Mid-Regional Pro-Adrenomedullin Can Predict Organ Failure and Prognosis in Sepsis?

Sepsis causes immune dysregulation and endotheliitis, with an increase in mid-regional pro-adrenomedullin (MR-proADM). The aim of the study is to determine an MR-proADM value that, in addition to clinical diagnosis, can identify patients with localized infection or those with sepsis/septic shock, with specific organ damage or with the need for intensive care unit (ICU) transfer and prognosis. The secondary aim is to correlate the MR-proADM value with the length of stay (LOS). In total, 301 subjects with sepsis (124/301 with septic shock) and 126 with localized infection were retrospectively included. In sepsis, MR-proADM ≥ 3.39 ng/mL identified acute kidney injury (AKI); ≥2.99 ng/mL acute respiratory distress syndrome (ARDS); ≥2.28 ng/mL acute heart failure (AHF); ≥2.55 ng/mL Glascow Coma Scale (GCS) < 15; ≥3.38 multi-organ involvement; ≥3.33 need for ICU transfer; ≥2.0 Sequential Organ Failure Assessment (SOFA) score ≥ 2; and ≥3.15 ng/mL non-survivors. The multivariate analysis showed that MR-proADM ≥ 2 ng/mL correlates with AKI, anemia and SOFA score ≥ 2, and MR-proADM ≥ 3 ng/mL correlates with AKI, GCS < 15 and SOFA score ≥ 2. A correlation between mortality and AKI, GCS < 15, ICU transfer and cathecolamine administration was found. In localized infection, MR-proADM at admission ≥ 1.44 ng/mL identified patients with AKI; ≥1.0 ng/mL with AHF; and ≥1.44 ng/mL with anemia and SOFA score ≥ 2. In the multivariate analysis, MR-proADM ≥ 1.44 ng/mL correlated with AKI, anemia, SOFA score ≥ 2 and AHF. MR-proADM is a marker of oxidative stress due to an infection, reflecting severity proportionally to organ damage.

Mid-Regional Pro-Adrenomedullin and N-Terminal Pro-B-Type Natriuretic Peptide Measurement: A Multimarker Approach to Diagnosis and Prognosis in Acute Heart Failure

BACKGROUND

Acute heart failure (AHF) is a major cause of hospitalization and mortality worldwide. Early and accurate diagnosis, as well as effective risk stratification, are essential for optimizing clinical management and improving patient outcomes. In this context, biomarkers have gained increasing interest in recent years as they can provide important diagnostic and prognostic information in patients with AHF.

AIM AND METHODS

The primary objective of the present study was to compare the levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP), mid-regional pro-adrenomedullin (MR-proADM), and C-reactive protein (CRP) between patients diagnosed with acute heart failure (AHF) and those without AHF and sepsis. Furthermore, the study aimed to assess the diagnostic and prognostic value of the use of a multimarker approach in AHF patients. To achieve these objectives, a total of 145 patients with AHF and 127 patients without AHF and sepsis, serving as the control group, were consecutively enrolled in the study.

RESULTS

Levels of MR-proADM (median: 2.07; (25th-75th percentiles: 1.40-3.02) vs. 1.11 (0.83-1.71) nmol/L, p < 0.0001), and NT-proBNP (5319 (1691-11,874) vs. 271 (89-931.5) pg/mL, p < 0.0001) were significantly higher in patients with AHF compared to controls, whereas CRP levels did not show significant differences. The mortality rate in the AHF group during in-hospital stay was 12%, and the rate of new re-admission for AHF within 30 days after discharge was 10%. During in-hospital follow-up, Cox regression analyses showed that levels of NT-proBNP > 10,132 pg/mL (hazard ratio (HR) 2.97; 95% confidence interval (CI): 1.13-7.82; p = 0.0284) and levels of MR-proADM > 2.8 nmol/L (HR: 8.57; CI: 2.42-30.28; p = 0.0009) predicted mortality. The combined use of MR-proADM and NT-proBNP provided significant additive predictive value for mortality and new re-admission for AHF at 30 days after discharge. A logistic regression analysis showed that the presence of NT-proBNP pg/mL > 12,973 pg mL and/or MR-proADM > 4.2 nmol/L predicted hospital re-admission within 30 days (OR: 3.23; CI: 1.05-9.91; p = 0.041).

CONCLUSION

The combined assay of MR-proADM and NT-proBNP could be helpful in accurately identifying AHF and in defining prognosis and re-admission for AHF. The complementary use of these biomarkers can provide a useful clinical evaluation of AHF while also orienting clinicians to the pathophysiology underlying heart damage and assisting them in tailoring therapy.

Synergistic effect of myocardial injury and mid-regional proAdrenomedullin elevation in determining clinical outcomes of SARS-CoV-2 patients

OBJECTIVE

Coronavirus disease 2019 (COVID-19) is a systemic disease induced by SARS-CoV-2 causing myocardial injury. To date, there are few data on the correlation between mid-regional proAdrenomedullin (MR-proADM) and myocardial injury. The aim of this study was to evaluate whether the association of myocardial injury and elevated mid-regional proAdrenomedullin values could predict mortality of SARS-CoV-2 patients, to offer the best management to COVID-19 patients.

MATERIALS AND METHODS

All patients hospitalized for SARS-CoV-2 infection at the COVID-19 Center of the Campus Bio-Medico of Rome University were included between October 2020 and March 2021 and were retrospectively analyzed. Myocardial injury was defined as rising and/or fall of cardiac hs Troponin I values with at least one value above the 99th percentile of the upper reference limit (≥15.6 ng/L in women and ≥34.2 ng/L in men). The primary outcome was 30-day mortality. Secondary outcomes were the comparison of MR-proADM, CRP, ferritin, and PCT as diagnostic and prognostic biomarkers of myocardial injury. Additionally, we analyzed the development of ARDS, the need for ICU transfer, and length of stay (LOS).

RESULTS

A total of 161 patients were included in this study. Of these, 58 (36.0%) presented myocardial injury at admission. An MR-proADM value ≥ 1.19 nmol/L was defined as the optimal cut-off to identify patients with myocardial injury (sensitivity 81.0% and specificity 73.5%). A total of 121 patients (75.2%) developed ARDS, which was significantly more frequent among patients with myocardial injury (86.2 vs. 68.9%, p = 0.015). The overall 30-day mortality was 21%. Patients with myocardial injury presented significantly higher mortality compared to those without the same (46.6 vs. 6.8%, p < 0.001). When dividing the entire study population into four groups, based on the presence of myocardial injury and MR-proADM values, those patients with both myocardial injury and MR-proADM ≥ 1.19 nmol/L presented the highest mortality (53.2%, p < 0.001). The combination of myocardial injury and MR-proADM values ≥ 1.19 nmol/L was an independent predictor of death (OR = 7.82, 95% CI = 2.87-21.30; p < 0.001).

CONCLUSION

The study is focused on the correlation between myocardial injury and MR-proADM. Myocardial injury induced by SARS-CoV-2 is strongly associated with high MR-proADM values and mortality.

The histone methyltransferase SETD2 drives cardiometabolic heart failure with preserved ejection fraction

Background

Heart failure with preserved ejection fraction (HFpEF) is highly prevalent in patients with cardiometabolic disorders and associates with a poor outcome. Pathological gene expression in heart failure is accompanied by changes in active histone marks without major alterations in DNA methylation. Histone 3 trimethylation at lysine 36 (H3k36me3) – an active chromatin mark induced by the methyltransferase SETD2 – was recently found among the top epigenetic signatures in failing human hearts. Yet, the role of SETD2/H3k36me3 in heart failure is poorly understood.

Purpose

To investigate whether SETD2 participates in the transcriptional regulation of cardiometabolic HFpEF.

Methods

Mice with cardiomyocyte-specific deletion of SETD2 (c-SETD2−/−) and control littermates (SETD2fl/fl) were generated and subjected to high fat diet feeding and L-NAME treatment for 15 weeks to induce cardiometabolic HFpEF. Histology, mouse echocardiography (Vevo3100) and Treadmill exhaustion test were performed. ChIP-Seq datasets were employed to determine the biological pathways regulated by H3k36me3, whereas chromatin immunoprecipitation assays (ChIP) were performed to investigate SETD2/H3k36me3 enrichment on gene promoters. SETD2 gain- and loss-of-function experiments were performed in cultured cardiomyocytes (CMs) exposed to palmitic acid. Lipotoxic injury was assessed by mass spectrometry (MS)-based quantification of lipid species, autophagic flux (by Western blot) and apoptosis (by Caspase-3 activity assay). SETD2/H3k36me3 were also investigated in left ventricular myocardial specimens from patients with HFpEF and were correlated to passive stiffness.

Results

ChIP-Seq in mouse CMs showed a strong enrichment of SETD2/H3k36me3 in pathways underpinning triglyceride synthesis. SETD2 and H3k36me3 were upregulated in HFpEF vs. control mouse hearts and were highly enriched on the promoter of sterol regulatory element-binding transcription factor 1 (SREBF1) gene. These changes were associated with SREBF1 upregulation, myocardial triglyceride accumulation and lipotoxic damage. In HFpEF mice, cardiomyocyte-specific deletion of SETD2 prevented hypertrophic remodeling, diastolic dysfunction and lung congestion while improving exercise tolerance. Moreover, SETD2 deletion blunted H3K36me3 enrichment on SREBF1 promoter thus preventing SREBF1-related lipid accumulation, impaired autophagic flux and apoptosis. In cultured CMs exposed to palmitic acid, SETD2 depletion prevented H3k36me3-driven SREBF1 upregulation, whereas SETD2 overexpression recapitulated lipotoxic damage. SREBF1 knockdown prevented lipotoxic injury in SETD2-overexpressing CMs, suggesting its direct role in SETD2 signalling. Finally, SETD2 was upregulated in myocardial samples from obese patients with HFpEF and positively correlated with cardiomyocyte stiffness, a major feature of HFpEF.

Conclusions

SETD2 may represent an attractive molecular target for the prevention of cardiometabolic HFpEF.

Funding Acknowledgement

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

A methylation-dependent checkpoint by SETD7 promotes myocardial ischemic injury in mice and men

Background

Despite appropriate revascularization strategies, a significant number of patients with myocardial infarction (MI) develop ischemic heart failure suggesting that breakthrough therapies are yet to be approved in this setting. Methylation of non-histone proteins is emerging as a central regulatory mechanism in health and disease. The methyltransferase SETD7 has been shown to methylate and alter the function of a variety of proteins in vitro, however, its function in the heart is poorly understood.

