[Relationships. Art-affined physicians, gifted artist patients and the debate on art from a psychiatric context after 1945]

BACKGROUND

In 1945 the artist and art collector J. Dubuffet coined the term Art brut for original works by psychiatric inmates that had been created outside of traditions and art movements. In the following decades these works were at the center of negotiation processes in which not only psychiatrists but also exhibition organizers, gallery owners etc. increasingly became involved.

OBJECTIVE

Based on the evaluation of four exemplary pairs of psychiatrists and artist patients (H. Müller-Suur-P. Goesch; M. in der Beeck-E. Spießbach; J. Porret-Forel-A. Corbaz; L. Navratil-R. Limberger), this study explores the field of tension between art and psychiatry after 1945.

MATERIAL AND METHODS

The results of the subproject "Normal#Crazy Art. Works from a Psychiatric Context between Diagnostics and Aesthetics after 1945" of the German Research Foundation (DFG) research group "Normal#Crazy" (FOR 3031) are based on the evaluation of archival material, estates, interviews with contemporary witnesses and contemporary media.

RESULTS

It is shown that different attitudes of the psychiatrists towards "their" artist patients strongly influenced their entry into the art world. In this context, impulses from beyond psychiatry were important in order to expand purely diagnostic views of the works with other approaches.

DISCUSSION

The renewed interest in the individual creativity of patients after 1945 can be understood as a reaction to their dehumanization under fascism and National Socialism; however, the focus on the pathologized personality of artist patients could obscure alternative perspectives on their art, just as the disposal of their works by psychiatrists could hinder their dissemination.

β-(1→3)-D-glucan- and mannan-guided early termination of antifungal therapy in ICU patients: a randomized controlled study

Candida spp. are frequently encountered in specimens from ICUs. However, most of these detections represent colonization. Nevertheless, clinical practice shows that a considerable proportion of these patients will receive antifungal therapy (AT). β-(1→3)-D-glucan (BDG) and mannan are fungal biomarkers with high negative predictive values. We aimed to examine whether biomarker-guided discontinuation of AT can reduce the antifungal consumption. Therefore, we conducted a prospective, randomized intervention study between 1 April 2019 and 31 March 2020. All adult ICU patients with a newly started systemic AT but without fungal infection were eligible for inclusion. Enrolled patients were randomized into an intervention and a control group. In both groups, serum BDG and mannan were determined on days 1 and 2 of AT. If all measurements were negative, AT was discontinued in the intervention group. The primary endpoint was antifungal use. The study was terminated after 12 months. Until this time-point, 41 patients had been included. In the intervention group (n = 19), AT was stopped in only two patients because all others showed either positive BDG and/or mannan levels. One of these two patients developed candidemia and AT had to be restarted. There was no significant difference in the primary and secondary endpoints. In summary, the strategy of using two negative BDG and mannan levels to stop AT failed to reduce antifungal consumption in our cohort. Indeed, there will inevitably be patients with invasive candidiasis in whom necessary AT is discontinued. The optimal patient population, biomarker set, and termination criteria are critical to the success of biomarker-based termination strategies.

Thermal ablation compared to stereotactic body radiation therapy for hepatocellular carcinoma: A multicenter retrospective comparative study

BACKGROUND AIMS

Early-stage HCC can be treated with thermal ablation or stereotactic body radiation therapy (SBRT). We retrospectively compared local progression, mortality, and toxicity among patients with HCC treated with ablation or SBRT in a multicenter, US cohort.

APPROACH RESULTS

We included adult patients with treatment-naïve HCC lesions without vascular invasion treated with thermal ablation or SBRT per individual physician or institutional preference from January 2012 to December 2018. Outcomes included local progression after a 3-month landmark period assessed at the lesion level and overall survival at the patient level. Inverse probability of treatment weighting was used to account for imbalances in treatment groups. The Cox proportional hazard modeling was used to compare progression and overall survival, and logistic regression was used for toxicity. There were 642 patients with 786 lesions (median size: 2.1 cm) treated with ablation or SBRT. In adjusted analyses, SBRT was associated with a reduced risk of local progression compared to ablation (aHR 0.30, 95% CI: 0.15-0.60). However, SBRT-treated patients had an increased risk of liver dysfunction at 3 months (absolute difference 5.5%, aOR 2.31, 95% CI: 1.13-4.73) and death (aHR 2.04, 95% CI: 1.44-2.88, p < 0.0001).

CONCLUSIONS

In this multicenter study of patients with HCC, SBRT was associated with a lower risk of local progression compared to thermal ablation but higher all-cause mortality. Survival differences may be attributable to residual confounding, patient selection, or downstream treatments. These retrospective real-world data help guide treatment decisions while demonstrating the need for a prospective clinical trial.

Assessment of Immune Status Using Inexpensive Cytokines: A Literature Review and Learning Approaches

The emergence of point-of-care (POC) testing has lately been promoted to deliver rapid, reliable medical tests in critical life-threatening situations, especially in resource-limited settings. Recently, POC tests have witnessed further advances due to the technological revolution in smartphones. Smartphones are integrated as reliable readers to the POC results to improve their quantitative detection. This has enabled the use of more complex medical tests by the patient him/herself at home without the need for professional staff and sophisticated equipment. Cytokines, the important immune system biomarkers, are still measured today using the time-consuming Enzyme-Linked Immunosorbent Assay (ELISA), which can only be performed in specially equipped laboratories. Therefore, in this study, we investigate the current development of POC technologies suitable for the home testing of cytokines by conducting a PRISMA literature review. Then, we classify the collected technologies as inexpensive and expensive depending on whether the cytokines can be measured easily at home or not. Additionally, we propose a machine learning-based solution to even increase the efficiency of the cytokine measurement by leveraging the cytokines that can be inexpensively measured to predict the values of the expensive ones. In total, we identify 12 POCs for cytokine quantification. We find that Interleukin 1β (IL-1β), Interleukin 3 (IL-3), Interleukin 6 (IL-6), Interleukin 8 (IL-8) and Tumor necrosis factor (TNF) can be measured with inexpensive POC technology, namely at home. We build machine-learning models to predict the values of other expensive cytokines such as Interferon-gamma (IFN-γ), IL-10, IL-2, IL-17A, IL-17F, IL-4 and IL-5 by relying on the identified inexpensive ones in addition to the age of the individual. We evaluate to what extent the built machine learning models can use the inexpensive cytokines to predict the expensive ones on 351 healthy subjects from the public dataset 10k Immunomes. The models for IFN-γ show high results for the coefficient of determination: R2 = 0.743. The results for IL-5 and IL-4 are also promising, whereas the predictive model of IL-10 achieves only R2 = 0.126. Lastly, the results demonstrate the vital role of TNF and IL-6 in the immune system due to its high importance in the predictions of all the other expensive cytokines.

Magnetic field therapy enhances muscle mitochondrial bioenergetics and attenuates systemic ceramide levels following ACL reconstruction: Southeast Asian randomized-controlled pilot trial

Background

Metabolic disruption commonly follows Anterior Cruciate Ligament Reconstruction (ACLR) surgery. Brief exposure to low amplitude and frequency pulsed electromagnetic fields (PEMFs) has been shown to promote in vitro and in vivo murine myogeneses via the activation of a calcium–mitochondrial axis conferring systemic metabolic adaptations. This randomized-controlled pilot trial sought to detect local changes in muscle structure and function using MRI, and systemic changes in metabolism using plasma biomarker analyses resulting from ACLR, with or without accompanying PEMF therapy.

