OP0147 THE SLE-DAS REMISSION AND LOW DISEASE ACTIVITY STATES DISCRIMINATE DRUG FROM PLACEBO AND BETTER HEALTH-RELATED QUALITY OF LIFE: POST-HOC ANALYSIS OF THE BLISS-52 AND BLISS-76 PHASE III TRIALS

Background

Accurate and practical outcome measures for clinical trials in systemic lupus erythematosus (SLE) are lacking. The SLE Disease Activity Score (SLE-DAS) is a recently validated 17-item instrument, with high accuracy and sensitivity to changes in SLE disease activity. The SLE-DAS definitions of remission and low disease activity (LDA) were newly validated in the clinical setting1,2. These definitions may constitute accurate and easy to apply endpoints for SLE trials.

Objectives

(1) To evaluate the ability of SLE-DAS remission and LDA definitions to discriminate drug from placebo in SLE phase 3 trials; (2) To determine if attainment of these SLE-DAS targets are associated with better health-related quality of life (HR-QoL).

Methods

Post-hoc analysis of the merged study population in the BLISS-52 and -76 trials (NCT00424476; NCT00410384) of intravenous belimumab versus placebo for moderate to severe SLE disease activity. We analyzed the British Isles Lupus Assessment Group (BILAG), Physician Global Assessment (PGA), Functional Assessment of Chronic Illness Therapy (FACIT) and 36-Item Short Form Survey (SF-36) trial data. The fulfillment of SLE-DAS remission and LDA definitions were retrospectively assessed from the individual participants’ data. Proportion of patients attaining SLE-DAS Boolean remission (defined as absence of all SLE-DAS clinical items and prednisone ≤5mg/day) and LDA (defined as SLE-DAS≤2.48 and prednisone ≤7.5mg/day), at week 52, was compared between belimumab and placebo arms, using likelihood ratio chi-square test. We further compared the SF-36 physical component summary (PCS) and mental component summary (MCS) and domain scores and the FACIT score between patients attaining SLE-DAS remission vs non-remission and SLE-DAS LDA vs non-LDA, using t-test and Mann-Whitney test.

Results

A total of 1684 SLE patients were included: 562 on placebo, 559 on belimumab 1mg/Kg and 563 on belimumab 10mg/Kg. At week 52, significantly more patients attained SLE-DAS LDA on belimumab 1mg/Kg and 10mg/Kg as compared with placebo (13.0% vs 17.9%, OR=1.459, p=0.023, and 13.0% vs 21.7%, OR=1.853, p<0.001, respectively). Likewise, more patients attained SLE-DAS remission on belimumab 10mg/Kg as compared with placebo (10.1% vs 14.7%, OR= 1.532, p=0.019) (Table 1). Importantly, none of the patients achieving SLE-DAS remission or LDA presented a new BILAG A or more than 1 new B domain score, neither a worsening in PGA≥0.3.

Table 1.

Attainment of SLE-DAS Boolean remission and LDA at week 52 in BLISS-52 and BLISS-76 trials, according to the treatment groups (n =1684).

PlaceboBelimumab 1mg/KgBelimumab 10mg/KgSLE-DAS remission (n=211)10.1%12.7%, OR=1.289 (0.89-1.866), p=0.17814.7%, OR 1.532 (1.069-2.195), p=0.019SLE-DAS LDA (n=295)13.0%17.9%, OR=1.459 (1.052-2.025), p=0.02321.7%, OR 1.853 (1.349-2.545), p<0.001

LDA: Low disease activity; SLE-DAS Boolean remission: absence of all SLE-DAS clinical items and prednisone ≤5mg/day; SLE-DAS LDA: SLE-DAS≤2.48 and prednisone ≤7.5mg/day.

At week 52, patients attaining SLE-DAS remission and SLE-DAS LDA presented higher SF-36 domain and summary scores (all p<0.001) (Figure 1). Additionally, FACIT scores were higher in patients attaining SLE-DAS remission than non-remission patients (mean±SD: 38.24±10.65 vs 33.45±12.13, p<0.001), and in patients attaining SLE-DAS LDA than non-LDA (mean±SD: 37.22±11.00 vs 33.37±12.17, p<0.001), at week 52.

Figure 1.

Mean SF-36 domain and summary scores at week 52; *p<0.001; MCS, Mental Component Summary; PCS, Physical Component Summary; SF-36, Medical Outcomes Survey Short Form.

Conclusion

The SLE-DAS remission and LDA showed discriminant validity for identifying patients receiving active drug in clinical trials. These treatment targets are associated with better HR-QoL and lower fatigue.

References

[1]Jesus D, et al. Ann Rheum Dis 2021;80:1568-74.

[2]Assuncao H, et al. Rheumatology (Oxford) 2021;3;keab895.

Acknowledgements

The authors would like to thank GlaxoSmithKline (Uxbridge, UK) for granting access to the data from the BLISS-52 and 76 trials through the Clinical Study Data Request consortium.

Disclosure of Interests

None declared

POS0119 SLE-DAS REMISSION AND LOW DISEASE ACTIVITY STATES ARE ASSOCIATED WITH IMPROVED HEALTH-RELATED QUALITY OF LIFE AND FATIGUE: POST-HOC ANALYSIS OF THE BLISS-52 AND BLISS-76 PHASE III TRIALS

Background

Accurate and practical outcome measures for clinical trials in systemic lupus erythematosus (SLE) are lacking. The SLE Disease Activity Score (SLE-DAS) is a recently validated 17-item instrument, with high accuracy and sensitivity to changes in SLE disease activity. The SLE-DAS definitions of remission and low disease activity (LDA) were newly validated against disease activity physician-applied measures in the clinical setting [1, 2]. Criterion validity of SLE-DAS for Patient Reported Outcomes, namely health-related quality of life (HR-QoL) and fatigue needs to be assessed.

Objectives

To evaluate if the attainment of SLE-DAS remission and LDA states is associated with improvements in HR-QoL and fatigue.

Methods

Post-hoc analysis of the merged study population in the BLISS-52 and -76 trials (NCT00424476; NCT00410384) of intravenous belimumab versus placebo for moderate to severe SLE disease activity. We analysed the Functional Assessment of Chronic Illness Therapy (FACIT) and 36-Item Short Form Survey (SF-36) trial data. Fulfillment of SLE-DAS remission (defined as absence of all SLE-DAS clinical items and prednisone ≤5mg/day) and LDA (defined as SLE-DAS≤2.48 and prednisone ≤7.5mg/day) definitions were retrospectively assessed from the individual participants’ data. Mean changes from study baseline to week 52 in FACIT and SF-36 physical component summary (PCS) and mental component summary (MCS) and domain scores were compared between patients attaining at week 52 the SLE-DAS remission vs non-remission and the SLE-DAS LDA vs non-LDA using multivariate regression analysis adjusted for baseline scores.