Purpose

To determine the role of SETD7 in myocardial ischemic injury.

Methods

Neonatal rat ventricular myocytes (NRVM) were exposed to normal glucose levels or glucose deprivation (GD) for 15 h, in the presence of the selective SETD7 inhibitor (R)-PFI-2 or its inactive enantiomer (S)-PFI-2. Western blot and real-time PCR were employed to investigate the effects of energy stress on SETD7 and the Hippo pathway, while apoptosis and oxidative stress were assessed by Caspase-3 activity assay and mitoSOX staining. YAP transcriptional activity was assessed by chromatin immunoprecipitation assay (ChIP) while its localization and methylation were examined by confocal microscopy and immunoblotting, respectively. SETD7 knockout (SETD7−/−) mice and wild-type (WT) littermates underwent myocardial ischemia-reperfusion (I/R) injury (1h coronary ligation /24 h of reperfusion) followed by assessment of cardiac function by echocardiography. Left ventricular (LV) myocardial samples were collected from I/R mice and patients with ischemic cardiomyopathy (ICM), and isolated cardiomyocytes were treated with (R)-PFI-2. Finally, SETD7 expression was also assessed in peripheral blood mononuclear cells (PBMCs) from patients with ST-elevation MI (STEMI).

Results

SETD7 was activated upon energy deprivation in cultured NRVMs and methylated YAP, leading to its cytosolic retention and impaired transcription of antioxidant genes MnSOD and CAT. Pharmacological inhibition of SETD7 by (R)-PFI-2 restored YAP nuclear localization thus preventing mitochondrial reactive oxygen species (mtROS) and apoptosis. SETD7 deletion in mice attenuated I/R injury, mtROS and LV dysfunction by restoring YAP-dependent transcriptional programs. SETD7/YAP dysregulation was also observed in LV specimens from ICM patients. Moreover, in cardiomyocytes isolated from I/R mice and ICM patients, (R)-PFI-2 restored YAP nuclear localization, prevented mtROS accumulation while improving myofibrillar protein contractility and Ca2+ sensitivity. Finally, SETD7 was upregulated in PBMCs from STEMI patients and negatively correlated with the expression of MnSOD and CAT.

Conclusions

SETD7-dependent methylation of YAP is an important mechanism underpinning myocardial oxidative stress and apoptosis during ischemia. Pharmacological modulation of SETD7 by (R)-PFI-2 may represent a potential therapeutic approach to prevent myocardial ischemic damage through modulation of the Hippo pathway.

Funding Acknowledgement

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

Targeting Neurofibromin 2 (NF2) prevents endothelial dysfunction in obesity: a study in mice and humans

Introduction

The mechanisms underlying endothelial dysfunction (ED) in obesity are poorly understood. Neurofibromin 2 (NF2) is a scaffold-like protein involved in cell growth and survival. However, its role in the vascular endothelium is unknown.

Purpose

To investigate NF2 function in obesity-related ED.

Methods

Human aortic endothelial cells (HAECs) were exposed to palmitic acid (PA, 200 uM) or vehicle for 48 hours. Gene silencing of NF2 was performed by small interfering RNA (siRNA). Gene and protein expression were assessed by real time PCR and Western blot, respectively. The interaction of NF2 with endothelial proteins was investigated by co-immunoprecipitation. A constitutive active mutant form of NF2 (Ala518) was employed to study the effects of NF2 gain-of-function. To specifically investigate NF2 role in the vascular endothelium, we generated mice with endothelium-specific deletion of NF2 (NF2 ECKO) by crossing NF2flox/flox mice with tamoxifen-inducible endothelial-specific Cre mice [Cdh5(PAC)-CreERT2]. Endothelium-dependent relaxations to acetylcholine (Ach) were assessed in aortas from NF2 ECKO and wild type (WT) littermates, fed a control and a high fat diet (60 kcal% fat) for 20 weeks. NF2 signalling and endothelial function were also assessed in small visceral fat arteries (VFA) isolated from 18 obese and 18 age-matched healthy subjects undergoing bariatric surgery and cholecystectomy, respectively. Gene in silencing of NF2 by siRNA was performed in VFA from obese patients.

Results

In HAECs, PA promoted NF2 activation by decreasing its phosphorylation at Ser518. Akt and MYPT-1 were responsible for NF2 dephosphorylation. In PA-treated HAECs, NF2 was mainly found in the plasma membrane as compared to other cell fractions. Among different membrane proteins implicated in endothelial homeostasis, NF2 binds and activates Caveolin 1 (Cav-1), a pivotal repressor of endothelial NO synthase (eNOS). NF2 knockdown in PA-treated HAECs prevented eNOS–Cav-1 interaction, thus preserving eNOS activity and NO levels. By contrast, HAECs expressing the constitutive active mutant form of NF2 displayed reduced eNOS activity. In aortas from obese mice, we found that NF2-Cav-1 interaction was responsible for impaired eNOS activity and ED. Cav-1 gene silencing in NF2-overexpressing aortas prevented ED, thus confirming the direct involvement of Cav-1 in NF2-induced ED. Interestingly, Ach-dependent vasorelaxation was preserved in obese NF2 ECKO mice as compared to WT littermates. Moreover, NO bioavailability was preserved in aortas from NF2 ECKO mice. In VFA from obese patients, NF2 was upregulated, and its activity negatively correlated with Ach-dependent vasorelaxation. Of note, NF2 gene silencing in VFA from obese patients rescued ED.

Conclusions

In human endothelial cells, mice with endothelium-specific deletion of NF2 and VFA from obese patients, we show that NF2 drives ED by repressing Cav-1. Targeting NF2 may prevent ED in obese patients.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Holcim Stiftung

Increased Tenascin-C expression contributes to cardiac dysfunction and fibrosis in Duchenne muscular dystrophy

Introduction and aims

Cardiac fibrosis is characterized by the net accumulation of extracellular matrix (ECM) proteins in the cardiac interstitium and contributes to cardiac contractile dysfunction. In Duchenne muscular dystrophy (DMD), cardiomyopathy develops as a result of a dystrophin deficiency causing fibrofatty replacement of the myocardium, however the underlying mechanisms are not fully understood. There is a growing collection of evidence that ECM proteins, including Tenascin C (TN-C), plays a maladaptive role in left ventricular (LV) remodelling and cardiac fibrosis in ischemic heart disease. The aims of our study were 1) to assess TN-C levels, fibrosis and cardiac dysfunction in DMD patients, and 2) to clarify the role of TN-C in cardiovascular dysfunction and fibrosis using male mdx (n=10) and mdx TN-C KO mice (n=8).

Results

In male patients with DMD (n=18) and age matched controls (n=12) undergoing cardiac MRI, we detected greater myocardial fibrosis than in control hearts. In addition, we observed an elevation of TN-C plasma levels [median concentration (3.55); interquartile range (0.61–7.43) ng/mL] in DMD patients, and its expression negatively correlated to LV ejection fraction (EF) [median LVEF (45); interquartile range (37.5–51.5) %]. Male wt, mdx and mdx TN-C KO age-matched (10 months) mice were used. Transthoracic echocardiography was performed and fibrosis was assessed on cardiac tissue sections. Wire myography was used to assess vascular endothelial function. To explore the signalling pathways contributing to cardiac fibrosis, human cardiac fibroblasts (hCFs) were treated with recombinant human TN-C or TGF-β and gene expression and epigenetic regulation of NF-kB/p65 were assessed. Mdx mice showed significantly increased cardiac fibrosis which was accompanied with markedly elevated TN-C level in cardiac tissue and plasma compared to wt animals (p&lt;0.05, respectively). Moreover, TN-C level in plasma correlated positively with the degree of cardiac dilation in dystrophic mice. In addition, vascular endothelial function was notably impaired in mdx mice. In contrast, we observed preserved vascular function in mdx- TN-C KO mice, this was accompanied by a significant reduction in cardiac fibrosis in compared to age-matched mdx mice (p&lt;0.05, respectively). hCFs treated with TN-C or TGF-β showed increased collagen and α-SMA expressions which could be prevented by application of siRNA against TN-C. In addition, both TN-C and TGF-β caused p65/NF-κB promoter demethylation and subsequently triggered pro-inflammatory and pro-fibrotic signalling, which could be reversed by applying p38 MAPK inhibitor in hCFs.

Conclusion

TN-C is a critical component of cardiac fibrosis and cardiac dysfunction in DMD. The activation of NF-κB p65 signalling pathway may play a role in TN-C induced fibrosis. Thus, TN-C may be a mediator and potential target for therapy in DMD-associated cardiovascular complications.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Österreichische MuskelforschungFWF - Austrian Science Found P 35878

A chromatin signature by the methyltransferase SETD7 orchestrates angiogenic response in diabetic limb ischemia

Background

Peripheral artery disease (PAD) is highly prevalent in patients with diabetes (DM) and associates with a high rate of limb amputation and poor prognosis. Surgical and catheter-based revascularization have failed to improve outcome in DM patients with PAD. Hence, a need exists to develop new treatment strategies able to promote blood vessel growth in this setting. Mono-methylation of histone 3 at lysine 4 (H3K4me1) – a specific epigenetic signature induced by the histone methyltransferase SETD7 – favours an open chromatin thus enabling gene transcription.

Purpose

To investigate whether SETD7-dependent epigenetic changes modulate angiogenic response in diabetes.

Methodology

Primary human aortic endothelial cells (HAECs) were exposed to normal glucose (NG, 5 mM) or high glucose (HG, 25 mM) concentrations for 48 hours. Unbiased gene expression profiling was performed by RNA sequencing (RNA-seq) followed by Ingenuity Pathway Analysis (IPA). In vitro assays, namely cell migration and tube formation were employed to study angiogenic properties in HAECs. SETD7 and H3K4me1 levels were investigated by Western blot and Chromatin immunoprecipitation (ChIP). Pharmacological blockade of SETD7 was achieved by using the highly selective inhibitor (R)-PFI-2. Mice with streptozotocin-induced diabetes were orally treated with (R)-PFI-2 or vehicle and underwent hindlimb ischemia by femoral artery ligation for 14 days. Blood flow recovery was analysed at 30 minutes, 7 and 14 days by laser Doppler imaging. Our experimental findings were also translated in gastrocnemius muscle samples from patients with and without diabetes.

