Sjögren's syndrome and pulmonary hypertension: Exploring the intricate link with interstitial lung disease

BACKGROUND

Primary Sjögren's syndrome (pSS) is a systemic autoimmune disease commonly presenting with sicca symptoms and, in approximately one-third of cases, extra-glandular manifestations, including pulmonary involvement. Pulmonary hypertension (pH) is a recognized, though less frequently studied, complication in pSS, particularly in patients with interstitial lung disease (ILD). This study evaluates the prevalence of PH in pSS and the relationship between ILD and cardiovascular risk in this population.

METHODS

This cross-sectional study included 63 patients with pSS, diagnosed according to ACR/EULAR criteria. Among them, 24 patients (38.1 %) had ILD, with 9 presenting pulmonary fibrosis. Comprehensive evaluations were conducted, including 2D/3D echocardiography, HRCT, and pulmonary function tests. Right heart catheterization confirmed PH when indicated. Patients were categorized into pSS-ILD and pSS-noILD groups for comparative analysis.

RESULTS

The cohort comprised 7 males (11.1 %) and 56 females (88.9 %), with a mean age of 69.1 ± 12.5 years. The prevalence of PH was low (1.6 %), with only one confirmed case via right heart catheterization, significantly below previous reports. Notably, pSS-ILD patients were older (77.1 ± 10.7 years) and diagnosed with pSS later (68.5 ± 12.6 years; p = 0.001) than pSS-noILD patients. Cardiovascular comorbidities, including arterial hypertension (32.8 %) and dyslipidemia (24.2 %), were more prevalent in pSS-ILD patients (p = 0.003 and p = 0.001, respectively). Pulmonary function tests revealed lower FVC (2.23 ± 0.70 vs. 2.98 ± 0.56; p = 0.004) and DLCO-Sb (3.87 ± 1.52 vs. 5.31 ± 1.26; p = 0.017) in pSS-ILD patients, indicating reduced lung function. Echocardiographic findings showed higher sPAP values (>35 mmHg) and reduced TAPSE/sPAP ratios in the pSS-ILD group (p = 0.028 and p = 0.026, respectively), suggesting early signs of right ventricular impairment.

CONCLUSIONS

PH prevalence in pSS is lower than previously reported, likely due to rigorous diagnostic criteria. Patients with pSS-ILD exhibit a higher risk of cardiovascular comorbidities and lung function decline. Echocardiographic monitoring of parameters like TAPSE/sPAP may aid in early PH detection, emphasizing the need for tailored management in pSS-ILD patients. Further studies are warranted to explore PH subtypes in diverse populations and to optimize follow-up protocols for at-risk patients.

Global impact of hMPV virus: Transmission, pathogenesis, diagnostic and treatment

The Human Metapneumovirus (hMPV), a member of the Pneumovirinae subfamily, is a substantial cause of acute lower respiratory infections, notably in young children, the elderly, and immunocompromised patients. It was first identified in 2001, hMPV has displayed a seasonal pattern of infection, with symptoms ranging from moderate to severe respiratory disease. This study investigates the worldwide effect of hMPV, concentrating on its transmission, etiology, diagnostics, and treatment techniques, underlining the need for better public health measures. hMPV is spread by respiratory droplets, with a normal incubation period of 3-5 days. The virus induces an immune response characterized by pro-inflammatory cytokines, leading to respiratory symptoms and probable tissue damage. Diagnostic breakthroughs, including RT-qPCR and mNGS, have enhanced detection sensitivity. However, therapy is generally supportive, with potential breakthroughs in mRNA vaccines targeting hMPV fusion proteins. Current clinical studies evaluate the effectiveness and safety of these new vaccinations, which might pave the road for effective prevention. Despite tremendous gains in understanding hMPV, there remains a crucial need for targeted antiviral treatments and vaccines to minimize its worldwide health impact.

Exploring the association between urticaria subtypes, anxiety, and depression and potential role of gut microbiota

AIMS

In observational studies, the causal relationship between urticaria and the risk of psychiatric disorders (anxiety and depression) remains inconclusive. Furthermore, there is growing evidence that gut microbiota (GM) contributes to the pathogenesis of urticaria. This study aimed to assess the causal relationships between the genetically predicted urticaria subtypes and psychiatric disorders and further examined the role of GM in influencing the risk of these urticaria subtypes.

METHODS

We conducted a meta-analysis of observational studies identified from four databases to evaluate the associations between urticaria, anxiety, and depression over the past decade. In addition, we estimated the genetic correlation and causality between genetically predicted urticaria subtypes and psychiatric disorders using linkage disequilibrium score regression and Mendelian Randomization (MR) analyses. Finally, univariable two-sample MR and multivariable MR analyses were employed to evaluate the combined and independent effects of GM from two datasets on urticaria subtypes associated with psychiatric disorders.

RESULTS

Thirteen observational studies comprising 7321 participants were included in the meta-analysis. There was a positive association between urticaria and anxiety risk (n = 13, OR: 3.96; 95%CI: 2.90-5.41) as well as depression risk (n = 12, OR: 3.03; 95%CI: 2.30-4.01). The MR results indicated that idiopathic urticaria increased the risk of anxiety (OR = 1.14; 95%CI = 1.01-1.28; P = 3.31 × 10-2), while allergic urticaria increased the risk of major depressive disorder (OR = 1.07; 95%CI = 1.02-1.13; P = 6.65 × 10-3). Our analysis identified nineteen gut bacterial taxa that were causally associated with idiopathic and allergic urticaria. Notably, Intestinibacter and Victivallales were strongly associated with an increased risk of allergic urticaria, even after accounting for the effect of smoking or alcohol consumption in the multivariable MR analysis. FamilyXIIIAD3011group and Bacteroides vulgatus were found to exert protective roles in idiopathic urticaria.

CONCLUSIONS

The study provides evidence for the association between urticaria subtypes and psychiatric disorders, complementing existing observational studies. In addition, our study implies the involvement of gut microbiota in idiopathic and allergic urticaria. However, the specific mechanisms of bacterial action remain to be clarified.

The regulatory effect and molecular mechanism of Epstein-Barr virus protein LMP-1 in SLE susceptibility gene expression

The development of systemic lupus erythematosus (SLE) involves both genetic and environmental factors. Epstein-Barr virus (EBV) infection has been implicated in SLE pathogenesis, particularly through the activity of latent membrane protein 1 (LMP-1). This study aimed to explore the role of LMP-1 in regulating susceptibility gene expression in SLE. Peripheral blood mononuclear cells (PBMCs) from SLE patients and H9 T cells were used to investigate this mechanism both in vivo and in vitro. RNA-seq analysis revealed that LMP-1 and the SLE susceptibility gene AT-rich interactive domain 5B (ARID5B) were significantly upregulated in SLE. Overexpression of LMP-1 in H9 T cells further increased ARID5B expression. Histone H3K27 methylation, catalyzed by enhancer of zeste homolog 2 (EZH2), was significantly elevated, suggesting epigenetic modifications play a role in this regulation. H3K27 methylation was studied due to its known involvement in transcriptional repression and chromatin remodeling in autoimmune diseases. Furthermore, phosphorylated p65 (p-p65), a marker of nuclear factor-kappa-B (NF-κB) pathway activation, was increased. Blocking the NF-κB signaling pathway reduced ARID5B expression, indicating that LMP-1 may regulate susceptibility genes through NF-κB signaling and histone modifications. These findings suggest that EBV LMP-1 contributes to SLE pathogenesis by epigenetically modulating susceptibility gene expression and activating inflammatory pathways.

Diagnostic biomarkers and immune infiltration profiles common to COVID-19, acute myocardial infarction and acute ischaemic stroke using bioinformatics methods and machine learning

BACKGROUND

COVID-19 is a disease that affects people globally. Beyond affecting the respiratory system, COVID-19 patients are at an elevated risk for both venous and arterial thrombosis. This heightened risk contributes to an increased probability of acute complications, including acute myocardial infarction (AMI) and acute ischemic stroke (AIS). Given the unclear relationship between COVID-19, AMI, and AIS, it is crucial to gain a deeper understanding of their associations and potential molecular mechanisms. This study aims to utilize bioinformatics to analyze gene expression data, identify potential therapeutic targets and biomarkers, and explore the role of immune cells in the disease.

METHODS

This study employed three Gene Expression Omnibus (GEO) datasets for analysis, which included data on COVID-19, AMI and AIS. We performed enrichment analysis on the co-DEGs for these three diseases to clarify gene pathways and functions, and also examined the relationship between co-DEGs and immune infiltration. Machine learning techniques and protein-protein interaction networks (PPI) were used to identify hub genes within the co-DEGs. Finally, we employed a dual validation strategy integrating independent GEO datasets and in vitro experiments with human blood samples to comprehensively assess the reliability of our experimental findings.

RESULTS

We identified 88 co-DEGs associated with COVID-19, AMI and AIS. Enrichment analysis results indicated that co-DEGs were significantly enriched in immune inflammatory responses related to leukocytes and neutrophils. Immune infiltration analysis revealed significant differences in immune cell populations between the disease group and the normal group. Finally, genes selected through machine learning methods included: CLEC4E, S100A12, and IL1R2. Based on the PPI network, the top ten most influential DEGs were identified as MMP9, TLR2, TLR4, ITGAM, S100A12, FCGR1A, CD163, FCER1G, FPR2, and CLEC4D. The integration of the protein-protein interaction (PPI) network with machine learning techniques facilitated the identification of S100A12 as a potential common biomarker for early diagnosis and a therapeutic target for all three diseases. Ultimately, validation of S100A12 showed that it was consistent with our experimental results, confirming its reliability as a biomarker. Moreover, it demonstrated good diagnostic performance for the three diseases.