Methods

20 patients requiring ACLR were randomized into two groups either undergoing PEMF or sham exposure for 16 weeks following surgery. The operated thighs of 10 patients were exposed weekly to PEMFs (1 ​mT for 10 ​min) for 4 months following surgery. Another 10 patients were subjected to sham exposure and served as controls to allow assessment of the metabolic repercussions of ACLR and PEMF therapy. Blood samples were collected prior to surgery and at 16 weeks for plasma analyses. Magnetic resonance data were acquired at 1 and 16 weeks post-surgery using a Siemens 3T Tim Trio system. Phosphorus (³¹P) Magnetic Resonance Spectroscopy (MRS) was utilized to monitor changes in high-energy phosphate metabolism (inorganic phosphate (P_i), adenosine triphosphate (ATP) and phosphocreatine (PCr)) as well as markers of membrane synthesis and breakdown (phosphomonoesters (PME) and phosphodiester (PDE)). Quantitative Magnetization Transfer (qMT) imaging was used to elucidate changes in the underlying tissue structure, with T1-weighted and 2-point Dixon imaging used to calculate muscle volumes and muscle fat content.

Results

Improvements in markers of high-energy phosphate metabolism including reductions in ΔP_i/ATP, P_i/PCr and (P_i ​+ ​PCr)/ATP, and membrane kinetics, including reductions in PDE/ATP were detected in the PEMF-treated cohort relative to the control cohort at study termination. These were associated with reductions in the plasma levels of certain ceramides and lysophosphatidylcholine species. The plasma levels of biomarkers predictive of muscle regeneration and degeneration, including osteopontin and TNNT1, respectively, were improved, whilst changes in follistatin failed to achieve statistical significance. Liquid chromatography with tandem mass spectrometry revealed reductions in small molecule biomarkers of metabolic disruption, including cysteine, homocysteine, and methionine in the PEMF-treated cohort relative to the control cohort at study termination. Differences in measurements of force, muscle and fat volumes did not achieve statistical significance between the cohorts after 16 weeks post-ACLR.

Conclusion

The detected changes suggest improvements in systemic metabolism in the post-surgical PEMF-treated cohort that accords with previous preclinical murine studies. PEMF-based therapies may potentially serve as a manner to ameliorate post-surgery metabolic disruptions and warrant future examination in more adequately powered clinical trials.

The Translational Potential of this Article

Some degree of physical immobilisation must inevitably follow orthopaedic surgical intervention. The clinical paradox of such a scenario is that the regenerative potential of the muscle mitochondrial pool is silenced. The unmet need was hence a manner to maintain mitochondrial activation when movement is restricted and without producing potentially damaging mechanical stress. PEMF-based therapies may satisfy the requirement of non-invasively activating the requisite mitochondrial respiration when mobility is restricted for improved metabolic and regenerative recovery.

Bicuspid aortic valve is associated with less coronary artery calcium and coronary artery disease burden by computed tomography

Background

Bicuspid aortic valve (BAV) is associated with genetic defects (NOTCH 1, GATA 5 mutations) and aortopathy. Differences in flow pattern and a genetic predisposition could also affect coronary arteries.

Purpose

To assess the coronary artery calcium score (CACS) and coronary artery disease (CAD) burden by coronary computed tomography angiography (CTA) in patients with BAV stenosis, as compared to those with tricuspid aortic valve (TAV) stenosis.

Methods

47 patients with congenital BAV (68.9 years±12.9, 38.3% females) who underwent cardiovascular CTA for TAVR planning were matched with 47 TAV patients for age, gender, smoking, arterial hypertension, dyslipidemia, diabetes, body-mass-index and chronic kidney disease. The coronary artery calcium score (CACS) (Agatston Units=AU) and coronary stenosis severity by CTA (CADRAD:&lt;25% minimal,&lt;50%milde,50–70%moderate,&gt;70/%severe) were quantified.

Results

The coronary artery calcium score (CACS) was lower in BAV (237.4 vs. 1013.3AU; p&lt;0.001), and coronary stenosis severity was less (CAD-RAD:p&lt;0.001) as compared to patients with TAV.

More patients with BAV had CACS zero (27.7% vs. 0%, p&lt;0.001). The majority (68.1%) of patients with BAV had no or non-obstructive CAD but only 25.5% of tricuspid (p&lt;0.001).

Obstructive CAD (&gt;50% stenosis) by CTA was more frequently observed in TAV patients (68.1%; p&lt;0.001). There were no differences in statin use and NOAC, and other co-morbidities such as AF and COPD.

Conclusion

Patients with BAV have markedly less coronary artery calcium load and yielded less severe coronary stenosis. CTA succeeds to rule out obstructive CAD in the majority of patients with BAV, with adherent implications for TAVR planning.

Funding Acknowledgement

Type of funding sources: None. 72 YOM with BAV, zero CACS and no CADCACS was lower in BAV

The atherosclerosis profile by coronary CTA compared to the coronary artery calcium score (CACS) in a young symptomatic high-risk population between 19 and 49 years

Background

Whether the coronary artery calcium score (CACS) or coronary CTA should be used in young high-risk adults for screening of coronary artery disease (CAD), is an open debate and data sparse.

Aims

To evaluate the coronary atherosclerosis profile by coronary computed tomography angiography (CTA) in a young symptomatic high-risk population (age, 19–49 years) in comparison with the coronary artery calcium score (CACS).

Methods and results

1137 symptomatic high-risk patients between 19–49 years (mean 42.4y; 33.2%females) with suspected CAD who underwent CTA and CACS were assigned into 6 age groups (19–30; 31–35; 36–40; 41–45; 46–47; 48–49y).CTA-analysis included stenosis severity (CADRADS) and high-risk-plaque (“HRP”) criteria.

Atherosclerosis was more often detected by CTA than by CACS (45% vs. 27%; p&lt;0.001), &gt;50% stenosis in 13.6% and HRP in 17.7%. Prevalence of atherosclerosis was low and not different between CACS and CTA in the youngest (19–30y:5.2% and 6.4%; 30–35y:10.6% and 16%). Above &gt;35 years, atherosclerosis detection by CTA increased (p=0.004, OR: 2.8, 95% CI: 1.45–5.89); and was higher by CTA as compared to CACS (34.9% vs 16.7%; p&lt;0.001).

CTA outperformed CACS among all higher age groups &gt;35 years, with an increasing gap towards a superior performance of CTA along with age: Above 35 years, stenosis severity (CADRADS) (p=0.002) and &gt;50% stenosis increased from 2.6% to 12.5% (p&lt;0.001).

The rate of HRP increased linearly with age from 6.4% to 26.5%.The distribution of HRP into CACS0 and CACS&gt;0.1AU was similar among all age groups (CACS 0:45.1% had HRP), with an increasing proportion of HRP in CACS&gt;0.1AU with age. 24.9% of CACS 0 patients had CAD by CTA, 4.4% &gt;50% stenosis and 11.5% HRP.