Results

RNA-seq in HG-treated HAECs revealed a profound upregulation of the methyltransferase SETD7, an enzyme involved in mono-methylation of lysine 4 at histone 3 (H3K4me1). SETD7 upregulation in HG-treated HAECs was associated with increased H3K4me1 levels as well as with impaired endothelial cell migration and tube formation. Both SETD7 gene silencing and pharmacological inhibition by (R)PFI-2 rescued hyperglycemia-induced impairment of HAECs migration and tube formation, while SETD7 overexpression blunted the angiogenic response. RNA-seq and ChIP assays showed that SETD7-dependent H3K4me1 regulates the transcription of the angiogenesis inhibitor semaphorin-3G (SEMA-3G). Moreover, SEMA-3G overexpression blunted migration and tube formation in SETD7-depleted HAECs. In diabetic mice with hindlimb ischemia, treatment with (R)-PFI-2 improved limb vascularization and perfusion as compared to vehicle. Finally, SETD7/SEMA3G axis was upregulated in muscle specimens from T2D patients as compared to controls.

Conclusion

Targeting SETD7 represents a novel epigenetic-based therapy to boost neovascularization in diabetic patients with PAD.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): University of Zurich - Forshungskredit candoc grant

A chromatin mark by SETD7 regulates myocardial inflammation in obesity-related heart failure with preserved ejection fraction

Background

Obesity is a major risk factor for heart failure with preserved ejection fraction (HFpEF). Post-translational modification of histones by chromatin modifying enzymes (CMEs) are emerging as pivotal regulators of gene transcription in cardiovascular disease.

Purpose

To investigate the role of chromatin remodelling in obese HFpEF (obHFpEF).

Methods

Gene expression profiling of CMEs (PCR array) was performed in left ventricular (LV) myocardial specimens from obHFpEF patients and age-matched control donors (n=8/group). Among myocardial CMEs, the methyltransferase SETD7 showed the highest variation in gene expression. Hence, we investigated the role of SETD7 and its chromatin mark H3K4me1 in a murine model of obHFpEF. Mice with cardiomyocyte-specific deletion of SETD7 (c-SETD7−/−) and control littermates (SETD7fl/fl) were subjected to high fat diet feeding and L-NAME treatment for 15 weeks to induce obHFpEF. Echocardiography and Treadmill exhaustion test were performed. ChIP-Seq datasets were employed to determine the biological pathways regulated by SETD7, whereas chromatin immunoprecipitation assays (ChIP) were performed to investigate SETD7/H3k4me1 enrichment on target gene promoters. SETD7 gain- and loss-of-function experiments were performed in cultured neonatal rat ventricular myocytes (NRVMs) exposed to palmitic acid (200μM) for 48h. Selective inhibition of SETD7 by (R)-PFI-2 was performed in skinned cardiomyocytes isolated from left ventricular specimens of obHFpEF patients. Passive stiffness, a main feature of HFpEF, was assessed before and after (R)-PFI-2 treatment.

Results

CMEs profiling showed SETD7 as the top-ranking transcript (fold change, 7.36, P&lt;0.01) in myocardial specimens from obHFpEF patients as compared to controls. ChIP-Seq in CMs showed a strong enrichment of SETD7 and H3k4me1 on the promoter of NF-kB p65 gene, a master regulator of inflammation. SETD7 and H3k4me1 were upregulated in HFpEF vs. control mouse hearts, showed enrichment on NF-kB p65 promoter and were associated with IL-1β and IL-6 upregulation. In HFpEF mice, cardiomyocyte-specific deletion of SETD7 protected against LV hypertrophy, diastolic dysfunction (assessed by E/E' ratio) and lung congestion while improving exercise tolerance. At the molecular level, SETD7 deletion blunted H3K4me1 enrichment on p65 promoter thus preventing the upregulation of inflammatory genes and myocardial apoptosis. In cultured CMs exposed to PA, SETD7 inhibition by (R)-PFI-2 prevented H3k4me1-driven p65 upregulation, whereas SETD7 overexpression mimicked HFpEF features. Moreover, knockdown of NF-kB p65 prevented IL-1β/IL-6 transcription in SETD7-overexpressing CMs. Of clinical relevance, (R)-PFI-2 reduced passive stiffness in skinned CMs isolated from obHFpEF patients.

Conclusions

Our results unveil a new epigenetic mechanism underpinning inflammation in obHFpEF. Targeting SETD7 may represent a novel therapeutic approach to prevent HFpEF in obesity.

Funding Acknowledgement

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

Tenascin-C provokes cardiac fibrosis and endothelial impairment in Duchenne Muscular Dystrophy

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): FWF Austrian Science Fund

Cardiac fibrosis and dilated cardiomyopathy are major contributors to mortality in Duchenne muscular dystrophy (DMD) patients. There is a growing collection of evidence that Tenascin C (TN-C) plays a maladaptive role in cardiac remodelling and fibrosis.

Our aims were to 1) assess the vascular dysfunction and cardiac fibrosis and its link to TN-C in a mouse model of DMD and 2) explore the effect of knocking out TN-C in dystrophic mice.

Male wt, mdx and mdx TN-C KO age-matched mice were used. Cardiac fibrosis was assessed on tissue sections. Wire myography was used to test the vascular reactivity and endothelial cells (ECs) were isolated from mouse lung tissues to characterize the oxidative stress and inflammatory marker expression. To study the signalling pathways contributing to cardiac fibrosis, human cardiac fibroblasts (hCFs) were treated with TN-C or TGF-β and gene expression and epigenetic regulation of p65 were assessed.

Cardiac fibrosis was markedly increased in mdx mice which was accompanied with elevated TN-C level in cardiac tissue and plasma compared to wt animals. In addition, endothelial cells isolated from mdx mice also showed a marked upregulation of oxidative stress and inflammatory markers and in line with that vascular endothelial function was impaired in mdx mice. Interestingly, mdx- TN-C KO mice showed preserved vascular function as well as reduced cardiac fibrosis compared to age-matched mdx mice. hCFs treated with TN-C or TGF-β showed increased collagen and α-SMA expressions which could be reduced by TN-C siRNA. In addition, both TN-C and TGF-β promote p65/NF-κB promoter demethylation and subsequently stimulate pro-inflammatory and pro-fibrotic signalling, which could be reversed by applying p38 MAPK inhibitor in hCFs.

TN-C promotes oxidative stress and inflammation in ECs and fibroblasts, contributing to severe endothelial dysfunction and cardiac fibrosis. In addition, activation of NF-κB p65 signalling pathway may play a role in TN-C induced fibrosis. Thus, TN-C may be a critical mediator and potential target for therapy in DMD.

Access site bleeding complications comparing oral anticoagulation therapy with NOACs and VKAs in patients with atrial fibrillation undergoing cardiac implantable device intervention

Funding Acknowledgements

Type of funding sources: None.

Background

Atrial fibrillation is frequent in patients undergoing cardiac implantable electronic device (CIED) intervention. Such population require oral anticoagulation therapy, which increases risk of procedure related bleeding. There is a lack on data on procedure-related bleeding outcome with non-vitamin K antagonist anticoagulants (NOACs) vs vitamin K antagonist anticoagulants (VKAs) in patients with AF undergoing CIED intervention.

Study purpose

Aim of the present stud was to evaluate whether NOACs have a safety benefit compared to VKAs in terms of fewer hemorrhagic complications at the site of CIED implant.

Methods

Consecutive AF patients receiving NOACs or VKAs at the time of CIED procedure were included in this observational, retrospective, monocentric investigation. Primary endpoint was the incidence of post-intervention clinically significant pocket hematoma. Multivariate analysis was performed to investigate the association between covariates and the primary endpoint.

Results

A total of 311 patients were enrolled, 146 on NOACs and 165 on VKAs. The incidence of pocket hematoma was 3.4% in the NOAC vs 13.3% in the VKA group (p=0.002) (Figure 1). Primary outcome-free survival at 30-days was 96.6 % in patients on NOACs and 86.0% in those on VKAs (p=0.019) (Figure 2). Multivariate analysis, adjusted by propensity-score calculation of inverse-probability-weighting, showed a significantly lower occurrence of pocket hematoma in patients receiving NOACs vs VKAs (HR 0.35, 95% CI 0.13-0.96, p=0.042). Such NOACs benefit was confirmed vs patients on VKAs without peri-procedural bridging with low-molecular weight heparin (HR 0.34, 95% CI 0.11-0.99, p=0.048). The incidence of pocket infection, surgical pocket evacuation, ischemic events and major bleeding complications at 30 days (secondary endpoints) was similar in the two groups.

Conclusion

Among patients with AF undergoing implantable cardiac defibrillator or pace-maker intervention, the use of NOACs vs VKAs is associated with significant reduction of post-procedural pocket hematoma, regardless of bridging with low molecular-weight heparin in the VKA group.

Active Surveillance Cultures and Procalcitonin in Combination With Clinical Data to Guide Empirical Antimicrobial Therapy in Hospitalized Medical Patients With Sepsis

Objective

The prevalence of colonization with multidrug-resistant organisms (MDRO) has increased over the last decade, reaching levels as high as 23% in certain patient populations. Active surveillance cultures (ASC) represent a valuable tool to identify patients colonized with MDRO to apply preventive measures, reduce transmission, and guide empiric antimicrobial therapy. There is a paucity of data evaluating the impact of admission ASCs to predict future infection. The aim of this study was to evaluate the concordance between ASCs results and the development of clinical infection by the same microorganism identified in the surveillance swab ("swab-related infection"), in hospitalized septic patients, and to evaluate the presence of specific risk factors associated with the development of a swab-related infection.

Methods

All adults admitted to the Diagnostic and Therapeutic Medicine Department of the University Hospital Campus Bio-Medico of Rome with a diagnosis of infection or any other medical reason with admission surveillance swabs (rectal or nasal) between January 2018 and February 2021 were included in the study. A retrospective chart review was conducted to identify patients that developed infections with concordant MDROs identified on ASC, and the risk factors for swab-related infection. Secondary outcomes were need of intensive care unit transfer, length of stay, sepsis or septic shock development, and all-cause mortality.

Results

A total of 528 patients were included in the study, of which 97 (18.3%) had a positive surveillance swab. Among patients with positive surveillance swabs, 18 (18.5%) developed an infection with the same microorganism recovered from the swab, 57 (58.8%) developed an infection with a different microorganism than that recovered from the surveillance swab, and 22 (22.7%) did not develop an infection during hospitalization. The number of colonized sites, an interventional procedure within the previous 3 months, a Systemic Inflammatory Response Syndrome (SIRS) score ≥ 2, and a quick Sequential Organ Failure Assessment (q-SOFA) score ≥ 2 were associated with a significantly higher risk of developing a swab-related infection. SIRS and q-SOFA scores ≥ 2 and procalcitonin ≥ 0.43 ng/ml help for identifying patients with a swab-related infection.