CONCLUSION

We employed bioinformatics methods and machine learning to investigate common diagnostic biomarkers and immune infiltration characteristics of COVID-19, AMI and AIS. Functional and pathway analyses indicated that the co-DEGs were primarily enriched in immune inflammatory responses related to leukocytes and neutrophils. Through two machine learning approaches and the PPI network, and subsequent validation and evaluation, we identified S100A12 as a potential common therapeutic target and biomarker related to immune response that may influence these three diseases.

Tofacitinib as a possible treatment in macrophage activation syndrome: a pilot single-center study in China

OBJECTIVES

Our pilot study investigated the efficacy and safety of tofacitinib (TOF) in patients with macrophage activation syndrome (MAS), providing a new therapeutic option.

METHODS

This was a historical comparator, single-center study. Patients enrolled in our study were screened using the 2016 Pediatric Rheumatology International Trials Organization (PRINTO) criteria of MAS. MAS patients deemed suitable for TOF therapy were enrolled in the experimental group. The control group included MAS patients from Yantai Yuhuangding Hospital who had received biological and/or conventional synthetic disease-modifying anti-rheumatic drugs (b/csDMARDs) treatment in a similar period. Clinical characteristics, laboratory test results, MAS treatment response rates, and glucocorticoid discontinuation rates were compared between the two groups before and after treatment. Serious adverse events such as thrombosis or severe infection were recorded.

RESULTS

A total of 36 MAS patients were included-17 in the TOF treatment group and 19 in the b/csDMARDs control group. Baseline demographic and clinical characteristics were comparable between groups. After six weeks, the proportion of febrile patients was significantly lower in the TOF group compared to the control group (11.8% [2/17] vs. 47.3% [9/19], P = 0.021). Significant reductions were also observed in C-reactive protein levels at week 6 (5.9% [1/17] vs. 36.8% [7/19], P = 0.026) and ferritin levels at week 12 (100.0% [17/17] vs. 26.3% [5/19], P = 0.023). The MAS treatment response rate was significantly higher in the TOF group at weeks 2 and 6 (P = 0.029 and P = 0.023, respectively). Glucocorticoid discontinuation was more frequent in the TOF group, with a 12-week discontinuation rate of 100.0% (17/17) compared to 57.9% (11/19) in the control group (P = 0.002). No serious adverse events, including thrombosis or severe infections, were reported.

CONCLUSION

Our results suggest that TOF may be as effective as or even better than b/csDMARDs, with a quicker and higher response rate in patients with MAS without severe adverse events. Key Points •Tofacitinib may be as effective or better than b/csDMARDs in MAS. •Tofacitinib may act at a quicker and higher response rate in MAS. •Tofacitinib might be an alternative therapeutic option for patients with MAS.

Hydroxychloroquine improves pregnancy outcomes by inhibiting excessive autophagy in extravillous trophoblast caused by an anti-phospholipid syndrome

OBJECTIVES

This study aims to investigate the mechanism of hydroxychloroquine (HCQ) immunoregulation therapy in improving adverse pregnancy outcomes of recurrent miscarriages (RM) caused by antiphospholipid syndrome (APS).

METHODS

(i) Immunofluorescence staining was used to analyse the potential targets of antiphospholipid antibodies at the maternal-fetal interface in normal early pregnancy; (ii) Immunohistochemical and immunofluorescence techniques were used to compare and analyse the placenta vascular remodeling, villus tissue synthetic secretion function, trophoblastic autophagy and apoptosis levels in first trimester decidual tissue between normal and APS caused recurrent miscarriages (APS-RM) cases; (iii) HTR8/SVneo and BeWo cell lines were treated with serum from normal and APS-RM cases, and quantified by RT-PCR and Western blot to analysis the expression levels of cell invasion, secretion, autophagy and apoptosis-related molecules; (iv) After adding 0.1 μg/ml HCQ to the serum-treated cell line, the expression of autophagy and invasion-related proteins were detected, and invasion and tube formation of HTR8/SVneo cells was assessed by transwell experiments and tube formation assay.

RESULTS

(i)β2-glycoprotein Ⅰ antigen is expressed in all types of trophoblasts at the maternal-fetal interface in first trimester; (ii) The extravillous trophoblast cells (EVTs) have excessive autophagy in the decidual tissue of the APS-RM cases, and the uterine spiral artery was remodelled insufficiently; (iii) APS-RM cases serum can lead to cell excessive autophagy, and decrease cell invasion and tube formation in vitro; (iv) 0.1 μg/ml HCQ could rescue abnormal cell status caused by APS cases serum in HTR8/SVneo cells in vitro; (v) APS cases serum mainly affects the invasion and tube formation of EVTs, but has little effect on the function of villous trophoblast cells.

CONCLUSIONS

Antiphospholipid antibodies can lead to excessive autophagy in EVTs, thereby affecting ability of invasion and remodeling of spiral arteries, which is one of the mechanisms leading to adverse pregnancy outcomes. HCQ can rescue adverse pregnancy outcomes in APS patients by inhibiting excessive autophagy.

Hypogammaglobulinemia in patients affected by limited cutaneous systemic sclerosis: Case series and review of the literature

Background

Hypogammaglobulinemia is a condition that can be related to both primary and secondary immunodeficiencies. While the role of primary immunodeficiency in immune-mediated diseases is well known, its occurrence in systemic sclerosis is not reported.

Objectives

This study aims to describe the clinical features associated with hypogammaglobulinemia in a cohort of limited cutaneous systemic sclerosis patients.

Methods

We retrospectively reviewed medical records of systemic sclerosis patients from two Italian referral centres (2010-2024). Included patients had limited cutaneous systemic sclerosis and presented reduced serum concentrations of one or more Ig isotypes (IgG < 700 mg/dL, IgA < 70 mg/dL or IgM < 50 mg/dL) in at least two separate measurements. Patients with secondary causes of hypogammaglobulinemia were excluded. Data collected included demographics, clinical features, Ig levels, infection history and comorbidities.

Results

We identified 30 systemic sclerosis patients (93% female, mean age 62 years) with limited cutaneous involvement and hypogammaglobulinemia. Most patients were positive for anti-centromere antibodies and received periodic intravenous infusions of prostaglandin analogues. No patient received immunosuppressive therapy. Median (interquartile range) serum IgG levels 519.5 (175) mg/dL, median IgA 65.5 (48) mg/dL and median IgM 71.5 (49) mg/dL. Four patients who met the European Society for Immunodeficiencies (ESID) criteria for common variable immunodeficiency experienced recurrent infections and had associated immune-mediated diseases. Five patients had selective IgA deficiency, with frequent immune-mediated comorbidities (thyroiditis, Sjögren's syndrome, arthritis, psoriasis). The other patients exhibited mild IgG deficiency without a significant infectious history.

Conclusions

This is the first study describing a cohort of patients with limited cutaneous systemic sclerosis and hypogammaglobulinemia. Our population presented a high prevalence of immune-mediated comorbidities but low infection rates. Further research is needed to explore the underlying mechanisms and clinical significance of hypogammaglobulinemia in these patients.

Inhibition of hepatitis C virus replication in HepG2 cells via modulation of the Raf-1 and interferon-alpha signaling pathways by thymoquinone

Hepatitis C virus (HCV) infection is a significant global health concern, as both acute and chronic hepatitis caused by HCV can lead to liver cancer and long-term liver damage. Thymoquinone (TQ), the active compound found in the remarkable herb Nigella sativa, has various anti-inflammatory and antiproliferative effects. In this study, we investigated the effect of TQ on the interferon-alpha (IFN-α) pathway and its ability to prevent HCV replication in the HepG2 cell line. Our findings showed no significant alterations in cell viability or lactate dehydrogenase (LDH) production in TQ-treated cells, while significant alteration in both factors was detected in cells treated with Sovaldi, the most commonly used drug for treatment of HCV infection. Interestingly, the level of the HCV NS5A protein was significantly reduced in infected cells treated with either TQ or Sovaldi in a dose-dependent manner. The expression of phosphorylated Raf-1 (phospho-Raf-1) and phospho-Mek-1 in infected cells was inhibited by TQ treatment, and the potential interaction between TQ and Ref-1 was confirmed by a molecular docking simulation. Unlike autophagy-related 12 (Atg12), the expression of LC3B in infected cells was also inhibited in a dose-dependent manner by TQ treatment. Conversely, the levels of interleukin-27 (IL-27) and interferon-alpha (IFN-α) in infected cells were significantly increased in a time- and dose-dependent manner by TQ treatment. These data suggest that TQ exerts antiviral effects in HepG2 cells by disrupting HCV replication through targeting of the Raf-1 signaling pathway and promoting the overproduction of IL-27 and IFN-α in infected cells.

