Time to Publication and Time-Lag Publication Bias for Randomized Trials on Connective Tissue Diseases

OBJECTIVE

To assess the time from completion to publication of randomized controlled trials (RCTs) on connective tissue diseases (CTDs), investigate the factors associated with, and explore the influence of significance of study results on time to publication (time-lag publication bias).

METHODS

We included interventional, phase 2/3, 3, or 4 RCTs on CTDs registered in Clinicaltrials.gov from 2000 to 2016, whose results had been published in a peer-review journal less than 5 years after their completion. Main trial features, including the significance of primary outcome results, were collected. Time to publication was the time from study completion to the earliest publication date. Multivariable linear regression was used to identify factors associated with time to publication.

RESULTS

We included 62 studies, mostly phase 3 (61%) trials on pharmacologic treatments (94%); we recruited patients with systemic lupus (55%) or systemic sclerosis (23%) and planned to enroll a median of 131 (IQR [interquartile range]: 61-288) patients. Twenty-two (35%) reported at least a statistically significant primary outcome. Median time to publication was 28 months (IQR: 17-36). In a multivariable analysis, time to publication progressively improved over time (faster publication in recent years, with the average time to publication decreasing by 1.3 [95% CI: 0.3-2.3] months per year) and was not influenced by the significance of primary outcome results, funder, impact factor of the journal, number of recruiting countries, and comparator.

CONCLUSION

A high proportion of CTDs-RCTs is published beyond 2 years from completion. We did not find evidence of time-lag publication bias, and time to publication improved over time.

Inflammation modulates intercellular adhesion and mechanotransduction in human epidermis via ROCK2

Aberrant mechanotransduction and compromised epithelial barrier function are associated with numerous human pathologies including inflammatory skin disorders. However, the cytoskeletal mechanisms regulating inflammatory responses in the epidermis are not well understood. Here we addressed this question by inducing a psoriatic phenotype in human keratinocytes and reconstructed human epidermis using a cytokine stimulation model. We show that the inflammation upregulates the Rho-myosin II pathway and destabilizes adherens junctions (AJs) promoting YAP nuclear entry. The integrity of cell-cell adhesion but not the myosin II contractility per se is the determinative factor for the YAP regulation in epidermal keratinocytes. The inflammation-induced disruption of AJs, increased paracellular permeability, and YAP nuclear translocation are regulated by ROCK2, independently from myosin II activation. Using a specific inhibitor KD025, we show that ROCK2 executes its effects via cytoskeletal and transcription-dependent mechanisms to shape the inflammatory response in the epidermis.

Contribution of keratinocytes to dermal fibrosis

PURPOSE OF REVIEW

The cellular pathogenesis of fibrotic disorders including systemic sclerosis (SSc) remains largely speculative. Currently, the altered function of endothelial cells and fibroblasts under the influence of an inappropriate immune response are considered central pathogenic events in SSc. Adding to this complexity, novel evidence here reviewed suggests that keratinocytes may concur in the development of skin fibrosis.

RECENT FINDINGS

Epidermal equivalents (EE) generated from primary SSc keratinocytes display a distinct gene expression program when compared to healthy donor (HD) EE. SSc-EE, among others, exhibited enhanced oxidative and metabolic response pathways. Immunohistochemical studies demonstrated similarities between SSc-EE and SSc epidermis including altered keratinocyte differentiation, enhanced expression of activation markers, and reduced rate of basal keratinocytes proliferation. SSc-EE supernatants more than HD-EE modified the inflammatory and extracellular matrix deposition/resorption program of dermal fibroblasts. Further evidence indicated that the relative lack rather than the excess of interleukin-25 in keratinocytes may contribute to enhanced dermal fibrotic changes. Overall, these data support keratinocyte-intrinsic SSc-related modifications.

SUMMARY

Improved methods for engineering epidermal and skin equivalents are helping to address the question whether keratinocyte alterations in SSc are primary and capable to dysregulate dermal homeostasis or secondary following dermal fibrotic changes.

The evaluation of tactile dysfunction in the hand in type 1 diabetes: a novel method based on haptics

AIMS

We present an innovative method based on haptics for the evaluation of the sense of touch in the hand, in people affected by type 1 diabetes.

METHODS

Forty individuals affected by diabetes and 20 healthy controls took part in the study; the diabetes group was further divided into two subgroups based on vibration sensitivity in the lower limb. By means of a novel haptic device, tactile sensitivity in the fingertip was measured as the ability of the participants to discriminate slip motion speed.

RESULTS

Tactile sensitivity was significantly lower in individuals affected by diabetes as compared to controls. Depending on the subgroup, the difference from the controls was equal to 0.11 (95% CI from 0.029 to 0.186) and to 0.267 (95% CI from 0.198 to 0.336). Within the diabetes group, tactile sensitivity correlated with vibration sensitivity in the upper (p = 0.001) and lower limb (p = 0.003). A significant relationship between nerve conduction parameters and tactile sensitivity was found (p = 0.03). Finally, we combined the different predictors (clinical, vibratory and electroneurography data) by using cluster analysis; tactile sensitivity was found to be significantly different between different clusters (p = 0.004).

CONCLUSIONS

Early signs of tactile dysfunction in the hand were found in individuals affected by diabetes, even in absence of diabetic neuropathy. The protocol presented in this study is a promising tool for the assessment of tactile dysfunction in the hand in people affected by type 1 diabetes.

