Clinical and computed tomography findings in cats with nasopharyngeal stenosis

OBJECTIVES

Concurrent anomalies are often found in nasopharyngeal stenosis and choanal atresia; some seem to be of primary nature, whereas others may be coincidental. This study aimed to report the computed tomography features and related comorbidities of these diseases.

MATERIALS AND METHODS

A cross-sectional retrospective study was performed using case and control groups defined according to the presence of signs of upper airway disease and the presence/absence of nasopharyngeal stenosis, respectively. The inclusion criteria were full-head tomography scans and access to clinical records. The exclusion criteria were brachycephalic breed, head trauma and neoplasm. Clinical and computed tomographic findings and relevant comorbidities were recorded.

RESULTS

Forty-three cats were included, 23 cases and 20 controls. The case group was significantly younger, had more paranasal sinus anomalies and never had turbinate lysis, also, had significantly more soft palate anomalies, which was significantly shorter. Nasopharyngeal stenosis varied from membrane appearance to partial or complete adhesion of the soft palate to the nasopharynx, was mainly located in the caudal region of the nasopharynx and was imperforated in approximately half of the cases. Imperforated membranes were significantly thicker in the sagittal plane and were significantly associated with nasal obstruction and soft tissue attenuation of the tympanic bulla. Hiatal hernia and ventricular asymmetry were only encountered in three and two cases, respectively, with nasopharyngeal stenosis.

CLINICAL SIGNIFICANCE

Computed tomography in cats with nasopharyngeal stenosis can identify concurrent anomalies, can help to differentiate a possible choanal atresia and evaluate the magnitude of its significance.

Hosing of a Long Relativistic Particle Bunch in Plasma

Experimental results show that hosing of a long particle bunch in plasma can be induced by wakefields driven by a short, misaligned preceding bunch. Hosing develops in the plane of misalignment, self-modulation in the perpendicular plane, at frequencies close to the plasma electron frequency, and are reproducible. Development of hosing depends on misalignment direction, its growth on misalignment extent and on proton bunch charge. Results have the main characteristics of a theoretical model, are relevant to other plasma-based accelerators and represent the first characterization of hosing.

Single-cell protein expression profiling resolves circulating and resident memory T cell diversity across tissues and infection contexts

Memory CD8⁺ T cells can be broadly divided into circulating (T_CIRCM) and tissue-resident memory T (T_RM) populations. Despite well-defined migratory and transcriptional differences, the phenotypic and functional delineation of T_CIRCM and T_RM cells, particularly across tissues, remains elusive. Here, we utilized an antibody screening platform and machine learning prediction pipeline (InfinityFlow) to profile >200 proteins in T_CIRCM and T_RM cells in solid organs and barrier locations. High-dimensional analyses revealed unappreciated heterogeneity within T_CIRCM and T_RM cell lineages across nine different organs after either local or systemic murine infection models. Additionally, we demonstrated the relative effectiveness of strategies allowing for the selective ablation of T_CIRCM or T_RM populations across organs and identified CD55, KLRG1, CXCR6, and CD38 as stable markers for characterizing memory T cell function during inflammation. Together, these data and analytical framework provide an in-depth resource for memory T cell classification in both steady-state and inflammatory conditions.

Controlled Growth of the Self-Modulation of a Relativistic Proton Bunch in Plasma

A long, narrow, relativistic charged particle bunch propagating in plasma is subject to the self-modulation (SM) instability. We show that SM of a proton bunch can be seeded by the wakefields driven by a preceding electron bunch. SM timing reproducibility and control are at the level of a small fraction of the modulation period. With this seeding method, we independently control the amplitude of the seed wakefields with the charge of the electron bunch and the growth rate of SM with the charge of the proton bunch. Seeding leads to larger growth of the wakefields than in the instability case.