Calcium and vitamin D supplements and burnout in anesthesiologists: A national cross-sectional study from China

ObjectiveJob burnout among anesthesiologists has been consistently high. This study evaluated the association of calcium and vitamin D supplementation with burnout among Chinese anesthesiologists.MethodA cross-sectional online survey was conducted during April and May 2023. Burnout was evaluated using the Maslach Burnout Inventory, which assesses emotional exhaustion, depersonalization, and low personal accomplishment. Data on calcium and vitamin D supplementations were self-reported. Sociodemographic information and medical history were also assessed. Binary and ordinal logistic regression were used to evaluate the risk of burnout and burnout levels, respectively. The excess risk and the attributable proportion due to interaction were examined to determine the synergistic effects of calcium and vitamin D supplementations on burnout risk.ResultsAmong the 4222 invited anesthesiologists, 3766 submitted eligible questionnaires (89% response rate). Just under half (49.8%) met the criteria for general burnout. Among anesthesiologists with burnout, 58.4% experienced emotional exhaustion, 35.8% depersonalization, and 61.2% low personal accomplishment. Anesthesiologists receiving calcium supplementation had a decreased risk of emotional exhaustion (OR = .83, 95% CI = .70-.99). Supplementation of vitamin D with or without calcium was not associated with overall burnout or any of its dimensions. No additive interaction of calcium and vitamin D on burnout was observed.ConclusionsJob burnout among anesthesiologists is of concern in China. Burnout is negatively associated with calcium supplementation but not with vitamin D. Further research is warranted to confirm the mechanism and causal relationship.

Comprehensive profiling of the heterogeneity of molecular endotypic traits in chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is a common clinical disease with molecular endotypes. In the present study, we performed a comprehensive transcriptomic profiling to investigate the heterogeneity of endotypes in CRS with nasal polyps (CRSwNP). The GSE23552 dataset, which includes microarray, was acquired from the Gene Expression Omnibus database. Additionally, surgical specimens were collected at Gunma University Hospital, and reverse transcription-quantitative PCR was performed. We performed gene expression analysis, Gene Set Enrichment Analysis (GSEA), deconvolution analysis, and hierarchical clustering of samples. Gene expression analysis and GSEA revealed that type 1, type 2, and Treg-related responses, were upregulated in nasal polyp tissues when compared with those in controls. Deconvolution analysis indicated the enrichment of type 1-related cells and generation of memory T cells. Furthermore, nasal polyps exhibited higher expression of effector function- and immune checkpoint-related genes than controls. In addition, hierarchical clustering revealed the heterogeneity in patients with type 2-inflamed CRSwNP. Notably, type 1 and type 2 scores correlated with the duration from surgery to biopharmaceuticals initiation. In conclusion, our study demonstrated the heterogeneity of molecular endotypes in CRSwNP. Further characterisation and stratification are required to develop a new endotype-based precision medicine for patients with CRS.

Role of COVID-19 in the Progression of Scleroderma Interstitial Lung Disease and New Onset Pulmonary Hypertension: A Challenging Case Report

This case report describes an 80-year-old woman with systemic sclerosis (SSc), complicated by interstitial lung disease (ILD) and new-onset pulmonary hypertension (PH), likely triggered by an atypical SARS-CoV-2 infection. Diagnosed with SSc in 2016 and previously stable ILD, she experienced clinical deterioration in 2023 with worsening respiratory failure and PH. Despite negative PCR and antigen tests, high anti-SARS-CoV-2 IgG levels and CT findings were consistent with COVID-19-related organising pneumonia. Intravenous glucocorticoids led to partial symptom improvement, although ILD progression continued. The patient died in December 2023 from pneumococcal pneumonia. This case highlights the complex interaction between SSc and COVID-19, where overlapping mechanisms of endothelial injury and fibrosis may exacerbate pre-existing organ damage. It underscores the need for a multidisciplinary approach and timely interventions, including vaccination, early clinical assessment and appropriate immunosuppressive or antiviral treatments, to prevent severe infectious complications and halt disease progression in this high-risk patient population.

Advancing women's health with a pioneering implant to treat breast cancer related lymphedema

Lymphedema (LE) is a globally recognized chronic and disabling condition with a high prevalence. At present, there is no curative treatment for LE, and management options are primarily limited to conservative approaches. To address this unmet need, we developed an innovative implantable device - the first-of-its-kind designed to replicate the function of lymphatic vessels in the affected limb. This novel device utilizes subcutaneous catheters and a micropump system to actively manage lymphatic fluid, representing a significant departure from traditional treatments. To evaluate feasibility, preliminary safety, and efficacy of this novel device, we conducted the first-in-human pilot study LymphoPilot. Nine patients with unilateral breast cancer-related LE (BCRL) underwent implantation of the device and discontinued conventional LE treatment. The device remained implanted for 8 weeks, during which its safety and efficacy were assessed. Results demonstrated no safety concerns and showed significant reductions in limb volume without the need for manual lymphatic drainage or compression treatment. These promising findings highlight the potential of this innovative approach and emphasize the need for further research into its long-term use as an alternative to current LE management strategies. This pioneering development offers hope for a transformative shift in LE treatment.

Imaging the microvasculature using nailfold capillaroscopy in patients with coronavirus disease-2019; A cross-sectional study

OBJECTIVES

It is understood that microvascular dysfunction plays a key role in the pathogenesis of SARS-CoV-2 coronavirus disease (COVID-19). The aim of this study was to evaluate the usefulness of an automated, quantitative nailfold capillaroscopy system in identifying microvascular changes in those confirmed with or having had COVID-19.

METHODS

Ninety-seven participants were enrolled into this study and grouped as follows: 52 participants with acute COVID-19 (further grouped by disease severity) and 45 participants with convalescent COVID-19 (further grouped into long COVID i.e. symptoms beyond 12 weeks, and fully recovered). Nailfold capillaroscopy images were obtained from the bilateral ring fingers using a Dino-Lite CapillaryScope 200 Pro, a small USB handheld microscope. Images were assessed quantitatively using bespoke automated measurement software and the number of haemorrhages noted for each participant.

RESULTS

Capillaries were predominantly 'normal' in appearance with narrow capillary loops and evenly distributed, but with an increased number of haemorrhages (40 % in the convalescent group and 17 % in the acute group, p = 0.007). There was no statistically significant difference in the mean width of capillaries (20.9-21.8 μm) or vessel density (9.6-9.9 caps/mm; acute and convalescent group, respectively).

CONCLUSIONS

This study has demonstrated the feasibility of nailfold capillaroscopy at the critical care bedside. Capillary structure appeared normal across all groups of individuals affected by COVID-19. Although the small differences in the microvasculature in recovered patients compared to in acutely unwell patients may suggest delayed structural change due to COVID-19, these differences are unlikely to be clinically relevant. Longitudinal studies would be required to explore this in more detail.

Age-related peculiarities of antibody-mediated humoral immune response following SARS-CoV-2 infection

Thousands of articles were published about the COVID-19 disease and hundreds about the immune response. But still little is known about the features of SARS-CoV-2-specific immunity in elderly. The aim of current research was to evaluate the age-related peculiarities of antibody mediated humoral immune response following SARS-CoV-2 infection. Our study presents an intriguing divergence from the classical concept of immunosenescence, where aging has been assumed to cause poor antibody responses, reduced or inefficient vaccination, and overall blunted immune responses in elderly people. Our findings were opposite to some of these expectations; participants aged over 60 expressed elevated titers of anti-SARS-CoV-2 antibodies in comparison to younger adults. Analyzing the data of relative neutralization and avidity of anti-SARS-Cov-2 (S) antibodies we propose that although older adults produce a higher quantity of antibodies, their functional efficiency appears relatively reduced exhibiting lower neutralizing capacity and binding strength per antibody compared to younger adults. We can assume that the immune system of the elderly may require a higher level of antibody production to obtain a comparable level of protection. Our findings highlight the intricate nature of immune responses in convalescent older adults. This has particular relevance to understanding immunity and vaccine responses in different age groups.

The (neuro)inflammatory system in anxiety disorders and PTSD: Potential treatment targets

Targeting the immune system has recently garnered attention in the treatment of stress- associated psychiatric disorders resistant to existing pharmacotherapeutics. While such approaches have been studied in considerable detail in depression, the role of (neuro)inflammation in anxiety-related disorders, or in anxiety as an important transdiagnostic symptom, is much less clear. In this review we first critically review clinical and in part preclinical evidence of central and peripheral immune dysregulation in anxiety disorders and post-traumatic stress disorder (PTSD) and briefly discuss proposed mechanisms of how inflammation can affect anxiety-related symptoms. We then give an overview of existing and potential future targets in inflammation-associated signal transduction pathways and discuss effects of different immune-modulatory drugs in anxiety-related disorders. Finally, we discuss key gaps in current clinical trials such as the lack of prospective studies involving anxiety patient stratification strategies based on inflammatory biomarkers. Overall, although evidence is rather limited so far, there is data to indicate that increased (neuro)inflammation is present in subgroups of anxiety disorder patients. Although exact identification of such immune subtypes of anxiety disorders and PTSD is still challenging, these patients will likely particularly benefit from therapeutic targeting of aspects of the inflammatory system. Different anti-inflammatory treatment approaches (microglia-directed treatments, pro-inflammatory cytokine inhibitors, COX-inhibitors, phytochemicals and a number of novel anti-inflammatory agents) have indeed shown some efficacy even in non-stratified anxiety patient groups and appear promising as novel alternative or complimentary therapeutic options in specific ("inflammatory") subtypes of anxiety disorder and PTSD patients.

Integrative gut microbiota, metabolomics and proteomics studies unraveled the mechanism of Shaoteng decoction in treating Sjogren's syndrome

BACKGROUND

Sjögren's syndrome (SS) is a complicated autoimmune disorder, encompassing multifaceted pathogenesis of inflammatory response, immune dysregulation and metabolic abnormalities. Shaoteng Decoction (STD) is a type of traditional Chinese medicine preparation that has been shown to effectively improve inflammatory damage and immune dysfunction in patients with SS. Nevertheless, the exact mechanism has not been unspecified.

