Oestradiol and osteoclast differentiation: Effects on p53 and mitochondrial metabolism

BACKGROUND

Oestrogen deficiency increases bone resorption, contributing to osteoporosis development. Yet, the mechanisms mediating the effects of oestrogen on osteoclasts remain unclear. This study aimed to elucidate the early metabolic alteration induced by RANKL, the essential cytokine in osteoclastogenesis and 17-beta-oestradiol (E2) on osteoclast progenitor cells, using RAW 264.7 macrophage cell line and primary bone marrow-derived macrophages as biological models.

RESULTS

This research demonstrated that, in osteoclast precursors, RANKL stimulates complex I activity, oxidative phosphorylation (OXPHOS) and mitochondria-derived ATP production as early as 3 h of exposure. This effect on mitochondrial bioenergetics is associated with an increased capacity to oxidize TCA cycle substrates, fatty acids and amino acids. E2 inhibited all effects of RANKL on mitochondria metabolism. In the presence of RANKL, E2 also decreased cell number and stimulated the mitochondrial-mediated apoptotic pathway, detected as early as 3 h. Further, the pro-apoptotic effects of E2 during osteoclast differentiation were associated with an accumulation of p392S-p53 in mitochondria.

CONCLUSIONS

These findings elucidate the early effects of RANKL on osteoclast progenitor metabolism and suggest novel p53-mediated mechanisms that contribute to postmenopausal osteoporosis.

Refining the identity of mesenchymal cell types associated with murine periosteal and endosteal bone

Single-cell RNA-seq has led to novel designations for mesenchymal cells associated with bone as well as multiple designations for what appear to be the same cell type. The main goals of this study were to increase the amount of single-cell RNA sequence data for osteoblasts and osteocytes, to compare cells from the periosteum to those inside bone, and to clarify the major categories of cell types associated with murine bone. We created an atlas of murine bone-associated cells by harmonizing published datasets with in-house data from cells targeted by Osx1-Cre and Dmp1-Cre driver strains. Cells from periosteal bone were analyzed separately from those isolated from the endosteum and trabecular bone. Over 100,000 mesenchymal cells were mapped to reveal 11 major clusters designated fibro-1, fibro-2, chondrocytes, articular chondrocytes, tenocytes, adipo-Cxcl12 abundant reticular (CAR), osteo-CAR, preosteoblasts, osteoblasts, osteocytes, and osteo-X, the latter defined in part by periostin expression. Osteo-X, osteo-CAR, and preosteoblasts were closely associated with osteoblasts at the trabecular bone surface. Wnt16 was expressed in multiple cell types from the periosteum but not in cells from endocortical or cancellous bone. Fibro-2 cells, which express markers of stem cells, localized to the periosteum but not trabecular bone in adult mice. Suppressing bone remodeling eliminated osteoblasts and altered gene expression in preosteoblasts but did not change the abundance or location of osteo-X or osteo-CAR cells. These results provide a framework for identifying bone cell types in murine single-cell RNA-seq datasets and suggest that osteoblast progenitors reside near the surface of remodeling bone.

Single-cell Transcriptome Analysis Identifies Senescent Osteocytes as Contributors to Bone Destruction in Breast Cancer Metastasis

Breast cancer bone metastases increase fracture risk and are a major cause of morbidity and mortality among women. Upon colonization by tumor cells, the bone microenvironment undergoes profound reprogramming to support cancer progression that disrupts the balance between osteoclasts and osteoblasts, leading to bone lesions. Whether such reprogramming affects matrix-embedded osteocytes remains poorly understood. Here, we demonstrate that osteocytes in breast cancer bone metastasis develop premature senescence and a distinctive senescence-associated secretory phenotype (SASP) that favors bone destruction. Single-cell RNA sequencing identified osteocytes from mice with breast cancer bone metastasis enriched in senescence and SASP markers and pro-osteoclastogenic genes. Using multiplex in situ hybridization and AI-assisted analysis, we detected osteocytes with senescence-associated distension of satellites, telomere dysfunction, and p16Ink4a expression in mice and patients with breast cancer bone metastasis. In vitro and ex vivo organ cultures showed that breast cancer cells promote osteocyte senescence and enhance their osteoclastogenic potential. Clearance of senescent cells with senolytics suppressed bone resorption and preserved bone mass in mice with breast cancer bone metastasis. These results demonstrate that osteocytes undergo pathological reprogramming by breast cancer cells and identify osteocyte senescence as an initiating event triggering bone destruction in breast cancer metastases.