AB0125 IL-25 PARTICIPATES IN KERATINOCYTE-DRIVEN DERMAL MATRIX TURNOVER AND IS REDUCED IN SYSTEMIC SCLEROSIS (SSc) EPIDERMIS

Background

Evidence shows that dysfunctional SSc keratinocytes contribute to fibrosis by altering dermal homeostasis (1, 2). Whether interleukin-25 (IL-25), an IL-17 family member regulating many epidermal functions (3), takes part in skin fibrosis is unknown.

Objectives

To investigate the role of IL-25 in skin fibrosis.

Methods

The expression of IL-25 was evaluated by immunofluorescence and in situ hybridization in 10 SSc and 7 healthy donors (HD) skin biopsies. Epidermal equivalents (EE) reconstituted by primary HD keratinocytes were used as a model to study transcriptomic changes induced by IL-25 in the epidermis. RNA expression profile in EE was characterized by RNAseq. The conditioned medium (CM) from primary SSc and HD keratinocytes primed with IL-25 was used to stimulate fibroblasts. IL-6, IL-8, MMP-1, type-I collagen (col-I), and fibronectin production by fibroblasts was assessed by ELISA.

Results

SSc epidermis expressed lower levels of IL-25 compared to HD. In EE, IL-25 regulated several molecular pathways related to wound healing and extracellular matrix (ECM) remodeling. Compared to control CM, the CM from IL-25-primed keratinocytes enhanced the fibroblast production of MMP-1, IL-6, IL-8, but not of Col-I nor fibronectin. However, IL-25 significantly reduced the production of Col-I when applied directly to fibroblasts and partially inhibit α-smooth muscle actin (α-SMA) expression promoted by TGFβ. The activation of keratinocytes by IL-25 was receptor-dependent and evident after a very short incubation time (10 min), largely mediated by IL-1, suggesting enhanced and specific release of preformed mediators.

Conclusion

These results show that IL-25 participates to skin homeostasis and its decreased expression in SSc may contribute to skin fibrosis by favoring ECM deposition over degradation.

References

[1]Russo B, Brembilla NC, Chizzolini C. Interplay between Keratinocytes and Fibroblasts: A Systematic Review Providing a New Angle for Understanding Skin Fibrotic Disorders. Frontiers in immunology. 2020; 11:648.

[2]Russo B, Borowczyk J, Boehncke WH, Truchetet ME, Modarressi A, Brembilla NC, et al. Dysfunctional keratinocytes increase dermal inflammation in systemic sclerosis. Results from tissue-engineered scleroderma epidermis. Arthritis & rheumatology. 2021.

[3]Borowczyk J, Shutova M, Brembilla NC, Boehncke WH. IL-25 (IL-17E) in epithelial immunology and pathophysiology. J Allergy Clin Immunol. 2021.

Acknowledgements

We thank Natacha Civic and Mylène Docquier (Genomics Platform) for performing the RNA sequencing; Nicolas Laudet (Bioimaging Core Facility) for quantification of immune-histology, François Prodon and Olivier Brun for microscope imaging (Bioimaging Core Facility), Marie Ebrahim Malek and Laura de Luca (Histology Core Facility) for contribution to tissue preparation (all at University Medical Center, Geneva, Switzerland).

Disclosure of Interests

Barbara Russo: None declared, Julia Borowczyk: None declared, Pietro Cacialli: None declared, Philippe Moguelet: None declared, Marie-Elise Truchetet Speakers bureau: Abbvie, Lilly, SOBI and Boehringer Ingelheim, Ali Modaressi: None declared, Nicolò Brembilla: None declared, Julian Bertrand: None declared, Wolf-Henning Boehncke Speakers bureau: Abbvie, Almirall, BMS, Celgene, Leo, Lilly, Novartis, and UCB, Carlo Chizzolini Speakers bureau: GSK, Roche, Boehringer Ingelheim

IL-25 participates in keratinocyte-driven dermal matrix turnover and is reduced in Systemic Sclerosis epidermis

OBJECTIVES

Evidence shows that dysfunctional SSc keratinocytes contribute to fibrosis by altering dermal homeostasis. Whether interleukin-25 (IL-25), an IL-17 family member regulating many epidermal functions, takes part in skin fibrosis is unknown. Here we address the role of IL-25 in skin fibrosis.

METHODS

The expression of IL-25 was evaluated by immunofluorescence and in situ hybridization in 10 SSc and 7 healthy donors (HD) skin biopsies. Epidermal equivalents (EE) reconstituted by primary HD keratinocytes were used as a model to study transcriptomic changes induced by IL-25 in the epidermis. RNA expression profile in EE was characterized by RNAseq. The conditioned medium (CM) from primary SSc and HD keratinocytes primed with IL-25 was used to stimulate fibroblasts. IL-6, IL-8, MMP-1, type-I collagen (col-I), and fibronectin production by fibroblasts was assessed by ELISA.

RESULTS

SSc epidermis expressed lower levels of IL-25 compared with HD. In EE, IL-25 regulated several molecular pathways related to wound healing and ECM remodeling. Compared with control CM, the CM from IL-25-primed keratinocytes enhanced the fibroblast production of MMP-1, IL-6, IL-8, but not of Col-I nor fibronectin. However, IL-25 significantly reduced the production of Col-I when applied directly to fibroblasts. The activation of keratinocytes by IL-25 was receptor-dependent and evident after a very short incubation time (10 min), largely mediated by IL-1, suggesting enhanced and specific release of preformed mediators.