PURPOSE

This work aims to determine the mechanism of STD treatment on SS, identifying potential therapeutic targets and their relationships.

METHODS

Non-obese diabetic mice served as a disease model. This study analyzes potential signaling pathways of STD treatment for SS through network pharmacology, and assesses the role of STD in reducing inflammatory damage using pathological staining, ELISA, and immunohistochemistry. Additionally, the study apply gut microbiota, metabolomics, and proteomics analyses to identify the key microbiota, metabolites and proteins, aiming to find potential action targets of STD. We use Western blotting and immunohistochemistry to verify the authenticity of the relevant targets and study the interactions among gut microbiota, metabolites, and proteins.

RESULTS

Proteobacteria is the important intestinal bacteria, Bile Acid Biosynthesis is the main metabolic pathway, IfI30, Ndufv3, and Ndufs6 are the crucial differential expressed proteins. Moreover, there is a strong correlation among the three. STD treats SS by reducing the abundance of Proteobacteria, increasing Bile Acid Biosynthesis, decreasing IfI30 expression, and increasing the expression of Ndufv3 and Ndufs6.

CONCLUSION

STD inhibits inflammatory responses, improves immune dysregulation and energy metabolism abnormalities, and prevents the progression of SS through regulating the gut microbiota, enhancing Bile Acid Biosynthesis, and modulating proteins expression levels.

Interaction between redox regulation, immune activation, and response to treatment in HER2+ breast cancer

In HER2+ breast cancer (BC), neoadjuvant therapy represents an ideal scenario for translational research, considering pathological complete response (pCR) as an endpoint. In these patients, achieving pCR after neoadjuvant therapy is associated with a better prognosis. However, biomarkers are needed to tailor optimal treatment for each patient. Evaluating tumour-infiltrating lymphocytes (TILs) has gained attention in predicting pCR. In the context of metastatic disease, TILs also appear to play a role in predicting outcomes. The interaction between the presence of TILs and reactive oxygen species (ROS) remains an area to be explored. ROS are critical for tumour cell homeostasis, and different levels can trigger differential biological responses in cancer cells and their microenvironment. Nevertheless, the influence of ROS on treatment efficacy and prognosis in patients with HER2+ BC remains to be elucidated. In this article, we reviewed the interplay between treatment response, immune system activation, and ROS production in HER2+ BC and suggested novel areas of intervention and research. We also present a bioinformatic analysis demonstrating that the altered expression of several redox-related genes could be associated with the prevalence of immune cell populations in the tumour microenvironment and with patient survival. New biomarkers are thus suggested and should be further explored to tailor the best treatment to each patient.

Risk of new-onset polymyalgia rheumatica following COVID-19 vaccination in South Korea: a self-controlled case-series study

BACKGROUND

While several studies have reported some cases of polymyalgia rheumatica (PMR) following COVID-19 vaccination, studies using large databases are lacking.

OBJECTIVES

To investigate the risk of PMR after COVID-19 vaccination using self-controlled case series (SCCS) analysis METHODS: We used the National Health Insurance Database, linked with the COVID-19 registry between February 2021 and August 2023, to identify adults aged 50 years or older who received at least one dose of COVID-19 vaccine and subsequently diagnosed with PMR within the observation period, defined as 240 days after the first dose of vaccine. The risk window was defined as 28 days after each dose of COVID-19 vaccination, and the control window encompassed the remainder of the observation period. Incidence rate ratios (IRRs) were estimated using conditional Poisson regression with 95% CIs, stratified by dose and vaccine type.

RESULTS

Among 44 818 078 COVID-19 vaccine recipients, 376 patients were diagnosed with PMR. The analysis indicated that COVID-19 vaccination was not associated with an increased risk of PMR (IRR, 0.74; 95% CI 0.59 to 0.94). Rather, the risk of PMR was slightly reduced after the first dose (0.52; 0.34 to 0.79), with no significant association with other doses of COVID-19 vaccine (0.83; 0.59 to 1.16 for second dose, 0.77, 0.48 to 1.25 for third dose).

CONCLUSION

In this nationwide SCCS, there was no association with the increased risk of PMR following COVID-19 vaccination. While these findings support the safety of COVID-19 vaccines, interpretation of the decreased risk of PMR should be cautious.

Disproportionality analysis of European safety reports on autoimmune and rheumatic diseases following COVID-19 vaccination

The safety profile of COVID-19 vaccines is well-established, yet the widespread immunization campaign has led to an increase in reported cases of Immune-Mediated and Rheumatic Diseases (IMDRs). This study aimed to assess the reporting of Adverse Events Following Immunization (AEFIs) related to IMDRs after COVID-19 vaccination. We analyzed all individual case safety reports (ICSRs) related to COVID-19 vaccines authorized in the European Union (i.e., tozinameran, elasomeran, ChAdOx1-S NCoV-19, and Ad26.Cov2.S) registered in the EudraVigilance (EV) database from January 1, 2021, to October 23, 2023. Our analysis identified ICSRs with events indicative of IMDRs and conducted disproportionality analysis (i.e., Reporting Odds Ratio (ROR) with 95% CI) to examine the frequency of different IMDR types linked to each vaccine. In total, 45,352 ICSRs reported at least one AEFI associated with rheumatic or autoimmune conditions, with 54% of them implicating tozinameran as the suspected vaccine. More than half of the reported AEFIs were classified as serious, with approximately 45% remaining unresolved. The most frequently reported conditions were other immune-mediated diseases, followed by arthritis, vasculitis, systemic lupus erythematosus, and tendinopathies. Our disproportionality analysis suggested that mRNA vaccines may be more frequently associated with new autoimmune rheumatic diseases. Stratified analysis revealed significant associations for ChAd, particularly in vasculitis and tendinopathies, only when compared to Ad26.Cov2.S. Real-world pharmacovigilance data suggest that autoimmune and rheumatic diseases may be under-reported following COVID-19 vaccination, highlighting the need for further research to better understand the underlying mechanisms. The findings from this disproportionality analysis suggest the need for further studies to investigate these results in greater depth.

Immune evasion strategies in AFP-producing gastric carcinoma: characterized by HLA-G expression and HLA class I deficiency

Alpha-fetoprotein-producing gastric carcinoma (AFPGC) is an aggressive subtype of gastric cancer characterized by a primitive cellular phenotype and poor prognosis. The tumor immunology of AFPGC remains largely unexplored. Given its embryonic-like properties, AFPGC is hypothesized to employ distinct immune evasion strategies, with the oncofetal protein human leukocyte antigen (HLA)-G-a key mediator of maternal-fetal immune tolerance-likely playing a pivotal role. To test this, we assessed the expression of HLA-G, along with other key immune evasion markers, including HLA class I (HLA-I) deficiency and PD-L1 expression, in 39 cases of AFPGC, and compared them with those of 44 Epstein-Barr virus (EBV)-positive, 57 microsatellite instability (MSI), 54 intestinal-type, and 45 diffuse-type gastric carcinomas. HLA-G expression was significantly higher in AFPGCs (71%) than in other subtypes (7-28%; P < 0.001). HLA-I deficiency (≥ 1% of tumor cells) was most prevalent in AFPGC (69%), followed by MSI tumors (56%), with lower rates in other subtypes (22-29%). PD-L1 positivity (combined positive score ≥ 5) was observed in 41% of AFPGCs, lower than in EBV-positive (77%) and MSI tumors (44%), but higher than in intestinal-type (13%) and diffuse-type (9%) carcinomas. Furthermore, CD8-positive T-cell infiltration was found to be lowest in AFPGC compared to the other subtypes. These findings suggest that AFPGC employs multiple immune evasion mechanisms, notably through increased HLA-G expression and HLA-I deficiency, likely linked to its primitive cellular phenotype and reactivation of immunogenic oncofetal antigens. Such immune evasion features may underlie the aggressiveness of AFPGC and present promising targets for immunotherapeutic interventions.

Unveiling spatial clusters of systemic sclerosis mortality in Spain: A comprehensive geographical analysis

OBJECTIVES

This study examined the spatial patterns of systemic sclerosis mortality in Spain from 2003 to 2022, identifying provincial-level clusters and sex-specific differences to explore potential underlying factors.

METHODS

Mortality and population data (2003-2022) were sourced from the National Institute of Statistics. Age-standardized mortality rates were calculated, and spatial patterns were analyzed using standardized mortality ratios and smoothed relative risks via the Besag, York, and Mollié model, with statistical inference performed using the Integrated Nested Laplace Approximation (INLA) technique. Spatial clustering was assessed using Tango's and Kulldorff's tests.

RESULTS

A total of 2016 SSc deaths were recorded, revealing a marked gender disparity. SSc mortality rates showed a consistent annual increase of 2.1% for both sexes, with women experiencing rates approximately 3.4 times higher than men. Age-specific analysis demonstrated higher mortality rates among women across all age groups, with an average sex ratio of 2.9, and rates increased with age for both sexes. Spatial analysis identified significant clusters of elevated SSc mortality in northwestern Spain, primarily in León and Asturias, with additional clusters extending to nearby provinces. These regions, characterized by silica mining and related industries, exhibited notable variations between men and women in the specific provinces affected.

CONCLUSIONS

This study identifies significant geographic and sex-based disparities in SSc mortality across Spain, with prominent clusters in the north. The results highlight the potential impact of environmental and occupational exposures on disease outcomes, emphasizing the need for targeted public health interventions in high-risk areas.