Results

A total of 1684 SLE patients were included. Few patients were in SLE-DAS remission (0.5%) and LDA (0.8%) at study entry. At week 52, 12.5% patients attained SLE-DAS remission and 17.5% attained SLE-DAS LDA. Mean improvements in SF-36 PCS and MCS scores were greater in patients that attained SLE-DAS remission vs non-remission (5.4 vs 3.4, and 4.6 vs 2.7, respectively; multivariate p<0.005 for both) and SLE-DAS LDA vs non-LDA (5.0 vs 3.4 and 4.6 vs 2.6, respectively; multivariate p<0.005 for both), at week 52 (Figure 1). Similarly, improvements in all individual domain scores were greater in SLE-DAS remission vs non-remission patients (all multivariate p<0.005) and SLE-DAS LDA vs non-LDA patients (all multivariate p<0.005) (Figure 1). Importantly, improvements in the summary scores and in all the individual domain scores largely exceeded the minimum clinically important differences (MCIDs) of 2.5 and 5 points, respectively, in those patients attaining SLE-DAS remission or LDA.

Figure 1.

Mean changes in SF-36 domains and summary scores from baseline to week 52. #p<0.005; *p<0.001; MICD, Minimum Clinically Important Difference; MCS, Mental Component Summary; PCS, Physical Component Summary; SF-36, Medical Outcomes Survey Short Form; SLE-DAS, Systemic Lupus Erythematosus Disease Activity Score.

Additionally, mean improvements in FACIT scores were higher in SLE-DAS remission than non-remission (6.3 vs 3.6, multivariate p<0.001) and in SLE-DAS LDA than non-LDA (5.9 vs 3.6, multivariate p<0.001), and exceeded the MCID of 4 points.

Conclusion

Attainment of SLE-DAS remission and LDA is associated with meaningful improvement in HR-QoL and fatigue.

References

[1]Jesus D, et al. Systemic Lupus Erythematosus Disease Activity Score (SLE-DAS) enables accurate and user-friendly definitions of clinical remission and categories of disease activity. Ann Rheum Dis 2021;80:1568-74.

[2]Assunção H, et al. Definition of Low Disease Activity State based on the SLE-DAS: Derivation and validation in a multicentre real-life cohort. Rheumatology (Oxford) 2021;3;keab895.

Acknowledgements

The authors would like to thank GlaxoSmithKline (Uxbridge, UK) for granting access to the data from the BLISS-52 and 76 trials through the Clinical Study Data Request consortium.

Disclosure of Interests

None declared

POS0762 CAN THE SLE-DAS SUBSTITUTE BILAG TO MEASURE LUPUS DISEASE ACTIVITY IN CLINICAL TRIALS? POST-HOC ANALYSIS OF THE BLISS-76 TRIAL

Background:

The primary endpoint for randomized clinical trials (RCT) in Systemic lupus erythematosus (SLE) is usually defined as proportion of responders in a composite index. The most widely used are British Isles Lupus Assessment Group (BILAG)-based Composite Lupus Assessment (BICLA) and Systemic Lupus Responder Index (SRI). Both comprise BILAG along with SLE Disease Activity Index (SLEDAI). BICLA and SRI are complex and time-consuming to assess.

The SLE Disease Activity Score (SLE-DAS) is an easy to apply, validated, continuous disease activity measure, highly correlated with SLEDAI, with higher accuracy and sensitivity-to-change as compared to SLEDAI1.

We hypothesize that SLE-DAS can also identify the SLE disease activity information from BILAG, thus dispensing the use of composite indexes for RCT.

Objectives:

To compare the ability of the SLE-DAS and the Safety of Estrogen in Lupus National Assessment (SELENA)-SLEDAI to discriminate between BILAG classification of mild vs. moderate vs. severe disease activity.

Methods:

Post-hoc analysis of all intention-to-treat patients in the BLISS-76 (NCT00410384) RCT at the baseline study visit. SELENA-SLEDAI and BILAG were assessed at time of the study visits and SLE-DAS was retrospectively scored from the study database. Patients’ disease activity was classified as: (i) mild (no BILAG B or A scores in any organ domain); (ii) moderate (1 BILAG B, no A scores); (iii) severe (≥2 BILAG B and/or ≥1 BILAG A). Ability of the SLE-DAS and SELENA-SLEDAI to differentiate between: (i) mild vs. moderate/severe disease activity; (ii) mild/moderate vs. severe disease activity (according to BILAG), were evaluated using receiver operating characteristic (ROC) analysis. The area under the ROC curves (AUCs) with 95% confidence intervals (95%CI) as a measure of discriminatory ability of the SLE-DAS and SELENA-SLEDAI were compared using Delong’s test for two correlated curves. Because AUC measurements might have restricted accuracy for imbalanced datasets, precision-recall (PR) curves and area under PR curves (AUC-PR) were also performed. Statistical significance was set at 0.05.

Results:

We included 819 patients, classified by BILAG as presenting mild (7.7%), moderate (28.8%) or severe (63.5%) disease activity. To differentiate mild vs. moderate/severe disease activity, the discriminatory ability of SLE-DAS was outstanding (AUC 0.948; 95%CI 0.923-0.973), while that of SELENA-SLEDAI was acceptable (AUC 0.729; 95%CI 0.657-0.801) (p<0.005) (figure 1A). To differentiate mild/moderate vs. severe disease activity, the discriminatory ability of SLE-DAS was excellent (AUC 0.873; 95%CI 9.846-0.899), while that of SELENA-SLEDAI was acceptable (AUC 0.707; 95%CI 0.670-0.744) (p<0.005) (figure 1B). The AUC-PR confirmed the higher performance of SLE-DAS over SELENA-SLEDAI to differentiate mild vs. moderate/severe disease activity (0.995 vs. 0.965, respectively) (figure 1C) and mild/moderate vs. severe disease activity (0.902 vs. 0.794, respectively) (figure 1D).

Figure 1.

Receiver operating characteristics (ROC) curves comparing the ability of the SLE-DAS and SELENA-SLEDAI to differentiate (A) mild vs. moderate/severe disease activity and (B) mild/moderate vs. severe disease activity, as assessed by BILAG; and Precision-recall (PR) curves comparing the performance of the SLE-DAS and SELENA-SLEDAI to differentiate (C) mild vs. moderate/severe disease activity and (D) mild/moderate vs. severe disease activity.

Conclusion:

The SLE-DAS presents excellent performance in assessing SLE disease activity categorized by BILAG scores, which is not the case for SELENA-SLEDAI. Further studies will aim to better define ability of SLE-DAS to substitute composite responder indices.

References:

[1]Jesus D, et al. Derivation and validation of the SLE Disease Activity Score (SLE-DAS): a new SLE continuous measure with high sensitivity for changes in disease activity. Ann Rheum Dis 2019;78:365-71.