Conclusion

Patients with positive surveillance swabs were at increased risk for development of infections by the same MDRO identified in surveillance swabs (swab-related infection). This study is the first to show that the positivity of surveillance swabs, in combination with anamnestic data, PCT values, and SIRS or q-SOFA scores, serves as a valuable tool to help clinicians predict patients at higher risk for swab-related infection development and guide the administration of appropriate empiric antimicrobial therapy in septic patients.

Targeting the methyltransferase setd7 prevents myocardial ischemic injury: a translational study

Background

Despite appropriate revascularization strategies, a significant number of patients with myocardial infarction (MI) develop ischemic heart failure suggesting that breakthrough therapies are yet to be approved in this setting. Methylation of non-histone proteins is emerging as a central regulatory mechanism in health and disease. The methyltransferase SETD7 has shown to methylate and alter the function of a variety of proteins in vitro, however its function in the heart is poorly understood.

Purpose

In the present study we sought to determine the role of SETD7 in myocardial ischemic injury.

Methods

Neonatal rat ventricular myocytes (NRVM) were exposed to glucose deprivation (GD) for 15 h, in the presence of the selective SETD7 inhibitor [(R)-PFI-2] or its inactive enantiomer [(S)-PFI-2]. Western blot and real time PCR were employed to investigate the effects of energy stress on SETD7 and the Hippo pathway, while apoptosis and oxidative stress were assessed by Caspase-3 activity assay and mitochondrial swelling. YAP activity was assessed through chromatin immunoprecipitation assay (ChIP), its localization was examined by confocal microscopy while mono-methylation was assessed by immunoblotting. Expression of YAP-dependent antioxidant genes was assessed by western blot. SETD7 knockout (SETD7−/−) mice and wild-type (WT) littermates underwent ischemia/reperfusion (I/R) injury. Rats underwent permanent ligation of left anterior descending coronary artery (MI). Left ventricular (LV) myocardial samples were collected from mice undergoing I/R injury and patients with ischemic cardiomyopathy (ICM) and treated ex-vivo with (R)-PFI-2. SETD7 and antioxidant genes expression was assessed in peripheral blood mononuclear cells (PBMCs) from patients with ST-elevation MI (STEMI).

Results

We show that SETD7 is activated upon energy deprivation in cultured NRVMs and methylates the Hippo pathway effector YAP, leading to its cytosolic retention and impaired transcription of antioxidant genes. Pharmacological inhibition of SETD7 by (R)-PFI-2 restored YAP nuclear localization thus preventing mitochondrial reactive oxygen species (mtROS) and apoptosis. SETD7 deletion in mice attenuated I/R injury, mtROS and LV dysfunction by restoring YAP-dependent transcriptional programs. SETD7/YAP dysregulation was also observed in rats with MI and LV specimens from ICM patients. Of note, (R)-PFI-2 treatment prevented titin oxidation and myofilament stiffness in cardiomyocytes isolated from I/R mice and patients with ICM. Finally, SETD7 was upregulated in STEMI patients and its expression negatively correlated with antioxidant genes.

Conclusions

Targeting SETD7 may represent a valid therapeutic strategy to protect the heart during ischemia.

Funding Acknowledgement

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

Diagnostic Accuracy and Prognostic Value of Neutrophil-to-Lymphocyte and Platelet-to-Lymphocyte Ratios in Septic Patients outside the Intensive Care Unit

Background and Objectives: The aim of this study was to evaluate the diagnostic accuracy and prognostic value of neutrophil-to-lymphocyte (NLR) and platelet-to-lymphocyte (PLR) ratios and to compare them with other biomarkers and clinical scores of sepsis outside the intensive care unit. Materials and methods: In this retrospective study, 251 patients with sepsis and 126 patients with infection other than sepsis were enrolled. NLR and PLR were calculated as the ratio between absolute values of neutrophils, lymphocytes, and platelets by complete blood counts performed on whole blood by Sysmex XE-9000 (Dasit, Italy) following the manufacturer’s instruction. Results: The best NLR value in diagnosis of sepsis was 7.97 with sensibility, specificity, AUC, PPV, and NPV of 64.26%, 80.16%, 0.74 (p < 0.001), 86.49%, and 53.18%, respectively. The diagnostic role of NLR significantly increases when PLR, C-reactive protein (PCR), procalcitonin (PCT), and mid-regional pro-adrenomedullin (MR-proADM) values, as well as systemic inflammatory re-sponse syndrome (SIRS), sequential organ failure assessment (SOFA), and quick-sequential organ failure assessment (qSOFA) scores, were added to the model. The best value of NLR in predicting 90-day mortality was 9.05 with sensibility, specificity, AUC, PPV, and NPV of 69.57%, 61.44%, 0.66 (p < 0.0001), 28.9%, and 89.9%, respectively. Sensibility, specificity, AUC, PPV, and NPV of NLR increase if PLR, PCR, PCT, MR-proADM, SIRS, qSOFA, and SOFA scores are added to NLR. Conclusions: NLR and PLR represent a widely useful and cheap tool in diagnosis and in predict-ing 90-day mortality in patients with sepsis.

High value of mid-regional proadrenomedullin in COVID-19: A marker of widespread endothelial damage, disease severity, and mortality

The widespread endothelial damage due to severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) may lead to a disruption of the adrenomedullin (ADM) system responsible for vascular leakage, increased inflammatory status, and microvascular alteration with multi‐organs dysfunction. The aim of this study was to evaluate the role of mid‐regional proadrenomedullin (MR‐proADM) as a marker of SARS‐CoV2 related widespread endothelial damage, clinically identified by organs damage, disease severity and mortality. Patients with SARS‐CoV‐2 infection has been prospectively enrolled and demographic characteristic, clinical and laboratory data has been evaluated. In the overall population, 58% developed acute respiratory distress syndrome (ARDS), 23.3% of patients died, 6.5% acute cardiac injury, 1.4% of patients developed acute ischemic stroke, 21.2% acute kidney injury, 11.8% acute liver damage, and 5.4% septic shock. The best MR‐proADM cut‐off values for ARDS development and mortality prediction were 3.04 and 2 nmol/L, respectively. Patients presenting with MR‐proADM values ≥2 nmol/L showed a significantly higher mortality risk. In conclusion, MR‐proADM values ≥2 nmol/L identify those patients with high mortality risk related to a multiorgan dysfunction syndrome. These patients must be carefully evaluated and considered for an intensive therapeutic approach.

Abstract SP112: Spatial variance signatures/Intra-tumor zonation in TNBC

It is increasingly clear that triple negative breast cancer (TNBC) is a heterogeneous disease with variable clinical presentation, histological features and response to therapy. While these differences have been partially explained by inter- and intra-tumoral heterogeneity, spatial heterogeneity represented by the tumor architecture plays a critical role in clonal evolution and displays a landscape for different compartment-specific processes and cell-to-cell specific interactions. To better understand the impact of spatial heterogeneity on gene-expression-defined cell populations, we have coupled single-cell RNA sequencing with multiplex immunofluorescence (IF). Multiplex immunofluorescence using specific markers for each cell cluster, integrated with computational image analyses and neighborhood maps, has revealed spatial zonation of single cell subpopulations. Zonation of single cell populations was coupled to hypoxia and overlayed distinct metabolic tumor zones and defined areas of differential stress and cell plasticity that give rise to tumor cells with enhanced fitness and aggressivity.

Citation Format: M Park, C Martínez Ramirez, Y Yang, A Blanchet-Cohen, H Kuasne, A Fortier, J Ragoussis, P Savage, A Omeroglou, S Meterissian, S Costantino, C Kleinman. Spatial variance signatures/Intra-tumor zonation in TNBC [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr SP112.

A chromatin signature by the methyltransferase SETD7 regulates semaphorin-3G transcription and angiogenic response in diabetes: insights for personalized epigenetic therapies

Background

Despite advances in revascularization strategies, type 2 diabetic (T2D) patients with peripheral artery disease (PAD) continue to have a high risk of limb amputation. Modulation of blood vessel growth holds great promise for the treatment of PAD patients. Epigenetic modifications, namely histone post-translational modifications, have shown to regulate transcriptional programs implicated in the pathogenesis of cardiovascular disease.

Aim

To investigate the role of chromatin changes in regulating post-ischemic vascularization in experimental diabetes as well as in patients with T2D.

Methods

Experiments were performed in primary human aortic endothelial cells (HAECs), double-mutant leptin deficient mice (Lepdb/db) carrying a genetic deletion of the methyltransferase SETD7 (Setd7−/−Lepdb/db) as well as in gastrocnemius muscle samples from T2D patients with PAD and age-matched non-diabetic controls. Unbiased gene expression profiling was performed by RNA sequencing (RNA-seq) followed by Ingenuity Pathway Analysis (IPA). Pharmacological blockade of SETD7 was performed by using the selective inhibitor (R)-PFI-2. Scratch and tube formation assays were performed to investigate the impact of SETD7 on angiogenic response.

Results

RNA-seq in high glucose-treated HAECs revealed a profound upregulation of the methyltransferase SETD7 (fold change 2.8, p&lt;0.001), an enzyme involved in mono-methylation of lysine 4 at histone 3 (H3K4me1). Both SETD7 gene silencing and pharmacological inhibition by (R)PFI-2 rescued hyperglycemia-induced impairment of HAECs migration and tube formation, while SETD7 overexpression blunted the angiogenic response. RNA-seq and Chromatin Immunoprecipitation (ChIP) assays showed that SETD7-dependent H3K4me1 regulates the transcription of the angiogenesis inhibitor semaphorin-3G (SEMA-3G). Increased SEMA-3G transcript was associated with enhanced secretion from HAECs. Co-immunofluorescence experiments showed that SEMA-3G blunts the angiogenic response by competing with VEGF receptors VEGFR/Neuropillin2. Moreover, SEMA-3G overexpression blunted migration and tube formation in SETD7-depleted HAECs. SETD7 and SEMA-3G were significantly upregulated in endothelial cells from Lepdb/db mice, whereas SEMA-3G transcription was blunted in Setd7−/−Lepdb/db animals. Consistently, endothelial sprouting was defective in aortas from Lepdb/db as compared to WT mice, whereas Setd7−/−Lepdb/db mice displayed a preserved angiogenic response. Of clinical relevance, SETD7/SEMA-3G axis was upregulated in gastrocnemius muscle specimens from T2D patients with PAD as compared with non-diabetic controls.