Slowdown of interpenetration of two counterpropagating plasma slabs due to collective effects

The nonlinear evolution of electromagnetic instabilities driven by the interpenetration of two e^{-},e^{+} plasma clouds is explored using ab initio kinetic plasma simulations. We show that the plasma clouds slow down due to both oblique and Weibel generated electromagnetic fields, which deflect the particle trajectories, transferring bulk forward momentum into transverse momentum and thermal velocity spread. This process causes the flow velocity v_{inst} to decrease approximately by a factor of sqrt[1/3] in a time interval Δt_{αB}ω_{p}∼c/(v_{fl}sqrt[α_{B}]), where α_{B} is the magnetic equipartition parameter determined by the nonlinear saturation of the instabilities, v_{fl} is the initial flow speed, and ω_{p} is the plasma frequency. For the α_{B} measured in our simulations, Δt_{αB} is close to 10 times the instability growth time. We show that as long as the plasma slab length L>v_{fl}Δt_{αB}, the plasma flow is expected to slow down by a factor close to sqrt[1/3].

Sphingosine 1-phosphate receptor 5 (S1PR5) regulates the peripheral retention of tissue-resident lymphocytes

Tissue-resident memory T (TRM) cells provide long-lasting immune protection. One of the key events controlling TRM cell development is the local retention of TRM cell precursors coupled to downregulation of molecules necessary for tissue exit. Sphingosine-1-phosphate receptor 5 (S1PR5) is a migratory receptor with an uncharted function in T cells. Here, we show that S1PR5 plays a critical role in T cell infiltration and emigration from peripheral organs, as well as being specifically downregulated in TRM cells. Consequentially, TRM cell development was selectively impaired upon ectopic expression of S1pr5, whereas loss of S1pr5 enhanced skin TRM cell formation by promoting peripheral T cell sequestration. Importantly, we found that T-bet and ZEB2 were required for S1pr5 induction and that local TGF-β signaling was necessary to promote coordinated Tbx21, Zeb2, and S1pr5 downregulation. Moreover, S1PR5-mediated control of tissue residency was conserved across innate and adaptive immune compartments. Together, these results identify the T-bet-ZEB2-S1PR5 axis as a previously unappreciated mechanism modulating the generation of tissue-resident lymphocytes.

Management of congenital and acquired airway pathologies in newborns by a cross-disciplinary committee at a third level hospital

INTRODUCTION

Neonatal airway examination through flexible/rigid bronchoscopy has proved to be useful in the presence of persistent stridor and extubation failure, as well as to assess complications following cardiac surgery. At our institution, these examinations are carried out by a pulmonologist, a neonatologist, an otorhinolaryngologist, and a pediatric surgeon from the pediatric airway committee, established in 2014.

OBJECTIVE

To analyze the airway examinations performed in neonates during their stay at the neonatology/neonatal intensive care unit since the airway committee was established.

MATERIAL AND METHODS

A retrospective study of the airway examinations conducted in neonates from 2015 to 2019 was carried out. Clinical and demographic data, number of examinations, indications, findings, and complications were collected. Results are presented as mean and standard deviation. Statistical significance was established at p < 0.05.

RESULTS

92 airway examinations were analyzed in 51 patients (54.9% of whom were female). 51% of the patients were premature. Extubation failure and persistent respiratory symptoms following successful extubation were the most frequent indications for airway examination (35.3%). Stratification by gestational age or weight at birth was not associated with an increased risk of pathological findings at examination (p > 0.05). The most frequent finding was vocal cord paralysis (n = 14; 27.5%). In 10 patients (19.6%), no pathological findings were observed.

CONCLUSION

Airway examination is useful in patients with stridor to identify vocal cord paralysis following extubation failure. It also allows congenital airway pathologies to be diagnosed and treated. The number of examinations with no pathological findings was similar to that reported in international series.

Usefulness of digestive biopsy in the diagnosis of graft-versus-host disease

INTRODUCTION

Graft-versus-host disease (GVHD) is a frequent complication of allogeneic hematopoietic stem cell transplantation (allo-HSCT), with high morbidity and mortality rates. Intestinal clinical signs are unspecific, which means differential diagnosis with infections and drug-related etiology should be carried out. Even though intestinal biopsy is widely considered as the gold standard technique, there is no consensus as to which sampling method is best.

OBJECTIVE

To assess the results of the biopsy techniques used in patients with suspected intestinal GVHD.