The role of reactive oxygen species in bone cell physiology and pathophysiology

Hydrogen peroxide (H2O2), superoxide anion radical (O2-•), and other forms of reactive oxygen species (ROS) are produced by the vast majority of mammalian cells and can contribute both to cellular homeostasis and dysfunction. The NADPH oxidases (NOX) enzymes and the mitochondria electron transport chain (ETC) produce most of the cellular ROS. Multiple antioxidant systems prevent the accumulation of excessive amounts of ROS which cause damage to all cellular macromolecules. Many studies have examined the contribution of ROS to different bone cell types and to skeletal physiology and pathophysiology. Here, we discuss the role of H2O2 and O2-• and their major enzymatic sources in osteoclasts and osteoblasts, the fundamentally different ways via which these cell types utilize mitochondrial derived H2O2 for differentiation and function, and the molecular mechanisms that impact and are altered by ROS in these cells. Particular emphasis is placed on evidence obtained from mouse models describing the contribution of different sources of ROS or antioxidant enzymes to bone resorption and formation. Findings from studies using pharmacological or genetically modified mouse models indicate that an increase in H2O2 and perhaps other ROS contribute to the loss of bone mass with aging and estrogen deficiency, the two most important causes of osteoporosis and increased fracture risk in humans.

A framework for defining mesenchymal cell types associated with murine periosteal and endosteal bone

Single-cell RNA sequencing has led to numerous novel designations for mesenchymal cell types associated with bone. Consequently, there are now multiple designations for what appear to be the same cell type. In addition, existing datasets contain relatively small numbers of mature osteoblasts and osteocytes and there has been no comparison of periosteal bone cells to those at the endosteum and trabecular bone. The main goals of this study were to increase the amount of single cell RNA sequence data for osteoblasts and osteocytes, to compare cells from the periosteum to those inside bone, and to clarify the major categories of cell types associated with murine bone. To do this, we created an atlas of murine bone-associated cells by harmonizing published datasets with in-house data from cells targeted by Osx1-Cre and Dmp1-Cre driver strains. Cells from periosteal bone were analyzed separately from those isolated from the endosteum and trabecular bone. Over 100,000 mesenchymal cells were mapped to reveal 11 major clusters designated fibro-1, fibro-2, chondrocytes, articular chondrocytes, tenocytes, adipo-CAR, osteo-CAR, pre-osteoblasts, osteoblasts, osteocytes, and osteo-X, the latter defined in part by Postn expression. Osteo-X, osteo-CAR, and pre-osteoblasts were closely associated with osteoblasts at the trabecular bone surface. Wnt16 was expressed in multiple cell types from the periosteum but not in any cells from endocortical or cancellous bone. Fibro-2 cells, which express markers of skeletal stem cells, localized to the periosteum but not trabecular bone in adult mice. Suppressing bone remodeling eliminated osteoblasts and altered gene expression in pre-osteoblasts but did not change the abundance or location of osteo-X or osteo-CAR cells. These results provide a framework for identifying bone cell types in murine single cell RNA sequencing datasets and suggest that osteoblast progenitors reside near the surface of remodeling bone.

RANK ligand converts the NCoR/HDAC3 co-repressor to a PGC1β- and RNA-dependent co-activator of osteoclast gene expression

The nuclear receptor co-repressor (NCoR) complex mediates transcriptional repression dependent on histone deacetylation by histone deacetylase 3 (HDAC3) as a component of the complex. Unexpectedly, we found that signaling by the receptor activator of nuclear factor κB (RANK) converts the NCoR/HDAC3 co-repressor complex to a co-activator of AP-1 and NF-κB target genes that are required for mouse osteoclast differentiation. Accordingly, the dominant function of NCoR/HDAC3 complexes in response to RANK signaling is to activate, rather than repress, gene expression. Mechanistically, RANK signaling promotes RNA-dependent interaction of the transcriptional co-activator PGC1β with the NCoR/HDAC3 complex, resulting in the activation of PGC1β and inhibition of HDAC3 activity for acetylated histone H3. Non-coding RNAs Dancr and Rnu12, which are associated with altered human bone homeostasis, promote NCoR/HDAC3 complex assembly and are necessary for RANKL-induced osteoclast differentiation in vitro. These findings may be prototypic for signal-dependent functions of NCoR in other biological contexts.