Conclusion

In HAECs, genetically modified mice and T2D patients we show that SETD7-dependent chromatin changes regulate SEMA-3G transcription and angiogenic response. Pharmacological inhibition of SETD7 may represent a novel epigenetic therapy to boost neovascularization in T2D patients with PAD.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): University of Zurich/Universitätsspital Zürich

miR-673/menin/JunD axis modulates hyperglycemia-induced oxidative stress and inflammation in the diabetic heart

Background

Hyperglycemia-induced reactive oxygen species generation in diabetic heart contributes to myocardial dysfunction. JunD, a member of the activated protein 1 (AP-1) family of transcription factors, is emerging as a major gatekeeper against oxidative stress. Previous studies have shown that downregulation of AP-1 transcription factor JunD is involved in vascular aging and heart failure. However, the role of JunD in diabetes-induced myocardial dysfunction is unknown.

Purpose

The present study was designed to investigate whether hyperglycemia-driven epigenetic regulation of JunD contributes to oxidative stress, inflammation and myocardial dysfunction in the diabetic heart.

Methods

Diabetes (DB) was induced in C57BL/6 wild-type (WT) mice by streptozotocin. After four weeks of DB, left ventricular (LV) function was assessed by standard and 2D speckle-tracking echocardiography in both groups (n=10). Then, the animals were euthanized and LV specimens were collected to determine JunD mRNA and protein expression as well as superoxide anion production by ESR spectroscopy. Chromatin modifications of JunD gene promoter were assessed by chromatin immunoprecipitation. Isolated DNA was analyzed for promoter methylation following Methylminer kit. Cardiac biopsies were collected from age-matched patients with and without diabetes.

Results

DB mice showed LV dysfunction with reduced ejection fraction and fractional shortening. JunD mRNA and protein expression were reduced in the myocardium of DB as compared to control mice. JunD downregulation was associated with oxidative stress, increased NF-kB binding activity and expression of inflammatory mediators. Accordingly, expression of free radical scavenger superoxide dismutase 1 and aldehyde dehydrogenase 2 was reduced, whereas nicotinamide adenine dinucleotide phosphate oxidase subunits NOX2 and NOX4 were upregulated in DB. A reduction of JunD mRNA and protein expression was confirmed in LV specimens obtained from patients with diabetes. The downregulation of JunD was epigenetically regulated by promoter hypermethylation and histone modifications. Post-translational repression by tumor suppressor menin also contributed to JunD downregulation. Indeed, menin was significantly upregulated in DB hearts and co-immunoprecipitation experiments confirmed the binding of menin to JunD. Furthermore, rat ventricular myocytes exposed to high glucose (HG) showed increased menin expression. We found that miR-673 targeting menin was downregulated in hearts of DB mice. Reprogramming miR-673 in HG-treated myocytes was able to restore both menin and JunD expression to control levels.

Conclusions

Our findings show that downregulation of AP-1 transcription factor JunD contributes to diabetes-induced myocardial dysfunction and miR-673/menin/JunD represents a novel molecular axis involved in hyperglycemia-induced ROS-driven cardiac damage.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): European Society of Cardiology (ESC) Research Grant 2017

Methylation of the hippo signalling effector YAP by SETD7 drives myocardial ischemic injury

Introduction

Myocardial ischemia/reperfusion (I/R) injury is one of the most deleterious cardiovascular conditions and a leading cause of mortality. The Hippo pathway effector YAP critically regulates cardiomyocyte proliferation and survival during myocardial I/R injury. However, the mechanisms regulating YAP activation in this setting remain poorly understood. Post-translational modifications of proteins, namely methylation, modulate pathways implicated in myocardial I/R injury. The methyltransferase SETD7 is emerging as a regulator of cell survival via methylation of histone and non-histone proteins. Whether SETD7 participates to myocardial I/R injury remains elusive.

Purpose

To investigate the role of SETD7 in regulating Hippo signaling during myocardial I/R injury.

Methods

Neonatal rat ventricular myocytes (NRVM) were exposed to normal glucose levels or glucose deprivation (GD) for 15 h, in the presence of the selective SETD7 inhibitor [(R)-PFI-2] or its inactive enantiomer [(S)-PFI-2]. Western blot and real time PCR were employed to investigate the effects of energy stress on SETD7 and the Hippo pathway, while apoptosis was assessed by Caspase-3 activity assay. YAP activity was assessed through chromatin immunoprecipitation assay (ChIP), its localization was examined by confocal microscopy while mono-methylation was assessed by immunoblotting. SETD7 knockout (SETD7−/−) mice and wild-type (WT) littermates (male, 8–12 weeks old) underwent 1 h of left anterior descending (LAD) coronary artery ligation followed by 24 h of reperfusion. Infarct size was assessed by TTC staining and shown as infarct size per ventricle surface (I/V). Cardiac function was investigated at 24h by conventional and Tissue Doppler Imaging (TDI) echocardiography.

Results

GD in NRVMs led to upregulation of SETD7 and physical interaction with the pro-survival transcriptional cofactor YAP, resulting in its direct mono-methylation. Furthermore SETD7-dependent methylation of YAP led to its cytosolic retention and subsequent reduction of YAP binding to the promoter of pro-survival genes. Of note, pharmacological inhibition of SETD7 by (R)-PFI-2 blunted YAP mono-methylation while restoring its nuclear retention. Mechanistically, SETD7 inhibition promoted YAP binding to catalase and superoxide dismutase (SOD) gene promoters, thus preventing GD-induced mitochondrial oxidative stress and apoptosis. In line with our in vitro findings, SETD7−/− mice showed decreased infarct size as compared to WT littermates and preserved cardiac systolic (ejection fraction, fractional shortening) and diastolic function, as assessed by both conventional and TDI echocardiography.

Conclusions

We show that SETD7-dependent methylation of YAP is required for its inactivation, thus leading to myocyte oxidative stress and apoptosis. Pharmacological modulation of SETD7 by (R)-PFI-2 may represent a new therapeutic approach to prevent myocardial ischemic damage through modulation of the Hippo pathway.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Swiss Heart Foundation

Baseline interleukin1beta expression in peripheral blood monocytes predicts the extent of weight loss and nonalcoholic fatty liver improvement in obese subjects with prediabetes or type 2 diabetes

Background

Non-alcoholic fatty liver disease (NAFLD) represents a hallmark of metabolic syndrome. Interleukin-1β (IL-1β), a well-studied cytokine involved in obesity-related systemic inflammation as well as in the pathogenesis of type 2 diabetes (T2D), promotes hepatic steatosis by stimulating triglycerides and cholesterol accumulation in primary liver hepatocytes and lipid droplets formation. The most compelling evidence for a major role for IL-1β in metabolic imbalance and inflammation comes from the recent Canakinumab Anti-inflammatory Thrombosis Outcome (CANTOs)trial, where inhibition of IL-1β pathway was associated with a reduction of cardiovascular events in high-risk patients.

Purpose

The present study was designed to determine: i)whether an equal degree of weight loss by liraglutide or lifestyle changes has a different impact on NAFLD extent and IL-1β expression in peripheral blood mononuclear cells from obese subjects with prediabetes or early T2D; ii)whether baseline IL-1β levels may predict the extent of weight loss and related metabolic changes.

Methods

Thirty-two metformin-treated obese subjects with prediabetes [impaired fasting glucose (IFG) or impaired glucose tolerance (IGT) or both (n=16)] or newly diagnosed T2D (n=16), were randomized to the glucagon-like peptide receptor agonist (GLP-RA) liraglutide (1.8 mg/d) or lifestyle counselling until achieving a modest and comparable weight loss (−7% of initial body weight). Visceral (VAT) and adipose tissue distribution were assessed by magnetic resonance. Gene expression of IL-1β in peripheral blood mononuclear cells was assessed by real time PCR.

Results

At baseline, IL-1β positively correlated to body mass index (BMI) (rho=0.421, p=0.016), fasting plasma glucose (rho=0.415, p=0.018), HbA1c (rho=0.349, p=0.050), VAT (rho=0.388, p=0.028), NAFLD (rho=0.454, p=0.009), platelet count (rho=0.510, p=0.003), chemerin (rho=0.455, p=0.009) and interleukin-1 receptor agonist (IL1-RA) (rho=0.519, p=0.002). After achievement of the weight loss target in the two groups, a comparable reduction of IL-1 β (p&lt;0.001 lifestyle changes; p=0.029 liraglutide treatment) was observed in both arms, in parallel with a comparable improvement in glycaemic control, C-reactive protein (CRP),BMI and NAFLD. Furthermore, basal levels of IL-1β correlated directly with delta BMI (p=0.015) and delta NAFLD (p=0.002) (Figure 1).

Conclusion

In obese patients with initial impairment of glucose metabolism, IL-β-driven inflammation correlates with glycaemic control, adipose tissue distribution and platelet count. Successful weight loss, achieved with either lifestyle changes or an incretin-based therapy, is associated with a significant reduction of both IL-1β levels and NAFLD degree. Of interest, basal levels of IL-1β predicts the extent of weight loss and NAFLD improvement, regardless of the intervention. Our results may set the stage for ad-hoc studies investigating the usefulness of baseline IL-1β a levels as a drug-response biomarker.

Figure 1

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): This study was supported by a grant from the Italian Ministry of University and Research (PRIN no. 2010JS3PMZ to F.S.).

IL-23 promotes T-cell mediated cardiac inflammation but protects the heart from fibrosis

Introduction

Cardiac inflammation varies widely and, in some cases, triggers autoimmune myocarditis and further inflammatory dilated cardiomyopathy (iDCM) and heart failure. In children, myocarditis leads to cardiomyopathy in almost half of affected individuals and up to 20% of sudden death cases in young adults have been reported to be due to myocarditis. IL-12 and IL-23 belong to the same family of cytokines known to mediate inflammatory conditions. Both regulate the differentiation of T cells: IL-12 promotes towards IFN-gamma-producing Th-1 cells, while IL-23 induces IL-17-producing Th-17 cells. Heart-reactive CD4+Th17 cells play a leading role in the development of myocarditis, however, literature reports excessiveness of IL-23 in Th17-derived IL-17 production. Therapeutic strategies blocking IL-23 were suggested as a promising approach, though the specific role of IL-23 in pathogenesis is unclear and the long-term perspectives stay elusive.

Purpose

We aim to explore the role IL-23 compared to IL-12 in the manifestation of cardiac autoimmune myocarditis.