Conclusion

Above 35 years of age, CTA outperforms CACS with an increasing power. Between 19 and 35 years, CACS 0 does not reliably rule out CAD and high-risk-plaque; hence for “noRISK100%safety”, CTA is superior.(#eachlifematters)

Funding Acknowledgement

Type of funding sources: None. 30 YOM diabetic, CACS 0 and HRP by CTAAtherosclerosis vs age: CACS vs CTA

Potential of Point-of-Care and At-Home Assessment of Immune Status via Rapid Cytokine Detection and Questionnaire-Based Anamnesis

Monitoring the immune system's status has emerged as an urgent demand in critical health conditions. The circulating cytokine levels in the blood reflect a thorough insight into the immune system status. Indeed, measuring one cytokine may deliver more information equivalent to detecting multiple diseases at a time. However, if the reported cytokine levels are interpreted with considering lifestyle and any comorbid health conditions for the individual, this will promote a more precise assessment of the immune status. Therefore, this study addresses the most recent advanced assays that deliver rapid, accurate measuring of the cytokine levels in human blood, focusing on add-on potentials for point-of-care (PoC) or personal at-home usage, and investigates existing health questionnaires as supportive assessment tools that collect all necessary information for the concrete analysis of the measured cytokine levels. We introduced a ten-dimensional featuring of cytokine measurement assays. We found 15 rapid cytokine assays with assay time less than 1 h; some could operate on unprocessed blood samples, while others are mature commercial products available in the market. In addition, we retrieved several health questionnaires that addressed various health conditions such as chronic diseases and psychological issues. Then, we present a machine learning-based solution to determine what makes the immune system fit. To this end, we discuss how to employ topic modeling for deriving the definition of immune fitness automatically from literature. Finally, we propose a prototype model to assess the fitness of the immune system through leveraging the derived definition of the immune fitness, the cytokine measurements delivered by a rapid PoC immunoassay, and the complementary information collected by the health questionnaire about other health factors. In conclusion, we discovered various advanced rapid cytokine detection technologies that are promising candidates for point-of-care or at-home usage; if paired with a health status questionnaire, the assessment of the immune system status becomes solid and we demonstrated potentials for promoting the assessment tool with data mining techniques.

Immune-checkpoint blockade of CTLA-4 (CD152) in antigen-specific human T-cell responses differs profoundly between neonates, children, and adults

The monoclonal antibody against CTLA-4, Ipilimumab, is a first-in-class immune-checkpoint inhibitor approved for treatment of advanced melanoma in adults but not extensively studied in children. In light of the fact that the immune response early in life differs from that of adults, we have applied a human in vitro model stimulating CD4⁺ T-cells from neonates, children (1–5 years), and adults antigen-specifically with Staphylococcus aureus (S. aureus) for assessment of CTLA-4 blockade early in life. We show that T-cell proliferation as well as frequencies of antigen-specific T-cells (CD40L⁺CD4⁺) were enhanced in neonatal T-cells upon CTLA-4 blockade showing a larger variance within the group (F-test p < .0001). Using machine learning algorithm Random Forest, adult and neonatal T-cell responses can be unambiguously categorized (F1 score-0.75) on the basis of their cytokine (co-)expression. Blockade of CTLA-4 enhanced frequencies of IL-8, IFNγ, and IL-10 producers among CD40L⁺ T-cells. Of note, antigen-specific T-cells from neonates displayed higher cytokine coproduction at baseline, while T-cells from children caught up to neonates, and adults to baseline of children upon CTLA-4 blockade. These findings reveal that in neonatal T-cells blockade of CTLA-4 mainly unleashes the antigen-specific capacity by increasing the numbers of responding T-cells, whereas in children and adults it promotes the coexpression of cytokines by individual T-cells. Thus, CTLA-4 blockade boosts antitumor immunity through different mechanisms depending on the patients’ age. These data implicate a strong impact of the developmental stage of the T-cell compartment on the effects of immune-checkpoint therapy.

Reciprocal communication of perivascular epicardial adipose tissue and coronary atherogenesis

Purpose

Perivascular epicardial adipose tissue (PEAT) has been linked to underlying coronary artery disease (CAD) and proposed to modulate adjacent atherosclerotic plaque formation. In vitro and ex vivo studies support bilateral influence of adipose tissue and vessel wall. Therefore, we quantified PEAT volume and composition and its dynamics in a low coronary risk patient cohort with a semi-automate software in serial CT exams.

Methods and materials

We retrospectively included 120 patients (27% females) from a tertiary care hospital who underwent serial cardiac CT angiographies with a low cardiovascular risk profile. All coronary CTs were evaluated in a standardized approach: epicardial adipose tissue (EAT) volume and attenuation was quantified in total, in the atrioventricular (RCA, LCX) or interventricular (LAD) sulcus and in a 5mm radius for each coronary artery (PEAT). Coronary plaques were quantified using a semi-automated software and compared to progression, stability of regression between the two scans. The measurements were compared on a per-patient and per-vessel basis between plaque-naïve and diseased vessels.

Results

Of 120 patients (32% female), 59.2%) had atherosclerotic plaque formation. After 36 months mean follow-up, 22 (18.3%) showed a CAD regression plaques, 39 (32.5%) had stable coronary arteries and 49 (40.8%) progressive CAD. Total EAT volume decreased by −15.6±37.2 mm3 in the regressive group, increased by 2.7±30.6mm3 in the stable group and by 24.3±37.1mm3 in the progressive CAD group (p=0.003).

Per-vessel analysis showed a significant decrease of perivascular EAT attenuation in patients with CAD regression (−3.8±7.6 HU) compared to CAD stable (1.2±9.1 HU) and CAD progressive patients (3.5±8.2 HU, p&lt;0.0001). Mean sulcus EAT attenuation did not show a significant change at follow-up (p=0.135)

Conclusion

Epicardial adipose tissue volume is mutually changing with the progression or regression of coronary artery disease. Perivascular but not epicardial attenuation levels correlated to adjacent plaque and support a direct bilateral influence.

Change per-vessel-basis (n=360)

Funding Acknowledgement

Type of funding source: None

Modulatory effect of 17β-estradiol on myeloid cell infiltration into the male rat brain after ischemic stroke

Ischemic stroke is the leading cause of human disability and mortality in the world. Neuroinflammation is the main pathological event following ischemia which contributes to secondary brain tissue damage and is driven by infiltration of circulating immune cells such as macrophages. Because of neuroprotective properties against ischemic brain damage, estrogens have the potential to become of therapeutic interest. However, the exact mechanisms of neuroprotection and signaling pathways is not completely understood. In the current study, 12-week-old male Wistar rats underwent an experimental ischemia by occluding the middle cerebral artery transiently (tMCAO) for 1 h. Male rats subjected to tMCAO were randomly assigned to receive 17β-estradiol or vehicle treatment. The animals were sacrificed 72 h post tMCAO, transcardially perfused and the brains were proceeded either for TTC staining and gene analysis or for flow cytometry (CD45, CD11b, CD11c, CD40). We found that 17β-estradiol substitution significantly reduced the cortical infarct which was paralleled by an improved Garcia test scoring. Flow cytometry revealed that CD45+ cells as well as CD45+CD11b+CD11c+ cells were massively increased in tMCAO animals and numbers were nearly restored to sham levels after 17β-estradiol treatment. Gene expression analysis showed a reperfusion time-dependent upregulation of the markers CD45, CD11b and the activation marker CD40. The reduction in gene expression after 72 h of reperfusion and simultaneous 17β-estradiol substitution did not reach statistical significance. These data indicate that 17β-estradiol alleviated the cerebral ischemia-reperfusion injury and selectively suppressed the activation of the neuroinflammatory cascade via reduction of the number of activated microglia or infiltrated monocyte-derived macrophages in brain.