Quantitative assessment of salivary gland scintigraphy with SPECT/CT in the clinical application of Sjögren's syndrome

OBJECTIVE

This study aims to investigate the feasibility and clinical value of single-photon-emission computed tomography/computed tomography (SPECT/CT) in the quantitative assessment of salivary gland function in patients with Sjögren's syndrome (SS).

MATERIALS AND METHODS

Data were collected from 84 patients diagnosed with SS who underwent dynamic salivary gland scintigraphy at the First Affiliated Hospital of Anhui University of Science and Technology between October 2020 and October 2023. Additionally, a control group of 25 thyroid cancer patients who underwent thyroidectomy was selected. Imaging data from dynamic salivary gland scintigraphy were obtained and analyzed to calculate salivary gland functional parameters, including maximum accumulation rate (MAR), uptake ratio (UR), maximum secretion rate (MSR), Tmin (time from peak to lowest point on the time-activity curve), and average secretion rate (Vmin) following acidic stimulation.

RESULTS

Significant differences in MAR, UR, MSR, Vmin, and Tmin of the parotid and submandibular glands were observed between the SS group and the control group (P < 0.05). In the mild impairment group, significant differences were found in MSR, Tmin, and Vmin of the submandibular gland compared to the control group (P < 0.05). Moderate and severe impairment groups exhibited significant differences in MAR, MSR, Tmin, UR, and Vmin of the parotid gland compared to the control group (P < 0.05).

CONCLUSION

In SS patients, MAR, UR, MSR, Vmin, and Tmin are important indicators for evaluating salivary gland damage. The qualitative analysis of SPECT/CT salivary gland dynamic imaging and time-activity curves effectively assesses salivary gland function in SS patients, providing vital information for the development of clinical treatment strategies.

Different behavior of NK cells isolated from healthy women and women with recurrent spontaneous abortion after treatment with human amniotic epithelial cells

Maternal immunotolerance during pregnancy is heavily dependent on the critical properties of human amniotic epithelial cells (hAECs). Recurrent spontaneous abortion (RSA) is one of the most common diseases in women and is caused by feto-maternal immunotolerance disruption. The objective of this study is to investigate how hAEECs affect pNK cells isolated from RSA and healthy women in terms of immunomodulation. Peripheral blood NK cells were isolated from 20 women with RSA and 20 healthy women. Purified NK cells were co-cultured with hAECs, obtained from full-term healthy pregnant women at different cellular ratios. After 24 and 72 h of incubation, the expression of immunomodulatory genes in hAECs, immunophenotype, and cytotoxicity of NK cells, and cytokine production were investigated using real-time PCR, flow cytometry, and ELISA techniques, respectively. We observed a significant increase in TGF-β and IL-10 production, and CD56bright CD16+ subpopulation in pNK cells, a significant decrease in IFN-γ production and CD107a and FasL expression on NK cells. Also, NK cells' cytotoxicity against K562 cells was diminished after co-culture with hAECs. The expression of TGF-β and HLA-G genes by hAECs was diminished after co-culture with NK cells isolated from women with RSA. Our research indicates that the interaction between NK cells and hAECs influences the phenotype and function of both cells. Also, NK cells belonging to women with RSA and healthy women exhibit different behavior during treatment with hAECs, possibly due to NK cell dysfunction. However, extensive research is required to assess NK cell defects and their mutual interaction with hAECs.

Say hello to my little friend… micronutraceuticals in neuroenergetics, neuronal health, and neurodegenerative diseases

Vitamins and minerals (micronutraceuticals) maintain good health. However, the specific effects of these micronutraceuticals on brain health are often overlooked, or not even known. In this review, an overview of the direct and indirect effects of micronutraceuticals on brain energy metabolism (neuroenergetics) and neuronal health is provided. Thereafter, a holistic summary of the existing studies that have shown the impact of micronutraceuticals on neurodegenerative diseases. Lastly, this review concludes by identifying several research gaps that remain and provides suggestions for future research on these hot topics.

Mitochondrial dysfunction and fatigue in Sjögren's disease

OBJECTIVE

Sjögren's disease (SjD) is a chronic exocrine disorder typified by inflammation and dryness, but also profound fatigue, suggesting a pathological basis in cellular bioenergetics. In healthy states, dysfunctional mitochondria are recycled by mitophagic processes; when impaired, poorly functioning mitochondria persist and produce inflammatory reactive oxygen species. Employing a case-control study, we tested our hypothesis that mitochondrial dysregulation in T cells is associated with fatigue in SjD.

METHODS

We isolated pan T cells from peripheral blood mononuclear cells of 13 SjD and 4 non-Sjögren's sicca (NSS) subjects, who completed several fatigue questionnaires, along with 8 healthy subjects. Using Seahorse, we analysed T cells for mitochondrial oxygen consumption rate (OCR) and extracellular acidification rate, which we assessed for correlation with fatigue measures. Using public microarray data available for 190 SjD and 32 healthy subjects, we identified a mitophagic transcriptional signature that stratified SjD patients into 5 discrete clusters. Comparisons between the SjD subjects in these clusters to healthy individuals identified differentially expressed transcripts, which we subjected to bioinformatic interrogation.

RESULTS

Basal OCR, ATP-linked respiration, maximal respiration and reserve capacity were significantly lower in SjD and NSS subjects compared with healthy individuals, with no differences in non-mitochondrial respiration, basal glycolysis or glycolytic reserve. Scores related to a sleep questionnaire and Bowman's Profile of Fatigue and Discomfort showed correlation with altered OCR in SjD. Subgroup differential expression analysis revealed dynamic transcriptional activity between mitophagy subgroups, expanding the number of differentially expressed transcripts tenfold.

CONCLUSIONS

Mitochondrial dysfunction and fatigue are significant problems in SjD warranting further investigation.

The eye as a window to oral and pain symptoms in Sjögren's disease

BACKGROUND

To investigate whether certain dry eye (DE) metrics relate to oral and pain manifestations of Sjögren's disease (SjD).

METHODS

Secondary analysis of the Sjögren's International Collaborative Clinical Alliance dataset containing 1541 individuals with 2016 American College of Rheumatology/European League Against Rheumatism defined SjD. Binary logistic regression analyses examined which of 13 DE features related to various extraocular metrics.

RESULTS

The mean age of the population was 52±13.5 years; 45% identified as white and 94% as women. Heterogeneity in DE symptoms and signs was noted in individuals with SjD, with approximately one-third of individuals reporting significant spontaneous and/or evoked pain using various descriptors and indicating certain triggers, and approximately half having low tear production. Similarly, heterogeneity was noted with respect to oral and pain complaints, with extraocular pain symptoms found in approximately one-third of the population. Different ocular phenotypes aligned with different extraocular findings. Specifically, grittiness or scratchiness in the eyes (OR=1.6), blurred vision (OR=1.4) and low tear production (OR=1.8) most closely aligned with oral dryness ('Does your mouth feel dry?). On the other hand, burning or stinging in the eyes (OR=1.6), discomfort in low humidity (OR=1.2) and the absence of DE signs (normal tear production, OR=0.7; lack of ocular surface staining, OR=0.6) most closely aligned with pain outside the eye ('Do you experience persistent or frequent burning discomfort?').

CONCLUSIONS

Our findings suggest heterogeneity in SjD ocular presentations that predict extraocular features of disease and hint at mechanisms that underlie heterogeneity, namely divergent neurosensory processes.

Malignancy in Systemic Sclerosis: A Multicenter Retrospective Study

Background/Objectives: Systemic sclerosis (SSc) is associated with high malignancy risk. With improving SSc management, tumor risk could change, therefore re-evaluating the possibility of neoplasms is necessary. Our aim was to observe malignancy prevalence and its risk factors in the Hungarian SSc population, comparing them to our previous and international results. Methods: We retrospectively collected the data of SSc patients followed by and admitted to three Hungarian clinical centers between 2018 and 2024. The collected data included the characteristics of SSc and neoplasms, autoantibody positivities, immunosuppressive treatments, pregnancy and environmental factors. Results: Out of 541 patients, 85 had malignancy and, in total, 96 tumors were registered. Skin cancer was the most common (n = 24), followed by breast (n = 14) and lung cancer (n = 14). Among skin cancers, almost one-third was melanoma. Tumors mostly appeared in two peaks: around the time of SSc diagnosis and 10 years later. The occurrence of anti-RNA Polymerase III (anti-RNAPIII) was significantly higher in cancerous patients. Tumor risk was higher with anti-RNAPIII (Odds Ratio (OR) 4.33, 95% Confidence Interval (95% CI) 1.08, 15.1) and anti-topoisomerase I (ATA) (OR 2.34, 95% CI 0.94, 5.84) positivity. Women and patients with diffuse cutaneous SSc (dcSSc) were more likely to have malignancy. Smoking (OR 1.27, 95% CI 0.53, 3.00) also raised the possibility of carcinogenesis. Cancerous patients were older (p-value = 0.003), and their mortality was worse compared to non-cancerous patients (Hazard Ratio (HR) 4.75, 95% CI 2.12, 10.62). Pregnancy did not provide a protective effect against breast cancer. Conclusions: Malignancy significantly contributes to the increased mortality in SSc. Female gender, dcSSc, anti-RNAPIII positivity, smoking and older age represent a higher risk of tumors. Dermatological cancer screening is necessary for all patients with SSc.

