (knee) 3D UT images compared with MRI indicate regions of zero signal in the MRI are clearly displayed in the QT image. Explicit representation of the acoustic field is shown, indicating its 3D nature. An image of in vivo breast with the chest muscle is shown and speed of sound agreement with literature values are tabulated. Reference is made to a recently published paper validating pediatric imaging.

CONCLUSIONS

The high Spearman rho indicates a monotonic (not necessarily linear) relation between our method and industry gold standard Volpara™ density. The acoustic field verifies the need for 3D modeling. The MRMC study, the orthopedic images, breast density study, and references, all indicate the clinical utility of the SOS and reflection images. The QT image of the knee shows its ability to monitor tissue the MRI cannot. The included references and images herein indicate the proof of concept for 3D UT as a viable and valuable clinical adjunct in pediatric and orthopedic situations in addition to the breast imaging.

Severe asthma ILC2s demonstrate enhanced proliferation that is modified by biologics

BACKGROUND AND OBJECTIVE

Type 2 (T2) innate lymphoid cells (ILC2s) contribute to airway inflammation and disease in asthma. We hypothesize that ILC2s isolated from people with severe allergic and eosinophilic asthma would exhibit an enhanced T2 inflammatory activity that would be altered following treatment with mepolizumab and omalizumab. We compare peripheral blood (PB) isolated ILC2's proliferative capacity, IL-5 and IL-13 secretion and phenotype between healthy without asthma (HC), non-asthma allergic (NAA), mild asthma (MA) and severe allergic and eosinophilic asthma (SA) subjects. We then determined the impact of 6 months treatment with either mepolizumab or omalizumab on ILC2s physiology of SA subjects.

METHODS

ILC2s were sorted and cultured in the presence of IL-2, IL-25, IL-33 and thymic stromal lymphopoietin (TSLP) for 14 days. ILC2s proliferation, phenotypes and functions were assessed using flowcytometry. The ILC2s response was then reassessed following clinically successful treatment of SA subjects with mepolizumab and omalizumab.

RESULTS

SA ILC2s demonstrated increased proliferative capacity, TSLP receptor (TSLPR), GATA3 and NFATc1 protein expressions and increased IL-5 and IL-13 release. ILC2s were also capable of releasing IL-6 in response to stimulation. Mepolizumab treatment reduced ILC2s proliferative capacity and expression of TSLPR, GATA3 and NFATc1. Both mepolizumab and omalizumab were associated with reduced ILC2s release of IL-5 and IL-13, only mepolizumab reduced IL-6.

CONCLUSION

ILC2s from severe allergic and eosinophilic asthma demonstrated an active phenotype typified by increased proliferation, TSLPR, GATA3 and NFATc1 expression and increased IL-5, IL-13 and IL-6 release. Mepolizumab reduced markers of ILC2s activation.

Anaphylaxis to Lumason Contrast Agent in Echocardiography after Immune Sensitization: A Case Report and Literature Review

With the continued evolution of echocardiography techniques, novel contrast agents have been introduced to aid in evaluating cardiac structure and function. Lumason is an FDA-approved ultrasound-enhancing agent made of Sulfur hexafluoride lipid-type A microspheres. We report a case of Lumason-induced immune sensitization and subsequent anaphylaxis on re-exposure in a middle-aged male patient presenting with symptoms concerning for a cerebrovascular accident. The patient was successfully treated with steroids and antihistamines. Providers, including physicians, echocardiography technicians, and mid-level providers should be aware of and be prepared to respond to the possibility of anaphylaxis to contrast-enhancing agents used in echocardiography.

173 Transcriptional phenotypes of a human stem cell model of Spinal Bulbar Muscular Atrophy (SBMA)

Background

Spinal bulbar muscular atrophy is a slowly progressive neurodegenerative disease which affects lower motor neurons (MNs). It is caused by a trinucleotide polyglutamine (CAG) repeat expansion in the androgen receptor (AR) gene but the precise mechanisms of degeneration of the MNs in SBMA are complex and remain poorly understood. There are currently no available treatments for patients.

Objectives

The aim of this study was to develop a human iPSC model of SBMA patient MNs in order to characterise early transcriptomic events in SBMA.

Methods

Human iPSCs were differentiated into spinal MNs using an established, developmentally-rational- ised protocol. Samples were collected at key stages in motor neurogenesis for RNA-sequencing followed by transcriptomic and splicing analysis. Live-cell imaging assays for mitochondrial membrane potential and axonal transport of mitochondria and signal endosomes were performed to validate transcriptomic findings.

Results

Over-representation analysis of differentially expressed genes revealed enrichment of DNA damage response and cell cycle pathways. There were reduced transcripts of genes involved in mito- chondrial pathways with reduced mitochondrial membrane potential and anterograde mitochondrial transport in SBMA on live-cell imaging. Alternative splicing events were common and involved adherens junction and extracellular matrix pathways.