Translational engagement of lysophosphatidic acid receptor 1 in skin fibrosis: from dermal fibroblasts of patients with scleroderma to tight skin 1 mouse

Background and Purpose

Genetic deletion and pharmacological studies suggest a role for lysophosphatidic acid (LPA₁) receptor in fibrosis. We investigated the therapeutic potential in systemic sclerosis (SSc) of a new orally active selective LPA₁ receptor antagonist using dermal fibroblasts from patients and an animal model of skin fibrosis.

Experimental Approach

Dermal fibroblast and skin biopsies from systemic sclerosis patients were used. Myofibroblast differentiation, gene expression and cytokine secretion were measured following LPA and/or SAR100842 treatment. Pharmacolgical effect of SAR100842 was assessed in the tight skin 1 (Tsk1) mouse model.

Key Results

SAR100842 is equipotent against various LPA isoforms. Dermal fibroblasts and skin biopsies from patients with systemic sclerosis expressed high levels of LPA₁ receptor. The LPA functional response (Ca²⁺) in systemic sclerosis dermal fibroblasts was fully antagonized with SAR100842. LPA induced myofibroblast differentiation in systemic sclerosis dermal and idiopathic pulmonary fibrosis lung fibroblasts and the secretion of inflammatory markers and activated Wnt markers. Results from systemic sclerosis dermal fibroblasts mirror those obtained in a mouse Tsk1 model of skin fibrosis. Using a therapeutic protocol, SAR100842 consistently reversed dermal thickening, inhibited myofibroblast differentiation and reduced skin collagen content. Inflammatory and Wnt pathway markers were also inhibited by SAR100842 in the skin of Tsk1 mice.

Conclusion and Implications

The effects of SAR100842 on LPA‐induced inflammation and on mechanisms linked to fibrosis like myofibroblast differentiation and Wnt pathway activation indicate that LPA₁ receptor activation plays a key role in skin fibrosis. Our results support the therapeutic potential of LPA₁ receptor antagonists in systemic sclerosis.

SUN-294 The Effects of Traumatic Brain Injury on Pituitary Function: A Systematic Review and Meta-Analysis

Background: The impact of traumatic brain injury (TBI) on pituitary function remains unclear. Yet, applying appropriate diagnostic and treatment strategies for affected patients is crucial for mitigating morbidity related to hypopituitarism and improving patient outcomes. Currently, data regarding the prevalence of post-TBI hypopituitarism and its predisposing factors are inconsistent. The goals of this systematic review and meta-analysis were to evaluate the prevalence of acute and chronic post-TBI hypopituitarism and assess for predictors of pituitary dysfunction.

Methods: Ovid MEDLINE In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, Scopus, Web of Science, and references of key articles were searched from inception to 2019. Studies enrolling ≥20 adult patients with TBI and reporting on pituitary dysfunction were included. A total of 992 studies were generated by the initial search. Titles and abstracts were screened in duplicate by two independent reviewers for inclusion criteria. Of these, 265 full text manuscripts were subsequently reviewed for eligibility. Predefined data were extracted from 14 representative studies for the preliminary analysis (7 cross-sectional studies, 6 prospective studies, and 1 retrospective study).

Results: There was a total of 813 (78% male) patients with TBI. Of those with available data, 124/248 (50.0%) had mild TBI, 112/476 (23.5%) had moderate TBI, and 308/569 (54.1%) had severe TBI. Mean age at TBI diagnosis was 34.2±4.6 years, with time to evaluation of pituitary function following TBI ranging from 0 days to 120 months (mean, 27.1±35.1 months). Acute and chronic hypopituitarism was reported in 10.7% and 19.6% of patients, respectively. TBI was associated with increased risk for hypopituitarism compared to the general population (RR=765.8, 95% CI 538.8-1088.5). Secondary hypogonadism was noted in 15.7% of patients, growth hormone deficiency in 15.7%, secondary adrenal insufficiency in 11.6%, secondary hypothyroidism in 8.7%, and diabetes insipidus in 0.2%. Older age (40.4±5.5 vs 36.7±1.0 years, P<0.0001) and higher BMI (25.0±0.7 vs 23.9±0.2 kg/m², P<0.0001) were associated with increased risk of post-TBI hypopituitarism.

Conclusion: Available moderate- to low-quality evidence suggests that post-TBI hypopituitarism is common and correlates with older age and higher BMI. Secondary hypogonadism and growth hormone deficiency are the most predominant pituitary deficiencies. Further investigations are warranted to determine the most effective strategies for identifying patients at risk for post-TBI hypopituitarism in order to implement prompt assessment and management.

P6153High risk plaque by coronary CTA predict cardiac events but not all-cause mortality: long term follow up

Background

Ultra long-term (10 years) outcome data of coronary computed tomography angiography (CTA) for coronary heart disease (CHD) screening are lacking. Novel CTA imaging biomarkers (“high-risk-plaque”) may improve risk stratification.

Aims

To define CT-imaging predictors for long–term outcomes.

Methods

1430 low-to-intermediate-risk patients (mean age 57.9 years; 44.4% females) were included into our prospective cohort study. Coronary Calcium Score (CCS) and CTA were performed. CTA was evaluated for: Stenosis severity (minimal<25%; mild<50%; moderate 50–70%; severe >70%) (CADRADS 1–4), total mixed plaque burden (G-score), high–risk-plaque criteria: 1) low attenuation plaque 2) Napkin-ring (“lunar-eclipse” sign) 3) spotty calcification 4) remodeling index

Primary endpoint was all-cause mortality, secondary endpoints cardiovascular mortality and composite (non-fatal and fatal) MACE.

Results

Over a follow-up of mean 10.55 years ±1.98 (range, 6.1–12.8), all-cause mortality rate was 106 (7.4%), cardiovascular mortality 25 (1.75%) and composite MACE 57 (4%).

In patients with negative CTA, cardiovascular mortality was 0% and composite MACE rate 0.2%.

Stenosis severity (CADRADS) was the strongest predictor for all 3 endpoints (p<0.001) on multivariate analysis (unadjusted and adjusted for risk factors, p<0.001) but calcium score >100 AU only predicted mortality on the unadjusted multivariate analysis (p=0.045) but not on the adjusted.

On multivariate analysis, G-score (p<0.0001), LAP<60HU and the Napkin-Ring predicted composite MACE (p<0.001) but not all-cause mortality, before and after adjusting for risk factors (p=0.007 and 0.001 for LAP<60HU and Napkin-Ring, respectively) while spotty calcification and remodeling index did not. 465 had calcium score zero and in 156 (33.5%) of those, noncalcified fibroatheroma were found (total rate, 11%), 4.9% had >50% stenosis. However only 1 patient with calcium score zero died while there were 6 MACE.

High risk plaque with “lunar eclipse”

Conclusions

Long-term prognosis is excellent if CTA is negative. Stenosis severity by CTA predicts all-cause and cardiovascular mortality, while calcium score predicts only mortality. Plaque burden and the high-risk plaque criteria LAP<60 and Napkin-Ring (syn. “lunar eclipse”) are strong predictors of MACE, but not all–cause mortality. Coronary CTA outperforms calcium scoring for risk stratification.