Divergent disruptive effects of soluble recombinant tau assemblies on synaptic plasticity in vivo

Neurofibrillary tangles (NFTs), composed of tau protein fibrils, together with brain inflammation and synaptic loss, are neuropathological hallmarks of several neurodegenerative diseases, including Alzheimer's disease. Compared with tau fibrils, more water-soluble assemblies of either recombinant or patient-derived tau have been reported to exert relatively potent rapid synaptotoxic effects, including inhibition of synaptic long-term potentiation (LTP) in the hippocampus. Less is known regarding the action of exogenous tau soluble assemblies on the opposite form of synaptic plasticity, long-term depression (LTD). We compared the synaptic plasticity actions of two relatively standard preparations of soluble recombinant tau assemblies, (i) fibril-derived soluble sonicated tau aggregates (SτAs) and (ii) oligomer-enriched tau (oTau) prepared from monomers. Consistent with previous findings, intracerebroventricular injections of either SτAs or oTau acutely inhibited high-frequency stimulation-induced LTP at CA3-to-CA1 synapses in the anaesthetized rat hippocampus. However, LTP inhibition by oTau, but not SτAs, was prevented by co-injection with the conformational anti-tau monoclonal antibody, TOMA1. Furthermore, in contrast to SτAs, which inhibited LTD, injection of oTau potently facilitated LTD, decreasing the threshold for LTD induction by low-frequency stimulation. To test the role of pro-inflammatory cytokines in mediating the disruptive effects of the two forms of soluble tau on synaptic plasticity we pre-injected etanercept, a decoy receptor for tumor necrosis factor alpha (TNFα). Etanercept reduced the disruption of synaptic plasticity by oTau but not by SτAs. Moreover, injection of exogenous TNFα mimicked the facilitation of LTD by oTau, consistent with a role of this pro-inflammatory cytokine in LTD facilitation.These data provide evidence that preparations of soluble tau containing either monomer- or fibril-derived assemblies disrupt LTP and LTD via different mechanisms. Intriguingly, when oTau and SτAs were applied together, LTD block predominated. Thus, if similar synaptotoxic soluble tau assemblies are present together later during the disease process, as seems likely, inhibition of synaptic weakening processes is predicted to predominate. Equally, reducing TNFα would be expected to be more effective when the monomer-derived soluble tau assemblies are the dominant synaptotoxic species. We conclude that oTau and SτAs provide useful means to explore ways of targeting different synaptotoxic soluble tau species in tauopathies.

How to Assess Pulmonary Circulation and Right Heart Chambers in Systemic Sclerosis Patients?

Systemic sclerosis (SSc) is a rare autoimmune connective tissue disease characterized by a widespread accumulation of extracellular matrix components leading to fibrosis of the skin and internal organs. Vascular changes occur in all involved tissues and are responsible for several distinctive clinical manifestations of the disease. This review focuses on the usefulness of various diagnostic tools in clinical practice for the early identification of clinical, functional, and/or structural RV impairment in SSc patients at risk of PH. It aims to identify specific causes of RV dysfunction, describe potential differences in outcome measures, and, ultimately, determine different cut-off values compared to subjects with PH not related to SSc.

Clonal rearrangements of B and T lymphocytes in minor salivary gland biopsies of Sjögren's disease patients with a focus score of ≥1

INTRODUCTION

Sjögren's Disease (SjD) is a systemic autoimmune disease with an increased risk of developing hematolymphoid neoplasms, with mucosa-associated marginal zone lymphoma being the most common. This could be related to the lack of a diagnostic test to achieve early diagnosis. Clonal rearrangements are molecular tests used in the diagnosis of lymphoid neoplasms that have proven to be supportive in the diagnosis and may be useful in the early diagnosis process when applied to minor salivary gland biopsies (MSGB).

METHODS

Cross-sectional study including MSGB with a diagnosis of SjD between 2019 and 2022 at a university hospital in Bogota, Colombia. Sociodemographic data and histopathological characteristics were collected. Immunohistochemical studies and rearrangement tests were then performed according to the BIOMED-2 protocol.

RESULTS

Rearrangements were performed for T cell receptors and B cell immunoglobulins. A polyclonal result was found in most cases. Four cases were oligoclonal in IgH and two isolated clonal results: one in the TCR β segment and the other in the kappa light chain segment of immunoglobulin.

CONCLUSION

Clonal rearrangements may be a useful tool for the early diagnosis of hematolymphoid neoplasms. Further studies with longer follow-up and application to MSGB are needed to better define a clonal pattern.

Human leukocyte antigen-G in hepatocellular carcinoma driven by chronic viral hepatitis or steatotic liver disease

Hepatocellular carcinoma (HCC) is the sixth most common cancer globally and the third leading cause of cancer-related mortality, primarily driven by viral infections (HCV, HBV) and steatotic liver diseases (SLD). Despite advances in treatment, early detection and accurate prognosis remain challenging. The Human leukocyte antigen G (HLA-G) molecule is dysregulated in various conditions, including cancers and viral infections. This study aimed to investigate HLA-G's role in viral-related and SLD-driven HCC. We analyzed a cohort of 116 HCC patients and 140 healthy controls to assess HLA-G genetic variants and soluble levels. Results showed significantly higher levels of soluble HLA-G in HCC patients compared to controls (Pc = 0.003). Moreover, overall survival (OS) was significantly lower in patients with the extended HLA-G*01:01:01/UTR-1 haplotype (Log-rank test, p = 0.002), a trend consistent in both HCV and/or HBV-related HCC (p = 0.025) and SLD-related HCC (p = 0.018). Elevated sHLA-G levels were associated with shorter OS across both subgroups (p = 0.034 (HBV/HCV) and p = 0.010 (SLD), respectively). The findings suggest that elevated levels of soluble HLA-G and specific genetic variants are associated with poor prognosis in HCC patients, highlighting the potential of HLA-G as a prognostic biomarker in both viral-related and steatotic liver disease-related HCC.

The emergence of a novel mpox virus strain (clade Ib) in Central Africa: A global public health concern

Monkeypox (mpox) infection gained global attention when it spread outside Africa in 2003. A novel mpox strain was identified in the Central African Republic in 2024. This new variant presents significant clinical and epidemiological differences from previously known strains. The high rate of pediatric infection, shortened incubation period, rapid transmission, unusual symptoms, accelerated disease progression, and higher case fatality rate make this strain a potential public health concern. Current epidemiological data suggest a case fatality rate of approximately 8-10 %, higher than clade II (West African strain). We recommend considering this new mpox strain as a top priority for international healthcare authorities. International health organizations must provide support to nations with fragile healthcare infrastructures. Immediate actions are essential to prevent this emerging variant from escalating into a larger epidemic. Global healthcare organizations should apply lessons learned from previous outbreaks of infectious diseases to mitigate this new threat.

Association Between Residential Greenness and Risk of Stroke by Ecoregions: The REGARDS Study

BACKGROUND

Living in areas with more greenness has been associated with beneficial health outcomes. However, few studies have examined associations of greenness with incidence of stroke, and it is unclear how these associations may vary with the type of vegetation and surrounding ecology. This study evaluated associations between greenness and incidence of stroke by the major ecological regions in the United States.

METHODS AND RESULTS

We assessed the incidence of stroke in 27 369 participants from the REGARDS (Reasons for Geographic and Racial Differences in Stroke) study, a prospective cohort recruited across the contiguous United States. Greenness was estimated by the normalized difference vegetation index and enhanced vegetation index (EVI) at multiple buffers around home addresses. Participants were assigned to ecoregions using their baseline residence. We estimated the association between residential greenness and incidence of stroke using covariate-adjusted Cox proportional hazards models. Models were stratified by ecoregions to assess how associations varied by areas with unique vegetation and ecology. We observed 1581 incident cases of stroke during the study period. In the full study population, there was suggestive evidence of a protective association between greenness and stroke incidence (hazard ratio [HR], 0.989 [95% CI, 0.946-1.033]) for a 0.1 increase in normalized difference vegetation index within 250 m. Similar results were obtained using enhanced vegetation index and larger radii. In our analysis by ecoregions, we found greenness was associated with lower stroke risk in the Eastern Temperate Forests region (HR, 0.946 [95% CI, 0.898-0.997]), but higher risk in the Great Plains (HR, 1.442 [95% CI, 1.124-1.849]) and Mediterranean California regions (HR, 1.327 [95% CI, 1.058-1.664]).

CONCLUSIONS

Vegetation may lower the risk of stroke; however, benefits may be limited to certain contexts of the natural environment.

Treatment of xerostomia in Sjögren's syndrome - what effect does it have on the oral microbiome?

Sjögren's syndrome is an autoimmune disease characterized by lymphatic infiltration of secretory tissues. The disease results in dryness of the eyeball or mouth, which often occur simultaneously. Agents used to treat Sjögren's syndrome may improve oral hydration and the patient's quality of life. There are several pharmacological and non-pharmacological agents used to treat significant problem like xerostomia. The use of appropriate medicines (i.e. pilocarpine and cevimeline) may cause changes in the local microbiome, which is very sensitive to quantitative changes in water. As a result of Sjögren's syndrome, a new balance of the microbiome is established in the oral cavity, which, if disturbed by medical measures, may increase the risk of oral lesions (such as periodontopathies or caries) or reduce this risk. Overall, the knowledge regarding microbiological aspects and agents treating oral dryness is still not well described but initial results indicate some microbial alterations.