Conclusion

Early transcriptional dysregulation, alternative splicing and mitochondrial dysfunction were seen in SBMA MNs as well as genes linked to defective p53/DNA damage response and the cell cycle.

These cellular phenotypes offer potential targets for future clinical treatments.

Immune Thrombocytopenic Purpura (ITP) Following Natural COVID-19 Infection

Immune thrombocytopenic purpura (ITP) has been linked to the COVID-19 vaccine series as a rare adverse event but has recently emerged in the literature as a sequela of natural COVID-19 infection. ITP is a diagnosis of exclusion where a diagnosis is made by having isolated thrombocytopenia (platelet count <100,000/μL) and no other identifiable etiology for the thrombocytopenia. We share the case of a young male without any history of hematological or immunological disorders presenting with severe, symptomatic thrombocytopenia following a natural COVID-19 infection. Patients should be made aware of the potential risk of adverse events with not only vaccination but also even mild cases of natural infection with COVID-19. An emphasis should be placed on the fact that the benefits of vaccination continue to outweigh the potential risks of adverse events, even in those with a pre-existing diagnosis of ITP.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

AR cooperates with SMAD4 to maintain skeletal muscle homeostasis

Androgens and androgen-related molecules exert a plethora of functions across different tissues, mainly through binding to the transcription factor androgen receptor (AR). Despite widespread therapeutic use and misuse of androgens as potent anabolic agents, the molecular mechanisms of this effect on skeletal muscle are currently unknown. Muscle mass in adulthood is mainly regulated by the bone morphogenetic protein (BMP) axis of the transforming growth factor (TGF)-β pathway via recruitment of mothers against decapentaplegic homolog 4 (SMAD4) protein. Here we show that, upon activation, AR forms a transcriptional complex with SMAD4 to orchestrate a muscle hypertrophy programme by modulating SMAD4 chromatin binding dynamics and enhancing its transactivation activity. We challenged this mechanism of action using spinal and bulbar muscular atrophy (SBMA) as a model of study. This adult-onset neuromuscular disease is caused by a polyglutamine expansion (polyQ) in AR and is characterized by progressive muscle weakness and atrophy secondary to a combination of lower motor neuron degeneration and primary muscle atrophy. Here we found that the presence of an elongated polyQ tract impairs AR cooperativity with SMAD4, leading to an inability to mount an effective anti-atrophy gene expression programme in skeletal muscle in response to denervation. Furthermore, adeno-associated virus, serotype 9 (AAV9)-mediated muscle-restricted delivery of BMP7 is able to rescue the muscle atrophy in SBMA mice, supporting the development of treatments able to fine-tune AR-SMAD4 transcriptional cooperativity as a promising target for SBMA and other conditions associated with muscle loss.

Immunotherapy plus chemotherapy versus chemotherapy alone as first-line treatment for non-small cell lung cancer: A systematic review and meta-analysis

e21092

Background: There is an emerging role of immunotherapy plus chemotherapy (ICC) in the front-line setting for the treatment of Non-Small Cell Lung Cancer (NSCLC) with reported improvement in overall survival (OS) and progression-free survival (PFS). In this review, we highlighted the efficacy and safety of combination regimens as a first-line therapy for NSCLC. Methods: A comprehensive literature search was done on PubMed, Cochrane, Embase, WOS, and Scopus until Dec-2021. The outcomes included progression free survival (PFS) and/or overall survival (OS) and treatment-related adverse events (TRAEs). The inverse variance method was used to generate hazard ratios (HR) with the corresponding 95% confidence intervals for the OS and PFS. Meanwhile, Mantle-Hazard variance was used to create risk ratios for TRAEs. Results: The total eleven randomized controlled trials (RCTs) involving 6,386 patients (pts) were included. 3,850 pts received ICC while 2536 pts received chemotherapy., Four studies each used atezolizumab and pembrolizumab while one study each used nivolumab, tislelizumab, and camrelizumab. The ICC group showed a significant improvement in both PFS (HR, 0.60; 95% CI, 0.54-0.66; p = < 0.00001) and OS (HR, 0.77; 95% CI, 0.68-0.87; p = < 0.0001). Atezolizumab combinations have better PFS and OS compared to the other combinations; HR 0.65 (0.59-0.71) and 0.82 (0.74-0.90), respectively. There was no statistically significant difference between the ICC and control groups regarding TRAEs (RR, 1.07; 95% CI, 0.99-1.16; p = 0.09). Further subgroup analysis is mentioned in the table. Conclusions: The ICC seems to be a promising front-line therapy for NSCLC with superior PFS and OS compared to chemotherapy alone and without significant increase in TRAES. [Table: see text]