P6163Promotion of coronary plaque progression associated with different anticoagulation agents - a longitudinal CTA analysis

Objective

Possible antithrombotic effect of anticoagulants in coronary artery disease have been proposed but mechanism are poorly understood. Experimental and clinical data indicate a key role of coagulation factors in the progression of atherosclerosis. We sought to evaluate the effect of different oral anticoagulation agents on the progression of atherosclerosis.

Methods

This retrospective matched case controlled study included patients with atrial fibrillation (AF) who underwent repeated CT angiography for ablation planning. Patients with known structural cardiac pathologies or significant comorbidities were excluded.

Patients were stratified according to their anticoagulation into 3 groups: vitamin K antagonist (VKA), direct oral anticoagulation (DOAC) and control (CR; aspirin or no therapy) with equal distribution of age and cardiovascular risk factors. Baseline and follow-up CT exams for repeated AF ablations were evaluated for the CAD profile and (semi)automated quantitative plaque analysis.

Results

One-hundred sixty-one patients were included (mean CT time interval: 31 months). The three cohorts did not differ in patient characteristics or CT findings at baseline. Absolute plaque volume progression was significantly higher in patients using VKA (66.5±136.7 mm3) compared to both CR (27.2±73.6 mm3) and DOAC (−7.1±42.1 mm3, p<0.001), translating into an annual change of 23.2±47.0 mm3 for VKA, 12.3±4.3 mm3 for CR and −4.6±22.9 mm3 for DOAC (p=0.003). The number of affected segments (SIS) increased by 1.2±1.3 compared to 0.6±1.3 in the control group and 0.2±0.7 in the DOAC group (p<0.0001).

Baseline CTA findings Control (n=61) DOAC (n=50) VKA (n=50) p Vessel Volume (mm3) 26.9±42.9 23.1±43.3 27.9±40.7 0.85 Lumen Volume (mm3) 15.7±24.8 13.3±25.1 16.6±27.0 0.82 Coronary Calcium Score (AU) 63.4±187.2 42.0±114.6 53.8±118.6 0.75 Segment Involvement Score 1.8±2.1 1.8±2.3 1.9±2.2 0.96 Stenosis Average Area (%) 19.0±21.7 0.5±0.7 0.5±0.7 0.71 Maximal Plaque Thickness (mm3) 0.5±0.7 0.5±0.7 0.5±0.7 0.69 Total Plaque Volume (mm3) 33.6±60.0 30.0±55.6 34.2±48.0 0.92 AU, Agatston units; DOAC, direct oral anticoagulation; SIS, segment involvement score; VKA, vitamin K antagonist.

Changes between baseline and follow-up

Conclusion

In serial coronary CTs, patients using vitamin K antagonists showed the highest plaque volume progression while patients using a direct oral anticoagulant showed a regression of total plaque volume. Therefore, direct anticoagulation may have a beneficial effect on atherosclerosis.

P6156Coronary atherosclerosis characteristics in long-term antiretroviral therapy and HIV infection: insights from coronary CTA

Purpose

To assess coronary artery disease (CAD) characteristics by coronary CT-angiography (CTA) in individuals with HIV-infection on long-term ART in a retrospective matched case-controlled cohort study.

Methods

69 HIV positive patients who underwent 128-slice dual source coronary CTA (mean age 54.9 years, 26.1% females) with mean 17.8±9.4 years of HIV-infection and a mean duration on ART of 13±7.3 years were propensity score matched with 69 HIV negative controls.

CTA was evaluated for: Stenosis severity (CAD-RADS), total plaque burden, mixed-non-calcified plaque burden (G-score), high-risk-plaque (HRP) features (Napkin-Ring-Sign, low-attenuation-plaque, spotty calcification, positive remodeling), perivascular fat attenuation index (FAI) and ectatic coronary segments.

Results

CAD-RADS was higher in HIV-positive participants as compared to controls (2.21±1.4 vs 1.69±1.5, p=0.031). A higher prevalence of CAD and G-score (p=0.043 and p=0.003) were found.

HRP prevalence (23 (34.3%) vs 8 (12.1%); p=0.002) and the number of HRP (36 vs 10, p<0.001) were higher in HIV-positive individuals. A positive perivascular FAI >-70 HU was present in 27.8% of HRP. Ectatic coronary arteries were found in 10 (14.5%) individuals with HIV-infection vs 0% in controls (p=0.003).

Conclusion(s)

HIV positive individuals on long-term ART display higher CAD burden and more HRP indicating vulnerable, potentially inflamed plaques.

CT- Angiography results HIV+ (N=67) HIV− (N=67) P-value CAD prevalence (any plaque), n (%) 56 (83.6) 46 (68.7) 0.043 SSS, mean ±SD 1.16±1.6 0.95±2.1 0.038 CAD RADS   0 11 22   1 11 7   2 10 21 <0.001   3 23 4   4 12 13   Total >50%, n (%) 35 (52.2) 17 (25.4) 0.001 CAD RADS, mean ±SD 2.21±1.4 1.69±1.5 0.031 SIS, mean ±SD 3.93±3.0 3.06±3.1 0.067 G-score, mean ±SD 10.04±8.5 5.76±5.9 0.003 Calcium score, mean ±SD 149.4±287.1 133.2±329.3 0.015 HRP, n (%) 23 (34.3) 8 (12.1) 0.002 HRP, n 36 10 <0.001 Non-calcifying plaque component, n (%) 44 (65.7) 34 (51.5) 0.097 Ectatic coronary segments, n (%) 10 (14.5) 0 (0) 0.003 CAD RADS: coronary artery disease reporting and data system; CCS: coronary calcium score; HRP: high-risk plaque; SIS: segment involvement score; SSS: stenosis severity score.

60 yo HIV-infected (31 yrs) male patient

These features strongly support the predominant inflammatory theory of cardiovascular events in HIV-infected individuals.

Acknowledgement/Funding

None

Ambient and supplemental magnetic fields promote myogenesis via a TRPC1-mitochondrial axis: evidence of a magnetic mitohormetic mechanism

We show that both supplemental and ambient magnetic fields modulate myogenesis. A lone 10 min exposure of myoblasts to 1.5 mT amplitude supplemental pulsed magnetic fields (PEMFs) accentuated in vitro myogenesis by stimulating transient receptor potential (TRP)-C1-mediated calcium entry and downstream nuclear factor of activated T cells (NFAT)-transcriptional and P300/CBP-associated factor (PCAF)-epigenetic cascades, whereas depriving myoblasts of ambient magnetic fields slowed myogenesis, reduced TRPC1 expression, and silenced NFAT-transcriptional and PCAF-epigenetic cascades. The expression levels of peroxisome proliferator-activated receptor γ coactivator 1α, the master regulator of mitochondriogenesis, was also enhanced by brief PEMF exposure. Accordingly, mitochondriogenesis and respiratory capacity were both enhanced with PEMF exposure, paralleling TRPC1 expression and pharmacological sensitivity. Clustered regularly interspaced short palindromic repeats-Cas9 knockdown of TRPC1 precluded proliferative and mitochondrial responses to supplemental PEMFs, whereas small interfering RNA gene silencing of TRPM7 did not, coinciding with data that magnetoreception did not coincide with the expression or function of other TRP channels. The aminoglycoside antibiotics antagonized and down-regulated TRPC1 expression and, when applied concomitantly with PEMF exposure, attenuated PEMF-stimulated calcium entry, mitochondrial respiration, proliferation, differentiation, and epigenetic directive in myoblasts, elucidating why the developmental potential of magnetic fields may have previously escaped detection. Mitochondrial-based survival adaptations were also activated upon PEMF stimulation. Magnetism thus deploys an authentic myogenic directive that relies on an interplay between mitochondria and TRPC1 to reach fruition.-Yap, J. L. Y., Tai, Y. K., Fröhlich, J., Fong, C. H. H., Yin, J. N., Foo, Z. L., Ramanan, S., Beyer, C., Toh, S. J., Casarosa, M., Bharathy, N., Kala, M. P., Egli, M., Taneja, R., Lee, C. N., Franco-Obregón, A. Ambient and supplemental magnetic fields promote myogenesis via a TRPC1-mitochondrial axis: evidence of a magnetic mitohormetic mechanism.