CONCLUSIONS

These results show that IL-25 participates to skin homeostasis and its decreased expression in SSc may contribute to skin fibrosis by favoring ECM deposition over degradation.

Modeling Performance of Microservices Systems with Growth Theory

CONTEXT

The microservices architectural style is gaining momentum in the IT industry. This style does not guarantee that a target system can continuously meet acceptable performance levels. The ability to study the violations of performance requirements and eventually predict them would help practitioners to tune techniques like dynamic load balancing or horizontal scaling to achieve the resilience property.

OBJECTIVE

The goal of this work is to study the violations of performance requirements of microservices through time series analysis and provide practical instruments that can detect resilient and non-resilient microservices and possibly predict their performance behavior.

METHOD

We introduce a new method based on growth theory to model the occurrences of violations of performance requirements as a stochastic process. We applied our method to an in-vitro e-commerce benchmark and an in-production real-world telecommunication system. We interpreted the resulting growth models to characterize the microservices in terms of their transient performance behavior.

RESULTS

Our empirical evaluation shows that, in most of the cases, the non-linear S-shaped growth models capture the occurrences of performance violations of resilient microservices with high accuracy. The bounded nature associated with this models tell that the performance degradation is limited and thus the microservice is able to come back to an acceptable performance level even under changes in the nominal number of concurrent users. We also detect cases where linear models represent a better description. These microservices are not resilient and exhibit constant growth and unbounded performance violations over time. The application of our methodology to a real in-production system identified additional resilience profiles that were not observed in the in-vitro experiments. These profiles show the ability of services to react differently to the same solicitation. We found that when a service is resilient it can either decrease the rate of the violations occurrences in a continuous manner or with repeated attempts (periodical or not).

CONCLUSIONS

We showed that growth theory can be successfully applied to study the occurences of performance violations of in-vitro and in-production real-world systems. Furthermore, the cost of our model calibration heuristics, based on the mathematical expression of the selected non-linear growth models, is limited. We discussed how the resulting models can shed some light on the trend of performance violations and help engineers to spot problematic microservice operations that exhibit performance issues. Thus, meaningful insights from the application of growth theory have been derived to characterize the behavior of (non) resilient microservices operations.

Extent of and reasons for discontinuation and nonpublication of interventional trials on connective tissue diseases: an observational study

OBJECTIVES

To assess the proportion, the reasons, and the factors associated with discontinuation or nonpublication of randomized controlled trials (RCTs) on connective tissue diseases (CTDs).

METHODS

We searched all interventional RCTs on CTDs registered in Clinicaltrials.gov since 2000. Two reviewers selected studies according to pre-specified eligibility criteria. Completion status, publication status, reported reasons for discontinuation or nonpublication, were retrieved on Clinicaltrials.gov, through literature search, and by contacting investigators. Multivariable logistic regression was used to identify factors associated with study noncompletion and nonpublication.

RESULTS

We included 175 studies, mostly phase 3, placebo-controlled trials on pharmacologic treatments, recruiting patients with systemic lupus (51%), systemic sclerosis (20%), Sjögren syndrome (12%) or other CTDs. Fifty-eight (33%) had been discontinued, mainly for insufficient patient accrual, with no differences in discontinuation rates across the CTDs (P>0.5). Forty-six (35%) of 130 studies having included at least 1 patient resulted unpublished, and 86 (65%) were published in a peer-reviewed journal after a median of 24 months (IQ 15-41) from completion, with a significant higher publication rate in completed vs. discontinued studies (81% vs 22%; P<0.001). We were able to obtain reasons for nonpublication in one-third of cases. Small sample size (< 100 participants) was the only factor associated with study noncompletion and nonpublication.

CONCLUSIONS

One of three registered CTD-RCTs fails to be completed or published. This represents a waste of resources and raises ethical concerns regarding hidden clinical data and unfruitful participation by patients.

Dysfunctional Keratinocytes Increase Dermal Inflammation in Systemic Sclerosis: Results From Studies Using Tissue-Engineered Scleroderma Epidermis

OBJECTIVE

Evidence suggests that keratinocyte-fibroblast interactions are abnormal in systemic sclerosis (SSc). The present study was undertaken to investigate potential epidermal dysfunction in SSc and its effects on dermal homeostasis.

METHODS

Epidermal equivalents (EEs) were generated using keratinocytes from 6 healthy donors and 4 individuals with SSc. Skin and EE expression of markers of proliferation, differentiation, and activation was evaluated by immunohistochemistry. The transcriptomic profile of SSc EEs and healthy donor EEs was identified by RNA sequencing. EE conditioned medium (CM) was used to stimulate fibroblasts, and their production of interleukin-6 (IL-6), IL-8, matrix metalloproteinase 1 (MMP-1), type I collagen, and fibronectin was assessed by enzyme-linked immunosorbent assay.

RESULTS

Compared to healthy donor EEs, SSc EEs exhibited aberrant differentiation, enhanced expression of activation markers, and a lower rate of basal keratinocyte mitosis, reproducing most of the abnormalities observed in SSc epidermis. RNA sequencing analysis revealed that, compared to healthy donor EEs, SSc EEs were characterized by lower expression of homeobox gene family members and by enhanced metabolic and oxidative stress molecular pathways. EE CM enhanced fibroblast production of IL-6, IL-8, MMP-1, type I collagen, and fibronectin (P < 0.05). Except for type I collagen and fibronectin, this effect was 2-fold higher in the presence of CM generated form SSc EEs. IL-1 was responsible, at least in part, for keratinocyte-dependent fibroblast activation.