Vaping-Induced Sepsis and Rapidly Evolving Pleural Effusion in a Young, Otherwise Healthy Male

There have been increasing reports of electronic cigarette (e-cigarette) or vaping use-associated lung injury (EVALI), and the evolving literature demonstrates that the solvents used to dissolve flavors, including vitamin E, may be responsible, at least in part, for the injuries associated with this form of smoking. We present the case of a 26-year-old, otherwise healthy, African American male with a history of heavy use-cigarette use who presented with pleuritic chest pain. He was found to be septic and developed a rapidly accumulating pleural effusion with loculations during his hospitalization. He eventually underwent a thoracotomy due to his deteriorating respiratory status. This case highlights the importance of physician awareness regarding the growing evidence base suggesting that electronic cigarettes and vaporized tobacco products are not as safe as they have been perceived to be. Physicians should screen for and advise patients regarding the risks associated with the use of such products.

The Mediport Paradox: Mediastinitis and Pericardial Effusion With a Misplaced Mediport

Totally implantable subcutaneous devices (TISDs) have become excellent options for patients requiring long-term chemotherapy, parenteral nutrition, and fluid replacement. As with all invasive devices and procedures, they come with their inherent risks, which may manifest immediately or at a later point in time. We present the case of a 74-year-old female with a history of hypertension, chronic obstructive pulmonary disease (COPD), ischemic stroke, breast cancer, and lung cancer who had mediport placement for chemotherapy administration. She received several infusions of pembrolizumab through her mediport and developed progressive dyspnea over four weeks. Upon evaluation at our institution, she was found to have a misplaced mediport with mediastinitis and pericardial effusion due to direct mediastinal exposure to immunotherapy. This case highlights the importance of systematic imaging review, regardless of suspected pathology, and encourages providers to have a low threshold to re-evaluate patients after device placement or immunotherapy commencement.

The efficacy and safety of roxadustat for the treatment of anemia in non-dialysis dependent chronic kidney disease patients: An updated systematic review and meta-analysis of randomized clinical trials

Background

Roxadustat (ROX) is a new medication for anemia as a complication of chronic kidney disease (CKD). Our meta-analysis aims to evaluate the efficacy and safety of ROX, especially on the cardiovascular risks, for anemia in NDD-CKD patients.

Methods

Electronic databases were searched systematically from inception to July 2021 to look for randomized control trials (RCTs) that evaluated ROX NDD-CKD patients. Hemoglobin level and iron utilization parameters, including ferritin, serum iron, transferrin saturation (TSAT), total iron-binding capacity (TIBC), transferrin, and hepcidin were analyzed for efficacy. Pooled risk ratios (RRs) and standardized mean differences (SMDs) were calculated and presented with their 95% confidential intervals (CIs).

Results

Nine RCTs included a total of 3,175 patients in the ROX group and 2,446 patients in the control group. When compared the control group, ROX increased Hb level significantly (SMD: 1.65; 95% CI: 1.08, 2.22; P< 0.00001) and improved iron utilization parameters by decreasing ferritin (SMD: -0.32; 95% CI: -0.51, -0.14; P = 0.0006), TSAT (SMD: -0.19; 95% CI: -0.32, -0.07; P = 0.003), and hepcidin (SMD: -0.74; 95% CI: -1.09, -0.39; P< 0.0001) and increasing TIBC (SMD: 0.99; 95% CI: 0.76, 1.22; P< 0.00001) and transferrin (SMD: 1.20; 95% CI: 0.70, 1.71; P< 0.00001). As for safety, ROX was associated with higher serious adverse effects (RR: 1.07; 95% CI: 1.01, 1.13; P = 0.01), deep venous thrombosis (DVT) (RR: 3.80; 95% CI: 1.5, 9.64; P = 0.08), and hypertension (HTN) (RR: 1.37; 95% CI: 1.13, 1.65; P = 0.001).

Conclusion

We concluded that ROX increased Hb level and improved iron utilization parameters in NDD-CKD patients, but ROX was associated with higher serious adverse effects, especially DVT and HTN. Our results support the use of ROX for NDD-CKD patients with anemia. However, higher-quality RCTs are still needed to ensure its safety and risk of thrombosis.

