POS0738 BLUNTED CEREBRAL OXYGENATION DURING EXERCISE IN NON-NEUROPSYCHIATRIC SYSTEMIC LUPUS ERYTHEMATOSUS

Background:

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease affecting multiple organs, including the central nervous system. Subclinical brain lesions have been reported in SLE patients, even without overt neuropsychiatric manifestations (non-NPSLE). Studies using PET/MRI, examining structural or functional brain abnormalities in SLE, have been previously performed, either at rest or during a mental task (1–3). Exercise can be used to identify early alterations in brain oxygenation that might not detectable during resting conditions (4).

Objectives:

Our study aimed to examine possible differences in cerebral oxygenation during a handgrip exercise test between SLE patients without neuropsychiatric manifestations and age-matched controls.

Methods:

Fifty-two participants (26 non-NPSLE and 26 controls), following evaluation of handgrip strength, underwent a protocol involving a seated rest (baseline), a 3-min handgrip exercise (at 30% of maximal strength), and a 3-min recovery. Continuous-near-infrared-spectroscopy (NIRS) was used to monitor changes in cerebral-oxygenated hemoglobin (O2Hb), de-oxygenated (HHb) and total-hemoglobin (tHb). Beat-by-beat blood pressure (Finapres) was continuously monitored.

Results:

There were no differences between the two groups in age, body mass index, blood pressure, and smoking status. Median SLE duration was 7.5 (3.0 – 16.0) years. During exercise, cerebral -O2Hb increased in both groups; however, non-NPSLE exhibited a significantly lower increase in O2Hb vs. controls (average response:1.20±0.89 vs. 2.33±1.61μM, respectively, p<0.005) and lower tHb responses (p<0.05), with no differences in HHb.

Conclusion:

Our data show, for the first time, that SLE patients even without overt neuropsychiatric manifestations exhibit a blunted increase in cerebral-O2Hb during a submaximal exercise stimulus compared to age-matched controls. Examining brain oxygenation during a simple exercise task may assist in identifying patients with early alterations in cerebral function.

References:

[1]Mak A, Ren T, Fu EH yun, Cheak AA cia, Ho RCM. A Prospective Functional MRI Study for Executive Function in Patients with Systemic Lupus Erythematosus Without Neuropsychiatric Symptoms. Semin Arthritis Rheum. 2012;41(6):849–58.

[2]Kozora E, Brown MS, Filley CM, Zhang L, Miller DE, West SG, et al. Memory impairment associated with neurometabolic abnormalities of the hippocampus in patients with non-neuropsychiatric systemic lupus erythematosus. Lupus. 2011;20(6):598–606.

[3]Mackay M, Vo A, Tang CC, Small M, Anderson EW, Ploran EJ, et al. Metabolic and microstructural alterations in the SLE brain correlate with cognitive impairment. JCI Insight. 2019;4(1).

[4]Triantafyllou GA, Dipla K, Triantafyllou A, Gkaliagkousi E, Douma S. Measurement and Changes in Cerebral Oxygenation and Blood Flow at Rest and During Exercise in Normotensive and Hypertensive Individuals. Vol. 22, Current Hypertension Reports. Springer; 2020.

Disclosure of Interests:

None declared

Platelet microvesicles are associated with the severity of coronary artery disease: comparison between peripheral and coronary circulation

Microvesicles (MVs) have recently emerged as markers of thrombosis. Furthermore, there is an unexplained residual thrombotic risk is observed in patients with acute coronary syndrome (ACS) and/or stable coronary artery disease (CAD), despite treatment. We measured platelet (PMVs) and erythrocyte (ErMVs) in patients with ACS and stable CAD, both in the peripheral and coronary circulation. We studied consecutive eligible patients during a coronary angiography. Blood samples were collected from the stem of the left coronary artery and femoral artery. PMVs were significantly increased in CAD patients compared to controls. ACS patients had also increased PMVs in coronary and peripheral circulation, compared to controls. Furthermore, ACS patients exhibited increased PMVs in coronary compared to peripheral circulation. Lastly, coronary PMVs were associated with the severity of CAD based on the SYNTAX score. No significant differences were observed in the levels of ErMVs among groups. Therefore, PMVs emerge as novel markers of thrombosis in CAD, further augmenting the vicious cycle of inflammation and thrombosis during ACS. Importantly, coronary PMVs may reflect the severity of CAD in this population.