The NAD salvage pathway in mesenchymal cells is indispensable for skeletal development in mice

NAD is an essential co-factor for cellular energy metabolism and multiple other processes. Systemic NAD+ deficiency has been implicated in skeletal deformities during development in both humans and mice. NAD levels are maintained by multiple synthetic pathways but which ones are important in bone forming cells is unknown. Here, we generate mice with deletion of Nicotinamide Phosphoribosyltransferase (Nampt), a critical enzyme in the NAD salvage pathway, in all mesenchymal lineage cells of the limbs. At birth, NamptΔPrx1 exhibit dramatic limb shortening due to death of growth plate chondrocytes. Administration of the NAD precursor nicotinamide riboside during pregnancy prevents the majority of in utero defects. Depletion of NAD post-birth also promotes chondrocyte death, preventing further endochondral ossification and joint development. In contrast, osteoblast formation still occurs in knockout mice, in line with distinctly different microenvironments and reliance on redox reactions between chondrocytes and osteoblasts. These findings define a critical role for cell-autonomous NAD homeostasis during endochondral bone formation.

Hematopoietic cytoplasmic adaptor protein Hem1 promotes osteoclast fusion and bone resorption in mice

Hem1 (hematopoietic protein 1), a hematopoietic cell-specific member of the Hem family of cytoplasmic adaptor proteins, is essential for lymphopoiesis and innate immunity as well as for the transition of hematopoiesis from the fetal liver to the bone marrow. However, the role of Hem1 in bone cell differentiation and bone remodeling is unknown. Here, we show that deletion of Hem1 resulted in a markedly increase in bone mass because of defective bone resorption in mice of both sexes. Hem1-deficient osteoclast progenitors were able to differentiate into osteoclasts, but the osteoclasts exhibited impaired osteoclast fusion and decreased bone-resorption activity, potentially because of decreased mitogen-activated protein kinase and tyrosine kinase c-Abl activity. Transplantation of bone marrow hematopoietic stem and progenitor cells from wildtype into Hem1 knockout mice increased bone resorption and normalized bone mass. These findings indicate that Hem1 plays a pivotal role in the maintenance of normal bone mass.

ECSIT is essential for RANKL-induced stimulation of mitochondria in osteoclasts and a target for the anti-osteoclastogenic effects of estrogens

Introduction

Estrogens inhibit bone resorption and preserve bone mass, at least in part, via direct effects on osteoclasts. The binding of RANKL, the critical cytokine for osteoclast differentiation, to its receptor in osteoclast precursor cells of the monocyte lineage recruits the adaptor protein TRAF6 and activates multiple signaling pathways. Early effects of RANKL include stimulation of mitochondria. 17β-estradiol (E₂) prevents the effects of RANKL on mitochondria and promotes mitochondria mediated apoptotic cell death. However, the molecular mechanisms responsible for the actions of RANKL and estrogens on mitochondria remain unknown. Evolutionarily Conserved Signaling Intermediate in Toll Pathway (ECSIT) is a complex I-associated protein that regulates immune responses in macrophages following the engagement of Toll-like receptors, which also recruit TRAF6. Here, we examined whether ECSIT could be implicated in the rapid effects of RANKL and E₂ on osteoclast progenitors.