CONCLUSION

SSc EEs recapitulate the in vivo characteristics of SSc epidermis, demonstrating that SSc keratinocytes have an intrinsically altered differentiation program, possibly due to the dysregulation of genes from the homeobox family. The increased metabolic and oxidative stress associated with SSc epidermis may contribute to chronic inflammation and fibrosis of the dermis.

SAT0289 THE INS AND OUTS OF EPIDERMAL DYSFUNCTION IN SYSTEMIC SCLEROSIS (SSC): RESULTS FROM A NOVEL TISSUE ENGINEERED EPIDERMAL EQUIVALENT FROM SSC KERATINOCYTES

Background:

Skin fibrosis is a hallmark of systemic sclerosis (SSc). It is commonly accepted that vascular damage, immune system activation and, abnormal fibroblasts-to-myofibroblasts differentiation are pathological capital features. Nevertheless, recent evidence portrays a potential role of the epidermis in the pathogenesis of SSc skin fibrosis (1, 2). This new angle on skin fibrosis pathogenesis is particularly attractive as the epidermis is an easy to access therapeutic target.

Objectives:

To dissect the potential epidermal dysfunction in SSc and its effect on dermis homeostasis, using a novel epidermal equivalent reconstituted from SSc keratinocytes.

Methods:

Primary keratinocytes and fibroblasts cell lines were generated from skin biopsies obtained from 6 SSc and 6 healthy donors (HD), upon informed consent and ethical approval. Epidermal equivalents (EE) were generated from 4 SSc and 6 HD keratinocytes. Skin and EE expression of the mitotic marker Ki67, of the differentiation markers (K10, involucrin, filaggrin, loricrin), and activation markers (K6, K16) was evaluated by immunohistochemistry. The transcriptomic profile of SSc keratinocytes in monolayer or stratified in EE was identified by RNAseq analysis. EE conditioned medium was used to stimulate fibroblasts. The fibroblast production of interleukin (IL)-6, IL-8, matrix metalloproteinase (MMP)-1, type-I collagen (col-I), and fibronectin was assessed by ELISA.

Results:

Compared to HD, immunohistochemistry revealed that SSc epidermis is characterized by aberrant premature differentiation and enhanced expression of activation markers associated with a lower mitotic rate of basal keratinocytes. Of interest, EE reconstituted from SSc keratinocytes reproduced most of the abnormalities observed in SSc epidermis. RNAseq analysis revealed that SSc keratinocytes, either cultured in monolayer or in EE, have a distinct transcriptomic profile compared to their HD counterpart, characterized by the downregulation of genes from the HOX family.

The supernatant of EE enhanced the production of IL-6, IL-8, MMP-1, col-I, and fibronectin by HD fibroblasts (p<0.05). Except for col-I and fibronectin, this effect was 2-fold higher in the presence of supernatant from EE reconstituted by SSc keratinocytes. Neutralization experiments indicated that IL-1 was, at least in part, responsible for keratinocyte-dependent fibroblasts activation.

Conclusion:

We established a novel epidermal equivalent tissue engineered from SSc keratinocytes, that recapitulates thein vivocharacteristics of SSc epidermis. Our preliminary data suggest that SSc keratinocytes have an intrinsic altered program of differentiation, possibly due to the downregulation of some HOX genes. This altered phenotype is associated with increased production of mediators that stimulate fibroblasts production of inflammatory cytokines. In this scenario, we may hypothesize that SSc epidermis participates in modifying the dermis environment, favoring the development of chronic inflammation and fibrosis.

References

[1]Takahashi T, Asano Y, Sugawara K, Yamashita T, Nakamura K, Saigusa R, et al. Epithelial Fli1 deficiency drives systemic autoimmunity and fibrosis: Possible roles in scleroderma. J Exp Med. 20317;214(4):1129-51.

[2]Nikitorowicz-Buniak J, Shiwen X, Denton CP, Abraham D, Stratton R. Abnormally differentiating keratinocytes in the epidermis of systemic sclerosis patients show enhanced secretion of CCN2 and S100A9. J Invest Dermatol. 2014;134(11):2693-702.

Disclosure of Interests:

Barbara Russo: None declared, Julia Borowczyk-Michalowska: None declared, Wolf-Henning Boehncke Consultant of: WHB received honoraria as advisor or invited speaker from Abbvie, Almirall, BMS, Celgene, Leo, Lilly, Novartis, UCB., Speakers bureau: WHB received honoraria as advisor or invited speaker from Abbvie, Almirall, BMS, Celgene, Leo, Lilly, Novartis, UCB., Nicolò Brembilla: None declared, Carlo Chizzolini Consultant of: Boehringer Ingelheim, Roche

Interplay Between Keratinocytes and Fibroblasts: A Systematic Review Providing a New Angle for Understanding Skin Fibrotic Disorders

Background/Objective: Skin fibrosis is the result of aberrant processes leading to abnormal deposition of extracellular matrix (ECM) in the dermis. In healthy skin, keratinocytes participate to maintain skin homeostasis by actively crosstalking with fibroblasts. Within the wide spectrum of fibrotic skin disorders, relatively little attention has been devoted to the role of keratinocytes for their capacity to participate to skin fibrosis. This systematic review aims at summarizing the available knowledge on the reciprocal interplay of keratinocytes with fibroblasts and their soluble mediators in physiological states, mostly wound healing, and conditions associated with skin fibrosis.