MATERIAL AND METHODS

A retrospective study of patients with suspected intestinal GVHD undergoing allo-HSCT from 2010 to 2019 was carried out. They were assessed through digestive biopsy - esophagogastroduodenal biopsy (upper GI endoscopy - UGIE) or rectal biopsy (colonoscopy or direct biopsy). Quantitative variables, expressed as median and interquartile range, and qualitative variables, expressed as absolute frequency and percentage, were collected.

RESULTS

23 patients were studied, 60.9% of whom were male. Median age at biopsy was 9 years (7-14 years). UGIE was used in 47.8% of patients (n=11), colonoscopy was used in 26.1% of patients (n=6), and direct biopsy was used in 34.8% of patients (n=8), with GVHD positive results in 2 (18.2%), 2 (33.3%), and 4 (50%) patients, respectively.

CONCLUSIONS

Samples taken through direct biopsy stand as an effective alternative in GVHD diagnosis.

Fibrin glue treatment associated or not with diathermy for recurrent tracheoesophageal fistula: our results after more than 20 years' experience

INTRODUCTION

Recurrent tracheoesophageal fistula (RTEF) is a frequent complication (5-10%) in patients with esophageal atresia (EA). Open RTEF surgery has a high morbidity and mortality, so the endoscopic approach represents a promising alternative. We present the long-term results of fibrin glue (FG) bronchoscopic application in patients with RTEF secondary to EA, which was first used by our team in 1994.

MATERIAL AND METHODS

A retrospective review of all patients diagnosed with RTEF following EA repair and treated with FG bronchoscopic application from 1993 to 2019 was carried out. In most cases, diathermy was applied prior to FG sealing. The maximum number of endoscopic sessions was 5. In case of persistent RTEF following the fifth session, open surgery was performed.

RESULTS

14 RTEF patients were treated with FG. In all but the first 3 cases (11 patients, 78.6%), diathermy was applied concomitantly. Mean first treatment day was day 85 of life (range: 14-770). Patients received a mean of 2.1 (1-5) endoscopic sessions. Mean follow-up was 12.1 (10-20) years. Overall success rate was 71.4%, without significant differences according to whether diathermy was concomitantly applied or not (72.7% vs. 66.6%).

CONCLUSIONS

Fibrin glue bronchoscopic application associated or not associated with diathermy is an excellent option for RTEF treatment in EA patients. The endoscopic approach should be considered as the first-choice treatment for RTEF.

Developmental plasticity allows outside-in immune responses by resident memory T cells

Central memory T (TCM) cells patrol lymph nodes and perform conventional memory responses upon re-stimulation: proliferation, migration, and differentiation into diverse T cell subsets while also self-renewing. Resident memory T (TRM) cells are parked within single organs, share properties with terminal effectors, and contribute to rapid host protection. We observed that reactivated TRM cells rejoined the circulating pool. Epigenetic analyses revealed that TRM cells align closely with conventional memory T cell populations, bearing little resemblance to recently activated effectors. Fully differentiated TRM cells isolated from small intestine epithelium exhibited the potential to differentiate into TCM, TEM, and TRM cells upon recall. Ex-TRM cells, former intestinal TRM that rejoined the circulating pool, heritably maintained a predilection for homing back to their tissue of origin upon subsequent reactivation and a heightened capacity to re-differentiate into TRM cells. Thus, TRM cells can rejoin the circulation but are advantaged to re-form local TRM when called upon.

Organ-specific isoform selection of fatty acid binding proteins in tissue-resident lymphocytes

Tissue-resident memory T (TRM) cells exist throughout the body where they are poised to mediate local immune responses. Although studies have defined a common mechanism of residency independent of location, there is likely to be a level of specialization that adapts TRM cells to their given tissue of lodgment. It has been shown that TRM cells in the skin rely on the uptake of exogenous fatty acids for their survival and upregulate fatty acid binding proteins (FABP) 4 and FABP 5 as part of their transcriptional program. However, FABPs exist as a larger family of isoforms with different members selected in a tissue-specific fashion that is optimized for local fatty acid availability. Here we show that although TRM cells in a range of tissue widely express FABPs, they are not restricted to FABP 4 and 5. Instead, TRM cells show varying patterns of isoform usage that are determined by tissue-derived factors. These patterns are malleable since TRM cells relocated to different organs modify their FABP expression in line with their new location. As a consequence, these results argue for tissue-specific overlays to the TRM cell residency program, including FABP expression that is tailored to the particular tissue of TRM cell lodgment.