Methods

Bone marrow-derived macrophages (BMMs) from C57BL/6 mice were cultured with RANKL (30 ng/ml) with or without E₂ (10^-8 M). ECSIT-TRAF6 interaction was evaluated by co-immunoprecipitation and ECSIT levels in mitochondria and cytosolic fractions by Western blot. ShRNA lentivirus particles were used to knockdown ECSIT. Osteoclasts were enumerated after tartrate-resistant acid phosphatase staining. Oxygen consumption and extracellular acidification rates were measured with Seahorse XFe96 Analyzer. ATP, lactate, and NAD/NADH were measured with commercial assay kits. NADH oxidation to NAD was used to evaluate Complex I activity. Total and mitochondrial ROS, and mitochondrial membrane potential were measured with H2DCFDA, MitoSOX, and TMRM probes, respectively. Degradation of DEVD-AFC was used to measure Caspase-3 activity.

Results

We found that RANKL promoted ECSIT-TRAF6 interaction and increased the levels of ECSIT in mitochondria. E₂ abrogated these effects of RANKL. Silencing of ECSIT decreased osteoclast differentiation and abrogated the inhibitory effects of E₂ on osteoclastogenesis. Loss of ECSIT decreased complex I activity, oxygen consumption, NAD⁺/NADH redox ratio, and ATP production and increased mitochondrial ROS. In the absence of ECSIT, the stimulatory actions of RANKL on complex I activity and all other markers of oxidative phosphorylation, as well as their inhibition by E₂, were prevented. Instead, RANKL stimulated apoptosis of osteoclast progenitors.

Discussion

These findings suggest that dysregulated mitochondria cause a switch in RANKL signaling from pro-survival to pro-apoptotic. In addition, our results indicate that ECSIT represents a central node for the early effects of RANKL on mitochondria and that inhibition of ECSIT-mediated mitochondria stimulation might contribute to the bone protective actions of estrogens.

Seroprevalence and Risk Factors Associated with Leishmania Infection in Dogs from Portugal

Canine leishmaniosis (CanL) caused by Leishmania infantum is an important zoonosis in southwestern European countries where this disease is endemic, and dogs, as domestic animals in close contact with humans, are the reservoir hosts for the parasite. In Portugal, CanL is of relevant veterinary concern. The previous national study revealed an overall seroprevalence of 6.3%. Since then, new prophylactic measures, such as vaccines, have been introduced in Europe. The aim of this study was to update seroprevalence for Leishmania infection and reassess risk factors in Portugal. A cross-sectional study was conducted from January-March 2021 with 1860 client-owned dogs from continental Portugal. A questionnaire and whole blood samples on filter paper were collected and a direct agglutination test was used to calculate anti-Leishmania antibody titres. True seroprevalence was 12.5% (95% CI 10.3-13.2%). Potential risk factors associated with L. infantum infection in dogs were age ≥ 2 years (aOR = 1.68, 95% CI 1.1-2.6) and residing in the interior regions of the country (aOR = 1.92, 95% CI 1.3-2.9) and non-use of repellents (aOR = 1.75, 95% CI 1.2-2.5). The key to controlling CanL and its impact on Public Health in endemic areas lies in continuous implementation of prophylactic measures, through the correct use of repellents/insecticides and vaccines and early detection and monitoring of infected dogs.

The Potency of the Genus Uncaria from East Borneo for Herbal Medicine Purposes: A Mini-review

Uncaria is a genus of plants that are widely distributed in the tropics. There are about 5 of the 38 species of this genus growing in the tropical rain forests of East Borneo, Indonesia. For a long time, Uncaria is commonly used as a traditional medicine to treat various diseases by the Dayak tribe in Kalimantan, traditional people believe that Uncaria may be cured cancer, tumors, mioms, and cycts. Based on previous studies, the activity of the genus Uncaria has been widely reported such as cytotoxic, antimicrobial, antioxidant, antidiabetic, and thrombolytic activities. This article aims to summarize the potential of the Uncaria genus, focusing on 5 species from East Borneo, namely Uncaria nervosa, Uncaria longiflora, Uncaria gambir, Uncaria tomentosa and Uncaria cordata. The method used in this article is a literature study by collecting previous research articles related to the Uncaria genus. The results of the literature study show that the Uncaria genus in East Borneo has many secondary metabolites with diverse chemical structures that show good biological potential so that they can be used as broad and promising insights for drug discovery and development. This paper is also expected to provide input for the policy of conservation of medicinal plants in the forests of East Borneo.