PU.1 controls fibroblast polarization and tissue fibrosis

Fibroblasts are polymorphic cells with pleiotropic roles in organ morphogenesis, tissue homeostasis and immune responses. In fibrotic diseases, fibroblasts synthesize abundant amounts of extracellular matrix which lead to scaring and organ failure. In contrast, the hallmark feature of fibroblasts in arthritis is matrix degradation by the release of metalloproteinases and degrading enzymes, and subsequent tissue destruction. The mechanisms driving these functionally opposing pro-fibrotic and pro-inflammatory phenotypes of fibroblasts are enigmatic. We identified the transcription factor PU.1 as an essential orchestrator of the pro-fibrotic gene expression program. The interplay between transcriptional and post-transcriptional mechanisms which normally control PU.1 expression is perturbed in various fibrotic diseases, resulting in upregulation of PU.1, induction of fibrosis-associated gene sets, and a phenotypic switch in matrix-producing pro-fibrotic fibroblasts. In contrast, pharmacological and genetic inactivation of PU.1 disrupts the fibrotic network and enables re-programming of fibrotic fibroblasts into resting fibroblasts with regression of fibrosis in different organs.

How to Analyze (Intentional) Consciousness in Terms of Meta-Belief and Temporal Awareness

The paper presents and defends a metadoxastic view on (intentional) consciousness that is novel in four respects: (1) It is motivated both by Husserl’s dynamic approach, which looks upon mental acts as momentary components of certain cognitive structures – “dynamic intentional structures” – in which one and the same object is intended throughout a period of time (during which the subject’s cognitive perspective upon that object is constantly changing) and by his conception of consciousness in terms of internal time-consciousness (temporal awareness). (2) It combines a dispositionalist higher-order judgment theory about the structure of (intentional) consciousness with the claim that the contents of these judgments are such that they can be expressed by essentially indexical sentences containing the temporal indexical “now,” thus accommodating the basic role of internal time-consciousness. (3) It is immune against the “objection from lack of mental concepts” raised, e.g., by Dretske against any higher-order representation theory, as it employs counterfactuals in the framework of a disjunctive account of (intentional) consciousness. (4) It explains the unity of consciousness at a time as well as across time.

The tyrosine phosphatase SHP2 controls TGFβ-induced STAT3 signaling to regulate fibroblast activation and fibrosis

Uncontrolled activation of TGFβ signaling is a common denominator of fibrotic tissue remodeling. Here we characterize the tyrosine phosphatase SHP2 as a molecular checkpoint for TGFβ-induced JAK2/STAT3 signaling and as a potential target for the treatment of fibrosis. TGFβ stimulates the phosphatase activity of SHP2, although this effect is in part counterbalanced by inhibitory effects on SHP2 expression. Stimulation with TGFβ promotes recruitment of SHP2 to JAK2 in fibroblasts with subsequent dephosphorylation of JAK2 at Y570 and activation of STAT3. The effects of SHP2 on STAT3 activation translate into major regulatory effects of SHP2 on fibroblast activation and tissue fibrosis. Genetic or pharmacologic inactivation of SHP2 promotes accumulation of JAK2 phosphorylated at Y570, reduces JAK2/STAT3 signaling, inhibits TGFβ-induced fibroblast activation and ameliorates dermal and pulmonary fibrosis. Given the availability of potent SHP2 inhibitors, SHP2 might thus be a potential target for the treatment of fibrosis.

Expression profile of pattern recognition receptors in skeletal muscle of SOD1(G93A) amyotrophic lateral sclerosis (ALS) mice and sporadic ALS patients

AIMS

Amyotrophic lateral sclerosis (ALS) is characterized by degeneration of motoneurons and progressive muscle wasting. Inflammatory processes, mediated by non-neuronal cells, such as glial cells, are known to contribute to disease progression. Inflammasomes consist of pattern recognition receptors (PRRs), apoptosis-associated speck-like protein (ASC) and caspase 1 and are essential for interleukin (IL) processing and a rapid immune response after tissue damage. Recently, we described inflammasome activation in the spinal cord of ALS patients and in SOD1^(G93A) ALS mice. Since pathological changes in the skeletal muscle are early events in ALS, we hypothesized that PRRs might be abnormally expressed in muscle fibre degeneration.

METHODS

Western blot analysis, real-time PCR and immunohistochemistry were performed with muscle tissue from presymptomatic and early-symptomatic male SOD1^(G93A) mice and with muscle biopsies of control and sporadic ALS (sALS) patients. Analysed PRRs include nucleotide-binding oligomerization domain-like (NOD-like) receptor protein 1 (NLRP1), NLR protein 3 (NLRP3), NLR family CARD domain-containing 4 (NLRC4) and absent in melanoma 2. Additionally, expression levels of ASC, caspase 1, interleukin 1 beta (IL1β) and interleukin 18 (IL18) were evaluated.

RESULTS

Expression of PRRs and ASC was detected in murine and human tissue. The PRR NLRC4, caspase 1 and IL1β were significantly elevated in denervated muscle of SOD1^(G93A) mice and sALS patients. Furthermore, levels of caspase 1 and IL1β were already increased in presymptomatic animals.

CONCLUSION

Our findings suggest that increased inflammasome activation may be involved in skeletal muscle pathology in ALS. Furthermore, elevated levels of NLRC4, caspase 1 and IL1β reflect early changes in the skeletal muscle and may contribute to the denervation process.

Participants' perspectives of weekly telephonic mood monitoring in South Africa: a feasibility study

BACKGROUND

Mood and anxiety disorders have a high lifetime prevalence, and their chronicity adds to the management burden of already scarce and strained mental health care resources, particularly in developing countries. Non-professional-assisted interventions and technology (such as weekly telephonic mood monitoring) could assist in the early identification of symptoms of relapse and hospitalization prevention. The present study aimed to determine participants' perspectives and the feasibility of weekly telephonic mood monitoring in order to inform the development of the full study.

METHOD

Semi-structured telephonic interviews (n = 37; 89.2% female; mean age = 33.1 years) were conducted as part of the full-scale feasibility study (N = 61; named the Bipolar Disorder Mood Monitoring (BDMM) Study). The BDMM Study was conducted to determine the viability of weekly telephonic mood monitoring, spanning 26 weeks and starting 1 week post-discharge. Frequency and descriptive statistical analyses (using SPSS version 24) were undertaken, and qualitative data were analyzed using thematic content analysis.

