A review of exercise pulmonary hypertension in systemic sclerosis

In general, pulmonary vascular disease has important negative prognostic implications, regardless of the associated condition or underlying mechanism. In this regard, systemic sclerosis is of particular interest as it is the most common connective tissue disease associated with pulmonary hypertension, and a well-recognized at-risk population. In the setting of systemic sclerosis and unexplained dyspnea, the concept of using exercise to probe for underlying pulmonary vascular disease has acquired significant interest. In theory, a diagnosis of systemic sclerosis-associated exercise pulmonary hypertension may allow for earlier therapeutic intervention and a favorable alteration in the natural history of the pulmonary vascular disease. In the context of underlying systemic sclerosis, the purpose of this article is to provide a comprehensive review of the evolving definition of exercise pulmonary hypertension, the current role and methodologies for non-invasive and invasive exercise testing, and the importance of the right ventricle.

Abstract P147: Changes in Renal Function Precede the Development of Hypertension in Female Mice With Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease characterized by inflammation, hypertension, renal injury, and cardiovascular disease. Kidney involvement is common to patients with SLE and renal hemodynamic dysfunction is evident in patients with active renal disease. However, little is known about early changes in renal hemodynamic function that may contribute to the pathogenesis of hypertension during SLE. We hypothesize that the loss of immunological tolerance and subsequent production of autoantibodies in SLE leads to impaired renal hemodynamic function that precedes the development hypertension. Female NZBWF1 (SLE) and female NZW (control) mice were instrumented with carotid artery and jugular vein catheters to determine MAP and glomerular filtration rate (GFR) respectively at ages 15, 20, 24, 28, 31, and 34 weeks. MAP was measured in conscious, freely-moving mice. GFR was measured by the clearance of fluorescein isothiocyanate-inulin (FITC-inulin) after achieving steady state through continuous infusion for five hours. GFR increases at 28 weeks of age followed by a significant decline by 34 weeks of age (P = 0.0127, P = 0.0001) compared to 34 and 15 weeks of age respectively, in the mice with SLE. GFR is increased in control mice by 28 weeks of age (P = 0.002) and remains unchanged at other time points. Compared with control mice, female mice with SLE have higher MAP by 34 weeks of age (P = <0.0001). These data suggest that changes in renal hemodynamic function occur in female SLE mice prior to changes in MAP suggesting an important mechanistic role for autoimmunity to directly impair renal hemodynamic function and promote the development of hypertension.

Abstract 128: Leptin Accelerates Autoimmune Disease Progression and the Development of Hypertension in an Experimental Model of Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) is a chronic autoimmune disorder that predominately affects women and is associated with high rates of hypertension and cardiovascular disease. SLE is characterized by B and T lymphocyte dysfunction and altered cytokine production, including elevated levels of the adipocytokine leptin. Leptin promotes the expansion of proinflammatory T helper (T H ) 1 and T H 17 cells and inhibits the differentiation of regulatory T cells (T REG ). Because T cells are mechanistically linked to the development of hypertension in SLE, we hypothesized that administration of leptin would alter T H subsets and accelerate the development of hypertension in a female mouse model of SLE. To test this hypothesis, 30 week old female SLE (NZBWF1, n=21) and control (NZW, n=25) mice were implanted with minipumps to continuously deliver recombinant mouse leptin (0.5 mg/kg/day) or vehicle for four weeks. At the conclusion of the study, splenic CD4 + T H subsets were analyzed by flow cytometric analyses and no significant alterations in T H 1, T H 2, T H 17, or T REG cells were detected; however, circulating T REG in SLE mice were lower after leptin administration (1.1±0.2% SLE-vehicle vs. 0.52±0.1% SLE-leptin, p<0.05). Circulating IgG isotypes were also analyzed to correlate with T H subset activities and circulating levels of IgG2a were higher in SLE mice administered leptin (0.79±0.2 mg/mL SLE-vehicle vs. 1.2±0.05 mg/mL SLE-leptin, p<0.05), indicating increased T H 1 activity. In further support of inflammatory T cell activity, circulating levels of TNF-α and IL-17 were elevated in SLE mice administered leptin (TNF-α: 18.6±8.4 pg/mL SLE-vehicle vs. 80.5±15.9 pg/mL SLE-leptin, p<0.01) (IL-17: 0.46±0.1 pg/mL SLE-vehicle vs. 1.68±0.5 pg/mL, p<0.01). Mean arterial pressure (MAP; mmHg), measured in conscious mice by carotid catheter, was higher in SLE mice than in control mice (113±3 Control-vehicle vs. 128±3, p=0.06), and leptin further increased blood pressure in SLE mice (SLE-leptin: 134±3; p<0.01 vs. Control-vehicle and Control-leptin). In conclusion, these data suggest that leptin plays a pathogenic role in the development of hypertension in autoimmunity, in part by altering the balance of T H 1, T H 17, and T REG activity.