Methodology

We use dendritic cell (DC) model of experimental autoimmune myocarditis in IL-12 and IL-23-deficient mice. Mice were injected with bone marrow-derived in vitro activated and loaded with cardiac-specific peptide DCs. This model mimics natural processes taking place during heart inflammation and provides a unique method to address the role of DCs-derived cytokines. Cardiac inflammation, as well as remodeling and heart function, were analysed at the acute and chronic stages of the disease.

Results

Surprisingly, all mice developed acute myocarditis, though wt receiving IL-23−/−bmDCs showed a twofold decrease in heart-infiltrating T cells and lower numbers of Th17 population. Further decrease of heart-infiltrating T cells appeared upon total systemic IL-23 deficiency. In comparison to IL-12, directly inducing differentiation of IFN-gamma–producing Th1, IL-23 cannot induce Th17 differentiation. None of the two cytokines affect proliferation, though, IL-23 activates T cell migratory potential and increases T cell migration by twofold. At the same time, deficiency of IL-23-production by bmDCs leads to lower migration of T cells. We also show an involvement of RhoA, and the other Rho GTPases, in the mechanism of migration as blocking revoke the IL-23 effect on T cells. Moreover, we further observed more fibrosis and worse heart functioning in IL-23−/−, but not IL-12−/− mice at the chronic stage what underlines the importance of IL-23-dependent T cell trafficking in the resolution of the acute stage of autoimmune myocarditis.

Conclusion

Our observations underline IL-23 as an important cytokine responsible for T cell trafficking and resolution of the inflammation in autoimmune myocarditis. Therapeutic approaches involving inflammatory cytokine targeting are a promising clinical perspective though IL-23 deficiency might lead to increased cardiac remodeling and iDCM progression.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): The Swiss National Science Foundation

Best diagnostic accuracy of sepsis combining SIRS criteria or qSOFA score with Procalcitonin and Mid-Regional pro-Adrenomedullin outside ICU

Early diagnosis and treatment significantly reduce sepsis mortality. Currently, no gold standard has been yet established to diagnose sepsis outside the ICU. The aim of the study was to evaluate the diagnostic accuracy of sepsis defined by SIRS Criteria of 1991, Second Consensus Conference Criteria of 2001, modified Second Consensus Conference Criteria of 2001 (obtaining SIRS Criteria and SOFA score), Third Consensus Conference of 2016, in addition to the dosage of Procalcitonin (PCT) and MR-pro-Adrenomedullin (MR-proADM). In this prospective study, 209 consecutive patients with clinical diagnosis of sepsis were enrolled (May 2014-June 2018) outside intensive care unit (ICU) setting. A diagnostic protocol could include SIRS criteria or qSOFA score evaluation, rapid testing of PCT and MR-proADM, and SOFA score calculation for organ failure definition. Using this approach outside the ICU, a rapid diagnostic and prognostic evaluation could be achieved, also in the case of negative SIRS, qSOFA or SOFA scores with high post-test probability to reduce mortality and improve outcomes.

A Staphylococcus aureus Coinfection on a COVID-19 Pneumonia in a Breast Cancer Patient

Introduction

Coronavirus disease 19 (COVID-19), due to severe acute respiratory syndrome-coronavirus 2 (SARS-CoV2), comprises a broad spectrum of clinical presentation ranging from flu-like syndrome to organ failure. The risk of coinfections is high and responsible for a worse prognosis, mainly in the case of bacterial involvement and in the presence of particular comorbidity. We present the clinical, laboratory, radiologic characteristic along with therapeutic management of a patient with COVID-19 and Staphylococcus aureus coinfection.

Case Presentation

A 55-year-old Caucasian woman was admitted to our hospital due to a two-day history of fever and acute dyspnea with severe respiratory failure worsened after the administration of atezolizumab and nab-paclitaxel. Her medical history comprehended a triple negative, BRCA1-related, PD-L1 positive right breast cancer with multiple bone metastasis, causing bone marrow infiltration-related severe pancytopenia. Her physical examination revealed scattered wheezes, rales, and bilateral dry crackles in the middle and lower lung fields and lower limb paresis. The body mass index was 30 kg/m² and arterial blood gas evaluation revealed a stage III acute respiratory distress syndrome. Microbiological specimens revealed a Staphylococcus aureus positivity from endotracheal aspirate. The chest computed tomography (CT) scan showed the presence of large areas of parenchymal consolidation and aerial bronchogram, bilateral “ground glass” areas reaching the highest extension on the upper and middle zones. The high clinical and radiological suspicion of COVID-19 along with the negative result of nasopharyngeal specimen make necessary an endotracheal aspirate resulting positive for SARS-CoV2. Patient started an antimicrobial treatment and lopinavir-ritonavir plus hydroxychloroquine but, unfortunately, died five days after hospital admission.

Conclusion

The high risk of mortality of our patient was due to viral-bacterial coinfection, advanced cancer status with active immunotherapy. This case highlights the need for a prompt clinical, laboratory, and radiological evaluation to allow a correct diagnosis and start a specific therapy.

An algorithm of good clinical practice to reduce intra-hospital 90-day mortality and need for Intensive Care Unit transfer: a new approach for septic patient management

Sepsis accounts for 50% of intra-hospital mortality. Septic shock is diagnosed in 2% of patients with half of these needing for Intensive Care Unit (ICU) transfer. An algorithm was applied for mortality, need for intensive care transfer and length of stay decrease. The observational study was performed on 231 consecutive enrolled patients with sepsis or septic shock admitted to the University Campus Bio-Medico of Rome. The algorithm was based on good clinical practice application of antimicrobial stewardship. Data were compared with data from comparable population of National and European surveys. In the study group, the global mortality rate was 26.8% (3.9% was intra-hospital and 23% 90-d mortality), need of ICU transfer was registered in 21.6%, and the median length of stay was 15 days. Globally, intra-hospital and 90-day mortality, were significantly lower than at national level (26.8% vs 63.6%, P<0.0001; 3.9% vs 25%, P<0.0001 and 23% vs 37.5%, P=0.0092). Need for ICU transfer in patients with septic shock was significantly lower than in the English survey (31.9% by vs 80.8% P<0.0001). A significant decrease of intra-hospital, 90-d mortality and need of ICU transfer was achieved.

Acute Epstein-Barr related myocarditis: An unusual but life-threatening disease in an immunocompetent patient

Myocarditis is an uncommon but potentially life-threatening disease. Clinical manifestations could range from subclinical disease to sudden death, due to fulminant heart failure and/or malignant ventricular arrhythmias. The most common cause of myocarditis is viral infection, including Epstein-Barr virus (EBV). Nevertheless, EBV rarely presents with cardiac involvement in immunocompetent hosts.

We report a case of acute EBV-related myocarditis in a young female, complicated with malignant ventricular arrhythmias and cardiac arrest. After 20 days of hospitalization and treatment, the patient was fit for discharge on pharmacological therapy (tapering steroids, beta-blockers, amiodarone, angiotensin-converting enzyme inhibitors, and diuretics). Clinical course is described, cardiac magnetic resonance images are shown.

This case underlines how myocarditis is a disease that should not be underestimated: it could present with life-threatening complications such as malignant arrhythmias and/or severe systolic dysfunction.

<Learning objective: Although Epstein-Barr virus rarely presents with cardiac involvement in immunocompetent hosts, the risk should not be underestimated, as it could present with life-threatening complications.>

Use of sacubitril/valsartan in Marfan syndrome-related cardiomyopathy: The first case report

RATIONALE

Marfan syndrome is a rare cause of heart failure due to primary or secondary cardiomyopathy. Recently, sacubitril/valsartan-an angiotensin receptor blocker-neprilysin inhibitor-has been added in clinical practice as a standard therapy for heart failure. To our knowledge, there are no data on sacubitril/valsartan's effects on cardiovascular outcomes in patients with Marfan syndrome.

PATIENT CONCERNS

A 24-year-old man was admitted to our Internal Medicine Department due to dyspnea, ascites, and leg swelling. Arterial blood gas analysis revealed severe hypoxemia with respiratory and metabolic alkalosis. Hilar congestion was highlighted on chest x-ray.

DIAGNOSES

Recurrent acute decompensated heart failure with reduced ejection fraction despite optimal medical therapy in Marfan-related cardiomyopathy.

INTERVENTIONS AND OUTCOMES

Sacubitril/valsartan was added to optimal medical therapy after hemodynamic stabilization allowing progressive clinical, laboratoristic, and echocardiographic improvement. Patient maintained a free survival from heart failure and a good quality of life until 9-month follow-up.

LESSONS

Sacubitril/valsartan should be effective on pathophysiologic mechanisms and cardiovascular outcomes of Marfan syndrome-related cardiovascular complications.

P736Histone marks induced by the methyltransferase SETD7 modulate angiogenic response in diabetes

Introduction

Despite advances in revascularization strategies, type 2 diabetic (T2D) patients with peripheral artery disease (PAD) continue to have a high risk of limb amputation. Hence, strategies that promote vascularization can be considered as a novel therapeutic option in T2D patients with PAD. Epigenetic modifications of histones and DNA have emerged as key modulators of gene expression. Mono-methylation of histone 3 at lysine 4 (H3K4m1) – a specific epigenetic signature induced by the methyltransferase SETD7 – favours a chromatin conformation enabling the transcription of genes involved in inflammation and oxidative stress.

Purpose

To investigate whether SETD7 modulates angiogenesis in experimental diabetes.

Methods

Human aortic endothelial cells (HAECs) were cultured in growth factor-free medium and exposed either to normal glucose (NG, 5 mM) or high glucose (HG, 25 mM) for 48 hours. SETD7 protein and H3K4me1 levels were investigated by Western blot and chromatin immunoprecipitation (ChIP). Knockdown of SETD7 was achieved by small interfering RNA (siRNA). Pharmacological blockade of SETD7 was performed by using the highly selective inhibitor (R)-PFI-2, while its inactive enantiomer, (S)-PFI-2, was used as a control. Scratch and tube formation assays were performed to investigate the impact of SETD7 on angiogenic properties of HAECs. RNA sequencing (RNA-seq) and Ingenuity Pathway Analysis (IPA) were employed to unveil putative genes regulated by SETD7 in HG-treated HAECs. SETD7 expression was also investigated in muscular specimens isolated from type 2 diabetic (db/db) mice and non-diabetic mice undergoing hindlimb ischemia for 21 days.