Organ-specific isoform selection of fatty acid–binding proteins in tissue-resident lymphocytes

Tissue-resident memory T (TRM) cells exist throughout the body, where they are poised to mediate local immune responses. Although studies have defined a common mechanism of residency independent of location, there is likely to be a level of specialization that adapts TRM cells to their given tissue of lodgment. It has been shown that TRM cells in the skin rely on the uptake of exogenous fatty acids for their survival and up-regulate fatty acid–binding protein 4 (FABP4) and FABP5 as part of their transcriptional program. However, FABPs exist as a larger family of isoforms, with different members selected in a tissue-specific fashion that is optimized for local fatty acid availability. Here, we show that although TRM cells in a range of tissue widely express FABPs, they are not restricted to FABP4 and FABP5. Instead, TRM cells show varying patterns of isoform usage that are determined by tissue-derived factors. These patterns are malleable because TRM cells relocated to different organs modify their FABP expression in line with their new location. As a consequence, these results argue for tissue-specific overlays to the TRM cell residency program, including FABP expression that is tailored to the particular tissue of TRM cell lodgment.

Análise da estrutura populacional de ovinos deslanados do núcleo de conservação

RESUMO Este estudo analisou a estrutura populacional de ovinos deslanados do núcleo de conservação do estado do Ceará, Brasil. Os parâmetros populacionais foram estimados com base nos dados genealógicos de indivíduos das raças Santa Inês (SI), Somalis (SO) e Morada Nova (MN), nascidos entre os anos de 2001 e 2014. Os parâmetros estimados foram: número de gerações completas equivalentes (GCE), intervalo entre gerações (IEG), número de fundadores (Nf), número efetivo de fundadores (fe), número efetivo de ancestrais (fa), coeficiente de endogamia (F) e índice de contribuição genética (ICG). O GCE médio foi de 1,82, 2,78 e 1,52 para SI, SO e MN, respectivamente. O IEG foi próximo entre as raças, 3,67 anos em média. O Nf para SI, SO e MN foi igual a 225, 194 e 153, respectivamente. As razões fe/fa foram distantes de 1 nas três populações, o que indica ocorrência de gargalo genético, principalmente para SO. Os coeficientes médios de endogamia foram de 1,81%, 0,78% e 0,78% para SI, SO e MN, respectivamente. O ICG foi de 3,32, 5,38 e 2,87 para SI, SO e MN, respectivamente. Os parâmetros populacionais estimados apontam que parte da genética original desses rebanhos foi perdida, principalmente na população da raça Somalis.

Developmental plasticity allows outside-in immune responses by resident memory T cells

Central memory T (T_CM) cells patrol lymph nodes and perform conventional memory responses on restimulation: proliferation, migration and differentiation into diverse T cell subsets while also self-renewing. Resident memory T (T_RM) cells are parked within single organs, share properties with terminal effectors and contribute to rapid host protection. We observed that reactivated T_RM cells rejoined the circulating pool. Epigenetic analyses revealed that T_RM cells align closely with conventional memory T cell populations, bearing little resemblance to recently activated effectors. Fully differentiated T_RM cells isolated from small intestine epithelium exhibited the potential to differentiate into T_CM cells, effector memory T cells and T_RM cells on recall. Ex-T_RM cells, former intestinal T_RM cells that rejoined the circulating pool, heritably maintained a predilection for homing back to their tissue of origin on subsequent reactivation and a heightened capacity to redifferentiate into T_RM cells. Thus, T_RM cells can rejoin the circulation but are advantaged to re-form local T_RM when called on.