Acute inflammatory arthritis in the elderly; Old flames, new sparks

BACKGROUND

The overall world prevalence of rheumatoid arthritis (RA) ranges from 0.5-1.0%. The annual incidence of RA in most European countries ranges from roughly 0.4 to >2.5 per 1,000 adults, increasing with age. A significant proportion of newly diagnosed cases will evolve into true erosive RA.

METHODS

The aim of this cohort study was to study the characteristics of new developing, acute (<1 year), rheumatoid arthritis in an elderly (>65 years) population; its presenting features, accompanying manifestations and laboratory findings. One hundred twenty eight patients (103♀, 25♂) who presented to the rheumatology outpatients clinic with new-onset RA were included in the study. 42.2% of the patients had pre-existing osteoarthritis.

RESULTS

At presentation, 14.3% of the patients had systemic manifestations (fever, weight loss), 25.78% reported concomitant sicca symptomatology, and 50.9% were found to have abnormal haematological parameters (anemia and/or thrombocytosis). Clinical and laboratory parameters of the disease were analyzed and related to disease manifestations.. Haematological abnormalities were found to be associated both with increased inflammatory markers, as well as with increased titres of rheumatoid factor (RF), but not anti - cyclic citrullinated peptide (CCP) antibodies, in contrary to systemic manifestations which were not found to be related to the above mentioned parameters.

CONCLUSIONS

As the global population is becoming older, physicians will be challenged with the recognition and treatment of these conditions and their particular features in an increasing number of geriatric patients; within the context of the specific characteristics and comorbidities of this age group. Hippokratia 2014; 18 (3): 231-233.

Everolimus plus exemestane as first-line therapy in HR⁺, HER2⁻ advanced breast cancer in BOLERO-2

The present exploratory analysis examined the efficacy, safety, and quality-of-life effects of everolimus (EVE) + exemestane (EXE) in the subgroup of patients in BOLERO-2 whose last treatment before study entry was in the (neo)adjuvant setting. In BOLERO-2, patients with hormone-receptor-positive (HR⁺), human epidermal growth factor receptor-2-negative (HER2⁻) advanced breast cancer recurring/progressing after a nonsteroidal aromatase inhibitor (NSAI) were randomly assigned (2:1) to receive EVE (10 mg/day) + EXE (25 mg/day) or placebo (PBO) + EXE. The primary endpoint was progression-free survival (PFS) by local assessment. Overall, 137 patients received first-line EVE + EXE (n = 100) or PBO + EXE (n = 37). Median PFS by local investigator assessment nearly tripled to 11.5 months with EVE + EXE from 4.1 months with PBO + EXE (hazard ratio = 0.39; 95 % CI 0.25–0.62), while maintaining quality of life. This was confirmed by central assessment (15.2 vs 4.2 months; hazard ratio = 0.32; 95 % CI 0.18–0.57). The marked PFS improvement in patients receiving EVE + EXE as first-line therapy for disease recurrence during or after (neo)adjuvant NSAI therapy supports the efficacy of this combination in the first-line setting. Furthermore, the results highlight the potential benefit of early introduction of EVE + EXE in the management of HR⁺, HER2⁻ advanced breast cancer in postmenopausal patients.

Cerebral amyloid angiopathy

The aim of this report was to describe the case of an elderly patient with cerebral amyloid angiopathy and associated dementia who presented with new onset symptomatology compatible with an acute cerebrovascular event. Computed tomography scanning was suggestive of an incipient ischemic cerebrovascular event. Magnetic resonance imaging was requested due to the presence of small hyperdense lesions on CT, and revealed multiple diffuse hypodense parenchymal lesions with hemosiderin deposits, indicative of cerebral amyloid angiopathy. Diagnosis of the underlying pathology is of importance, as aspirin use, and antiplatelet use in general, may in these patients be associated with microbleed burden.