Results

HG exposure in HAECs led to a time-dependent increase of both SETD7 gene and protein expression, as compared to NG. SETD7 upregulation in HG-treated HAECs was associated with an increase of H3K4me1 levels as well as with impaired endothelial cell migration and tube formation. Of interest, both gene silencing and pharmacological blockade of SETD7 rescued hyperglycemia-induced impairment of angiogenic properties in HAECs. RNA-seq in HG-treated HAECs with and without SETD7 depletion unveiled an array of differentially expressed genes, which were mainly involved in blood vessel growth and angiogenic response, as assessed by IPA analysis. Among dysregulated genes, ChIP assays showed that SETD7-dependent chromatin changes enabled the transcription of Semaphorin 3G (SEMA-3G), a negative regulator of endothelial cell migration. Indeed, gene silencing of SETD7 blunted SEMA-3G expression in HAECs exposed to HG. Consistent with our in vitro observations, SETD7 was upregulated in adductor muscle specimens from db/db mice undergoing hindlimb ischemia as compared to non-diabetic animals.

Conclusions

Pharmacological blockade of SETD7 by (R)-PFI-2 may represent a potential therapeutic approach to boost post-ischemic vascularization in T2D patients with PAD.

2162Neurofibromin 2 (NF2) drives obesity-related endothelial dysfunction by targeting Caveolin-1: a study in mice and humans

Introduction

Endothelial dysfunction (ED) is a key underpinning of cardiovascular disease in obesity, but the underlying molecular mechanisms remain elusive. Neurofibromin 2 (NF2) is a scaffold-like protein implicated in various cellular processes, namely growth, differentiation and survival. NF2 is inactivated by Akt-dependent phosphorylation at Ser518, whereas its dephosphorylation by the myosin phosphatase target subunit 1 (MYPT-1) leads to an active conformation. The role of NF2 in obesity-related alterations of endothelial phenotype remains elusive.

Purpose

To investigate whether NF2 participates to ED in obesity.

Methods

Human aortic endothelial cells (HAECs) were exposed to palmitic acid (PA, 200 uM) or vehicle for 48 hours. Gene silencing of NF2 was performed by small interfering RNA (siRNA). Protein expression was assessed by Western blot. Nitric oxide (NO) levels were measured by using a colorimetric assay. The interaction of NF2 with endothelial proteins was investigated by co-immunoprecipitation. To specifically determine NF2 role in the endothelium, we generated mice with endothelium-specific deletion of NF2 (NF2 ECKO) by crossing NF2flox/flox mice with tamoxifen-inducible endothelial-specific cre mice [Cdh5(PAC)-CreERT2]. Endothelium-dependent relaxations to acetylcholine (Ach, 10–9 to 10–5 mol/L) were assessed in aortas isolated from male NF2 ECKO and wild type littermates, fed a control (10 kcal% fat) and a high fat diet (60 kcal% fat) for 20 weeks. NF2 signalling and endothelial function were also assessed in small visceral fat arteries (VFA) isolated from 18 obese and 18 age-matched healthy subjects undergoing bariatric surgery and cholecystectomy, respectively.

Results

Exposure of HAECs to PA decreased NF2 phosphorylation at Ser518, thus leading to an active protein conformation. Blunted NF2 phosphorylation was explained by a reduction of Akt phosphorylation at Ser473 and a concomitant increase of MYPT-1 phosphorylation at Thr696. Pull-down experiments revealed that NF2 binds and activates Caveolin 1 (Cav-1), a pivotal repressor of endothelial NO synthase (eNOS). NF2 knockdown in PA-treated HAECs prevented eNOS–Cav-1 interaction, thus preserving eNOS activity and NO levels. In aortas from obese mice, we found that NF2-Cav-1 interaction was responsible for impaired eNOS activity, reduced NO levels and endothelial dysfunction. By contrast, Ach-dependent vasorelaxation were preserved in obese mice with endothelium-specific deletion of NF2. Moreover, we found that NF2 is activated in VFA from obese patients as compared to healthy controls, and its activity negatively correlated with Ach-dependent vasorelaxation of isolated VFA, as assessed by organ chamber experiments.

Conclusions

The present findings – obtained in human endothelial cells, conditional mouse models and visceral fat arteries from obese patients – suggest that targeting NF2 may represent a potential therapeutic strategy to prevent ED in patients with obesity.

P5378The methyltransferase SETD7 promotes myocardial ischemic injury by activating Hippo signalling

Introduction

Despite significant advances in coronary revascularization, acute myocardial infarction remains the leading cause of heart failure and death worldwide. The Hippo pathway is a master regulator of cell survival during myocardial ischemia. Upon cellular stress, activation of Hippo signaling leads to cytosolic retention and degradation of the pro-survival transcription factor YAP. Post-translational modifications, namely methylation, critically affect protein functionality in conditions of cellular stress. The SET domain-containing lysine methyltransferase 7 (SETD7) - which induces a specific mono-methylation of both histone and non-histone proteins - has recently emerged as key player in the pathogenesis of vascular disease. However, the role of SETD7 in the heart is largely unknown.

Purpose

The present study investigates whether SETD7 regulates the Hippo pathway during myocardial ischemia.

Methods

Neonatal rat ventricular myocytes (NRVM) were exposed to normal glucose levels or glucose deprivation (GD) for 15 h, in the presence of the selective SETD7 inhibitor [(R)-PFI-2] or its inactive enantiomer [(S)-PFI-2]. Western blot and real time PCR were employed to investigate the effects of energy stress on SETD7 and the Hippo pathway, while apoptosis was assessed by Caspase-3 activity assay. YAP localization was examined by confocal microscopy while its mono-methylation was assessed by immunoblotting. SETD7 knockout (SETD7−/−) mice and wild-type (WT) littermates (male, 8–12 weeks old) underwent 1 h of left anterior descending (LAD) coronary artery ligation followed by 24 h of reperfusion. Infarct size was assessed by TTC staining and shown as infarct size per ventricle surface (I/V). Cardiac function was investigated at 24h by conventional and Tissue Doppler Imaging echocardiography (Vevo 3100, Visualsonics).

Results

GD for 15h in NRVMs led to both YAP phosphorylation and mono-methylation, and subsequent cytosolic retention, as assessed by confocal microscopy. Reduced nuclear content of YAP was confirmed by downregulation of YAP-dependent pro-survival genes, namely Ctgf and Fgf2. GD-induced YAP inactivation was associated with an increase in SETD7 expression. Interestingly, pharmacological inhibition of SETD7 by (R)-PFI-2 blunted YAP mono-methylation, thus restoring nuclear retention of YAP and transcription of pro-survival genes in GD-treated NRVMs. Moreover, (R)-PFI-2 prevented NRVMs apoptosis. In line with our in vitro findings, SETD7−/− mice showed decreased infarct size as compared to WT littermates (I/V: 16.27%±2 vs. 20.54%±3, p<0.005, respectively). Consistently, cardiac function, as assessed by ejection fraction (EF: 46%±2 vs. 38%±5, p<0.001), fractional shortening (FS: 22%±1 vs. 18%±3, p<0.001) as well as by TDI, was preserved in mice lacking SETD7 as compared to WT animals.

Conclusions

Pharmacological modulation of SETD7 by (R)-PFI-2 may represent a novel therapeutic approach to prevent myocardial ischemic damage.

2287Endothelial SIRT6 exerts a beneficial role in cerebral ischemia/reperfusion injury by preserving blood-brain barrier integrity

Introduction

Stroke is a major cause of mortality and morbidity worldwide. Yet, therapeutic strategies are limited to the early reperfusion which can, on the other hand, worsen the brain damage trough ischemia/reperfusion (I/R) injury. Post-stroke blood-brain barrier (BBB) impairment is associated with worsened outcome. Aging is a major risk factor for stroke and genes regulating lifespan also contribute to the determination of cerebral damage during I/R injury.

Purpose

Given the pivotal role of endothelial cells in BBB, we hypothesized that the endothelial-specific expression of the longevity gene SIRT6 may protect the BBB from ischemia/reperfusion damage thus having a beneficial role on stroke outcome.

Methods

Endothelial-specific SIRT6 knockout (eSIRT6−/−) mice and control littermates (CTRL) underwent transient middle cerebral artery occlusion (tMCAO) for 45 min followed by 48 hours of reperfusion. Immunohistochemistry (IHC) was used to investigate BBB permeability by IgG extravasation and molecular mechanisms. Primary human brain microvascular endothelial cells (HBMVECs) transfected with either SIRT6 (siSIRT6) or scrambled (siSCR) small interfering RNA were subjected to hypoxia/reoxygenation (H/R). An in vitro BBB model consisting of a monolayer of siRNA-treated HBMVECs was established and barrier function was assessed by 48 h-lasting transendothelial electrical resistance measurement. SIRT6 expression in monocytes from stroke patients was correlated with the short-term neurological outcome [ΔNIHSS% = (NIHSS discharge-NIHSS admission)/ NIHSS admission*100].

Results

eSIRT6−/− displayed higher infarct volumes and lower survival rate compared to WT mice 48 h after tMCAO. The increased infarct volume was functionally relevant as eSIRT6−/− also showed worse post-stroke neurological impairment. Analysis of brain sections revealed increased BBB damage and increased endothelial expression of cleaved caspase-3 in eSIRT6−/− as compared to control littermates. In vitro, H/R reduced SIRT6 expression in HBMVECs. Mirroring the animal results, SIRT6 silencing impaired the barrier function of HBMVECs 48 h after exposure to H/R. In line with this, SIRT6-silenced HBMVECs showed reduced viability, increased cleaved caspase-3 expression and reduced activation of the anti-apoptotic survival pathway Akt as compared to control cells after H/R. The direct interaction between SIRT6 and Akt was confirmed by co-immunoprecipitation. In ischemic stroke patients, SIRT6 expression was higher in those with short-term neurological improvement (ΔNIHSS% >0) and negatively correlated with ΔNIHSS%.

Conclusion

Endothelial SIRT6 exerts a beneficial role in ischemic stroke by blunting I/R-mediated BBB damage. Specifically, SIRT6 reduces endothelial I/R-induced apoptotic death through activation of the protective Akt pathway. The longevity gene SIRT6 may represent a novel therapeutic target for the treatment of ischemic stroke.

Acknowledgement/Funding

Swiss National Science Foundation

The epigenetic landscape in the cardiovascular complications of diabetes

A growing body of evidence suggests that epigenetic modifications-changes to the genome that do not involve changes in DNA sequence-may significantly derail transcriptional programs implicated in angiogenesis, oxidative stress and inflammation, thus fostering cardiovascular damage in patients with diabetes. Notably, adverse epigenetic signals acquired over the life course can be transmitted to the offspring, and may contribute to early cardiovascular phenotypes in the young generations. Hyperglycaemia and insulin resistance-key hallmarks of diabetes-induce an array of epigenetic modifications (i.e., DNA methylation, histone marks, and non-coding RNAs) which are responsible for a long-lasting impairment of vascular and cardiac function, even after intensive glycemic control. Hence, unveiling the "epigenetic landscape" in patients with diabetes may provide a post-genomic snapshot of global cardiovascular risk, and may furnish the tools to design personalized, epigenetic-based therapies to alleviate the burden of cardiovascular disease in diabetic patients. The present review aims to acquaint the scientific community with the rapidly advancing field of epigenetics and its implications in the cardiovascular complications of diabetes.