The effects of curcumin as dietary supplement for patients with COVID-19: A systematic review of randomized clinical trials

Accumulating evidence has been reported regarding the effect of curcumin as a dietary antiviral on patients with COVID-19; however, findings are controversial. Our systematic review aimed to evaluate the effects of curcumin in patients with COVID-19. Electronic databases (PubMed, EMBASE, Scopus, Web of Science, Cochrane Central, and Google Scholar) were systematically searched to identify only randomized clinical trials (RCTs) that assessed curcumin in patients with COVID-19 from inception to September 23, 2021 relevant keywords. The Cochrane risk-of-bias tool for randomized trials was used to evaluate the risk of bias. After a critical review of 1,098 search hits, only six RCTs were selected for discussion. A total of 480 patients were included, with 240 amongst the curcumin groups and 240 in the control group. The lymphocyte count was significantly higher in the curcumin group compared to the placebo group. Curcumin was found to decrease the number of T-helper 17 cells, downregulate T-helper-17 cell-related factors, reduce levels of T-helper-17 cell-related cytokines, yet increase the gene expression of Treg transcription factor forkhead box P3 (FOXP3), and decrease T-Box transcription factor 21 (TBX21). Our review revealed that curcumin might have a positive effect on relieving COVID-19 related inflammatory response due to its powerful immune-modulatory effects on cytokines production, T-cell responses, and gene expression. These findings suggest that curcumin confers clinical benefits in patients with COVID-19. However, due to the limited number of the included studies, further high-quality studies are needed to establish the clinical efficacy of the curcumin.

Emergent Hemodialysis Followed by Continuous Renal Replacement Therapy: A Management Challenge in a Patient With Life-Threatening Metabolic Acidosis of Multifactorial Etiology

Metabolic acidosis is a frequently encountered laboratory finding in daily clinical practice. Rapid pH correction is almost always preferred and necessary while performing workup to identify the causative factors. We present the case of a 73-year-old male presenting with progressive dyspnea and severe metabolic acidosis. He had a pH of 6.6, bicarbonate of 1.8 mg/dL, lactic acid of 18.1 mg/dL, and pCO2 of 14.1 mmHg. The intensivist and nephrologist made a joint decision to rapidly correct the pH using bicarbonate and emergent hemodialysis. Subsequently, continuous renal replacement therapy (CRRT) was started, leading to a favorable outcome. Our patient's most likely etiology of lactic acidosis was metformin because he had a very high lactic acid, high anion gap metabolic acidosis, and acute renal failure on presentation. From our case and literature review, we suggest using hemodialysis, CRRT, and bicarbonate replacement for a better prognosis in patients with critical acidosis in view of frank renal failure and concurrent metformin use.

An Exploratory Multi-reader, Multi-case Study Comparing Transmission Ultrasound to Mammography on Recall Rates and Detection Rates for Breast Cancer Lesions

BACKGROUND

Three-dimensional Quantitative Transmission (QT) ultrasound imaging is an emerging modality for improving the detection and diagnosis of breast cancer. QT ultrasound has high resolution and high contrast to noise ratio, making it effective in evaluating breast tissue. This study compares radiologists' performance of noncancer recall rates and lesion detection rates using QT Ultrasound versus full-field digital mammography (FFDM) in a cross section of female subjects.

MATERIALS AND METHODS

In this multi-reader multi-case (MRMC) study, we examined retrospective data from two clinical trials conducted at five sites. All subjects received FFDM and QT scans within 90 days. Data were analyzed in a reader study with full factorial design involving 22 radiologists and 108 breast cases (42 normal, 39 pathology-confirmed benign, and 27 pathology-confirmed cancer cases). The main results used a random-reader random-case analysis adjusted for location bias performed after a primary predefined random-reader fixed-case analysis.

RESULTS

The readers' mean rate of detecting lesions of any type was 4% higher (p-value > 0.05) with QT imaging. The mean non-cancer recall rate improved significantly, showing a decrease of 16% with QT (p-value = 0.03), at the expense of a 2% decrease in the mean cancer recall rate (p-value >0.05) in comparison to FFDM. Combining performance on cancer and noncancer recall rates, the mean area under the receiver operator curve of confidence scores improved significantly by 10% with QT (p-value = 0.01).

CONCLUSION

This MRMC study indicates that QT improves non-cancer recall rates without substantially affecting cancer recall rates. The main limitation is the small number of cases from retrospective data. A larger prospective MRMC study is warranted for further assessment.

Outpatient Management of COVID-19 With Monoclonal Antibody Therapy in a Young Renal Transplant Patient

At baseline, solid organ transplant recipients are at an increased risk for infectious complications due to the complex immunosuppressive regimens. The available data in renal transplant patients who contract coronavirus disease 2019 (COVID-19) demonstrates dangerously high mortality rates (33%) in those who require hospitalization and/or ICU level care. Interestingly, the data for transplant patients who do not require hospitalization shows significantly lower mortality (3%) despite being on an immunosuppressive regimen. We present the case of a young male patient with a history of renal transplant who tested positive for COVID-19; he was mildly symptomatic with cough, sinusitis, and headache, was worked up as an outpatient, and treated as an outpatient with bamlanivimab monotherapy with no adjustment to his immunosuppressive regimen. This case aims to highlight the possibility of safely managing mild cases of COVID-19 in solid organ transplant patients receiving immunosuppression as an outpatient with monoclonal antibody (mAb) therapy.