Exploring endothelial dysfunction in major rheumatic diseases: current trends and future directions

The relationship between rheumatic diseases (RDs) and endothelial dysfunction (ED) is intricate and multifaceted, with chronic inflammation and immune system dysregulation playing key roles. RDs, including Osteoarthritis (OA), Rheumatoid arthritis (RA), Systemic Lupus erythematosus (SLE), Ankylosing spondylitis (AS), Psoriatic arthritis (PsA), Sjogren's syndrome (SS), Systemic sclerosis (SSc), Polymyalgia rheumatica (PMR) are characterized by chronic inflammation and immune dysregulation, leading to ED. ED is marked by reduced nitric oxide (NO) production, increased oxidative stress, and heightened pro-inflammatory and prothrombotic activities, which are crucial in the development of cardiovascular disease (CVD) and systemic inflammation. This association persists even in RD patients without conventional cardiovascular risk factors, suggesting a direct impact of RD-related inflammation on endothelial function. Studies also show that ED significantly contributes to atherosclerosis, thereby elevating cardiovascular risk in RD patients. This review synthesizes the molecular mechanisms connecting major RDs and ED, highlighting potential biomarkers and therapeutic targets. Ultimately, the review aims to enhance understanding of the complex interactions leading to ED in rheumatic patients and inform strategies to mitigate cardiovascular risks and improve patient outcomes.

Mucosal immunotherapy targeting APC in lung disease

Several studies have demonstrated that the pulmonary immune response is primarily facilitated by antigen-presenting cells (APCs), and that both professional and non-professional APCs contribute to overall pulmonary immunity. APCs play unique roles and mechanisms in pathogen elimination and immunomodulation. Mucosal immunity exhibits potential advantages over traditional parenteral immunity in that it stimulates immune defenses in mucosal and systemic tissues, which is important for reducing the burden of lung disease. However, obtaining a comprehensive understanding of the crosstalk between mucosal immunity and APC in the context of various lung diseases remains challenging. This mini-review aimed to elucidate the mechanisms of novel mucosal immunity, targeting APC action during lung infections, allergies, and malignant tumorigenesis. This minreview provides important insights into more effective therapeutic approaches for various lung diseases.

Transcriptomic sequencing of multiple salivary glands combined with bioinformatics analysis reveals key genes in primary Sjögren's syndrome

OBJECTIVE

Reveal key genes involved in the pathogenesis of Primary Sjögren's Syndrome (pSS) and identify new potential biomarkers and therapeutic targets.

METHODS

mRNA transcriptome data from pSS patients'and healthy controls'parotid and minor salivary glands were collected from the Gene Expression Omnibus (GEO) database. mRNA sequencing was performed on pSS mouse model submandibular glands. Differentially expressed genes (DEGs) were identified and core genes were screened using protein-protein interaction (PPI)networks. Validation was done through Gene Ontology (GO),Kyoto Encyclopedia of Genes and Genomes (KEGG), immune cell infiltration, heatmap, and Receiver Operating Characteristic (ROC) curve analyses, followed by external validation. Finally, review the clinical studies of drugs targeting these genes.

RESULTS

A total of 113 DEGs were identified, yielding 15core DEGs CD8 A, LCK, SYK, CD2, CD247, CD3D, LCP2, CD3G, CCR7, ITK, CXCR4, B2M, CXCL10, CXCL13, and CXCL9.These core genes were enriched in antigen receptor-mediated and T cell receptor signaling pathways, as well as in the chemokine signaling pathway. Immunocell infiltration analysis revealed that, except for B2M, the expression of other core genes is correlated with the proportion of immune cells. Genes like, CXCL13, CXCL9, CXCR4,CD2,CCR7,and ITK exhibited high diagnostic accuracy for distinguish in pSS patients. Core DEGs such as LCK, SYK, LCP2, and ITK was validated in salivary gland data from pSS patients and mouse models. Drugs targeting LCK, SYK, ITK, and other core genes, with their clinical status, were identified.

CONCLUSION

This study identified key genes in pSS, providing novelinsights into pathogenesis, promising biomarkers, and potential therapeutictargets. Key Points • mRNA transcriptomic sequencing was conducted on submandibular gland specimens from NOD mice simulating pSS and normal mice. • Commonly dysregulated core genes were identified across the minor and parotid salivary glands of pSS patients and healthy controls, as well as in the submandibular glands of NOD and normal mice. • ROC analysis was employed to evaluate their predictive value in the diagnosis of pSS.Genes such as CXCL13, CXCL9, CXCR4, CD2, CCR7, and ITK exhibited high diagnostic accuracy for distinguishing pSS patients. • Genes such as LCK, SYK, and ITK have been validated through external verification and qPCR, and have been identified as targets for clinical drugs.

Emerging variants of Mpox virus and tecovirimat resistance: Genomic insights and implications for treatment strategies

Mpox is a zoonotic viral infection caused by the monkeypox virus (MPXV) genus Orthopoxvirus. The MPXV, possesses a large and complex double-stranded DNA genome, encoding approximately 190 genes. The virus has gained attention due to recent outbreaks and the emergence of resistant variants. MPXV exists in two distinct clades: Central African (Clade I) and West African (Clade II), with Clade I being more virulent. Genomic surveillance has revealed significant mutations across MPXV lineages, with Clade IIb, responsible for the 2022 outbreak, exhibiting rapid adaptation through APOBEC3-mediated deamination associated with sustained human-to-human transmission. The recent outbreak of highly mutated Clade 1b MPXV (hMpox-1) strain was associated with increased human-to-human transmission, underscoring the importance of monitoring viral mutations to track diversity and identify resistance to antiviral therapies. Tecovirimat, an antiviral drug authorized for treating Mpox, targets the F13L protein involved in viral egress. However, the rise of MPXV variants resistant to tecovirimat, linked to mutations in the F13L gene, presents a growing challenge. Mutations in the F13L gene, such as H238Q, A288P, A290V, D294V, P243S, N267D, A295E, I372N, and A184T, have been linked to resistance, reducing tecovirimat's efficacy. Therefore, understanding the Clade-specific mutation patterns and genomic adaptations offers crucial insights into the mechanisms driving resistant variant emergence to inform targeted therapeutic and vaccine development strategies, ensuring effective containment of future Mpox outbreaks. This review highlights the genomic diversity of MPXV, its implications for antiviral resistance, and strategies to enhance treatment effectiveness, particularly in vulnerable populations.

Perioperative management of caesarean section for a pregnant woman with Sjögren's disease and pulmonary embolism: a case report

Background

Sjögren's disease (SjD) is a chronic inflammatory autoimmune disease with significant female predominance, characterised by lymphocyte proliferation and progressive damage to exocrine glands. The complexity of the condition of women with SjD and the incidence of complications substantially increase during pregnancy, which undoubtedly has consequences on both maternal health and neonatal outcomes. Pulmonary embolism (PE) is associated with increased perinatal mortality. However, PE has rarely been reported in pregnant women with SjD.

Case presentation

A 40-year-old pregnant woman was diagnosed as having SjD. During admission, she experienced chest tightness and suffocation and was scheduled for caesarean section under combined spinal-epidural anaesthesia because of sustained low oxygen saturation and foetal distress. Postoperative pulmonary artery computed tomography angiography confirmed that the patient had developed a pulmonary embolism during the perioperative period. After multidisciplinary consultation, the patient underwent inferior vena cava filter implantation, anticoagulation, oxygen therapy, and anti-infection therapy; both the mother and neonate recovered and were discharged.

Conclusion

Early identification and comprehensive perioperative monitoring during the prenatal period are vital in patients with SjD complicated by PE.

HIV Tat as a latency reversing agent: turning the tables on viral persistence

The 'shock and kill' approach to an HIV cure involves the use of latency reversing agents (LRAs) to reactivate latent HIV, with the aim to induce death of infected cells through virus induced cytolysis or immune mediated clearance. Most LRAs tested to date have been unable to overcome the blocks to transcription elongation and splicing that persist in resting CD4+ T cells. Furthermore, most LRAs target host factors and therefore have associated toxicities. Therefore, there remains a high need for HIV-specific LRAs that can also potently upregulate expression of multiply-spliced HIV RNA and viral protein. The HIV Transactivator of Transcription (Tat) protein plays an important role in viral replication - amplifying transcription from the viral promoter - but it is present at low to negligible levels in latently infected cells. As such, it has been hypothesized that providing Tat in trans could result in efficient HIV reactivation from latency. Recent studies exploring different types of Tat-based LRAs have used different nanoparticles for Tat delivery and describe potent, HIV-specific induction of multiply-spliced HIV RNA and protein ex vivo. However, there are several potential challenges to using Tat as a therapeutic, including the ability of Tat to cause systemic toxicities in vivo, limited delivery of Tat to the HIV reservoir due to poor uptake of nucleic acid by resting cells, and challenges in activating truly transcriptionally silent viruses. Identifying ways to mitigate these challenges will be critical to developing effective Tat-based LRA approaches towards an HIV cure.

Uncovering the mysteries of human gamma delta T cells: from origins to novel therapeutics

Gamma delta (γδ) T cells represent a unique and distinct population of lymphocytes that bridge the innate and adaptive immune responses. This functional duality positions them as one of the pivotal elements in the evolution and development of the human body's defense mechanisms. This review aims to provide a comprehensive and in-depth overview of γδ T cells, covering their origins, development, classification, and functional roles in immunology. Special attention is given to their involvement in the pathogenesis of autoimmune and cancer-related diseases-areas that remain subjects of intensive research with many unanswered questions. Additionally, this article explores the therapeutic potential of γδ T cells, which hold promise as a novel approach to treating various difficult-to-manage diseases. The review also presents an analysis of the latest clinical studies utilizing γδ T cells, emphasizing their emerging role in modern medicine. The ultimate goal of this work is to offer a holistic perspective on the current state of research on γδ T cells and their prospective applications in immunotherapy and cancer treatment, highlighting their potential to become a groundbreaking tool in future medical interventions.