Estimação de parâmetros genéticos para características de pesos e pesos metabólicos na desmama e pós-desmama em bovinos Brahman

RESUMO Objetivou-se estimar herdabilidades e correlações de características ponderais com 36.505 animais, da Associação Brasileira de Criadores Zebu. O modelo incluiu efeito genético direto, materno, ambiente permanente, residual - aleatórios e efeitos de grupos contemporâneos - fixos. Os parâmetros foram estimados pelo método de máxima verossimilhança restrita (REML), utilizando-se software Wombat. Os resultados das herdabilidades variaram de 0,20 a 0,25 peso à desmama e ao sobreano; 0,16 a 0,20 peso metabólico não ajustado e ajustado à desmama, 0,21 a 0,25 peso metabólico ajustado à desmama e metabólico ajustado ao sobreano. As correlações genéticas entre peso à desmama e peso metabólico não ajustado à desmama, peso à desmama e peso metabólico ajustado à desmama são, respectivamente 0,76 e 1,00. A correlação genética entre peso ao sobreano e metabólico ao sobreano não ajustado, peso ao sobreano com metabólico sobreano ajustado foram 0,97 e 1,00. Correlação genética entre peso à desmama e ao sobreano foi 0,72, peso metabólico não ajustado à desmama e metabólico não ajustado ao sobreano 0,54, peso metabólico ajustado à desmama e metabólico ajustado ao sobreano foi 0,71. Correlações genéticas entre peso à desmama e metabólico ajustado à desmama e peso ano com metabólico ano ajustado foram 1,00 e 1,00. Portanto, utilização de peso metabólico sem ajuste de idade pode viesar estimativas de parâmetros genéticos.

MyD88 activation in cardiomyocytes contributes to the heart immune response to acute Trypanosoma cruzi infection with no effect on local parasite control

Cardiomyopathy is the most serious consequence of Chagas disease, a neglected human disorder caused by Trypanosoma cruzi infection. Because T. cruzi parasites invade cardiomyocytes, we sought to investigate whether these cells recognize the parasite in vivo by receptors signaling through the MyD88 adaptor, which mediates the activation pathway of most Toll-like receptors (TLRs) and IL-1/IL-18 receptors, and influence the development of acute cardiac pathology. First, we showed that HL-1 cardiac muscle cell line expresses MyD88 gene and protein at resting state and after T. cruzi infection. To evaluate the role in vivo of MyD88 expression in cardiomyocytes, we generated Mer+MyD88flox+/+ mice in which tamoxifen treatment is expected to eliminate the MyD88 gene exclusively in cardiomyocytes. This Cre-loxP model was validated by both PCR and western blot analysis; tamoxifen treatment of Mer+MyD88flox+/+ mice resulted in decreased MyD88 gene and protein expression in the heart, but not in the spleen, while had no effect on littermates. The elimination of MyD88 in cardiomyocytes determined a lower increase in CCL5, IFNγ and TNFα gene transcription during acute infection by T. cruzi parasites of the Y strain, but it did not significantly modify heart leukocyte infiltration and parasitism. Together, our results show that cardiomyocytes can sense T. cruzi infection through MyD88-mediated molecular pathways and contribute to the local immune response to the parasite. The strong pro-inflammatory response of heart-recruited leukocytes may overshadow the effects of MyD88 deficiency in cardiomyocytes on the local leukocyte recruitment and T. cruzi control during acute infection.

The purinergic receptor P2RX7 directs metabolic fitness of long-lived memory CD8+ T cells