30-day outcomes of P2Y12 inhibitor pretreatment in patients with STEMI submitted to primary PCI – systematic review and meta-analysis

Introduction

Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor is the cornerstone of antithrombotic therapy in patients with ST-segment elevation myocardial infarction (STEMI). Yet, there is uncertainty surrounding the optimal timing for the initiation of the P2Y12 inhibitor. This study aims to evaluate the effectiveness and safety of P2Y12 pretreatment by means of a systematic review and meta-analysis of studies in primary percutaneous coronary intervention (PCI) in STEMI.

Methods

We performed a systematic search of electronic databases Pubmed, CENTRAL and Scopus until March of 2021. Studies were considered eligible if they were: a) comparing P2Y12 inhibitor upstream administration vs. treatment during PCI; b) patients enrolled for STEMI and submitted to primary PCI. Studies with patients treated with fibrinolysis or medical therapy only were excluded. Major clinical outcomes included 30-day occurrence of all-cause death, definite stent thrombosis and re-infarction. Thrombolysis in myocardial infarction (TIMI) flow-grade pre-PCI and post-PCI, in-hospital cardiogenic shock and major bleeding events were analysed.

Results

Out of 2193 articles, 18 studies were included (1 randomized clinical trial [RCT] and 17 observational studies [non-RCT]), with a total of 76,836 patients, 52,181 in the pretreatment arm. At 30 days, pretreatment was associated with a reduction in definite stent thrombosis (1 RCT & 4 Non-RCT: OR 0.40; 95% CI 0.18–0.90), but no significant reduction in all-cause death (1 RCT & 7 Non-RCT: OR 0.77; 95% CI 0.56–1.04) or re-infacrtion (1 RCT & 4 Non-RCT: OR 0.73; 95% CI 0.49–1.09). Regarding in-hospital outcomes, pretreatment showed a significant reduction in the occurrence of cardiogenic shock (5 Non-RCT: 0.62; 95% CI 0.51–0.79), major bleeding events (1 RCT & 14 Non-RCT: 0.83; 95% CI 0.75–0.92) and in the number of patients with TIMI flow <3 postPCI (1 RCT & 8 Non-RCT: 0.82; 95% CI 0.73–0.93). Pretreatment was not associated with lower number of patients with TIMI flow <3 pre-PCI (1 RCT & 5 Non-RCT: 0.85; 95% CI 0.66–1.09).

Conclusion

Pretreatment with DAPT, including a P2Y12 inhibitor, was associated with lower risk for definite stent thrombosis and cardiogenic shock, but was not associated with lower all-cause death or re-infarction.

Funding Acknowledgement

Type of funding sources: None.

Prognostic impact of aborted cardiac arrest in patients with acute myocardial infarction

Background

Aborted cardiac arrest (ACA) during the acute ischaemic phase is a relatively frequent but often undervalued complication of acute myocardial infarction (AMI). The aim of this study was to evaluate the clinical and prognostic impact of aborted cardiac arrest in AMI patients and investigate its correlation with infarct size.

Methods

We conducted a single-centre retrospective study enrolling consecutive patients admitted for AMI, from January 2016 to December 2018. ACA was defined as the need for advanced life support measures and defibrillation, either out-of-hospital or in-hospital, up until culprit vessel revascularisation. Infarct size was estimated using peak serum troponin T, impact on left ventricular ejection fraction (LVEF ≤50%) and echocardiographic wall motion index (WMI). Clinical outcomes included cardiogenic shock (SCAI C or more), need for mechanical circulatory support (MCS), major bleeding events (BARC ≥3) during in-hospital phase and all-cause mortality during follow-up.

Results

A total of 571 patients were included (65±13 years old, 72% male). Overall, 237 had anterior STEMI, 39 patients (6,8%) suffered ACA (21 out of hospital), 60 progressed into cardiogenic shock throughout the hospitalisation, 7 needed MCS, and 52 had BARC ≥3 bleeding. During a mean follow-up of 32 months, 96 patients died.