Methods: We performed a systematic literature search on PubMed to identify in vitro and ex vivo human studies investigating the keratinocyte characteristics and their interplay with fibroblasts in physiological conditions and within fibrotic skin disorders including hypertrophic scars, keloids, and systemic sclerosis. Studies were selected according to pre-specified eligibility criteria. Data on study methods, models, stimuli and outcomes were retrieved and summarized according to pre-specified criteria.

Results: Among the 6,271 abstracts retrieved, 73 articles were included, of which 14 were specifically dealing with fibrotic skin pathologies. Fifty-six studies investigated how keratinocyte may affect fibroblast responses in terms of ECM-related genes or protein production, phenotype modification, and cytokine production. Most studies in both physiological conditions and fibrosis demonstrated that keratinocytes stimulate fibroblasts through the production of interleukin 1, inducing keratinocyte growth factor (KGF) and metalloproteinases in the fibroblasts. When the potential of keratinocytes to modulate collagen synthesis by healthy fibroblasts was explored, the results were controversial. Nevertheless, studies investigating keratinocytes from fibrotic skin, including keloids, hypertrophic scar, and scleroderma, suggested their potential involvement in enhancing ECM deposition. Twenty-three papers investigated keratinocyte proliferation differentiation and production of soluble mediators in response to interactions with fibroblasts. Most studies showed that fibroblasts modulate keratinocyte viability, proliferation, and differentiation. The production of KGF by fibroblast was identified as key for these functions.

Conclusions: This review condenses evidence for the active interaction between keratinocytes and fibroblasts in maintaining skin homeostasis and the altered homeostatic interplay between keratinocytes and dermal fibroblasts in scleroderma and scleroderma-like disorders.

T-Cell Proapoptotic and Antifibrotic Activity Against Autologous Skin Fibroblasts in vitro Is Associated With IL-17A Axis Upregulation in Systemic Sclerosis

Background: Systemic sclerosis (SSc) T cells can induce apoptosis of autologous skin fibroblasts in vitro. Th17 cells have been reported to increase in SSc patients, and interleukin-17A (IL-17A) has a profibrotic function. We used a system based on T-cell-autologous fibroblast co-cultures to further investigate a possible role of IL-17A in SSc.

Methods: T cells from diffuse SSc patients were co-cultured with autologous skin fibroblasts. IL17A mRNA was assessed by real-time PCR in co-cultured and control T cells, while IL17RA, CXCL1, CCL2, CCL3, COL1A1, COL3A1, CTGF, TGFBR2, and SMAD3 mRNAs were assessed in co-cultured and control fibroblasts. In subset experiments, co-cultures and control cells were treated with either IL-17A or IL-17A plus anti-IL17 receptor monoclonal antibody (α-IL-17RA mAb). Chemokine and procollagen type I (PCI) production was further investigated at the protein level in cell culture supernatants by multiple suspension immunoassay and sandwich ELISA, respectively. Co-cultured and control fibroblasts were also stained with Annexin V and analyzed by flow cytometry.

Results: T cell–fibroblast co-cultures overexpressed IL17A and IL17RA. Furthermore, co-cultured fibroblasts upregulated IL-17A targets CXCL1, CCL2, and CCL3, while COL1A1, COL3A1, CTGF, and two key effectors of the TGF-β signaling, TGFBR2 and SMAD3, were found downregulated. Consistently, chemokine concentrations were increased in co-culture supernatants, while PCI levels were reduced, especially after stimulation with ectopic IL-17A. Finally, simultaneous α-IL-17RA mAb treatment restored PCI levels and reduced fibroblast apoptosis in IL-17A-stimulated co-cultures.

Conclusion: These data suggest that IL-17A upregulation might play a role in modulating T cell-mediated antifibrotic and proapoptotic effects in co-cultured autologous skin fibroblasts.

Performance of a new quantitative computed tomography index for interstitial lung disease assessment in systemic sclerosis

Quantitative high resolution computed tomography (HRCT) may objectively assess systemic sclerosis (SSc)-interstitial lung disease (ILD) extent, using three basic densitometric measures: mean lung attenuation (MLA), skewness, and kurtosis. This prospective study aimed to develop a composite index - computerized integrated index (CII) – that accounted for MLA, skewness, and kurtosis by means of Principal Component Analysis over HRCTs of 83 consecutive SSc subjects, thus eliminating redundancies. Correlations among CII, cardiopulmonary function and immune-inflammatory biomarkers (e.g. sIL-2Rα and CCL18 serum levels) were explored. ILD was detected in 47% of patients at visual HRCT assessment. These patients had worse CII values than patients without ILD. The CII correlated with lung function at both baseline and follow-up, and with sIL-2Rα and CCL18 serum levels. The best discriminating CII value for ILD was 0.1966 (AUC = 0.77; sensitivity = 0.81 [95%CI:0.68–0.92]; specificity = 0.66 [95%CI:0.52–0.80]). Thirty-four percent of patients without visual trace of ILD had a CII lower than 0.1966, and 67% of them had a diffusing lung capacity for CO <80% of predicted. We showed that this new composite CT index for SSc-ILD assessment correlates with both lung function and immune-inflammatory parameters and could be sufficiently sensitive for capturing early lung density changes in visually ILD-free patients.