Acknowledgements:

The authors would like to thank GlaxoSmithKline (Uxbridge, UK) for granting access to the data from the BLISS-76 trial through the Clinical Study Data Request consortium.

Disclosure of Interests:

None declared

OP0297 THE SLE-DAS ENABLES ACCURATE AND USER-FRIENDLY DEFINITIONS OF REMISSION AND CATEGORIES OF LUPUS DISEASE ACTIVITY: DERIVATION AND VALIDATION STUDY IN 1190 SLE PATIENTS

Background:

Treatment of systemic lupus erythematosus (SLE) is tailored according to the intensity of SLE disease activity and aims to achieve remission. Current definitions of remission and disease activity categories are mostly based on the SLE Disease Activity Index (SLEDAI), which has important limitations. The SLE Disease Activity Score (SLE-DAS) is a validated continuous disease activity score with higher accuracy in measuring SLE activity and higher sensitivity-to-change as compared to SLEDAI1. SLE-DAS is user-friendly with its online calculator.

Objectives:

To derive and validate the SLE-DAS cut-off values for defining SLE disease activity categories and SLE clinical remission state.

Methods:

Derivation study was conducted at the Padova Lupus Clinic. Validation was performed prospectively in patients from the Cochin Lupus Clinic and by post-hoc analysis of BLISS-76 (NCT00410384) trial. Gold-standard for clinical remission state was fulfillment of Definition Of Remission In SLE (DORIS). In Padova and Cochin Clinics, at time of inclusion, a senior clinician classified each patient as presenting: (i) remission, (ii) mild, or (iii) moderate/severe disease activity. Derivation of the SLE-DAS cut-offs for disease activity categories was performed using ROC curve analysis against this expert clinical classification. Performance of these SLE-DAS categories of disease activity was assessed as compared with: (i) expert classification (in Cochin cohort); (ii) British Isles Lupus Assessment Group (BILAG) index (in BLISS-76). An index-based and a Boolean definition of remission were tested applying decision trees, using CHAID (chi-square automatic interaction detection) algorithm and their performance estimated.

Results:

We included 1190 SLE patients (221 in Padova, 150 in Cochin and 819 from BLISS-76 cohorts). In the derivation cohort, best SLE-DAS cut-off values for disease activity categories were: (i) remission, SLE-DAS≤2.08; (ii) mild activity, 2.08<SLE-DAS≤7.10; (iii) moderate/severe activity, SLE-DAS>7.10. Table 1 shows the performance of these SLE-DAS cut-offs. The SLE-DAS Boolean-based definition of remission (all SLE-DAS clinical items scores = 0 and prednisone ≤5mg/day) showed sensitivity and specificity of 100% in the derivation (Padova) and validation (Cochin) clinical cohorts. The SLE-DAS index-based definition of remission (SLE-DAS ≤2.08 and prednisone ≤5mg/day) presented sensitivity =100% and specificity =97.4% in the derivation and validation clinical cohorts. The SLE-DAS definitions of remission were fully substantiated by CHAID.

Table 1.

Performance of SLE-DAS cut-offs for remission and disease activity categories compared to physician’s classification and BILAG (n =1190).

Disease activity categorySensitivity (%)Specificity (%)Accuracy (%)DerivationPadova CohortRemission(SLE-DAS≤2.08)99.397.198.6Mild Disease Activity(2.08<SLE-DAS≤7.10)74.298.995.5Moderate and Severe Disease Activity(SLE-DAS>7.10)97.496.796.8ValidationCochin CohortRemission(SLE-DAS≤2.08)99.193.998.0Mild Disease Activity(2.08<SLE-DAS≤7.10)82.699.296.7Moderate and Severe Disease Activity(SLE-DAS>7.10)100.098.698.7ValidationBLISS-76Remission and Mild Disease Activity§vs. Moderate and Severe Disease Activity§§ (SLE-DAS≤7.10 vs. >7.10)91.484.190.8

§ Remission/Mild: No BILAG B or A scores

§§ Moderate/severe: ≥1 BILAG B or A scores

Conclusion:

The SLE-DAS is an accurate and easy to use tool for defining clinical remission state and SLE disease activity categories, validated with both the expert assessment and BILAG.

References:

[1]Jesus D, et al. Derivation and validation of the SLE Disease Activity Score (SLE-DAS): a new SLE continuous measure with high sensitivity for changes in disease activity. Ann Rheum Dis 2019;78:365-71.

Acknowledgements:

The authors would like to thank GlaxoSmithKline (Uxbridge, UK) for granting access to the data from the BLISS-76 trial through the Clinical Study Data Request consortium.

Disclosure of Interests:

None declared

Relationship between dental and periodontal health status and the salivary microbiome: bacterial diversity, co-occurrence networks and predictive models

The present study used 16S rRNA gene amplicon sequencing to assess the impact on salivary microbiome of different grades of dental and periodontal disease and the combination of both (hereinafter referred to as oral disease), in terms of bacterial diversity, co-occurrence network patterns and predictive models. Our scale of overall oral health was used to produce a convenience sample of 81 patients from 270 who were initially recruited. Saliva samples were collected from each participant. Sequencing was performed in Illumina MiSeq with 2 × 300 bp reads, while the raw reads were processed according to the Mothur pipeline. The statistical analysis of the 16S rDNA sequencing data at the species level was conducted using the phyloseq, DESeq2, Microbiome, SpiecEasi, igraph, MixOmics packages. The simultaneous presence of dental and periodontal pathology has a potentiating effect on the richness and diversity of the salivary microbiota. The structure of the bacterial community in oral health differs from that present in dental, periodontal or oral disease, especially in high grades. Supragingival dental parameters influence the microbiota’s abundance more than subgingival periodontal parameters, with the former making a greater contribution to the impact that oral health has on the salivary microbiome. The possible keystone OTUs are different in the oral health and disease, and even these vary between dental and periodontal disease: half of them belongs to the core microbiome and are independent of the abundance parameters. The salivary microbiome, involving a considerable number of OTUs, shows an excellent discriminatory potential for distinguishing different grades of dental, periodontal or oral disease; considering the number of predictive OTUs, the best model is that which predicts the combined dental and periodontal status.

Pneumopericardium and pleural effusion: a rare complication of paediatric pericardiocentesis

Pneumopericardium is a rare complication of pericardiocentesis (PC), occurring as a result of either a direct pleuropericardial communication or a leaky drainage system. Pneumopericardium is often self-limiting; however, physicians should be aware of this complication as it may progress to tension pneumopericardium, which requires immediate recognition and management. PC has been associated with pneumothorax, pneumomediastinum or subcutaneous emphysema, but the association with pleural effusion has been less reported. The authors present the case of a 14-year-old healthy boy who developed post-PC pneumopericardium and pleural effusion, a rare association reported in the literature. The diagnosis of this potential life-threatening event was made using readily available complementary diagnostic methods, such as transthoracic echocardiography and chest X-ray.