Phase III, randomized, double-blind, placebo-controlled multicenter trial of daily everolimus plus weekly trastuzumab and vinorelbine in trastuzumab-resistant, advanced breast cancer (BOLERO-3)

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Background: Everolimus (EVE) is an inhibitor of mammalian target of rapamycin (mTOR), a protein kinase central to a number of signaling pathways regulating cell growth and proliferation. Data from preclinical and phase 1/2 clinical studies indicated that adding EVE to trastuzumab (TRAS) plus chemotherapy may restore sensitivity to and enhance efficacy of human epidermal growth factor receptor 2 (HER2)-targeted therapy. The international BOLERO-3 phase 3 study is being conducted to evaluate the addition of EVE to TRAS plus vinorelbine. Methods: Adult women with HER2+ advanced breast cancer and who received prior taxane therapy and experienced recurrence or progression on TRAS were randomized 1:1 to receive either EVE or placebo (5 mg/day) in combination with weekly TRAS and vinorelbine (25 mg/m2). The primary endpoint is progression-free survival (PFS). Secondary endpoints included overall survival, response rate, clinical benefit rate, safety, quality of life, and pharmacokinetics. Final analysis will be conducted after approximately 417 PFS events. Results: The trial accrued 569 patients between October 2009 and May 2012. Previous therapy included TRAS (100%), a taxane (100%), and lapatinib (28%). The median age was 54 years, and 76% of patients had visceral metastases, 5% had stable brain metastases, 56% had hormone-receptor–positive disease, 33% had Eastern Cooperative Oncology Group performance status of 1 or 2, and 41% had 3 or more metastatic sites. The median number of prior chemotherapy lines in the metastatic setting was 1. As of February 4, 2013, a total of 396 PFS events were reported. Conclusions: Final PFS analysis will be performed in early May 2013; primary and secondary efficacy endpoints will be presented. Clinical trial information: NCT01007942.

Mercury exposure and risks from dental amalgam in the US population, post-2000

Dental amalgam is 50% metallic mercury (Hg) by weight and Hg vapour continuously evolves from in-place dental amalgam, causing increased Hg content with increasing amalgam load in urine, faeces, exhaled breath, saliva, blood, and various organs and tissues including the kidney, pituitary gland, liver, and brain. The Hg content also increases with maternal amalgam load in amniotic fluid, placenta, cord blood, meconium, various foetal tissues including liver, kidney and brain, in colostrum and breast milk. Based on 2001 to 2004 population statistics, 181.1 million Americans carry a grand total of 1.46 billion restored teeth. Children as young as 26 months were recorded as having restored teeth. Past dental practice and recently available data indicate that the majority of these restorations are composed of dental amalgam. Employing recent US population-based statistics on body weight and the frequency of dentally restored tooth surfaces, and recent research on the incremental increase in urinary Hg concentration per amalgam-filled tooth surface, estimates of Hg exposure from amalgam fillings were determined for 5 age groups of the US population. Three specific exposure scenarios were considered, each scenario incrementally reducing the number of tooth surfaces assumed to be restored with amalgam. Based on the least conservative of the scenarios evaluated, it was estimated that some 67.2 million Americans would exceed the Hg dose associated with the reference exposure level (REL) of 0.3 μg/m(3) established by the US Environmental Protection Agency; and 122.3 million Americans would exceed the dose associated with the REL of 0.03 μg/m(3) established by the California Environmental Protection Agency. Exposure estimates are consistent with previous estimates presented by Health Canada in 1995, and amount to 0.2 to 0.4 μg/day per amalgam-filled tooth surface, or 0.5 to 1 μg/day/amalgam-filled tooth, depending on age and other factors.

Environmental and human health risk assessment for essential trace elements: considering the role for geoscience

In environmental and human health protection, the role for geoscience may be expressed by how it enhances certainty in the hazard potential models that support risk assessment. For geochemical hazards, certainty reflects how well geoscience simplifies variability in the element concentrations and in the environmental conditions associated with exposure pathways. Through mineralogy, geoscience establishes natural geochemical background variability in terms of provenance, process, and past, and it links hazard potential to the physical and chemical transformation due to weathering and soil formation. The interpretation of hazard potential may be expressed by how analytical protocol, expressed by grain size and strength of acid decomposition, combines with geological factors, expressed by (1) mineralogy and mineral partitioning and (2) environmental cofactors, including moisture, pH, buffering capacity, and porosity. With this type of knowledge, geoscience enhances the potential to identify covariant relations between hazard indicators and disease, and to resolve potential causal factors.

Neurofibromatosis type 1: should we screen for other genetic syndromes? A case report of co-existence with multiple endocrine neoplasia 2A

BACKGROUND

NF 1 is a genetic disorder with an autosomal dominant pattern of inheritence. It is associated with neoplastic disorders mainly derived from the neural seath. However, the co-existence of NF1 with the full spectrum of MEN 2A has rarely been reported. The aim of the study was to investigate the presence of secondary neoplasias in a patient with diagnosed NF1, and in particular the presence of hyperparathyroidism and the possible co-existence with another pheochromocytoma-related syndrome.