Racial disparities in the use of mechanical circulatory support devices in cardiogenic shock

Background

Racial bias has always been a concern for healthcare. Lack of guideline directed utilization of mechanical circulatory support (MCS) devices in cardiogenic shock (CS) may lead to implicit and racial bias.

Purpose

To identify the racial differences in the use of mechanical circulatory support in cardiogenic shock and its association with outcomes.

Methods

National Inpatient Database from 2015–2018 using ICD 10 codes was used. Patients &gt;18 years of age admitted for cariogenic shock were included.

Results

Among 1,021,274 patients hospitalized for cardiogenic shock, overall MCS was utilized in 11.4% (N=116,539). Use of MCS for patients stratified by race was 12.2% white (N=85543), 8% Blacks (N=14688), 11.3% Hispanics (N=11067), 13.8% Asian (N=4417), 12.3% Native American (N=825). IABP was the most commonly used MCS device, followed by Impella, ECMO and LVAD. Overall odds of MCS insertion was significantly higher in white population [1.18 (1.13–1.23) &lt;0.001] and significantly lower in Blacks [0.65 (0.61–0.69) &lt;0.001] and Hispanics [0.89 (0.83–0.97) 0.004]. Among black patients with CS requiring MCS, odds of LVAD insertion were similar compared to other races [1.03 (0.89–1.19) 0.714], while odds of all other types of MCS devices including ECMO [0.83 (0.72–0.95) 0.009], IABP [0.63 (0.59–0.68) &lt;0.001] and Impella [0.61 (0.54–0.70) &lt;0.001] were significantly lower compared to other races. This trend also holds true for patients with CS associated with acute myocardial infarction. Among all patients with CS, the odds of mortality were significantly lower among white patients [0.92 (0.90–0.95) &lt;0.001], on the contrary, odds of mortality were significantly higher in Blacks [1.06 (1.02–1.10) 0.001] and Asians [1.11 (1.02–1.20) 0.012]. Interestingly, when only comparing patients who underwent MCS utilization for CS, odds of mortality were similar in black population compared to other races. [1.03 (0.91–1.17) 0.636].

Conclusion(s)

There still exist significant racial differences in the use of mechanical circulatory devices for cardiogenic shock potentially leading to significantly higher mortality in black population compared to whites. This difference in mortality is mitigated with equal use of MCS devices in cardiogenic shock among all races.

Funding Acknowledgement

Type of funding sources: None.

A Case Report of Brown Recluse Spider Bite

Brown recluse spider is a spider of the genus Loxosceles and also known as violin spider or fiddle-back spider. Brown recluse spider is characterized by having six eyes, with a pair in front, a pair on both sides, and a gap between the pairs. The other spiders have eight eyes in two rows of four. Brown recluse spider bites are challenging to verify but may be clinically diagnosed with consideration of geographic location, seasonality, and clinical characteristics. We present a case that involves a brown recluse spider bite in a 59-year-old female with malnutrition and polysubstance use who developed systemic symptoms and a dermonecrotic wound. Local wound care and intravenous (IV) antibiotics lead to clinical improvement by hospital day three, at which time the patient left against medical advice. The case highlights the challenges of diagnosing a brown recluse spider bites, particularly in a patient with multiple risk factors for necrotizing soft tissue infection. Furthermore, the present case represents one of the few case reports of a brown recluse spider bite in Michigan.

Pulmonary embolism, transient ischaemic attack and thrombocytopenia after the Johnson & Johnson COVID-19 vaccine

As with past illnesses, an approach has been taken to vaccinate the population and halt the spread of COVID-19. On 13 April 2021, the US Food and Drug Administration called for a halt in the administration of the Johnson & Johnson (J&J) COVID-19 vaccine due to reports of thrombosis and thrombocytopenia being associated with vaccination. We present the case of a 43-year-old woman with a history of dyslipidaemia, depression, gastro-oesophageal reflux disease and obesity presenting with dyspnoea, headache and light headedness of 3 days' duration. Ten days prior, she had received the J&J COVID-19 vaccine. She was found to have thrombocytopenia, elevated D-dimers, pulmonary emboli and presented 1 day after discharge with an arterial clot despite being on apixaban. Six other US-based cases of venous thrombotic events are being reviewed at present. Patients should be informed of the possibility of such events to provide informed consent.