Sleep apnea in heart failure: in search of a better prognosis predictor

Background

Sleep apnea (SA) is a burdensome and often underdiagnosed condition in heart failure (HF). Portable devices, such as ApneaLinkTM, are currently validated as a screening tool for SA. The apnea-hypopnea index (AHI) as been long considered the gold-standard measurement for the diagnosis of SA, also having a prognosis impact. Recently, however, other respiratory variables have been proposed as better prognosis predictors in patients with HF. The main goal of this study was to assess the prognostic value of other respiratory measurements evaluated by ApneaLinkTM at discharge in a population admitted for HF.

Methods

This was a single-center retrospective study enrolling consecutive patients admitted in a HF Clinic for acute HF from 2013 and 2018. All stable patients without previously known sleep-disordered breathing underwent ApneaLinkTM screening the night before discharge in the euvolemic state. Those with a total respiratory evaluation time &lt;180 minutes or in need of supplemental oxygen were excluded. A primary endpoint of long-term HF hospitalizations was evaluated.

Results

Overall, 231 patients (mean age 74.5±10.6 years; 47% male; 83% hypertension; 41% chronic kidney disease; 44% anemia; 18% with a NYHA&gt;2 at discharge; 43% ischaemic HF; 41% with a left ventricle ejection fraction lower than 50%) were assessed. One-hundred and sixty-nine patients (59.1%) had an AIH &gt;15, with a median of 19 (IQR 7–42); the median number of obstructive apneas and central apneas was 13 (IQR 2–68), and 2 (IQR 0–10), respectively. Two-hundred patients (69.9%) had nocturnal periods of an oxygen saturation below 85% (T85), with a median time under that value of 8 (IQR 0–47) minutes. Over a median follow-up of 34.1 (IQR 18.40–54.37) months, 105 (45.7%) patients died and 128 (55.7%) were readmitted for AHF. After adjustment for cofounders (namely, the presence of anemia) a T85 above the 75th percentile was significantly correlated with a higher risk of HF readmission in a multivariate analysis (adjusted HR: 1.58, 95% CI: 1.08–2.30, p=0.017) (figure 1). These results were independent of the apnea-hypopnea index.

Conclusion

Nocturnal hypoxemia (T85) was an independent predictor of rehospitalization in patients with HF. These results further validate the utility and prognosis impact of other respiratory measurements (other than AHI) evaluated by ApneaLinkTM screening at discharge in a population of patients admitted for HF.

Figure 1

Funding Acknowledgement

Type of funding source: None

Dapagliflozin in a real-world population with chronic heart failure: how many would be eligible?

Background

In patients with heart failure (HF) and reduced left ventricle ejection fraction (LVEF), the sodium-glucose cotransporter inhibitor (iSGLT2) dapagliflozin has recently been shown to reduce the risk of worsening heart failure or death from cardiovascular causes in the DAPA-HF trial. Results of iSGLT2 in HF with preserved LVEF are awaited. Our goal was to investigate how many patients in a real-world setting would be eligible for dapagliflozin according to the DAPA-HF criteria.

Methods

This is a single-center retrospective study enrolling consecutive patients followed in an HF Clinic from 2013 to 2019. The key DAPA-HF inclusion criteria [i.e., Left Ventricular Ejection Fraction (LVEF) &lt;40% and NT-proBNP &gt;600pg/mL (or &gt;900pg/ml if AF)] and exclusion criteria [estimated glomerular filtration rate (eGFR) &lt;30ml/kg/1.73m2, systolic blood pressure (SBP) &lt;95mmHg] were considered.

Results

Overall, 479 patients (mean age 75.7±12.8 years; 50.4% male; 78.8% with hypertension; 45.0% with an eGFR &lt;60ml/min/1.73m2; 36.5% with type 2 diabetes mellitus; 33.5% ischaemic HF) were assessed. Of these, 155 (33.2%) patients had LVEF &lt;40%. Patients had a mean SBP of 131±28 mmHg, a median eGFR of 48 (IQR 33–65) ml/min/m2 and a NT-proBNP of 2183 (IQR 1010–5310) pg/mL Overall, according to the DAPA-HF trial key criteria, 88 patients (18.3%) would be eligible for dapagliflozin. The remainder would be excluded due to a LVEF&gt;40% (67.5%), eGFR &lt;30 ml/min/1.73m2 (19.4%), NT-proBNP &lt;600 pg/mL (or &lt;900 pg/mL if AF) (16.7%) and/or SBP &lt;90mmHg (2.1%) (figure 1). If we limit the analysis to those with a LVEF &lt;40%, 56.7% would be eligible for dapagliflozin. The remainder would be excluded due to a eGFR &lt;30ml/kg/1.73m2 (20%), NT-proBNP &lt;600 pg/mL (or &lt;900 pg/mL if AF) (16.1%) and/or SBP &lt;90mmHg (8.4%) (figure 1).

Conclusion

Roughly one in every five patients in our real-world HF cohort would be eligible to start dapagliflozin according to the key criteria of the DAPA-HF trial. The main reason for non-eligibility was a LVEF &gt;40%. These findings highlight the urgent need for disease-modifying drugs in mid-range and preserved LVEF. The results of ongoing iSGLT2 trials in these LVEF subgroups are eagerly awaited.

Funding Acknowledgement

Type of funding source: None

Influence of prenatal exposure to dexamethasone on neurodevelopmental behaviour

Introduction Early life stress, such as prenatal exposure to exogenous glucocorticoids (GC), can have a negative impact on brain development. Dexamethasone (DEX) is a synthetic GC used in preterm pregnancies to promote lung maturation. However, prenatal exposure to DEX induces an anxious-like behaviour in male and female offspring at adulthood. Notably, only males respond positively to therapeutics with a proposed anxiolytic.

Objectives Since the influence of prenatal DEX on neurodevelopmental behaviour remains to be elucidated and could help explain this difference in drug efficacy, we aim to clarify the effects of this GC on neurodevelopment during infancy, comparing male and female offspring neurodevelopment at this early age.

Methodology To obtain an animal model of chronic anxiety, Wistar pregnant dams were injected subcutaneously with DEX (1mg/kg) on gestational days 18 and 19. The vestibular system development, locomotion, upper limbs strength, discriminatory ability, auditory response and eye opening day were assessed in male and female offspring between P5 and P17. Animal procedures were approved by the Animal Welfare Committee and done in agreement with the law.

Results Male and female offspring prenatally exposed to DEX had a better performance in the tests assessing the vestibular system development and discriminatory ability, especially at P5 and P6. Additionally, DEX anticipated the day of eye opening and had a positive impact in the upper limb strength of the offspring of both sexes. However, the locomotor ability and auditory response were impaired comparing with controls.