RESULTS

This article presents the findings from the semi-structured interview section of the BDMM Study. Participants generally expressed positive experiences and perceptions of weekly telephonic mood monitoring, stating that they would advise others to also take part in weekly telephonic mood monitoring. Nonetheless, some participants did make suggestions for improvement of mood monitoring while others expressed negative experiences of weekly telephonic mood monitoring.

CONCLUSION

The results of the semi-structured interviews of the BDMM Study indicated that participants perceived weekly telephonic mood monitoring to be helpful in lightening the burden of mood and anxiety disorders (e.g., having someone to talk to, providing insight into their disorders). Not only did it help them, but they also perceived mood monitoring to be potentially helpful to future participants. However, weekly mood monitoring was also burdensome in itself (including being too time consuming and having to answer questions when feeling down). Importantly, the findings highlighted that participants' and researchers' perceptions and experiences may not be congruent (especially in terms of therapeutic misconception). The current findings may inform researchers' future approach to study design and participant relationships.

Brain inflammasomes in stroke and depressive disorders: Regulation by oestrogen

Neuroinflammation is a devastating pathophysiological process that results in brain damage and neuronal death. Pathogens, cell fragments and cellular dysfunction trigger inflammatory responses. Irrespective of the cause, inflammasomes are key intracellular multiprotein signalling platforms that sense neuropathological conditions. The activation of inflammasomes leads to the auto-proteolytic cleavage of caspase-1, resulting in the proteolysis of the pro-inflammatory cytokines interleukin (IL)1β and IL18 into their bioactive forms. It also initiates pyroptosis, a type of cell death. The two cytokines contribute to the pathogenesis in acute and chronic brain diseases and also play a central role in human aging and psychiatric disorders. Sex steroids, in particular oestrogens, are well-described neuroprotective agents in the central nervous system. Oestrogens improve the functional outcome after ischaemia and traumatic brain injury, reduce neuronal death in Parkinson's and Alzheimer's disease, as well as in amyotrophic lateral sclerosis, attenuate glutamate excitotoxicity and the formation of radical oxygen species, and lessen the spread of oedema after damage. Moreover, oestrogens alleviate menopause-related depressive symptoms and have a positive influence on depressive disorders probably by influencing growth factor production and serotonergic brain circuits. Recent evidence also suggests that inflammasome signalling affects anxiety- and depressive-like behaviour and that oestrogen ameliorates depression-like behaviour through the suppression of inflammasomes. In the present review, we highlight the most recent findings demonstrating that oestrogens selectively suppress the activation of the neuroinflammatory cascade in the brain in acute and chronic brain disease models. Furthermore, we aim to describe putative regulatory signalling pathways involved in the control of inflammasomes. Finally, we consider that psychiatric disorders such as depression also contain an inflammatory component that could be modulated by oestrogen.

Protein kinases G are essential downstream mediators of the antifibrotic effects of sGC stimulators

OBJECTIVES

Stimulators of soluble guanylate cyclase (sGC) are currently investigated in clinical trials for the treatment of fibrosis in systemic sclerosis (SSc). In this study, we aim to investigate the role of protein kinases G (PKG) as downstream mediators of sGC-cyclic guanosine monophosphate (cGMP) in SSc.

METHODS

Mice with combined knockout of PKG1 and 2 were challenged with bleomycin and treated with the sGC stimulator BAY 41-2272. Fibroblasts were treated with BAY 41-2272 and with the PKG inhibitor KT 5823.

RESULTS

PKG1 and 2 are upregulated in SSc in a transforming growth factor-β1 (TGFβ1)-dependent manner, as an attempt to compensate for the decreased signalling through the sGC-cGMP-PKG pathway. Inhibition or knockout of PKG1 and 2 abrogates the inhibitory effects of sGC stimulation on fibroblast activation in a SMAD-independent, but extracellular signal-regulated kinase (ERK)-dependent manner. In vivo, sGC stimulation fails to prevent bleomycin-induced fibrosis in PKG1 and 2 knockout mice.

CONCLUSIONS

Our data provide evidence that PKGs are essential mediators of the antifibrotic effects of sGC stimulators through interfering with non-canonical TGFβ signalling. TGFβ1 promotes its profibrotic effects through inhibition of sGC-cGMP-PKG signalling, sGC stimulation exerts its antifibrotic effects by inhibition of TGFβ1-induced ERK phosphorylation.

Enhancement of mesenchymal stem cell chondrogenesis with short-term low intensity pulsed electromagnetic fields

Pulse electromagnetic fields (PEMFs) have been shown to recruit calcium-signaling cascades common to chondrogenesis. Here we document the effects of specified PEMF parameters over mesenchymal stem cells (MSC) chondrogenic differentiation. MSCs undergoing chondrogenesis are preferentially responsive to an electromagnetic efficacy window defined by field amplitude, duration and frequency of exposure. Contrary to conventional practice of administering prolonged and repetitive exposures to PEMFs, optimal chondrogenic outcome is achieved in response to brief (10 minutes), low intensity (2 mT) exposure to 6 ms bursts of magnetic pulses, at 15 Hz, administered only once at the onset of chondrogenic induction. By contrast, repeated exposures diminished chondrogenic outcome and could be attributed to calcium entry after the initial induction. Transient receptor potential (TRP) channels appear to mediate these aspects of PEMF stimulation, serving as a conduit for extracellular calcium. Preventing calcium entry during the repeated PEMF exposure with the co-administration of EGTA or TRP channel antagonists precluded the inhibition of differentiation. This study highlights the intricacies of calcium homeostasis during early chondrogenesis and the constraints that are placed on PEMF-based therapeutic strategies aimed at promoting MSC chondrogenesis. The demonstrated efficacy of our optimized PEMF regimens has clear clinical implications for future regenerative strategies for cartilage.

Nintedanib inhibits macrophage activation and ameliorates vascular and fibrotic manifestations in the Fra2 mouse model of systemic sclerosis

Background

Nintedanib is an inhibitor targeting platelet-derived growth factor receptor, fibroblast growth factor receptor and vascular endothelial growth factor receptor tyrosine kinases that has recently been approved for the treatment of idiopathic pulmonary fibrosis. The aim of this study was to analyse the effects of nintedanib in the fos-related antigen-2 (Fra2) mouse model of systemic sclerosis (SSc).

Methods

The effects of nintedanib on pulmonary arterial hypertension with proliferation of pulmonary vascular smooth muscle cells (PVSMCs) and luminal occlusion, on microvascular disease with apoptosis of microvascular endothelial cells (MVECs) and on fibroblast activation with myofibroblast differentiation and accumulation of extracellular matrix were analysed. We also studied the effects of nintedanib on the levels of key mediators involved in the pathogenesis of SSc and on macrophage polarisation.

Results

Nintedanib inhibited proliferation of PVSMCs and prevented thickening of the vessel walls and luminal occlusion of pulmonary arteries. Treatment with nintedanib also inhibited apoptosis of MVECs and blunted the capillary rarefaction in Fra2-transgenic mice. These effects were associated with a normalisation of the serum levels of vascular endothelial growth factor in Fra2 mice on treatment with nintedanib. Nintedanib also effectively blocked myofibroblast differentiation and reduced pulmonary, dermal and myocardial fibrosis in Fra2-transgenic mice. The antifibrotic effects of nintedanib were associated with impaired M2 polarisation of monocytes and reduced numbers of M2 macrophages.