An Elderly Smoker Presenting With Pulmonary Langerhans Cell Histiocytosis: An Unusual Demographic

Pulmonary Langerhans cell histiocytosis (PLCH) is a rare neoplastic condition that occurs almost exclusively in young smokers and presents with multiple solid and/or cystic nodules in a primarily upper lobe distribution on chest imaging. Frequently, suspicion arises incidentally on imaging performed for alternative reasons, such as lung cancer screening, but diagnosis requires biopsy studies. We describe an uncommon case of PLCH in an elderly female patient presenting with mild dyspnea and a significant history of smoking. Diagnosis was made with a biopsy of a new pulmonary nodule in her left lung found on lung cancer screening computed tomography (CT) scan. No gold standard therapy exists, and novel agents are being studied for future use. At present, she has been advised to quit smoking and is being followed with serial imaging studies to determine additional measures.

Dysphagia as the Presenting Symptom of Laryngeal Tuberculosis

Laryngeal tuberculosis (TB) is a rare form of tuberculosis that most commonly presents with dysphagia and weight loss. We report a case of a 75-year-old Vietnamese male who presented with dysphagia, odynophagia, and a 30-pound weight loss over the two months prior to presentation. Nasopharyngeal evaluation with microdirect laryngoscopy was performed as part of the workup and revealed lesions of the epiglottis and left vocal cord. A tissue biopsy and quantiferon testing confirmed the diagnosis of tuberculosis. The patient was started on quadruple therapy and is currently receiving treatment. This case highlights the need for consideration of the rare, yet important, differential of laryngeal TB in patients presenting with non-specific complaints such as dysphagia and weight loss.

Pulmonary Fibrosis After COVID-19 Pneumonia

A novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), also known as coronavirus disease 2019 (COVID-19), emerged in Wuhan, China, and rapidly spread across the world. Today, we present an interesting case of a patient with no prior history of pulmonary disease who was diagnosed with COVID-19, recovered after a prolonged hospital course, and was diagnosed with pulmonary fibrosis requiring oxygen therapy thereafter. The patient is currently on pirfenidone and has had a significant improvement in his functional status. His oxygen requirements have decreased, and repeat computed tomography (CT) scanning has demonstrated improvement in the extent of his pulmonary fibrosis. This case highlights the possibility of pulmonary fibrosis being a major complication among COVID-19 survivors and the importance of using pirfenidone in the management of such cases.

A Case Report of Sick Sinus Syndrome as an Initial Presentation of Primary Amyloidosis

Primary light chain amyloidosis (AL amyloidosis) rarely presents as sick sinus syndrome (SSS), and only a few cases have been reported in the literature. A higher index of suspicion is needed to diagnose AL amyloidosis in patients presenting with SSS. Recognizing the electrocardiography (ECG) and transthoracic echocardiogram (TTE) findings for amyloidosis are crucial for early recognition, proper management, and to improve the patients' quality of life.

A 79-year-old female initially presented with dyspnea and was diagnosed with SSS that required a pacemaker insertion. Ten days later, the patient had complained of dysphagia and difficulty swallowing. She underwent an esophagogastroduodenoscopy (EGD) to investigate further, and it revealed esophageal and duodenal ulcers, and biopsy was positive for amyloidosis. The patient was worked up for amyloidosis, including bone marrow biopsy, renal biopsy, frees light chains, and serum electrophoresis, which all confirmed the diagnosis of primary amyloidosis. Unfortunately, due to the terminal nature of her condition, the patient was discharged with comfort measures to hospice care.

Primary Central Nervous System Vasculitis as an Unusual Cause of Intracerebral Hemorrhage: A Case Report

A 64-year-old male with a history of transverse myelitis presented to the hospital with a decreased level of consciousness of one day's duration. CT of the head revealed intracranial hemorrhage measuring 2 x 1.2 cm in the right temporal lobe and multiple small hemorrhages in the left hemisphere, suggestive of vasculitis. Initial vasculitis workup was negative for antinuclear antibody (ANA), complement component 3 (C3), and antineutrophil cytoplasmic antibodies: P-ANCA, C-ANCA. Syphilis, hepatitis B and C, West Nile virus antibody [immunoglobulin G (IgG) and immunoglobulin M (IgM)], herpes simplex virus (HSV) polymerase chain reaction (PCR), and HIV 1 and 2 were also negative. In view of the CT scan findings suggestive of vasculitis and the vague presentation of primary central nervous system vasculitis (PCNSV), a brain biopsy was performed. It revealed angiocentric granulomatous inflammation with focal vessel disruption and associated parenchymal hemorrhage, consistent with a diagnosis of granulomatous vasculitis. The patient received levetiracetam, multiple high doses of steroids, and six cycles of cyclophosphamide for a six-month duration. After induction, he has remained in remission without any maintenance therapy until now (eight years post-presentation).