Extracellular ATP (eATP) is an ancient 'danger signal' used by eukaryotes to detect cellular damage¹. In mice and humans, the release of eATP during inflammation or injury stimulates both innate immune activation and chronic pain through the purinergic receptor P2RX7^2-4. It is unclear, however, whether this pathway influences the generation of immunological memory, a hallmark of the adaptive immune system that constitutes the basis of vaccines and protective immunity against re-infection^5,6. Here we show that P2RX7 is required for the establishment, maintenance and functionality of long-lived central and tissue-resident memory CD8⁺ T cell populations in mice. By contrast, P2RX7 is not required for the generation of short-lived effector CD8⁺ T cells. Mechanistically, P2RX7 promotes mitochondrial homeostasis and metabolic function in differentiating memory CD8⁺ T cells, at least in part by inducing AMP-activated protein kinase. Pharmacological inhibitors of P2RX7 provoked dysregulated metabolism and differentiation of activated mouse and human CD8⁺ T cells in vitro, and transient P2RX7 blockade in vivo ameliorated neuropathic pain but also compromised production of CD8⁺ memory T cells. These findings show that activation of P2RX7 by eATP provides a common currency that both alerts the nervous and immune system to tissue damage, and promotes the metabolic fitness and survival of the most durable and functionally relevant memory CD8⁺ T cell populations.

[Multidisciplinary approach on subglottic pathology: a 5-year review]

INTRODUCTION

Pediatric subglottic pathology still represents a challenge when it comes to choosing the right treatment. We present the management of patients followed in our center for this reason during the last 5 years.

MATERIAL AND METHODS

Retrospective study of patients followed by glotosubglottic pathology (stenosis, cysts or granulomas) between 2011 and 2016 in a third level hospital.

RESULTS

Twenty-seven patients were included in the review. Treatment options varied according to the nature, location and severity of the subglottic stenosis. Two patients with congenital subglottic stenosis were treated by laryngotracheoplasty. Seventeen patients with acquired subglottic stenosis were included: in one (5.9%) laryngotracheoplasty was performed, one (5.9%) received cricotracheal split, two of them (11.8%) underwent partial cricotracheal resection (PCTR) , seven patients (41.2%) underwent microsurgery, three (17.6%) received tracheal dilatation, and the last three (17.6%) were submitted to observation without needing further treatment. Five patients with post-intubation subglottic cysts received microsurgery. Of three patients diagnosed with post-intubation subglottic granuloma, two (66%) resolved spontaneously and one (33%) required microsurgery.

CONCLUSIONS

Management of pediatric subglottic pathology remains a major challenge. Since the creation of the Airway Committee in our center, the improvement in the management of these patients has led to a multidisciplinary management, with the consequent impact on the clinical results.

Intravital mucosal imaging of CD8+ resident memory T cells shows tissue-autonomous recall responses that amplify secondary memory

CD8⁺ T cell immunosurveillance dynamics influence the outcome of intracellular infections and cancer. Here we used two-photon intravital microscopy to visualize the responses of CD8⁺ resident memory T cells (T_RM cells) within the reproductive tracts of live female mice. We found that mucosal T_RM cells were highly motile, but paused and underwent in situ division after local antigen challenge. T_RM cell reactivation triggered the recruitment of recirculating memory T cells that underwent antigen-independent T_RM cell differentiation in situ. However, the proliferation of pre-existing T_RM cells dominated the local mucosal recall response and contributed most substantially to the boosted secondary T_RM cell population. We observed similar results in skin. Thus, T_RM cells can autonomously regulate the expansion of local immunosurveillance independently of central memory or proliferation in lymphoid tissue.

Pomalidomide-dexamethasone in refractory multiple myeloma: long-term follow-up of a multi-cohort phase II clinical trial

Despite therapeutic advances, multiple myeloma remains incurable, with limited options for patients with refractory disease. We conducted a large, multi-cohort clinical trial testing various doses and treatment schedules of pomalidomide and dexamethasone (Pom/dex) in patients with refractory multiple myeloma. Overall, 345 patients were enrolled to six cohorts based on number and type of prior lines of therapy, pomalidomide dose and schedule. Median prior lines of therapy were three with near universal prior exposure to proteasome inhibitors and/or immunomodulatory drugs. A confirmed response rate of 35% was noted for all cohorts (range 23-65%) with higher responses in cohorts with fewer prior lines of therapy. Median time to confirmed response was ⩽2 months and the longest progression-free survival and overall survival seen in any cohort were 13.1 and 47.9 months, respectively. Observed adverse reactions were as expected, with myelosuppression and fatigue being the most common hematologic and non-hematologic adverse events (AEs), respectively. Longer durations of treatment and response, higher response rates and fewer AEs were noted with the 2 mg pomalidomide dose. This is the longest follow-up data for Pom/dex in refractory multiple myeloma and will help shape the real-world utilization of this regimen.