ActivinA: a new leukemia-promoting factor conferring migratory advantage to B-cell precursor-acute lymphoblastic leukemic cells

B-cell precursor-acute lymphoblastic leukemia modulates the bone marrow (BM) niche to become leukemia-supporting and chemo-protective by reprogramming the stromal microenvironment. New therapies targeting the interplay between leukemia and stroma can help improve disease outcome. We identified ActivinA, a TGF-β family member with a well-described role in promoting several solid malignancies, as a factor favoring leukemia that could represent a new potential target for therapy. ActivinA resulted over-expressed in the leukemic BM and its production was strongly induced in mesenchymal stromal cells after culture with leukemic cells. Moreover, MSCs isolated from BM of leukemic patients showed an intrinsic ability to secrete higher amounts of ActivinA compared to their normal counterparts. The pro-inflammatory leukemic BM microenvironment synergized with leukemic cells to induce stromal-derived ActivinA. Gene expression analysis of ActivinA-treated leukemic cells showed that this protein was able to significantly influence motility-associated pathways. Interestingly, ActivinA promoted random motility and CXCL12-driven migration of leukemic cells, even at suboptimal chemokine concentrations, characterizing the leukemic niche. Conversely, ActivinA severely impaired CXCL12-induced migration of healthy CD34⁺ cells. This opposite effect can be explained by the ability of ActivinA to increase intracellular calcium only in leukemic cells, boosting cytoskeleton dynamics through a higher rate of actin polymerization. Moreover, by stimulating the invasiveness of the leukemic cells, ActivinA was found to be a leukemia-promoting factor. Importantly, the ability of ActivinA to enhance BM engraftment and the metastatic potential of leukemic cells was confirmed in a xenograft mouse model of the disease. Overall, ActivinA was seen to be a key factor in conferring a migratory advantage to leukemic cells over healthy hematopoiesis within the leukemic niche.

Interleukin-6 and Type-I Collagen Production by Systemic Sclerosis Fibroblasts Are Differentially Regulated by Interleukin-17A in the Presence of Transforming Growth Factor-Beta 1

Functional cytokine networks have been poorly characterized in systemic sclerosis (SSc). While interleukin-17A (IL-17A) is increased in SSc skin and other organs, its role is still debated, particularly considering fibrogenesis. We uncover here a dual function of IL-17A in the presence of transforming growth factor-β 1 (TGF-β), the master pro-fibrotic cytokine. In the one hand, we report an unexpected synergic activity resulting in enhanced production of IL-6 by dermal fibroblasts; in the other hand, a substantial inhibition of type I collagen (col-I) production. IL-17A or TGF-β enhanced the production of IL-6 by 8- to 16-folds when compared to control in healthy donors (HD) and SSc cultures. However, the joint presence of IL-17A and TGF-β resulted in robustly exuberant responses with levels of IL-6 up to 100-folds higher than those observed in untreated cells. Inhibition of NFκB signaling pathway preferentially inhibited the production of IL-6 driven by IL-17A in HD fibroblasts, while inhibition of PI3K preferentially inhibited the production of IL-6 driven by TGF-β. Interestingly, when p38 MAPK was inhibited, substantial reduction of IL-6 production was observed for both IL-17A and TGF-β. Consistently with the inhibition experiments, the combined stimulation of fibroblasts by IL-17A and TGF-β resulted in 1.8-fold increase in p38 MAPK phosphorylation (P = 0.025), when compared to levels of phosphorylated p38 MAPK induced by IL-17A alone. Furthermore, the enhanced phosphorylation of p38 MAPK in the joint presence of IL-17A and TGF-β was unique among the signaling molecules we examined. As expected, TGF-β induced SMAD2 phosphorylation and col-I production. However, in fibroblasts cultured in the joint presence of TGF-β and IL-17A, SMAD2 phosphorylation was decreased by 0.6-folds (P = 0.022) when compared to that induced by TGF-β alone. Remarkably, in this condition, the production of col-I and fibronectin was significantly decreased in both HD and SSc. Thus, IL-17A and TGF-β reciprocally influence each other effector functions in fibroblasts. Intracellular molecular switches may favor synergic or antagonistic activities, which are revealed by specific readouts. The implications of these data in the context of SSc are far reaching, particularly in terms of therapeutic approaches since IL-6, IL-17A, and TGF-β are all putative targets of treatment.

Impact of obesity and acquisition protocol on (123)I-metaiodobenzylguanidine indexes of cardiac sympathetic innervation

BACKGROUND

This study was designed to assess the impact of obesity and acquisition protocol on (123)I-metaiodobenzylguanidine (MIBG) indexes of cardiac sympathetic innervation.

METHODS

Forty-five patients with heart failure (HF) (38 men, age 58±15 years) underwent (123)I-MIBG cardiac imaging. Of these patients, 10 were obese [body mass index (BMI) ≥30 kg/m(2)]. Ten-minute planar images of the thorax in anterior view were performed 15 minutes ("early" image) and 3 hours and 50 minutes ("late" image) after tracer administration in both supine- and prone-position. Early and late (123)I-MIBG heart-to-mediastinum (H/M) ratios and washout rate were computed.

RESULTS

In overall study population, early and late (123)I-MIBG H/M ratios and washout rate were comparable between supine- and prone-position acquisitions. Obese patients had a lower early and late (123)I-MIBG H/M ratios both in supine (P<0.01) and prone (P<0.05) positions compared to non-obese subjects.

CONCLUSIONS

Our results indicate that in HF patients, obesity has a significant impact on (123)I-MIBG indexes of cardiac sympathetic innervation. Prone-position did not change early and late (123)I-MIBG H/M ratios and washout rate compared to supine position both in obese and non-obese HF patients.