Conclusion

Nintedanib targets core features of SSc in Fra2-transgenic mice and ameliorates histological features of pulmonary arterial hypertension, destructive microangiopathy and pulmonary and dermal fibrosis. These data might have direct implications for the ongoing phase III clinical trial with nintedanib in SSc-associated interstitial lung disease.

Na+ deposition in the fibrotic skin of systemic sclerosis patients detected by 23Na-magnetic resonance imaging

Objective

Skin fibrosis is the predominant feature of SSc and arises from excessive extracellular matrix deposition. Glycosaminoglycans are macromolecules of the extracellular matrix, which facilitate Na + accumulation in the skin. We used 23 Na-MRI to quantify Na + in skin. We hypothesized that skin Na + might accumulate in SSc and might be a biomarker for skin fibrosis.

Methods

In this observational case-control study, skin Na + was determined by 23 Na-MRI using a Na + volume coil in 12 patients with diffuse cutaneous SSc and in 21 control subjects. We assessed skin fibrosis by the modified Rodnan skin score prior to 23 Na-MRI and on follow-up 12 months later.

Results

23 Na-MRI demonstrated increased Na + in the fibrotic skin of SSc patients compared with skin from controls [mean ( s . d .): 27.2 (5.6) vs 21.4 (5.3) mmol/l, P < 0.01]. Na + content was higher in fibrotic than in non-fibrotic SSc skin [26.2 (4.8) vs 19.2 (3.4) mmol/l, P < 0.01]. Furthermore, skin Na + amount was correlated with changes in follow-up modified Rodnan skin score (R 2 = 0.68).

Conclusions

23 Na-MRI detected increased Na + in the fibrotic SSc skin; high Na + content was associated with progressive skin disease. Our findings provide the first evidence that 23 Na-MRI might be a promising tool to assess skin Na + and thereby predict progression of skin fibrosis in SSc.

A Dual Role of Upper Zone of Growth Plate and Cartilage Matrix-Associated Protein in Human and Mouse Osteoarthritic Cartilage: Inhibition of Aggrecanases and Promotion of Bone Turnover

OBJECTIVE

Cartilage damage and subchondral bone changes are closely connected in osteoarthritis. Nevertheless, how these processes are interlinked is, to date, incompletely understood. This study was undertaken to investigate the mechanistic role of a cartilage-derived protein, upper zone of growth plate and cartilage matrix-associated protein (UCMA), in osteoarthritis-related cartilage and bone changes.

METHODS

UCMA expression was assessed in healthy and osteoarthritic human and mouse cartilage. For analysis of cartilage and bone changes, osteoarthritis was induced by destabilization of the medial meniscus (DMM) in wild-type (WT) and Ucma-deficient mice. UCMA-collagen interactions, the effect of UCMA on aggrecanase activity, and the impact of recombinant UCMA on osteoclast differentiation were studied in vitro.

RESULTS

UCMA was found to be overexpressed in human and mouse osteoarthritic cartilage. DMM-triggered cartilage changes, including increased structural damage, proteoglycan loss, and chondrocyte cell death, were aggravated in Ucma-deficient mice compared to WT littermates, thereby demonstrating the potential chondroprotective effects of UCMA. Moreover, UCMA inhibited ADAMTS-dependent aggrecanase activity and directly interacted with cartilage-specific collagen types. In contrast, osteoarthritis-related bone changes were significantly reduced in Ucma-deficient mice, showing less pronounced osteophyte formation and subchondral bone sclerosis. Mechanistically, UCMA directly promoted osteoclast differentiation in vitro.

CONCLUSION

UCMA appears to link cartilage with bone changes in osteoarthritis by supporting cartilage integrity as an endogenous inhibitor of aggrecanases while also promoting osteoclastogenesis and subchondral bone turnover. Thus, UCMA represents an important link between cartilage and bone in osteoarthritis.

Inhibition of phosphodiesterase 4 (PDE4) reduces dermal fibrosis by interfering with the release of interleukin-6 from M2 macrophages

OBJECTIVES

To investigate the disease-modifying effects of phosphodiesterase 4 (PDE4) inhibition in preclinical models of systemic sclerosis (SSc).

METHODS

We studied the effects of PDE4 inhibition in a prevention and a treatment model of bleomycin-induced skin fibrosis, in the topoisomerase mouse model as well as in a model of sclerodermatous chronic graft-versus-host disease. To better understand the mode of action of PDE4 blockade in preclinical models of SSc, we investigated fibrosis-relevant mediators in fibroblasts and macrophages from healthy individuals and patients suffering from diffuse-cutaneous SSc on blockade of PDE4.

RESULTS

Specific inhibition of PDE4 by rolipram and apremilast had potent antifibrotic effects in bleomycin-induced skin fibrosis models, in the topoisomerase I mouse model and in murine sclerodermatous chronic graft-versus-host disease. Fibroblasts were not the direct targets of the antifibrotic effects of PDE4 blockade. Reduced leucocyte infiltration in lesional skin on PDE4 blockade suggested an immune-mediated mechanism. Further analysis revealed that PDE4 inhibition decreased the differentiation of M2 macrophages and the release of several profibrotic cytokines, resulting in reduced fibroblast activation and collagen release. Within these profibrotic mediators, interleukin-6 appeared to play a central role.

CONCLUSIONS

PDE4 inhibition reduces inflammatory cell activity and the release of profibrotic cytokines from M2 macrophages, leading to decreased fibroblast activation and collagen release. Importantly, apremilast is already approved for the treatment of psoriasis and psoriatic arthritis. Therefore, PDE4 inhibitors might be further developed as potential antifibrotic therapies for patients with SSc. Our findings suggest that particularly patients with inflammation-driven fibrosis might benefit from PDE4 blockade.

ALS-Associated Endoplasmic Reticulum Proteins in Denervated Skeletal Muscle: Implications for Motor Neuron Disease Pathology

Alpha-motoneurons and muscle fibres are structurally and functionally interdependent. Both cell types particularly rely on endoplasmic reticulum (ER/SR) functions. Mutations of the ER proteins VAPB, SigR1 and HSP27 lead to hereditary motor neuron diseases (MNDs). Here, we determined the expression profile and localization of these ER proteins/chaperons by immunohistochemistry and immunoblotting in biopsy and autopsy muscle tissue of patients with amyotrophic lateral sclerosis (ALS) and other neurogenic muscular atrophies (NMAs) and compared these patterns to mouse models of neurogenic muscular atrophy. Postsynaptic neuromuscular junction staining for VAPB was intense in normal human and mouse muscle and decreased in denervated Nmd^2J mouse muscle fibres. In contrast, VAPB levels together with other chaperones and autophagy markers were increased in extrasynaptic regions of denervated muscle fibres of patients with MNDs and other NMAs, especially at sites of focal myofibrillar disintegration (targets). These findings did not differ between NMAs due to ALS and other causes. G93A-SOD1 mouse muscle fibres showed a similar pattern of protein level increases in denervated muscle fibres. In addition, they showed globular VAPB-immunoreactive structures together with misfolded SOD1 protein accumulations, suggesting a primary myopathic change. Our findings indicate that altered expression and localization of these ER proteins and autophagy markers are part of the dynamic response of muscle fibres to denervation. The ER is particularly prominent and vulnerable in both muscle fibres and alpha-motoneurons. Thus, ER pathology could contribute to the selective build-up of degenerative changes in the neuromuscular axis in MNDs.