Trends in overall survival and costs of multiple myeloma, 2000-2014

Little real-world evidence is available to describe the recent trends in treatment costs and outcomes for patients with multiple myeloma (MM). Using the Truven Health MarketScan Research Databases linked with social security administration death records, this study found that the percentage of MM patients using novel therapy continuously increased from 8.7% in 2000 to 61.3% in 2014. Compared with MM patients diagnosed in earlier years, those diagnosed after 2010 had higher rates of novel therapy use and better survival outcomes; patients diagnosed in 2012 were 1.25 times more likely to survive 2 years than those diagnosed in 2006. MM patients showed improved survival over the study period, with the 2-year survival gap between MM patients and matched controls decreasing at a rate of 3% per year. Total costs among MM patients have increased in all healthcare services over the years; however, the relative contribution of drug costs has remained fairly stable since 2009 despite new novel therapies coming to market. Findings from this study corroborate clinical data, suggesting a paradigm shift in MM treatment over the past decade that is associated with substantial survival gains. Future studies should focus on the impact on specific novel agents on patients' outcomes.

Effect of Comedication With Conventional Synthetic Disease-Modifying Antirheumatic Drugs on Retention of Tumor Necrosis Factor Inhibitors in Patients With Spondyloarthritis: A Prospective Cohort Study

OBJECTIVE

To evaluate whether use of comedication with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) influences the retention of tumor necrosis factor inhibitors (TNFi) in patients with spondyloarthritis (SpA).

METHODS

Patients with SpA from the Rheumatic Diseases Portuguese Register who started treatment with their first TNFi between 2001 and 2014 were included in this study. Cox regression analysis was used to estimate the effect of comedication with csDMARDs on TNFi retention in 2 types of models: a model in which baseline (time-fixed) variables were included, and a second model incorporating time-varying variables, including sociodemographic features, measures of disease activity, measures of physical function, and cotreatment with other drugs (nonsteroidal antiinflammatory drugs and oral steroids). To control for possible confounding by indication, the effect of csDMARD comedication on TNFi retention was also tested after adjustment for the treatment propensity score.

RESULTS

In total, 954 patients were included in the study, of whom 289 (30.3%) discontinued treatment with their first TNFi after a median follow-up time of 2.5 years (range 0.08-13 years). Inefficacy was the most common reason for TNFi discontinuation (55.7% of patients). In the multivariable analyses, comedication with csDMARDs had no measurable effect on TNFi retention, neither in the baseline model (hazard ratio [HR] 0.83, 95% confidence interval [95% CI] 0.59-1.16) nor during follow-up in the model adjusted for time-varying covariates (HR 1.07, 95% CI 0.68-1.68). The effect of csDMARD comedication remained nonsignificant after propensity score adjustment.

CONCLUSION

Comedication with csDMARDs does not prolong TNFi retention in patients with SpA in clinical practice, suggesting that there is no benefit conferred by the concomitant use of these drugs.

ATP receptor P2rX7 direct the generation of long-lived memory CD8+ T cells

P2rX7 is an ATP-sensitive purinergic receptor often known for its role in neuropathic pain and innate immunity. P2rX7 is also known to mediate CD4+ T cell death upon stimulation. To evaluate whether CD8+ T cell immune responses are also regulated by P2rX7, we infected mice with LCMV and tracked gp33-specific P14 CD8+ T cells. Unexpectedly, we found that P2rX7 expression on memory precursors (MPEC) positively correlated with generation of central memory CD8+ T cells (TCM). P2rX7KO CD8+ T cells also had reduced memory generation, especially TCM and resident memory (TRM). This defect was cell-intrinsic, as revealed by bone marrow chimeras and co-adoptive transfer of P2rX7KO and WT P14 T cells. Defective memory generation by P2rX7KO CD8+ T cells was preceded by impaired MPEC generation as well as diminished Tcf1 expression. Strikingly, P2rX7KO CD8+ T cells had an early and sustained impairment of proper mitochondrial function, as observed by flow cytometry (lower membrane potential and mitochondrial mass) or seahorse assays (lower SRC, higher proton leak). These defects were observed specifically on TCM, but not on effector memory (TEM) or long-lived effector cells (LLEC). P2rX7KO CD8+ T cells also showed reduced recall proliferation following secondary antigen stimulation. Importantly, treatment with P2rX7 pharmacological inhibitors during the immune response effector phase lead to similar defects in TCM and TRM. These findings show that P2rX7 is critical for development of a long-lived memory CD8+ T cell response. Also, they have important implications for the immunological effects of P2rX7 inhibitors used for pain control, and the impact of loss-of-function P2rX7 polymorphisms on immunity and the response to vaccines.