ACA was significantly associated with higher peak serum troponin T (4802 [1950; 9420] vs 2659 [555; 6708] ng/L – p=0.004), higher proportion of patients with reduced or mildly reduced LVEF (60% vs. 36.5%, p=0.018) and higher WMI (1.7 [1.4; 2.3] vs. 1.5 [1.2; 1.8], p=0.016). Moreover, ACA was also associated with higher risk of cardiogenic shock occurrence (64.1% vs. 6.6%, p<0.001 – OR 25.357 (12.115–53.073)), higher need for MCS (7.9% vs 0.8%, p<0.001 – OR 11.271 (2.427–52.343)) and higher incidence of BARC ≥3 bleeding events (28.2% vs. 8.4%, p<0.001 – OR 4.705 (2.185–10.128)) – Table 1.

On univariate Cox regression, ACA showed significant association with all cause death, which remained highly significant after multivariable adjustment (OR 2.431 (1.181; 5.002); p=0.016).

Conclusion

The occurrence of aborted cardiac arrest in patients with AMI was associated with increased morbidity and mortality. This may be driven by a larger area of arrhythmia prone ischemic myocardium.

Funding Acknowledgement

Type of funding sources: None.

Coronary sinus reducer device for the treatment of refractory angina therapy. A multicentric initial experience

Introduction

The coronary sinus Reducer device (CSRD) emerged as a complementary therapy in patients with severe angina refractory to optimal medical therapy and not amenable to revascularization. Our aim was to assess the safety and efficacy of the CSRD in a real-world setting.

Methods

Twenty-six patients with refractory angina (RA), evidence of myocardial ischemia attributable to the left coronary artery unsuitable for revascularization were treated with the CSRD at two centres between May 2017 and July 2019. Safety endpoints were procedural success and complications. Efficacy endpoints, assessed at 6-month follow-up, were a reduction in CCS class, improvement in quality of life (QoL) assessed using the short version of the Seattle Angina Questionnaire (SAQ-7) and reduction in anti-anginal therapy.

Results

Twenty-three patients had end-stage CAD without revascularization targets and 3 patients had microvascular disease without epicardial stenosis. Procedural success was achieved 23 patients, with 2 device/procedural-related complications and one anatomically-related failure to deliver the device. Ultimately 25 patients implanted the device and entered the efficacy analysis. Eighteen patients (75.0%) had at least 1 reduction in CCS class, 41.7% had at least 2 class reductions, and 16.7% became asymptomatic, with a mean reduction of CCS class of 1.3±0.2 (p=0.001) at 6-month follow-up. All SAQ-7 domains improved, namely physical limitation (p=0.001), angina frequency (p=0.005) and QoL (p=0.006). There was a mean reduction of anti-ischemic drugs from 3.4±1.1 to 2.9±1.2 (p=0.010).

Conclusion

In this real-world, multicentric experience, implantation of the CSRD was associated with improvement of angina and QoL in patients with RA.

Funding Acknowledgement

Type of funding sources: None.

TOO MUCH OF NOT ENOUGH: Exploring Lack of Fear and Its Consequences

Introduction

Fear is an unpleasant emotional response to perceiving a threat causing physiological changes. Humans feel fear for positive motives, as it plays a crucial role in our survival. Just as the right balance in life is ideal, pathological fear is often described in one of its exaggerations, of having too much. However, lack of fear or “hypophobia” can be just as devastating and debilitating. This can be demonstrated in the analogy between those who feel no pain who also demonstrate increased risk and decreased life expectancy.

Objectives

The authors aim to explore the concept of fear, discussing currently known physiological mechanisms in order to explain the effects that alterations of these mechanisms can have on fear responses, namely lack of fear, and subsequently the consequence of this on mental health.

Methods

A brief non-systematized literature review was performed based on works most pertinent to the topic discussed.

Results

Muted fear responses have been mentioned in the literature, principally associated with medical conditions affecting the physiological fear pathways, including Urbach-Wiethe disease. Amygdala damage provokes abnormal fear reactions and reduced fear experience. This appears to be similar to what is seen in psychopathy, where abnormalities in the limbic system produce abnormal fear responses.