Molecular determinants of positive allosteric modulation of the human metabotropic glutamate receptor 2

BACKGROUND AND PURPOSE

The activation of the metabotropic glutamate receptor 2 (mGlu2 ) reduces glutamatergic transmission in brain regions where excess excitatory signalling is implicated in disorders such as anxiety and schizophrenia. Positive allosteric modulators (PAMs) can provide a fine-tuned potentiation of these receptors' function and are being investigated as a novel therapeutic approach. An extensive set of mutant human mGlu2 receptors were used to investigate the molecular determinants that are important for positive allosteric modulation at this receptor.

EXPERIMENTAL APPROACH

Site-directed mutagenesis, binding and functional assays were employed to identify amino acids important for the activity of nine PAMs. The data from the radioligand binding and mutagenesis studies were used with computational docking to predict a binding mode at an mGlu2 receptor model based on the recent structure of the mGlu1 receptor.

KEY RESULTS

New amino acids in TM3 (R635, L639, F643), TM5 (L732) and TM6 (W773, F776) were identified for the first time as playing an important role in the activity of mGlu2 PAMs.

CONCLUSIONS AND IMPLICATIONS

This extensive study furthers our understanding of positive allosteric modulation of the mGlu2 receptor and can contribute to improved future design of mGlu2 PAMs.

Glucocorticoids in systemic sclerosis: patients' beliefs and treatment adherence

OBJECTIVES

To investigate how chronic intake of glucocorticoids (GCs) is perceived by patients with systemic sclerosis (SSc) in terms of necessity and concerns, and whether such beliefs influence treatment adherence.

METHOD

Ninety-eight consecutive SSc patients who they had been taking oral GCs for > 3 months prior to the study were enrolled. All patients underwent a clinical evaluation and laboratory investigations, and were asked to complete four self-administered questionnaires: the Beliefs about Medicines Questionnaire (Specific-BMQ), the four-item Morisky Medication Adherence Scale (MMAS-4), the 36-item Short Form Health Survey (SF-36), and the Health Assessment Questionnaire Disability Index (HAQ-DI). Moreover, patients answered two additional questions investigating their knowledge about GC-related adverse events (AEs).

RESULTS

Seventy-seven patients (83.6%) believed in the necessity of GCs for maintaining health but 72.8% also reported concerns about potential AEs to GCs. A high adherence rate was recorded in 64.1% of patients. Only about 20% of patients reported knowing that a daily GC dose and treatment duration influence the burden of GC-related AEs. Patients who believed that GC-related AEs were influenced by the dose scored lower concerns (p = 0.043) and were more frequently labelled as accepting (perceiving high necessity and low concerns) (p = 0.009).

CONCLUSIONS

The majority of patients taking GCs perceived them as necessary, but high concerns about chronic GC use exist. Patients with a poorer knowledge of the factors associated with GC-related AEs and those with a poorer quality of life were the most worried about these compounds. Experimental studies assessing the efficacy of educational programmes aiming to increase the adherence to GC therapy should be planned in these patients.

Adoption of free/libre open source software in public organizations: factors of impact

Purpose

In this paper the authors aim to investigate the importance of factors for the adoption of free/libre open source software (FLOSS) in the public sector. They seek to evaluate how different factors impact during the initiation and implementation phases of the adoption process.

Design/methodology/approach

The authors base the methodological approach on two exploratory case studies with a contrasting result logic. They build a multi‐level framework grounded both on literature review, and feedback from stakeholders. They then apply the framework to two case studies to better frame the findings. They consider phases of adoption (initiation, implementation) and the levels of adoption (technological, organizational, environmental, individual).

Findings

In the case studies, the authors found the importance of a strong and decision‐centric management board to give the impulse for the initiation phase of the process. As perceived by the stakeholders, a strong governmental support is of paramount importance to increase the adoption at the public level, although in the case studies examined the initiation stage started from the impulse of a championing management. Both case studies passed the initiation phase successfully. Continuous employees' training, organizational objectives consensus, and business process reengineering have been found important for the implementation phase. In the case study in which these factors were not in place, the implementation phase of adoption failed. Environmental factors – although relevant for the initiation of the adoption process – are less significant during the actual implementation of the adoption process, as the contrasting result logic from the case studies shows.

Research limitations/implications

The study refers to two public organizations in a specific environmental setting. No causality among factors has been inferred. Quantitative objective data have been used to determine the success of adoption, for qualitative data multiple sources have been used when possible to limit threats to validity.

Practical implications

The framework can be used by stakeholders in public organizations to better frame their adoption strategies and to compare results across institutions. Lessons learnt from the case studies can be useful to drive future adoptions of FLOSS.

Originality/value

The framework combines phases of adoption and levels making it possible to frame the analysis of the case studies. It has been operationalized with a set of metrics, and with a protocol for the case studies to increase replicability value.

Methodologies to study the surface hydraulic behaviour of urban catchments during storm events

A good knowledge of the hydraulic behaviour of an urban catchment and its surface drainage system is an essential requirement to guarantee traffic and pedestrian safety. In many cases, inlets have been situated according to spatial density criteria. Indeed a more rational location of inlets on urban catchments must be defined according to an accurate analysis of the relationship between street flow and inlet hydraulic efficiency. Moreover we lack specific hazard criteria in terms of the maximum acceptable flow depths and velocities on the streets that do not cause problems to pedestrians. In this paper the results of two different experimental campaigns are presented. The first was carried out to evaluate inlet hydraulic efficiency; the second was carried out to address the pedestrian stability in urban flood conditions, whose aim was to propose new hazard criteria. On the basis of the experimental results, a methodology was developed to assess flood hazard in urban areas during storm events. If a refined topographic representation of urban areas is available, a two-dimensional numerical simulation of urban flooding can be performed using complete shallow water equations. According to this approach a numerical application for flood hazard assessment in a street of Barcelona is shown.