Growth and geographical variation in the use of cardiac imaging in Australia

BACKGROUND AND AIM

Growth rates and regional differences in the use of cardiac imaging are potential metrics of quality of care. This study sought to define growth and regional variation in outpatient cardiac imaging in Australia.

METHODS

Analyses are based on the rate of outpatient transthoracic echocardiography (TTE), transoesophageal echocardiography (TOE) and stress echocardiography (SE) and single-photon emission computed tomography (SPECT) per 100 000 people in each geographic insurance region in Australia (Medicare local, ML). Numbers of tests from 2002 to 2013 were obtained from Medicare Australia Statistics, and the number of doctors was obtained from the Health Workforce data. Demographic data (total population, rural areas and quintiles of disadvantage) were obtained from census data.

RESULTS

Over the past 11 years, TTE reimbursements/100 000 people increased from 1780 to 3497 (8.8% annualised growth), TOE from 33 to 61, SE from 181 to 947 and SPECT from 287 to 337. SE had the biggest increment, an average growth rate of 38.5%/year. The relationships between the use of each cardiac imaging techniques and demographic, medical and illness factors were analysed in outpatient tests reimbursed in 2012. For each additional medical practitioner per 1000 people, there was an increase in the rate of TTE (β = 1.25 (95% confidence interval CI: 1.17-1.33), P < 0.001), and TOE use (β = 1.13 (1.04-1.24), P = 0.005), independent of regional burden of cardiovascular disease and social determinants. For SPECT the largest independent correlate for testing was the percentage of women within the ML; each additional percentage increase resulted in doubling of the rate of testing (β = 2.25 (1.72-2.94), P < 0.001).

CONCLUSION

Variation in the use of TTE in Australia does not appear illness related and may be evidence of under- and overutilisation. An appropriate use process may contain this variation.

Genomic characterization of high-count MBL cases indicates that early detection of driver mutations and subclonal expansion are predictors of adverse clinical outcome

High-count monoclonal B-cell lymphocytosis (MBL) is an asymptomatic expansion of clonal B-cells in the peripheral blood without other manifestations of chronic lymphocytic leukemia (CLL). Yearly, 1% of MBLs evolve to CLL requiring therapy; thus being critical to understand the biologic events that determine which MBLs progress to intermediate/advanced CLL. In this study, we performed targeted deep-sequencing on 48 high-count MBLs, 47 of them with 2-4 sequential samples analyzed, exploring the mutation status of 21 driver genes and evaluating clonal evolution. We found somatic non-synonymous mutations in 25 MBLs(52%) at the initial time-point analyzed, including 13(27%) with >1 mutated gene. In cases that subsequently progressed to CLL, mutations were detected 41 months (median) prior to progression. Excepting NOTCH1, TP53 and XPO1, which showed a lower incidence in MBL, genes were mutated with a similar prevalence to CLL, indicating the early origin of most driver mutations in the MBL/CLL continuum. MBLs with mutations at the initial time-point analyzed were associated with shorter time-to-treatment (TTT). Furthermore, MBLs showing subclonal expansion of driver mutations on sequential evaluation had shorter progression time to CLL and shorter TTT. These findings support that clonal evolution have prognostic implications already at the pre-malignant MBL stage, anticipating which individuals will progress earlier to CLL.