High Spare Respiratory Capacity is a Canonical Feature of Virtual Memory, but not Conventional Memory CD8 T Cells, and is Driven by IL-15 Signalling

Virtual memory T (TVM) cells are antigen-naïve CD8 T cell cells that exist in a semi-differentiated state. They exhibit some characteristics that are classically associated with conventional memory T cells (TMEM), including elevated expression of CD44, accelerated TCR-driven proliferation, and enhanced cytokine responsiveness. Despite rapid and robust proliferation of young TVM cells after TCR-mediated stimulation, aged TVM cells exhibit marked proliferative dysfunction. Recently, high spare respiratory capacity (SRC) was proposed as a defining metabolic characteristic of antigen-experienced memory T cells (TMEM) cells, thought to promote both their longevity and rapid functionality. Given the semi-differentated state of TVM cells, we sought to determine whether the SRC of TVM cells also corresponded to their longevity and functionality. Surprisingly, we found that elevated SRC was a feature of TVM cells, but not TMEM cells, and that SRC increased substantially with age in both subsets, repudiating a link between SRC and functionality. We further showed that SRC was closely linked with responsiveness to IL-15, since TVM cells alone were dependent on IL-15 for survival/accumulation, and showed increased receptor (CD122) expression, and IL-15 mediated STAT5 phosphorylation. Moreover, recent infection caused an increase in SRC in TVM cells but inhibition of IL-15 during infection was sufficient to prevent this increase. Collectively, these findings indicate that elevated SRC is a feature of TVM and not TMEM cells and is a consequence of their heightened IL-15 sensitivity. Moreover, elevated SRC is not associated with T cell functionality in young or aged cells, but may be associated with survival of TVM cells.

Transverse tendon stiffness is reduced in people with Achilles tendinopathy: A cross-sectional study

Objectives

The objective of the current cross-sectional study was to examine Achilles tendon transverse stiffness in a group of recreational runners with Achilles tendinopathy, in comparison to an asymptomatic group of runners with similar training history. We also aimed to determine the between-week intra-individual reliability of this measurement technique.

Design

Cross-sectional cohort study.

Methods

A hand-held dynamometer was used to assess the transverse stiffness of the Achilles tendon (AT) in twenty-five recreational runners. In ten people with midportion Achilles tendinopathy (5 men, 5 women), measurements were taken directly over the most symptomatic location. In 15 people who were free of AT symptoms (7 men, 8 women), measurements were taken at an equivalent location on the tendon. Participants returned after one week to determine measurement reliability (intra-class correlation coefficient/ICC and minimum detectable change/MDC95). We also collected information about people’s tendon loading activities, tendon thickness (ultrasound mesaurement), and symptoms (Victorian Institute of Sports Assessment–Achilles / VISA-A score).

Results

The AT transverse stiffness was lower in people with Achilles tendinopathy (777 N/m ± 86) compared to those who were asymptomatic (873 N/m ± 72) (p < 0.05). AT transverse stiffness was negatively correlated with age and tendon thickness, and positively correlated with VISA-A score and waist circumference. Reliability was good, with ICC of 0.81 in people with tendinopathy and 0.80 in healthy controls, and an MDC95 of 118 and 87N/m in these two respective groups.

Conclusions

Transverse Achilles tendon stiffness can be reliably measured in people with midportion Achilles tendinopathy, and appears to be lower in people who are older, more symptomatic, and with more extensive tendon thickening. The potential clinical utility of monitoring tendon stiffness in the management of tendon injuries merits further study.