Conclusion Exposure to DEX improves limb strength, balance, spatial orientation and anticipates eye opening. These results may suggest that prenatal DEX exposure promotes offspring development and maturation in both males and females. Prenatal DEX did not differently affect male and female neurodevelopment at early age. It remains to clarify the underlying motives that induce a dimorphic gender response to anxiolytic therapy in adulthood.

Performance of SLEDAI-2K to detect a clinically meaningful change in SLE disease activity: a 36-month prospective cohort study of 334 patients

OBJECTIVE

The objective of this paper is to evaluate the performance of the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI-2K) in detecting clinically meaningful changes in SLE disease activity.

METHODS

A longitudinal cohort study was conducted of 334 SLE patients during a 36-month follow-up. At each outpatient visit, disease activity was scored using the Physician Global Assessment (PGA) and SLEDAI-2K. Correlations between PGA and SLEDAI-2K were assessed. A clinically meaningful change in SLE disease activity was defined as a ΔPGA ≥ 0.3 points from baseline. Performance of SLEDAI-2K in detecting a clinically meaningful worsening or improvement was tested using receiver operating characteristic (ROC) analysis.

RESULTS

Adjusted mean PGA and SLEDAI-2K scores presented a high correlation (rho = 0.824, p < 0.0005). In ROC analysis, a SLEDAI-2K variation presented an area under the curve (AUC) of 0.697 (95% confidence interval (CI) (0.628-0.766), p < 0.0005) to detect a clinically meaningful improvement, with a sensitivity of 28.8% for a SLEDAI-2K ≥ 4 reduction. The AUC to detect a clinically meaningful worsening was 0.877 (95% CI (0.822-0.932), p < 0.0005), with a sensitivity of 35.3%.

CONCLUSIONS

SLEDAI-2K has a limited ability to detect clinically meaningful changes in SLE disease activity, failing to identify almost two-thirds of cases judged as having a clinically meaningful improvement or worsening. There is a need for more sensitive SLE disease activity measures in clinical practice and research.

2016 update of the Portuguese recommendations for the use of biological therapies in children and adolescents with Juvenile Idiopathic Arthritis

OBJECTIVE

To provide evidence-based guidance for the rational and safe prescription of biological therapies in children and adolescents with juvenile idiopathic arthritis (JIAs) considering the latest available evidence and the new licensed biologics.

METHODS

Rheumatologists and Pediatricians with expertise in Pediatric Rheumatology updated the recommendations endorsed by the Portuguese Society of Rheumatology and the Portuguese Society of Pediatrics based on published evidence and expert opinion. The level of agreement with final propositions was voted using an online survey.

RESULTS

In total, 20 recommendations to guide the use of biological therapy in children and adolescents with JIAs are issued, comprising 4 general principles and 16 specific recommendations. A consensus was achieved regarding the eligibility and response criteria, maintenance of biological therapy, and procedures in case of non-response, for each JIA category. Specific recommendations concerning safety procedures were also updated.

CONCLUSIONS

These recommendations take into account the specificities of each JIA category and are intended to continuously improve the management of JIA patients.

The future water environment--using scenarios to explore the significant water management challenges in England and Wales to 2050

Society gets numerous benefits from the water environment. It is crucial to ensure that water management practices deliver these benefits over the long-term in a sustainable and cost-effective way. Currently, hydromorphological alterations and nutrient enrichment pose the greatest challenges in European water bodies. The rapidly changing climatic and socio-economic boundary conditions pose further challenges to water management decisions and the achievement of policy goals. Scenarios are a strategic tool useful in conducting systematic investigations of future uncertainties pertaining to water management. In this study, the use of scenarios revealed water management challenges for England and Wales to 2050. A set of existing scenarios relevant to river basin management were elaborated through stakeholder workshops and interviews, relying on expert knowledge to identify drivers of change, their interdependencies, and influence on system dynamics. In a set of four plausible alternative futures, the causal chain from driving forces through pressures to states, impacts and responses (DPSIR framework) was explored. The findings suggest that scenarios driven by short-term economic growth and competitiveness undermine current environmental legislative requirements and exacerbate the negative impacts of climate change, producing a general deterioration of water quality and physical habitats, as well as reduced water availability with adverse implications for the environment, society and economy. Conversely, there are substantial environmental improvements under the scenarios characterised by long-term sustainability, though achieving currently desired environmental outcomes still poses challenges. The impacts vary across contrasting generic catchment types that exhibit distinct future water management challenges. The findings suggest the need to address hydromorphological alterations, nutrient enrichment and nitrates in drinking water, which are all likely to be exacerbated in the future. Future-proofing river basin management measures that deal with these challenges is crucial moving forward. The use of scenarios to future-proof strategy, policy and delivery mechanisms is discussed to inform next steps.

Combined C4d and CD3 immunostaining predicts immunoglobulin (Ig)A nephropathy progression

A number of molecules have been shown recently to be involved in the pathogenesis and progression of immunoglobulin (Ig)A nephropathy (IgAN). Among these, we have selected C4d (complement lectin pathway involvement), CD3 (T cell marker, traducing interstitial inflammation), transglutaminase 2 (TGase-2, involved in tissue fibrosis development) and p-extracelluar-regulated kinase (ERK)1/2 (protein kinase intracellular signaling molecule) to perform a panel of immunohistological biomarkers and assess its predictive value for disease progression. Immunohistochemical staining of these biomarkers was performed in paraffin sections from 74 renal biopsy cases with the clinical diagnosis of IgAN. Association between score analysis of these parameters and disease course was assessed through univariate and multivariate analysis, including baseline clinical and histological data. Univariate analysis showed that glomerular C4d, tubulointerstitial TGase2 and CD3 scores were associated with baseline proteinuria and disease progression. Multivariate analysis showed that only baseline estimated glomerular filtration rate (eGFR), C4d and CD3 were associated independently with progressive kidney disease (decline of at least 50% in the eGFR or progression to end-stage renal disease (ESRD) during the follow-up period). Establishing an accurate prediction model for IgAN progression is still a matter of research in clinical nephrology. The complement system, particularly lectin pathway activation, and T cell activation, have been shown previously to be potential modifiers of the disease course. Here we show that the combination of two histological biomarkers (C4d and CD3) can be a powerful predictor of IgAN progression and a potential useful tool for the clinical approach of this disease.