Subclinical coronary artery calcification in systemic sclerosis using high-resolution chest CT: Identification, extent, and disease-specific risk factors

OBJECTIVES

Early detection of subclinical atherosclerosis is pivotal for preventing symptomatic coronary artery disease. This study aimed to compare the proportion of patients with systemic sclerosis (SSc) having an Agatston coronary artery calcification (CAC) score ≥100 using high-resolution computed tomography (HRCT) chest scans to a background population using cardiac CT scans, and to identify disease-specific risk factors for subclinical CAC in patients with SSc.

METHODS

Logistic regression models, adjusted for cardiovascular risk factors, evaluated the odds ratio of patients having a CAC score ≥100. CAC scores for the background population were derived from two cardiac CT screening cohorts. CAC scores by HRCT chest scans were calibrated using a conversion factor to adjust for overestimation in comparison to CAC scores obtained from dedicated cardiac CT scans.

RESULTS

HRCT chest scans from 394 patients with SSc were evaluated. In total, 116 (29.4 %) had a CAC score of 0, while 162 (41.1 %) had a CAC score ≥100. Disease duration (OR=1.05, 95 % CI 1.01-1.09) and a history of digital ulcers (OR=2.25, 95 % CI 1.31; 3.86) were independently associated with a CAC score ≥100. Compared to the background population, a significantly higher proportion of SSc patients had a CAC score ≥100 (35.0 % vs. 23.2 %, p<0.001).

CONCLUSION

The identification of subclinical atherosclerosis using routine HRCT chest scans in patients with SSc offers the potential to detect individuals at increased risk of developing CAD and guide preventive treatment strategies. Additionally, digital ulcers appear to be a novel risk factor for subclinical CAD in these patients.

Defective Intracellular Insulin/IGF-1 Signaling Elucidates the Link Between Metabolic Defect and Autoimmunity in Vitiligo

Background: Vitiligo is featured by the manifestation of white maculae and primarily results from inflammatory/immune-selective aggression to melanocytes. The trigger mechanism leading to the activation of resident immune cells in the skin still lacks a molecular description. There is growing evidence linking altered mitochondrial metabolism to vitiligo, suggesting that an underlying metabolic defect may enable a direct activation of the immune system. Recent evidence demonstrated the association of vitiligo with disorders related to systemic metabolism, including insulin resistance (IR) and lipid disarrangements. However, IR, defined as a cellular defect in the insulin-mediated control of glucose metabolism, and its possible role in vitiligo pathogenesis has not been proven yet. Methods: In this study, we compared the Ins/IGF-1 intracellular signaling of dermal and epidermal cells isolated from non-lesional vitiligo skin to that belonging to cells obtained from healthy donors. Results: We demonstrated that due to the intensified glucose uptake, S6, and insulin receptor substrate 1 (IRS1) chronic phosphorylation, their inducibilities were downsized, a condition that coincides with the definition of insulin resistance at the cellular level. Correspondingly, the mitogenic and metabolic activities normally provoked by Ins/IGF-1 exposure resulted in significantly compromised vitiligo cells (p ≤ 0.05). Besides all the vitiligo-derived skin cells manifesting an energetic disequilibrium consisting of a low ATP, catabolic processes activation, and chronic oxidative stress, the functional consequences of this state appear amplified in the keratinocyte lineage. Conclusion: The presented data argue for insulin and IGF-1 resistance collocating dysfunctional glucose metabolism in the mechanisms of vitiligo pathogenesis. In vitiligo keratinocytes, the intrinsic impairment of intracellular metabolic activities, particularly when associated with stimulation with Ins/IGF-1, converges into an aberrant pro-inflammatory phenotype that may initiate immune cell recruitment.

Host-Strain-Specific Responses to Pneumonia Virus of Mice Infection: A Study of Lesions, Viral Load, and Cytokine Expression

Pneumonia virus of mice (PVM) infection is a reference animal model for human respiratory syncytial virus (hRSV), a leading cause of lower respiratory tract disease in children under 5 years of age and in the elderly. This longitudinal study employed necropsy to examine macroscopic lesions, histological slides to assess microscopic lesions, and qRT-PCR to measure lung viral load and cytokine expression in PVM-infected mice from three different genetic backgrounds, spanning from day 1 to day 6 post-infection. Our analysis reveals a strong correlation between viral load and microscopic lesions across the 129/Sv, BALB/c, and SJL/J mouse lines, indicating that PVM pathogenicity is partially driven by the virus itself. Additionally, a significant correlation between cytokine levels and lesion severity was observed in 129/Sv and BALB/c mice, suggesting an important role of cytokines in disease progression. This study emphasizes the interplay between viral load and cytokine-driven tissue damage, with genetic background significantly influencing disease outcomes.

The Jieduquyuziyin prescription alleviates systemic lupus erythematosus by modulating B cell metabolic reprogramming via the AMPK/PKM2 signaling pathway

ETHNOPHARMACOLOGICAL RELEVANCE

The Jieduquyuziyin prescription (JP) is an enhanced formula derived from the "Sheng Ma Bie Jia Tang" in the Golden Chamber. JP is an empirical formula approved for use in the treatment of systemic lupus erythematosus (SLE) in hospitals across China, demonstrating notable therapeutic effects. It has been shown to suppress B cell activation and alleviate symptoms; however, its underlying mechanism remains unclear.

AIM OF THE STUDY

The aim of this study is to investigate the effect of JP on B cell metabolic reprogramming in the treatment of SLE and to elucidate the underlying regulatory mechanisms.

MATERIALS AND METHODS

Core targets and pathways regulating B cell activation were identified through sequencing of activated and resting B cells from SLE patients and network pharmacology of JP. Targeted metabolomics was employed to assess JP's effect on B cell metabolism. In vivo experiments evaluated the effects of JP, JP combined with a PKM2 inhibitor, or an AMPK inhibitor on SLE activity, B cell activation and glycolysis.

RESULTS

Bioinformatics analyses identified PKM as a core target in B cell activation, which was significantly upregulated and linked to the inhibition of AMPK signaling. JP reduced B cell glycolysis and activation, leading to significant improvements in disease pathology. The combination of JP with an AMPK inhibitor diminished the therapeutic effect. Further studies suggested that JP inhibits glycolysis-dependent B cell activation via the AMPK/PKM2 pathway, reducing germinal center responses and effector B cells.

CONCLUSION

This study reveals that the AMPK/PKM2 pathway is a promising therapeutic target for regulating immune metabolic imbalance in SLE B cells. Additionally, it provides evidence that JP may improve SLE by activating the AMPK/PKM2 pathway to inhibit glycolysis-dependent B cell activation, laying the foundation for further investigation of its therapeutic mechanisms.

Tumor-associated antigens are associated with primary Sjögren's syndrome-related interstitial lung disease and disease activity

OBJECTIVES

Tumor-associated antigens (TAAs) have been shown to be associated with a variety of connective tissue diseases. However, the role of TAAs in primary Sjögren's syndrome (pSS) patients is still unclear. This study aims to explore the correlation between TAA levels and systemic clinical manifestations and disease activity in pSS patients.

METHODS

Data were retrospectively collected from 108 patients with pSS (pSS group) and 100 healthy subjects (HCs group). Comparison of clinical characteristics and serological parameters between the TAA-positive group and the TAA-negative group. The independent risk factors of TAAs positivity were analyzed by univariate and multivariate regression, and the receiver operating characteristic curve was used to analyze the diagnostic performance of TAAs for pSS-associated interstitial lung disease (pSS-ILD).

RESULTS

Compared with the control group, the positivity rates of CEA, CA125, CA15-3, and CYFRA21-1 were higher, and the levels of serum CA125, CA15-3, and CYFRA21-1were higher in the pSS group. The incidence of ILD, pleural effusion, pericardial effusion, and ESSDAI ≥5 in the TAA-positive group was higher than in the TAA-positive group. Multivariate logistic regression analysis showed that the incidence of ILD was identified as an independent risk factor for TAA positivity. The AUC of CEA, CYFRA21-1, and NSE in the diagnosis of pSS-ILD were 0.690, 0.840, and 0.872, respectively, and the combined diagnosis could reach 0.952.

CONCLUSION

Certain TAA-positive rates and serum levels were increased in pSS patients. The TAA-positive group is correlated with the ESSDAI scores. ILD was an independent risk factor for TAA positivity, and CYFRA21-1 and NSE had the best diagnostic value in patients with pSS-ILD.

Extracellular Traps in Inflammation: Pathways and Therapeutic Targets

New roles for immune cells, overcoming the classical cytotoxic response, have been highlighted by growing evidence. The immune cells, such as neutrophils, monocytes/macrophages, and eosinophils, are versatile cells involved in the release of web-like DNA structures called extracellular traps (ETs) which represent a relevant mechanism by which these cells prevent microbes' dissemination. In this process, many enzymes, such as elastase, myeloperoxidase (MPO), and microbicidal nuclear and granule proteins, which contribute to the clearance of entrapped microorganisms after DNA binding, are involved. However, an overproduction and release of ETs can cause unwanted and dangerous effects in the host, resulting in several pathological manifestations, among which are chronic inflammatory disorders, autoimmune diseases, cancer, and diabetes. In this review, we discuss the release mechanisms and the double-edged sword role of ETs both in physiological and in pathological contexts. In addition, we evaluated some possible strategies to target ETs aimed at either preventing their formation or degrading existing ones.