Splicing factor ESRP1 controls ER-positive breast cancer by altering metabolic pathways

The epithelial splicing regulatory proteins 1 and 2 (ESRP1 and ESRP2) control the epithelial-to-mesenchymal transition (EMT) splicing program in cancer. However, their role in breast cancer recurrence is unclear. In this study, we report that high levels of ESRP1, but not ESRP2, are associated with poor prognosis in estrogen receptor positive (ER+) breast tumors. Knockdown of ESRP1 in endocrine-resistant breast cancer models decreases growth significantly and alters the EMT splicing signature, which we confirm using TCGA SpliceSeq data of ER+ BRCA tumors. However, these changes are not accompanied by the development of a mesenchymal phenotype or a change in key EMT-transcription factors. In tamoxifen-resistant cells, knockdown of ESRP1 affects lipid metabolism and oxidoreductase processes, resulting in the decreased expression of fatty acid synthase (FASN), stearoyl-CoA desaturase 1 (SCD1), and phosphoglycerate dehydrogenase (PHGDH) at both the mRNA and protein levels. Furthermore, ESRP1 knockdown increases the basal respiration and spare respiration capacity. This study reports a novel role for ESRP1 that could form the basis for the prevention of tamoxifen resistance in ER+ breast cancer.

Multiple lymphatic-venous anastomoses (MLVA) for microsurgical drainage of primary peno-scrotal lymphedema: A case report

Single site Multiple Lymphatic-Venous Anastomoses (MLVA) provides optimal functional and cosmetic results with low complication rates in treatment of lower limb lymphedema. However, no evidence exists in literature concerning the use of this technique in treatment of peno-scrotal lymphedema. We report a case of a 44-year-old male patient who developed secondary peno-scrotal lymphedema with severe lymphorrhea, following a laser treatment for scrotal pustolosis, leading to recurrent infections and finally an established peno-scrotal lymphedema. Utilizing MLVA, a complete remission of scrotal lymphedema was achieved with significant volume reduction of the penile lymphedema. The post-operative course was uneventful with clear improvement in lymphatic flow demonstrable on lymphoscintigraphy (6 months) and no recurrence of scrotal lymphedema at 2 years follow-up. This article reports very promising results of a novel application of MLVA in the treatment of genital lymphedema and suggests that MLVA provides the possibility to shunt both superficial and deep lymphatics to improve the lymphatic drainage from the peno-scrotal area using a single surgical site.

Inclusion of targeted skin products in the pre-surgical treatment regimen of peripheral lymphedema & lipedema

Advanced lymphedema is associated with a number of adverse skin changes including color, thickening of the epidermis, dryness, and hyperkeratosis. These changes are related to prolonged lymph stasis and contribute to an increased risk of infection. Similarly, lipedema is associated with skin thickening and appearance of nodular adipose deposition. Skin care is essential in both conditions. We examined whether inclusion of targeted skin products for 2 weeks to an established pre-surgical conservative treatment program was associated with beneficial effects on the skin condition in 150 patients with lymphedema and lipedema. Patients were randomly assigned to control or one of two treatment groups. All three groups (and for both lymphedema and lipedema) demonstrated a significant reduction in softness. Dimpling/ redness was significantly reduced in the targeted skin product groups for both patients with lymphedema or lipedema. Only patients with lipedema demonstrated a significant reduction in dryness/ hyperkeratosis following targeted skin product treatment. This study demonstrates that short-term use of targeted skin products in both patients with lymphedema and lipedema can be of benefit and further studies are needed to replicate these results and explore possible mechanisms.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Diabetes Technology Society Report on the FDA Digital Health Software Precertification Program Meeting

Diabetes Technology Society (DTS) convened a meeting about the US Food and Drug Administration (FDA) Digital Health Software Precertification Program on August 28, 2018. Forty-eight attendees participated from clinical and academic endocrinology (both adult and pediatric), nursing, behavioral health, engineering, and law, as well as representatives of FDA, National Institutes of Health (NIH), National Telecommunications and Information Administration (NTIA), and industry. The meeting was intended to provide ideas to FDA about their plan to launch a Digital Health Software Precertification Program. Attendees discussed the four components of the plan: (1) excellence appraisal and certification, (2) review pathway determination, (3) streamlined premarket review process, and (4) real-world performance. The format included (1) introductory remarks, (2) a program overview presentation from FDA, (3) roundtable working sessions focused on each of the Software Precertification Program's four components, (4) presentations reflecting the discussions, (5) questions to and answers from FDA, and (6) concluding remarks. The meeting provided useful information to the diabetes technology community and thoughtful feedback to FDA.