METHODS

We report a case of a 70 years old female patient who had NF1. The patient was referred to our center and was diagnosed with an isolated pheochromocytoma of the right adrenal gland for which she underwent right adrenalectomy. We further investigated for the presence of another pheochromocytoma-related syndrome and in particular for the presence of hyperparathyroidism and medullary thyroid cancer. Molecular screening for germline mutations of the genes NF1, RET and VHL has also been performed.

RESULTS

The patient was further diagnosed with hyperparathyroidism and medullary thyroid cancer, having the full spectrum of the clinical picture of the MEN2A syndrome. The genetic testing revealed the germline mutation for NF1 but not for the RET proto-oncogene which is generally found in MEN2A cases.

CONCLUSION

To our knowledge this is a rare case of co-existence of two pheochromocytoma-related genetic syndromes, and generates the question of whether all patients with these syndromes should undergo a thorough clinical and laboratory investigation for the possibility of another co-existing pheochromocytoma-related genetic syndrome.

The pathogenesis of arterial stiffness and its prognostic value in essential hypertension and cardiovascular diseases

The elasticity of a given arterial segment of the aorta and of big elastic arteries is not constant but depends on its distending pressure. As distending pressure increases, there is greater recruitment of inelastic collagen fibers and thereby a reduction in elasticity. It also depends on structural changes in the medial layer of the elastic arteries (mainly aorta and major arterial conduits), and is largely the result of progressive elastic fibre degeneration.Aortic Pulse Wave Velocity (PWV), is the most robust marker of arterial stiffness, however additional useful information can also be provided by the Central Augmentation Index (AIx C), and pulse pressure. The presence of systemic inflammation in cardiovascular disease and in particular in essential hypertension affects arterial stiffness and increases PWV. Some pharmacological and non-pharmacological interventions may improve arterial stiffness and thereby decrease PWV.

Escape from premature senescence is not sufficient for oncogenic transformation by Ras

Resistance of primary cells to transformation by oncogenic Ras has been attributed to the induction of replicative growth arrest. This irreversible 'fail-safe mechanism' resembles senescence and requires induction by Ras of p19ARF and p53 (refs 3-5). Mutation of either p19ARF or p53 alleviates Ras-induced senescence and facilitates oncogenic transformation by Ras. Here we report that, whereas Rb and p107 are each dispensable for Ras-induced replicative arrest, simultaneous ablation of both genes disrupts Ras-induced senescence and results in unrestrained proliferation. This occurs despite activation by Ras of the p19ARF /p53 pathway, identifying pRb and p107 as essential mediators of Ras-induced antiproliferative p19ARF/p53 signalling. Unexpectedly, in contrast to p19ARF or p53 deficiency, loss of Rb/p107 function does not result in oncogenic transformation by Ras, as Ras-expressing Rb-/-/p107-/- fibroblasts fail to grow anchorage-independently in vitro and are not tumorigenic in vivo. These results demonstrate that in the absence of both Rb and p107 cells are resistant to p19ARF/p53-dependent protection against Ras-induced proliferation, and uncouple escape from Ras-induced premature senescence from oncogenic transformation.

Angiotensin converting enzyme gene polymorphism is not related to essential hypertension in a Greek population

Studies in various ethnic groups have shown contradictory evidence on the association of the angiotensin converting enzyme (ACE) insertion/ deletion (I/D) polymorphism with essential hypertension. In addition, mistyping of the insertion allele in heterozygotes has been reported. We analyzed the ACE genotype of 98 hypertensive and 84 normotensive subjects of Greek origin. Genomic DNA was extracted from blood samples and amplified by polymerase chain reaction (PCR). PCR primers were flanking the polymorphic region in intron 16 of the ACE gene. To avoid mistyping of heterozygotes, samples with the DD genotype were also amplified with primers that detect only the insertion allele. The distribution of the DD, ID, and II ACE genotypes was 30, 45, and 23 in hypertensive patients and 29, 40, and 15 in normotensive subjects, respectively. The estimated frequency of the insertion allele was 0.45 in hypertensive and 0.42 in normotensive subjects. The difference was not statistically significant. The results indicate a lack of association between ACE I/D polymorphism and essential hypertension in this Greek population, suggesting that other genes must contribute to the pathogenesis of hypertension.