Living versus cadaveric-donor renal transplant recipients: a comparison on sexual function

Erectile dysfunction is experienced by 50% of men with end-stage renal disease (ESRD) and uremia. The origin of this dysfunction is multifactorial. The aim of this study was to compare living donor versus cadaveric donor transplant recipients regarding male sexual function. Seventy-seven sexually active male kidney transplant recipients (44 from living donors; 33 from cadaveric donors) were randomly selected from our single-center prospective database of 2016 renal transplants. Epidemiological and clinical data were collected between June 2010 and June 2011. Male sexual function was evaluated with the International Index of Erectile Function questionnaire (IIEF-15). We assessed the prevalence of male sexual dysfunction according to established cutoff points for each of the IIEF-15 domains. Mann-Whitney and Pearson's chi- square statistical tests were used to compare continuous and categorical variables, respectively. The median age at the time of completion of the questionnaires was 43 and 51 years (P = .003) with median times from transplantation was of 36 and 42 months for living donor and cadaveric donor recipients, respectively (P = .31). Median durations of ESRD before surgery were 17.5 and 57 months for living donor and cadaveric donor recipients, respectively (P < .001). Living donor and cadaveric donor recipients had median creatinine clearance values of 55 and 57 mL/min, respectively (P = .44). Median time after renal transplantation for first sexual intercourse was 1 and 2 months for living donor and cadaveric donor recipients, respectively (P = .35). Median body mass indices for living donor and cadaveric donor recipients were 24.8 and 24, respectively (P = .31). Regarding sexual function domains, there were significant differences only for intercourse satisfaction. In our cohort, living donor recipients tended to be younger, have shorter time of ESRD, and less incidence of hypertension or diabetes mellitus but with greater tobacco use. In conclusion, living donor transplantation exerted a favorable impact on sexual function.

First-trimester Down syndrome screening: pregnant women's knowledge

OBJECTIVES

The primary aim of this study was to assess pregnant women's knowledge of first-trimester combined Down syndrome screening in a setting of required informed consent. As the secondary aim, we wanted to identify relevant differences in knowledge level among subgroups of pregnant women, including those informed in different ways about prenatal examinations.

METHODS

Data stem from a population-based cross-sectional questionnaire study including 15 multiple-choice questions assessing knowledge of different aspects of screening. Included were 6427 first-trimester pregnant women from three Danish obstetric departments offering prenatal screening free of charge. Both participants and non-participants in the screening program were included. The results are based on 4095 responders (64%). Differences between subgroups were examined using chi-squared tests and logistic regression analysis. Estimates are stated with 95% CI.

RESULTS

The majority of the participants (87.6 (86.6-88.6)% to 92.6 (91.7-93.3)%) correctly identified the test concept and the main condition being screened for. Fewer participants (16.4 (15.3-17.6)% to 43.3 (41.8-44.8)%) correctly recognized test accuracy and the potential risk of adverse findings other than Down syndrome. Knowledge level was positively associated with length of education (adjusted ORs 1.0 (0.8-1.4) to 3.9 (2.4-6.4)) and participation in the screening program (adjusted OR 0.9 (0.6-1.3) to 5.9 (3.9-8.8)). Participation in an individual information session was weakly associated with more knowledge.

CONCLUSION

The majority of the pregnant women correctly identified the test concept and the main condition being screened for. The pregnant women were found less knowledgeable on test accuracy and drawbacks.

A systematic study of solution and processing parameters on nanofiber morphology using a new electrospinning apparatus

We assembled a new electrospinning apparatus and used poly(ethylene oxide) as a model polymer to perform a systematic study on the influence of solution and processing parameters on the morphology of electrospun nanofibers. Solution parameters studied were polymer concentration and molecular mass. The solvent used, 60 wt% water, 40 wt% ethanol, was the same throughout the study. Processing parameters analyzed were: solution feed rate, needle tip-collector distance and electrostatic potential difference between the needle and collector. Solution viscosity increased both with polymer concentration and molecular mass. Polymer concentration plays a decisive role on the outcome of the electrospinning process: a low concentration led to the formation of beaded fibers; an intermediate concentration yielded good quality fibers; a high concentration resulted in a bimodal size distribution and at even higher concentration a distributed deposition. Fiber diameter increased with polymer molecular mass and higher molecular masses are associated with a higher frequency of splaying events. Fiber diameter increased linearly with solution feed rate. While an increase in needle-collector distance represents a weaker electric field, a greater distance to be covered by the fibers and a longer flight time, presumably favoring the formation of thinner fibers, as solvent evaporation leads to a local increase of concentration and viscosity, viscoelastic forces opposing stretching caused an increase of fiber diameter with needle-collector distance. A higher voltage applied at the needle is associated with a higher charging of the polymer and a higher electrical current through it ultimately leading to incomplete solvent evaporation and merged fibers being produced. Controlling the charging of the polymer independently of the electric field strength was achieved by applying a voltage to the collector while distance and potential difference were kept constant. The increased electrostatic repulsion associated with an increase of the high voltage applied to the needle led to the disappearance of merged fibers.

Aberrant signaling in T-cell acute lymphoblastic leukemia: biological and therapeutic implications

T-cell acute lymphoblastic leukemia (T-ALL) is a biologically heterogeneous disease with respect to phenotype, gene expression profile and activation of particular intracellular signaling pathways. Despite very significant improvements, current therapeutic regimens still fail to cure a portion of the patients and frequently implicate the use of aggressive protocols with long-term side effects. In this review, we focused on how deregulation of critical signaling pathways, in particular Notch, PI3K/Akt, MAPK, Jak/STAT and TGF-beta, may contribute to T-ALL. Identifying the alterations that affect intracellular pathways that regulate cell cycle and apoptosis is essential to understanding the biology of this malignancy, to define more effective markers for the correct stratification of patients into appropriate therapeutic regimens and to identify novel targets for the development of specific, less detrimental therapies for T-ALL.

Biochemical analysis of proteins and lipids found in parasitophorous vacuoles containing Leishmania amazonensis

One fundamental step of Leishmania-macrophage interaction is the phase of parasite internalization through an endocytic process, with the formation of the parasitophorous vacuole (PV). The present study analyzed this process using two approaches. First, to investigate the host cell proteins which take part in this compartment, the macrophage surface was biotinilated and allowed to interact with both Leishmania forms, the PV was then isolated, and the biotinilated proteins were analyzed by Western blot. The results obtained showed that the isolated PV from macrophages infected for 60 min with infective promastigotes displayed high molecular weight proteins, 220 kDa and 180 kDa, contrary to the isolated PV obtained from amastigotes. The isolated PV from amastigotes, after 60 min interaction, displayed a faint, biotinilated protein profile, in contrast to the PV containing amastigote which, after 30 min interaction, displayed a strong protein profile in the range of 120 kDa and 40-60 kDa. The biotinilated protein profile may represent proteins distributed in the PV membrane and may also correspond to biotinilated proteins incorporated by the intracellular parasite, as observed by confocal microscopy. In a second approach, to investigate the PV phospholipid composition, macrophages were incubated with (32)P, allowed to interact with the parasites, and the isolated PV was then processed for phospholipid analysis by thin layer chromatography and scintillation counting. An increase in the levels of lysophosphatidylcholine was observed in infected macrophages. The isolated PV from infective promastigotes and amastigotes, after 60 min interaction, displayed high levels of phosphatidylcholine. Then the PV was ruptured and the intravacuolar parasite's (32)P phospholipid composition was analyzed by TLC; and labeling of the parasites was found, suggesting that phospholipids from the macrophage are transferred to the parasite. Taken together, the results obtained show that several proteins and phospholipids found in the plasma membrane of the macrophage are also found in the PV compartment.