Clinical effects of early treatment with insulin glargine in patients with cystic fibrosis and impaired glucose tolerance

Diabetes mellitus is an increasing complication of cystic fibrosis (CF), as a result of the improved life expectancy. There is clear association between diabetes and increased morbidity and mortality. Lung function and clinical status deteriorate up to 2-4 yr before the diagnosis of CF-related diabetes (CFRD). The aim of our study was to evaluate the effects, on glucose homeostasis and clinical status, of the early treatment with insulin glargine in CF patients with impaired glucose tolerance (IGT). We selected six subjects with IGT diagnosed at oral glucose tolerance test (OGTT). Median age was 18.12 yr (range 9.2-27.8). Insulin glargine was administered at the median dosage of 0.3 U/kg/day (range 0.2-0.5). After the initial adjustment of the dosage, no patient manifested hypoglycemia during treatment. Median glycosylated hemoglobin (HbA1c) did not show any significant variation during treatment: it was 5.9% at baseline (range 5.5-6.2) and 6.1% (range 5.0-6.7) at the end of follow-up (p=0.496). Median body mass index (BMI) z-score significantly increased during treatment, from -0.95 (range -3.2-+0.6) at baseline to -0.5. (range -3.0-+0.9) at the end of follow-up (p=0.026). Lung function, measured by median forced expiratory volume in the first second (FEV1%), showed a mild but significant improvement during insulin treatment. It was 72.7% at baseline (range 41.5-98.4) and 76.7% (range 42.0-106.8) at the end of follow-up (p=0.027). No significant variation was found between the number of hospitalizations for clinical exacerbation (no./patient/yr) in the last 2 yr before treatment and during follow-up. Median number at baseline was 1.95/patient/yr (range 1-3) and 2.0/patient/yr (range 1-3) at follow-up (p=0.715). Our data seem to indicate that early insulin therapy can be safe, no patient manifested hypoglycemia or other adverse effects during treatment. Insulin is an anabolic hormone implicated in both lipid and protein metabolism. The appearance of IGT out of infections can indicate an early insulin deficiency, with a potential impact on the nutritional and clinical status of the patient, even before the appearance of overt diabetes. Larger controlled trials are necessary to verify if early insulin therapy is able to reduce the deterioration of nutritional status and lung function associated with the onset of IGT.

[Videolaparoscopic adrenalectomy in an unusual case of adrenal mycetoma]

The authors report a rare case of mycetoma of the adrenal gland. Mycetoma is a chronic, localized, non-contagious infection of cutaneous and subcutaneous tissue characterized by tumefaction, aggregates of aetiological agents (Actinomyces or true fungi). Sometimes an unusual site (other tissues or organs) is described in the literature, but to date no cases of adrenal gland mycetoma have been reported. The treatment of choice is surgical with associated penicillin and/or antifungal drugs. In the case reported surgical treatment is performed with a laparoscopic approach. This technique constitutes the gold standard in cases of benign neoplasms of the adrenal gland and incidentalomas. This therapeutic choice is open to criticism if a malignant neoplasm is suspected.

[Acute myocardial infarction complicated by ventricular aneurysm during pregnancy. A clinical case and review of the literature]

Acute myocardial infarction is an uncommon complication in pregnant women. The case of a 30-years-old patient who suffered of an acute myocardial infarction during the first trimester of pregnancy, with secondary development of left ventricular aneurysm is presented. She had a sudden death 3 months after delivery, while waiting for coronary arteriography.

[Laparoscopic surgical treatment of cholecysto-choledochal calculi. A single step solution]

The laparoscopic era has created a new basis for the management of choledocholithiasis. Many surgeons now regard laparoscopic cholecystectomy and exploration of the common bile duct as the "gold standard". The main advantages of single-stage treatment consist in a significantly shorter hospital stay, very low complication rates and a reduction of average hospital costs. Among 601 cases of cholelithiasis treated over the period from 1994 to 1999, we report 73 cases of common-bile-duct stones. Surgical sphincterotomy was performed in 20 cases and endoscopic sphincterotomy in 24; only in 7 cases was choledochotomy and/or hepaticojejunostomy (3 cases) performed for critical situations. Twenty-two cases of cholelithiasis were treated by laparoscopic cholecystectomy and exploration of the common bile duct. Stone extraction was obtained with a balloon catheter or Dormia basket via a choledochotomy. Surgery was completed by suturing, cholangiography and the placement of sub-hepatic drainages. No mortality or long-term complications were recorded with the laparoscopic procedure; only two immediate complications were reported, both of which were biliary leakages (9%) that resolved spontaneously. With the other procedures, high rates of mortality, morbidity, hospital admissions and technical failure were registered. We regard laparoscopic exploration of the common bile duct as the treatment of choice for bile-duct stones when combined with cholecystectomy. We reserve ERCP plus endoscopic sphincterotomy only for common-bile-duct stones alone, without a gallbladder or gallstones. Open surgery is performed in particular situations such as Mirizzi's syndrome or when other procedures have failed to yield satisfactory results.