Duloxetine-Induced Liver Injury: A Case Report

We present a case of a young (43-year-old), otherwise healthy, female patient who developed drug-induced liver injury (DILI) secondary to routine use of duloxetine. Our case aims to raise awareness amongst physicians about the possibility of duloxetine-induced liver injury. We recommend monitoring liver function tests (LFTs) when initiating or adjusting the dose of duloxetine, and intermittently thereafter, to facilitate early identification and management of potential DILI.

Recurrent Takotsubo Cardiomyopathy Presenting With Anterior Wall ST-Elevation Myocardial Infarction

Takotsubo cardiomyopathy (TC) or stress cardiomyopathy with the presence of transient apical ballooning of the left ventricle in the absence of obstructive coronary artery disease. The recurrence of TC is extremely rare, with an annual recurrence risk of 1.5% and approximately 5% recurrence risk after six years. We present a case of a patient with a history of TC who presented with chest pain and ST-segment elevation in her electrocardiogram and was found to have normal coronaries and diagnosed with recurrent TC.

Deterioration of muscle force and contractile characteristics are early pathological events in spinal and bulbar muscular atrophy mice

Spinal and bulbar muscular atrophy (SBMA), also known as Kennedy's Disease, is a late-onset X-linked progressive neuromuscular disease, which predominantly affects males. The pathological hallmarks of the disease are selective loss of spinal and bulbar motor neurons, accompanied by weakness, atrophy and fasciculations of bulbar and limb muscles. SBMA is caused by a CAG repeat expansion in the gene that encodes the androgen receptor (AR) protein. Disease manifestation is androgen dependent and results principally from a toxic gain of AR function. There are currently no effective treatments for this debilitating disease. It is important to understand the course of the disease in order to target therapeutics to key pathological stages. This is especially relevant in disorders such as SBMA, for which disease can be identified before symptom onset, through family history and genetic testing. To fully characterise the role of muscle in SBMA, we undertook a longitudinal physiological and histological characterisation of disease progression in the AR100 mouse model of SBMA. Our results show that the disease first manifests in skeletal muscle, before any motor neuron degeneration, which only occurs in late-stage disease. These findings reveal that alterations in muscle function, including reduced muscle force and changes in contractile characteristics, are early pathological events in SBMA mice and suggest that muscle-targeted therapeutics may be effective in SBMA.This article has an associated First Person interview with the first author of the paper.

Clinical label-free biochemical and metabolic fluorescence lifetime endoscopic imaging of precancerous and cancerous oral lesions

INTRODUCTION

Incomplete head and neck cancer resection occurs in up to 85% of cases, leading to increased odds of local recurrence and regional metastases; thus, image-guided surgical tools for accurate, in situ and fast detection of positive margins during head and neck cancer resection surgery are urgently needed. Oral epithelial dysplasia and cancer development is accompanied by morphological, biochemical, and metabolic tissue and cellular alterations that can modulate the autofluorescence properties of the oral epithelial tissue.

OBJECTIVE

This study aimed to test the hypothesis that autofluorescence biomarkers of oral precancer and cancer can be clinically imaged and quantified by means of multispectral fluorescence lifetime imaging (FLIM) endoscopy.

METHODS

Multispectral autofluorescence lifetime images of precancerous and cancerous lesions from 39 patients were imaged in vivo using a novel multispectral FLIM endoscope and processed to generate widefield maps of biochemical and metabolic autofluorescence biomarkers of oral precancer and cancer.

RESULTS

Statistical analyses applied to the quantified multispectral FLIM endoscopy based autofluorescence biomarkers indicated their potential to provide contrast between precancerous/cancerous vs. healthy oral epithelial tissue.

CONCLUSION

To the best of our knowledge, this study represents the first demonstration of label-free biochemical and metabolic clinical imaging of precancerous and cancerous oral lesions by means of widefield multispectral autofluorescence lifetime endoscopy. Future studies will focus on demonstrating the capabilities of endogenous multispectral FLIM endoscopy as an image-guided surgical tool for positive margin detection during head and neck cancer resection surgery.

Endogenous Fluorescence Lifetime Imaging (FLIM) Endoscopy For Early Detection Of Oral Cancer And Dysplasia

We have performed a pilot clinical study, in which multispectral endogenous fluorescence (or autofluorescence) lifetime imaging (FLIM) was performed on clinically suspicious oral lesions of 73 patients undergoing tissue biopsy for oral dysplasia and cancer diagnosis. The results from this pilot study indicated that mild-dysplasia and early stage oral cancer could be detected from benign lesions using a computed aided diagnosis system developed based on biochemical and metabolic biomarkers derived from the endogenous FLIM images. The diagnostic performance of this novel FLIM clinical tool was estimated using a leave-onepatient-out cross-validation approach, which reported levels of sensitivity >90%, specificity >85%, and Area Under the Receiving Operating Curve (ROC-AUC) >0.9.