Influenza B virus infection complicated by life-threatening pericarditis: a unique case-report and literature review

Background

Acute pericarditis may occur frequently after viral infections. To our knowledge, influenza B virus infection complicated by pericarditis without myocardial involvement has never been reported. We report the first case of life-threatening pericarditis caused by influenza B virus infection.

Case presentation

A 48-years-old woman with trisomy 21 and ostium primum atrial septal defect was transferred from Cardiology to our Internal Medicine Department for severe pericardial effusion unresponsive to ibuprofen and colchicine. Based on the recent patient history of flu-like syndrome, and presence of pleuro-pericardial effusion, a viral etiology was suspected. Laboratory evaluation and molecular assay of tracheal aspirate identified influenza B virus. Therefore, the ongoing metilprednisolone and colchicine therapy was implemented with oseltamivir with progressive patient improvement and no evidence of pericardial effusion recurrence during follow-up.

Conclusions

Especially in autumn and winter periods, clinicians should include Influenza B virus infection on differential diagnosis of pericarditis with large pericardial effusion.

Management and recommendations for the prevention of contrast-induced acute kidney injury: state of the art in clinical practice

Contrast-induced acute kidney injury (CI-AKI) is defined as an acute kidney failure following iodine-based contrast medium administration determining relevant health and socio-sanitary implications. Knowledge of pathophysiology, early diagnosis, and prevention in patients at risk are critical points in CI-AKI management. Determination of risk and functional kidney evaluation must precede every iodine-based contrast medium (CM) administration in order to eventually introduce medical prophylaxis. Furthermore, early laboratoristic evaluation after iodine-based CM exposure should be performed for a prompt identification of acute kidney injury. Therefore, clinicians must know and strictly follow valid recommendations to minimize the development of complications.

Diffuse maculopapular rash: A family cluster during the last Chikungunya virus epidemic in Italy

A family cluster of father, mother, and daughter with Chikungunya virus (CHIKV) infection was diagnosed during last epidemic in Italy. In temperate area, during the summer season, clinicians should consider CHIKV infection in the differential diagnosis of patients with fever, maculopapular rash, polyarthralgia, and conjunctival erythema.

Unusual Complication after Radiotherapy for Breast Cancer Bronchiolitis Obliterans Organizing Pneumonia Case Report and Review of the Literature

Breast-conserving surgery and postoperative radiotherapy play an important role in the treatment of early breast cancer. Bronchiolitis obliterans with organizing pneumonia (BOOP) is an uncommon syndrome reported to be one of the complications of adjuvant radiotherapy. We report the case of a 71-year-old woman who developed cough, dyspnea and fever three weeks after radiation therapy to the left breast for breast carcinoma. Chest X-ray and computed tomography scan demonstrated alveolar opacities within both lungs. Antibiotic therapy against any probable septic pathology did not improve the symptoms, while corticosteroid treatment resulted in rapid clinical improvement together with regression of the pulmonary opacities. Irradiation was thought to be the cause of the migratory pneumonitis, hence this case was clinically diagnosed as radiation-induced migratory pneumonitis similar to BOOP, without lung biopsy. The present case suggests that one should be mindful of this disease when treating patients with a history of irradiation to the breast. BOOP promptly responds to systemic corticosteroid therapy with rapid improvement of symptoms and regression of the pulmonary opacities.

What is changed in HBV molecular epidemiology in Italy?

Hepatitis B virus (HBV) infection represents the most common cause of chronic liver diseases worldwide. Consequently, to the introduction of the universal HBV vaccination program, the prevalence of hepatitis B surface antigen was markedly reduced and less than 1% of the population of Western Europe and North America is chronically infected. To date, despite great advances in therapeutics, HBV chronic infection is considered an incurable disease. Ten hepatitis B virus genotypes (A-J) and several subgenotypes have been identified so far, based on intergroup divergences of 8% and 4%, respectively, in the complete viral genome. HBV-D genotype has been found throughout the world, with highest prevalence in the Mediterranean area. In the present review, several articles concerning HBV epidemiology, and phylogeny in Italy have been analyzed, mainly focusing on the changes occurred in the last decade.

The role of procalcitonin in the diagnosis of bacterial infection after major abdominal surgery: Advantage from daily measurement

Postsurgical infections represent an important cause of morbidity after abdominal surgery. The microbiological diagnosis is not achieved in at least 30% of culture with consequent worsening of patient outcome. In this study, procalcitonin measurement, during the first 3 days after abdominal surgery, has been evaluated for the early diagnosis of postsurgical infection.Ninety consecutive patients subjected to major abdominal surgery at the University Campus Bio-Medico of Rome, have been included. PCT concentrations were measured by time-resolved amplified cryptate emission (TRACE) assay at admission and at the first, second, and third day after surgery. PCT levels were compared using the Mann-Whitney test and by ANOVA test for variance analysis. Receiver operating characteristic (ROC) analysis was performed to define the diagnostic ability of PCT in case of postsurgical infections.PCT values resulted significantly different between patients developing or not developing postsurgical infections. PCT >1.0 ng/mL at first or second day after surgery and >0.5 ng/mL at third day resulted diagnostic for infectious complication, whereas a value <0.5 ng/mL at the fifth day after surgery was useful for early and safety discharge of patients.In conclusion, PCT daily measurement could represent a useful diagnostic tool improving health care in the postsurgical period following major abdominal surgery and should be recommended.

Visceral leishmaniasis triggering an adult-onset Still's disease: a unique case

Adult‐onset Still's disease (AOSD) due to visceral leishmaniasis (VL) has not been previously reported. This case report analyzes a single episode of AOSD probably due to a visceral leishmaniasis successfully treated with pentamidine isethionate and prednisone.

Platypnoea-orthodeoxia syndrome in the elderly: A difficult-to-make diagnosis of intracardiac right-to-left shunt

Introduction

Platypnea-orthodeoxia syndrome is a combination of positional dyspnoea and hypoxemia; it is caused by several cardiac, pulmonary and hepatic diseases.

Case presentation

In this study, we describe a 77-year-old female affected by unexplained dizziness and hypoxia that exacerbated in upright position. After diagnosing platypnea-orthodeoxia syndrome and excluding all possible causes (liver cirrhosis, acute and chronic pulmonary diseases and arteriovenous malformations), the origin of the syndrome was individuated in the presence of a patent foramen ovale with right-to-left shunt. Endovascular patent foramen ovale closure permitted the resolution of symptoms and disappearance of platypnea-orthodeoxia syndrome.

Conclusion

Although patent foramen ovale may be present since birth without giving clinical signs, it may represent a common enough cause of platypnea-orthodeoxia syndrome and other vascular complications in the elderly.

Nosography of systemic inflammatory response syndrome, sepsis, severe sepsis, septic shock, and multiple organ dysfunction syndrome in internal medicine patients

Sepsis is defined by the presence of at least two systemic inflammatory response syndrome criteria associated with an infection microbiologically or clinically evidenced. In Italy sepsis is responsible for 80,000 hospital admissions per year and, in the last decades, severe sepsis and septic shock cases are increasing, in correlation with the increased prevalence of multi-drugresistant microbial strains. The predominant etiologic agents are Gram-positive and Gram-negative bacteria, but sepsis caused by fungi is increasing. The host response with both inflammatory and anti-inflammatory processes is responsible for organic failures, which complicate the syndrome, and for the susceptibility to secondary infections. The impairment of one or more organs or systems may be the onset clinical presentation. The organ dysfunctions complicating sepsis involve mainly cardiorespiratory system, kidneys, hemostatis and central nervous system. Fever or hypothermia, tachycardia, tachypnea, leukocytosis or leukopenia, elevated blood levels of lactate and procalcitonin, hypotension are diagnostically sensitive findings for sepsis. Definitive diagnosis requires isolation of the pathogen from blood sample or from the focus of infection. Therapeutic success against sepsis depends on the appropriate use of antibiotics, on the treatment of hemodynamic and respiratory disorder and on general supportive care. In some cases the use of activated protein C is to take in consideration.

Validation of a method for measuring (226)Ra in drinking waters by LSC

A simple method for measuring (226)Ra in drinking waters has been validated and validation parameters are provided. It is based on the measurement by LSC of (222)Rn, at equilibrium with (226)Ra, which is absorbed into a water immiscible scintillation cocktail (Ultima Gold F) inside the counting vial. The validated application field ranges between the detection limit (2·10(-3) Bq/kg) to 150 Bq/kg. The method has proven to be reliable, effective and suitable for wide-range measuring campaigns. A summary of results obtained in recent years is also given.

Diagnostic and prognostic role of procalcitonin (PCT) and MR-pro-Adrenomedullin (MR-proADM) in bacterial infections

Rapid diagnosis of bacterial infections is crucial for adequate antibiotic treatment. Serum molecules such as Procalcitonin (PCT) have been used as biomarkers of infection. Recently, the mid-regional pro-Adrenomedullin (MR-proADM) has been evaluated in combination with PCT for sepsis diagnosis. The diagnostic role of PCT and MR-proADM both in sepsis and in localized infections together with their contribution to effective antibiotic therapy has been evaluated. One hundred and eighty-two patients with bacterial infection has been enrolled: PCT and MR-proADM were measured at admission (T = 0), at 12-24 h (T = 1) and in the third or fifth day of antibiotic therapy (T = 3-5). ROC curve (receiver operating characteristic) and post-test probability were calculated. MR-proADM increased with the severity of the infection. PCT resulted significantly higher in sepsis than localized infection. After antibiotic therapy, PCT significantly decreased in localized respiratory infections and in sepsis, while MR-proADM decreased significantly after antibiotic therapy only in patients with severe sepsis/septic shock. The threshold values of PCT and MR-proADM were >0.1 ng/mL and >0.8 nmol/L, respectively. The combined use of PCT and MR-proADM increased the post-test probability of the diagnosis of bacterial infections compared to PCT alone. In conclusion, PCT and MR-proADM combination improves the diagnosis of bacterial infection and contribute to prognosis and antibiotic therapy effectiveness.