Adrenal insufficiency with enlarged adrenals

Five patients with adrenal insufficiency and large adrenal glands at presentation are reported. Addison's disease was due to adrenal tuberculosis in three patients, with important changes in adrenal configuration on CT reflecting the natural history of the disease. Adrenal infiltration by non-Hodgkin lymphoma and metastatic carcinoma of the lung was the cause of the disease in the fourth and fifth patients, respectively, who developed signs of adrenal insufficiency before the diagnosis of the primary lesion became apparent. Histologic confirmation was established after unilateral adrenalectomy in three patients. In two patients with adrenal tuberculosis, long clinical and laboratory follow-up confirmed the diagnosis. This report indicates that Addison's disease is not infrequently associated with adrenal enlargement. Adrenal size is related to the cause and duration of the various disease states leading to adrenal insufficiency. Moreover, adrenal insufficiency associated with enlarged adrenal glands can be the presenting manifestation of lymphoma or metastasis.

Percutaneous transluminal renal angioplasty in patients with renovascular hypertension: long-term results

This study evaluated the long-term effects of percutaneous transluminal renal angioplasty (PTRA) on blood pressure and renal function in patients with renovascular hypertension. Seventy-eight patients with hypertension and unilateral or bilateral stenoses of the renal arteries (16 with fibromuscular dysplasia and 62 with atherosclerosis) were studied. All patients with fibromuscular dysplasia (group A) had normal renal function, while 27 of the 62 patients with atherosclerosis (group B) presented with various degrees of renal failure. PTRA was technically successful in 87.5% patients of group A. The overall technical success rate (complete plus partial) was 72.3% (55/76 renal arteries) in group B. Mean follow-up (range) in months was 42 (12-108) for group A and 39 (13-106) for group B. After successful PTRA, the overall benefit rate (cure plus improved) for hypertension was 100% in group A; 10 of 14 patients were cured and 4 of 14 were improved. In group B, the overall benefit rate was 70.8%; 9 of 48 were cured and 25 of 48 were improved. PTRA was technically successful in 18 of 27 patients with renal failure. Renal function improved in 4 of 18 patients, remained stable in 9 of 18, and deteriorated in 5 of 18 patients. The above results suggest that PTRA is an effective method for the long-term management of patients with renovascular hypertension, although the results were less favorable in the presence of bilateral renal artery stenoses: in addition to improved control of blood pressure, PTRA might improve renal function or delay its progressive deterioration.

Changes of plasma noradrenaline levels in the renal and systemic circulation after successful percutaneous transluminal angioplasty in renovascular hypertension

The sympathetic nervous system involvement in the pathogenesis of human renovascular hypertension was studied in 10 hypertensive patients with unilateral renal artery stenosis, who underwent percutaneous transluminal angioplasty (PTA). Before PTA, systolic/diastolic BP readings were 185.3 +/- 7.8/123.2 +/- 5.1 mmHg, peripheral PRA values were 8.63 +/- 2.27 ngAl/ml/h, the ratio RVRR was 2.15 +/- 0.27, the ratio V1-IVC/IVC was 1.00 +/- 0.23 (V1 = PRA from the renal vein of the stenotic side, IVC = PRA from the inferior vena cava) and the ratio V2-IVC/IVC was 0.04 +/- 0.02 (V2 = PRA from the renal vein of the non-stenotic side); 30 min after successful PTA the respective values of the above measured parameters were: 144.2 +/- 6.7/98.2 +/- 3.1 mmHg (p less than 0.01), 8.13 +/- 2.21 ngAl/ml/h (p less than 0.005), 1.79 +/- 0.19 (p less than 0.01), 0.68 +/- 0.18 (p less than 0.001) and 0.06 +/- 0.02 (p less than 0.005). Peripheral plasma noradrenaline levels (plNA) were 0.694 +/- 0.058 ng/ml, plNA levels from the renal vein of the stenotic side were 0.962 +/- 0.108 ng/ml and plNA levels from the renal vein of the non-stenotic side were 0.759 +/- 0.092 ng/ml; 30 min after successful PTA the respective values were 0.518 +/- 0.055 ng/ml (p less than 0.01), 0.681 +/- 0.078 ng/ml (p less than 0.005) and 0.510 +/- 0.063 ng/ml (p less than 0.005). It is suggested that the reversal of chronic renal ischaemia by PTA induced statistically significant changes in the sympathetic nervous system activity, parallel to the changes of renin secretion.