Mammalian Taste Cells Express Functional Olfactory Receptors

The peripheral taste and olfactory systems in mammals are separate and independent sensory systems. In the current model of chemosensation, gustatory, and olfactory receptors are genetically divergent families expressed in anatomically distinct locations that project to disparate downstream targets. Although information from the 2 sensory systems merges to form the perception of flavor, the first cross talk is thought to occur centrally, in the insular cortex. Recent studies have shown that gustatory and olfactory receptors are expressed throughout the body and serve as chemical sensors in multiple tissues. Olfactory receptor cDNA has been detected in the tongue, yet the presence of physiologically functional olfactory receptors in taste cells has not yet been demonstrated. Here we report that olfactory receptors are functionally expressed in taste papillae. We found expression of olfactory receptors in the taste papillae of green fluorescent protein-expressing transgenic mice and, using immunocytochemistry and real-time quantitative polymerase chain reaction experiments, the presence of olfactory signal transduction molecules and olfactory receptors in cultured human fungiform taste papilla (HBO) cells. Both HBO cells and mouse taste papilla cells responded to odorants. Knockdown of adenylyl cyclase mRNA by specific small inhibitory RNA and pharmacological block of adenylyl cyclase eliminated these responses, leading us to hypothesize that the gustatory system may receive olfactory information in the periphery. These results provide the first direct evidence of the presence of functional olfactory receptors in mammalian taste cells. Our results also demonstrate that the initial integration of gustatory and olfactory information may occur as early as the taste receptor cells.

Quantitative assessment of breast density using transmission ultrasound tomography

Purpose

Breast density is important in the evaluation of breast cancer risk. At present, breast density is evaluated using two‐dimensional projections from mammography with or without tomosynthesis using either (a) subjective assessment or (b) a computer‐aided approach. The purpose of this work is twofold: (a) to establish an algorithm for quantitative assessment of breast density using quantitative three‐dimensional transmission ultrasound imaging; and (b) to determine how these quantitative assessments compare with both subjective and objective mammographic assessments of breast density.

Methods

We described and verified a threshold‐based segmentation algorithm to give a quantitative breast density (QBD) on ultrasound tomography images of phantoms of known geometric forms. We also used the algorithm and transmission ultrasound tomography to quantitatively determine breast density by separating fibroglandular tissue from fat and skin, based on imaged, quantitative tissue characteristics, and compared the quantitative tomography segmentation results with subjective and objective mammographic assessments.

Results

Quantitative breast density (QBD) measured in phantoms demonstrates high quantitative accuracy with respect to geometric volumes with average difference of less than 0.1% of the total phantom volumes. There is a strong correlation between QBD and both subjective mammographic assessments of Breast Imaging ‐ Reporting and Data System (BI‐RADS) breast composition categories and Volpara density scores — the Spearman correlation coefficients for the two comparisons were calculated to be 0.90 (95% CI: 0.71–0.96) and 0.96 (95% CI: 0.92–0.98), respectively.

Conclusions

The calculation of breast density using ultrasound tomography and the described segmentation algorithm is quantitatively accurate in phantoms and highly correlated with both subjective and Food and Drug Administration (FDA)‐cleared objective assessments of breast density.

Muscle and not neuronal biomarkers correlate with severity in spinal and bulbar muscular atrophy

OBJECTIVE

To determine whether blood biomarkers of neuronal damage (neurofilament light chain [NfL]), muscle damage (creatine kinase [CK]), and muscle mass (creatinine) are altered in spinal and bulbar muscular atrophy (SBMA) and can be used as biomarkers for disease severity.

METHODS

In this multicenter longitudinal prospective study, plasma and serum were collected from 2 cohorts of patients with SBMA in London, United Kingdom (n = 50), and Padova, Italy (n = 43), along with disease (amyotrophic lateral sclerosis [ALS]) and healthy controls, and levels of plasma and serum NfL, CK, and creatinine were measured. Disease severity was assessed by the SBMA Functional Rating Scale and the Adult Myopathy Assessment Tool at baseline and 12 and 24 months.

RESULTS

Blood NfL concentrations were increased in ALS samples, but were unchanged in both SBMA cohorts, were stable after 12 and 24 months, and were not correlated with clinical severity. Normal NfL levels were also found in a well-established mouse model of SBMA. Conversely, CK concentrations were significantly raised in SBMA compared with ALS samples, and were not correlated to the clinical measures. Creatinine concentrations were significantly reduced in SBMA, and strongly and significantly correlated with disease severity.

CONCLUSIONS

While muscle damage and muscle mass biomarkers are abnormal in SBMA, axonal damage markers are unchanged, highlighting the relevant primary role of skeletal muscle in disease pathogenesis. Creatinine, but not CK, correlated with disease severity, confirming its role as a valuable biomarker in SBMA.