Redistribution of plasma-membrane surface molecules during formation of the Leishmania amazonensis-containing parasitophorous vacuole

Leishmania amazonensis presents two developmental stages that gain access to the host macrophage through phagocytosis. The protozoan resides in a membrane-bound compartment, the parasitophorous vacuole (PV), which can fuse with the endocytic system. For evaluation of the parasite/host-cell interaction process and of PV biogenesis, the two parasite forms or host-cell membrane whose surface had previously been labeled with specific probes for lipids, proteins, and sialoglycoconjugates were allowed to interact for periods varying from 5 to 15 min for adhesion and from 30 to 60 min for PV formation. The fate of fluorescent probes was followed by confocal laser scanning microscopy. In host cells previously labeled with PKH26, DTAF and FITC-thiosemicarbazide, which label membrane lipids, proteins, and sialoglycoconjugates, respectively, interaction with both protozoan forms revealed that adhesion to the macrophage was sufficient for labeling of the parasite surface. In addition, recently formed PVs displayed strongly labeled intravacuolar parasites, except for amastigote-macrophage interaction in a DTAF-labeled macrophage that displayed slight labeling of intravacuolar parasites, with the membrane lining the PV evidently being stained. Therefore, the vacuole modulation presents some particularities such that different host-cell membrane components may be selected, depending on the protozoan form involved. Thereafter, amastigotes labeled with the probes mentioned above displayed a diffuse labeling pattern after interaction with unlabeled macrophages, suggesting the spreading of Leishmania surface molecules during the initial parasite-invasion stages. In particular, intravacuolar DTAF-labeled amastigotes showed a delineating halo around the PV, with the intravacuolar parasite being partially labeled. Promastigotes could not be labeled with 5-(4,6-dichlorotriazinyl)aminofluorescein (DTAF) or with fluorescein-5-thiosemicarbazide, but promastigotes labeled with PKH26 lost the fluorescent probe during the invasion process such that slightly labeled promastigotes were seen inside the PV. These observations indicate the existence of a dynamic process of exchange of membrane-associated glycoproteins and lipids between the parasite and the host cell.

[ROC analysis comparing screen film mammography and digital mammography]

PURPOSE

To compare the diagnosis performances of radiologists on screen film versus digital mammography.

MATERIAL

and methods: Two sets of 123 mammograms, screen film mammography and storage phosphor digital mammography, are studied comparatively with ROC analysis.

RESULTS

Phantom study show that conventional method give better scores for usual tension but the detectability of smaller microcalcification is equivalent. To obtain with digital technic the same conventional score you have to increase the radiation dose. Roc Curves, simulated "detection" mode showed that radiologists performed with higher accuracy with conventional system but this difference is weekly statistically significant. ROC Curves, simulated "diagnostic" mode showed the same results wit no statistically significant difference but when the decision to go to the biopsy is the gold standard, ROC Curves were essentially equivalent for both film screen and digital mammography system. The readers consistently considered the digital mammograms to be less suspicious for cancer findings. The agreement study as proposed by the FDA indicate that probability of a positive digital mammograms given a positive screen film is 75% (threshold value 90%) and the probability of a negative digital mammograms given a negative analog film is 85% (threshold value 85%).

CONCLUSION

Analysis of specific discrepancies indicate that spatial resolution is an essential limiting factor for digital method but high resolution phosphor plate are interesting in imaging treated breast, radioluscent lesion, fatty benign tumor, hamartoma, intramammary lymph node, breast with prosthesis.

NF-kappaB is involved in the induction of the rat hepatic alpha1-acid glycoprotein gene by phenobarbital

Phenobarbital, a classical inducer of the drug-metabolizing cytochrome P450 genes, induces alpha1-acid glycoprotein gene expression through a PB-responsive element (PBRE) located at position -142 to -126 from the transcriptional start site. The aim of this study was to investigate nuclear protein binding to the PBRE sequence after PB treatment. Cycloheximide treatment showed that de novo protein synthesis was not required for PB to induce AGP gene expression, pointing to post-translational modifications. Studies of the DNA-protein complex with the PBRE showed that phosphorylation status is a key regulator of the binding capacity of transactivating proteins involved in PB transcriptional activation. This DNA-protein complex, analyzed by southwestern blotting and UV cross-linking, involves three nuclear factors with molecular weights of 43, 52, and 65 kDa. Supershift and competition experiments showed that the 43-kDa factor can be related to C/EBPalpha and the 52- and 65-kDa factors to the two subunits of NF-kappaB.

Growth hormone inhibits rat liver alpha-1-acid glycoprotein gene expression in vivo and in vitro

The gene encoding alpha-1-acid glycoprotein (AGP), one of the major acute-phase proteins, is positively controlled at the transcriptional level by cytokines (interleukin-1 [IL-1], IL-6, and tumor necrosis factor alpha) and glucocorticoids. Here, we show that growth hormone (GH) treatment of isolated rat hepatocytes in vitro reduces AGP messenger RNA (mRNA) expression. AGP gene expression remained inducible by IL-1, IL-6, and phenobarbital (PB) in GH-treated hepatocytes. Interestingly, the repressive effect of GH on AGP gene expression was also observed in vivo: liver AGP mRNA content was strongly increased in hypophysectomized rats, and GH treatment of these animals led to a decrease in mRNA to levels lower than those in untreated control animals. Moreover, the inhibitory effect of GH mainly occurs at the transcriptional level and can be observed as little as 0.5 hours after GH adding in vitro to isolated hepatocytes. These results show negative regulation of AGP gene expression and strongly suggest that GH is a major endogenous regulator of constitutive AGP gene expression. Moreover, transfection assays showed that the region of the AGP promoter located at position -147 to -123 is involved in AGP gene regulation by GH. Furthermore, GH deeply modifies the pattern of nuclear protein binding to this region. GH treatment of hypophysectomized rats led to the release of proteins of 42 to 45 and 80 kd and to the binding of proteins of 48 to 50 and 90 kd.

[Large core of nonpalpable breast lesions]

The development of breast cancer screening has radically changed the diagnostic approach to breast lesions. Stereotactic large-core breast biopsy was developed to reduce the number of unnecessary surgical excisional biopsies in the increasing number of patients with doubtful or suspicious mammogram findings. The methods used to evaluate this new technique are discussed, as well as results in terms of efficacy, factors that may influence efficacy, and difficulties in interpreting large-core biopsies. Recommendations regarding the harvesting and interpretation of stereotactic large-core biopsies are made.

Cardiac consequences of renal transplantation changes in left ventricular morphology

OBJECTIVE

The aim of this study was to characterize changes in left ventricular morphology and function by conventional echocardiography in a pediatric population after renal transplantation (RT).