Wrestling with the complexity of evaluation for organizations at the boundary of science, policy, and practice

Boundary organizations are situated between science, policy, and practice and have a goal of supporting communication and collaboration among these sectors. They have been promoted as a way to improve the effectiveness of conservation efforts by building stronger relationships between scientists, policy makers, industry, and practitioners (Cook et al. 2013). Although their promise has been discussed in theory, the work of and expectations for boundary organizations are less defined in practice. Biodiversity conservation is characterized by complexity, uncertainty, dissent, and tight budgets, so boundary organizations face the challenging task of demonstrating their value to diverse stakeholders. We examined the challenges boundary organizations face when seeking to evaluate their work and thus aimed to encourage more productive conversations about evaluation of boundary organizations and their projects. Although no off-the-shelf solution is available for a given boundary organization, we identified 4 principles that will support effective evaluation for boundary organizations: engage diverse stakeholders, support learning and reflection, assess contribution to change, and align evaluation with assumption and values.

What Proportion of Cancers in the UK and Its Constituent Countries Could Be Prevented? An Updated Analysis

Background: Understanding population-level exposure to cancer risk factors is vital when devising risk-reduction policies. By reducing exposure to cancer risk factors, many cancers could be prevented. But what impact on cancer incidence do these risk factors have? And what proportion of cancers could be prevented if these risk factors are avoided? Aim: The aim of this analysis was to update the estimates of the number and proportion of theoretically preventable cancers in the UK to reflect the changing behavior as assessed in representative national surveys, and new epidemiologic evidence. Separate estimates were also calculated for England, Wales, Scotland, and Northern Ireland because prevalence of risk factor exposure varies between them. Methods: Population attributable fractions (PAFs) were calculated for combinations of risk factor and cancer type with sufficient/convincing evidence of a causal association. Relative risks (RRs) were drawn from meta-analyses of cohort studies where possible. Prevalence of exposure to risk factors was obtained from nationally representative population surveys. Cancer incidence data for 2015 were sourced from national data releases and, where needed, personal communications. Results: Around four in ten (38%) cancer cases in 2015 in the UK were attributable to known risk factors. The proportion was around two percentage points higher in UK males (39%) than UK females (37%). Comparing UK countries, the attributable proportion for persons was highest in Scotland (41%) and lowest in England (37%). Tobacco smoking contributed by far the largest proportion of attributable cancer cases, followed by overweight and obesity, accounting for 15% and 6%, respectively, of all cases in the UK in 2015. Conclusion: Around four in ten (38%) cancer cases in the UK could be prevented. Tobacco and obesity remain the top contributors of attributable cancer cases. Tobacco smoking has the highest PAF because it greatly increases cancer risk and has a large number of cancer types associated with it. Obesity has the second-highest PAF because it affects a high proportion of the UK population and is also linked with many cancer types. Public health policy may seek to reduce the level of harm associated with exposure or reduce exposure levels - both approaches may be effective in preventing cancer. The variation in PAFs between UK countries is affected by sociodemographic differences which drive differences in exposure to theoretically avoidable 'lifestyle' factors. PAFs at UK country level have not been available previously and they should be used by policymakers in the devolved nations to develop more targeted public health measures. This analysis demonstrates the importance of nationally representative exposure prevalence data and cancer registration in informing evidence-based public health policy.

Incidence of Thyroid Cancer among Patients with Thyroid Nodules

Aim To evaluate thyroid nodules and to determine the incidence of thyroid cancer. Methods This retrospective cohort study collected data from ten patients who presented with thyroid nodules to Barrington’s Hospital Limerick. Ultrasound/FNA results of thyroid nodules were used to measure the incidence of thyroid cancer. Results The number of thyroid nodules diagnosed as malignant was significantly greater than benign nodules (***p-value <0.0004, 95% confidence interval (-1.109 to -0.399)). This data indicates that females are more likely to develop thyroid cancer than males. Discussion The incidence of thyroid cancer is growing at a rapid pace. Papillary carcinoma is the most common thyroid cancer diagnosed. Notably, it is the most likely diagnoses in impalpable thyroid nodules. Females are more likely to develop thyroid cancer than males.