MATERIAL AND METHODS

This study includes 21 children, 11 female and 10 male, aged 11.8 +/-2.6 years at the time of renal transplantation. Eleven were on regular hemodialysis treatment and two on continuous peritoneal dialysis for 31.8 +/- 31.6 months; eight were transplanted without prior dialysis. Eight children were hypertensive before RT and nine (seven de novo) after RT. The patients were analysed in a prospective follow-up study with echocardiography immediately before and 30.2 +/- 15 months after successful renal transplantation. We measured the following echocardiographic parameters: Left ventricular end diastolic (LVED) and end systolic diameter (LVES), left atrial dimension (LAD), septal thickness (IVST), posterior wall thickness (PWT), shortening fraction (SF) and left ventricular index mass (LVIM). The paired Student's test, Fisher exact test and Pearson's correlation were used for statistical analysis. We analyzed the echocardiographic changes in the total group and separately in the subgroups with and without prior hemodialysis, as well as the influence of the duration of dialysis, anemia and hypertension.

RESULTS

1. After renal transplantation we found a decrease in the LVED LVES, LAD, IVST and PWT measurements (p < 0.05). There was a negligible increase in SF. The LVIM decreased from 139 g/m2 to 104 g/m2, representing a 21% reduction of the initial value, but this reduction was not of statistically significant. 2. The findings were similar in the hemodialysis group-LVIM decreased from 167.6 g/m2 to 94.9 g/m2, representing a 35% reduction in the initial value. 3. In the non dialysis group LVED, LVES, LAD and SVT decreased and LVIM showed a minor increase. There was a negligible increase in SF. 4. We found an increased LVIM in children with prior hemodialysis before RT, especially if dialysis lasted for more than two years. 5. Amelioration of hematocrit correlated with reduction of LVIM. 6. Regression of LV hypertrophy after RT was not dependent on blood pressure levels.

CONCLUSIONS

Renal transplantation resulted in a tendency towards normalization of the echocardiographic parameters analysed: Contractility, as assessed by shortening fraction, was normal in this population. Although cardiac hypertrophy and dilation is reversible after RT, it would seem that children may benefit from an earlier transplantation.

[Stereotaxic fine-needle aspirations of clinically latent breast cysts: an efficient and neat procedure]

The purpose was to evaluate the interest of stereotaxic fine-needle aspiration for round opacities when the ultrasound and echoguided punctures are inefficient; especially when women are under menopausal hormonal replacement therapy. Sixty stereotactic guided fine-needle aspirations detected by mammography have been performed between january 1990 and august 1996. The stereotaxic procedure is performed with a DMR unit (GE with Stereotix II). Stereotaxic views are done to verify needle position. After aspiration, cytologic examination is realised. Cystic fluid was always obtained and cytologic examination proved benign cysts in all cases. In 50 cases, cysts completely disappeared. There were 2 relapses that received after a second. This method is reliable for evaluation of non palpable mammographically detected opacities. The use of this technique spares the patient a surgical biopsy. This procedure enables women under menopausal hormone replacement therapy to continue the treatment.

Partial characterization of folate uptake in microvillous membrane vesicles isolated from human placenta

The purpose of the present study was to determine biochemical parameters of folate uptake, and the putative contribution of the membrane-anchored folate receptor in microvillous membrane vesicles obtained from the syncytiotrophoblast of human term placenta. Uptake of [3H]-pteroylglutamic acid (PGA) by microvillous membrane vesicles was pH dependent with a maximum at pH 6.0, and attained equilibrium at 60 min of incubation. Uptake was higher in the presence on an inward pH gradient (pHout = 6.0; pHin = 7.5) than in the absence of the gradient (pHout = pHin = 6.0). The effect of changes in medium osmolality showed that both binding to the vesicular membrane and internalization contributed to the measured [3H]-PGA uptake. Equilibrium uptake experiments using [3H]-PGA concentrations within the physiological range of folate in blood serum showed that saturation was achieved at 30 nM and revealed a single class of binding sites with a Kd of 1.8 nM for [3H]-PGA. Cleavage of the glycosyl-phosphatidylinositol moiety of the folate receptor, which anchors the receptor to the membrane, with phosphatidylinositol-specific phospholipase C resulted in a reduction of about 80% in [3H]-PGA uptake. In conclusion, our results showed that the folate uptake in the maternally facing membrane of the human placenta presents a saturable component and is mediated by the folate receptor to ensure an adequate maternal-fetal folate transfer.

[Morphologic course of the left ventricle after renal transplantation. Echocardiographic study]

OBJECTIVE

To characterize and to quantitate the morphologic changes in left ventricle, in renal transplant patients (Pts) treated with cyclosporine, through sequential echocardiographic examinations.

DESIGN

A prospective study of renal transplant patients, between October/88 and May/89, who maintained good function of the renal graft during the follow-up.

SETTING

Cardiology and Nephrology departments of Santo António Hospital.

MATERIAL AND METHODS

20 patients, 13 men and 7 women, mean age of 33 +/- 10, ranging from 20 to 56, constitute the final group of the study. These patients have been receiving dialysis during 3.8 +/- 2.3 years (0.4-8). Seven patients were excluded, five by echocardiographic criteria and another two because of chronic renal graft disfunction (creatinine greater than 2.0 mg%). The echocardiographic examinations were performed during the first week, and 1, 2, 3, 6 and 12 months after renal transplantation. The following measurements were performed: left ventricular end-diastole diameter (LVED), interventricular septal thickness (IVST), posterior wall thickness (PWT) and left ventricular mass index (LVMI). The measurements were obtained in M-mode following the conventional recommendations. Average values of at least 3 cardiac cycles were used. Heart rate, blood pressure, creatinine, hematocrit, body surface area and fistula patency, were determined at the time of each echocardiogram.

MAIN RESULTS

The LVED decreased progressively until the third month, from 51.9 +/- 7 mm to 47.8 +/- 6 mm (p less than 0.001), remaining stable thereafter. The baseline value of IVST, 13.6 +/- 5 mm, was similar at the twelfth month, 13.8 +/- 2 mm (ns). The baseline value of PWT, 13.7 +/- 4 mm, decreased gradually since the second month, having reached 12.7 +/- 2 mm at the twelfth month (ns). The LVMI (g/m2) reduced progressively, from 243 +/- 82 to 190 +/- 38 at the end of the study (p less than 0.05. A high incidence of arterial hypertension was detected during the follow-up period; at the twelfth month, 18 patients (90%) were on antihypertensive drug therapy, 11 of which had blood pressure greater than or equal to 160/95 mmHg.

CONCLUSIONS

We verified, one year after the renal transplantation, a significant decrease of LVMI, that was mainly determined by the LVED reduction. Left ventricular walls thickness had no significant variation; we think that the high incidence of hypertension during the follow-up period, in part due to the pressure effect of cyclosporine, may have been responsible for this fact.