Conclusions

Any extreme can cause havoc on a well-balanced machine. Just as the excess of fear results in mental issues such as anxiety, a lack of fear can also be debilitating. Those demonstrating less fear could help investigators better understand mental health disorders that have been demonstrated to be mediated by similar processes.

Disclosure

No significant relationships.

YOU’VE BEEN CATFISHED: An exploration of social deception on online platforms

Introduction

Life is a stage in which we are all actors and online we can choose who we want to be. Catfishing is a modern phenomenon in which individuals present themselves online as someone they are not as a means of engaging with others through an idealized avatar. This term has gained prominence since its portrayal in documentary and television series. With the emergence of catfishing, an expectation of betrayal in online relationships is anticipated with increasing caution being exercised by those that engage in online forums.

Objectives

The authors aim to explore this phenomenon and explore what personality traits might be associated with those who engage in catfishing others and in those that fall for the dupe.

Methods

A review of the recent literature on the topic with focus on that which is most relevant to the theme was included.

Results

The literature demonstrates that catfishing is an increasing trend as our online social interaction also increases. Catfishing appears to exist on a scale, where approximately 80% of the online population engage in some form, by means of amplifying their social status. Those with low self-esteem, poor self-worth with and a need to connect and to be validated were most susceptible.

Conclusions

The internet permits anonymity where trading “real world” skins with digital ones creating avatars in order to seek what is desired. Catfishing raises questions about the nature of the human self and the role it plays in deception. Understanding how patients use the internet may provide insight into how personality acts on a stage of total anonymity.

Disclosure

No significant relationships.

MURDEROUS MYTHOMANIA: Psychopathology of lying – Apropos a Clinical Case

Introduction

The capacity for lying is a common human phenomenon with evolutionary explanations, in which one seeks to deceive usually to avoid harmful or undesired consequences. The spectrum of lies is vast and varies from the content to the motivation. Pathological lying has the potential to affect mental evaluations thus motivating an important discussion regarding this behaviour.

Objectives

The authors aim to explore the psychopathological concept and spectrum of pathological lies, from their underlying motives to their implications and challenges in psychiatric diagnosis with recourse to a clinical case example.

Methods

A review of pertinent literature on the topic with focus on that which is most relevant to the theme was included. The authors present the clinical case of a middle-aged female who presented with mythomania which included the fabrication of having attempted murder.

Results

The literature demonstrates a relationship between compulsive lying and personality disorders. Head trauma and other central nervous system issues may also play a role. Some traits may facilitate the detection of deception, such as dramatic and unmotivated constructs with a positive self-portrayal. The clinical case description correlates the personality factors associated with mythomania, namely antisocial personality disorder, differing from the typical presentation as her fabrications portrayed her negatively.

Conclusions

The implication of pathological lying is that it may interfere with mental assessment thus altering, by way of deception, the psychiatric evaluation as lies may be difficult to detect upon a first evaluation. The psychiatrist should be alerted to the possibility of fabrication when dealing with a patient with predisposing factors.

Disclosure

No significant relationships.

Psychogenic epidemic - mass hysteria phenomena in Portugal

Introduction

Mass hysteria also called mass psychogenic illness (MPI), defined as a social phenomenon, consists of collective anxiety due to a perceived threat and can culminate in a cascade of symptoms suggestive of organic disease without an identifiable cause. Its history dates back to the 14th century and impacts people from all cultures and regions of the world. Before the 20thcentury, MPI emerged across Europe, often in socially isolated convents, in highly stressful environments.

Objectives

The aim of this study is to explore the available literature on mass hysteria phenomena in Portugal, historical origins, applications and eventual position in modern psychiatric semiology.

Methods

Non-systematic review of literature published in Medline/Pubmed. Search terms included: mass hysteria, nocebo, groupthink, emotional contagion.

Results

In Portugal two great phenomena of mass hysteria were described. In 1917, the “sun miracle” occurred, where thousands of individuals reported having seen the sun rotating in the sky and changing its size and colours. Years later, more than 300 students from 14 schools described the same symptoms: dizziness, dyspnea and rash, without an identifiable cause. In common these young people had “sugar strawberries”. In May 2006, the young people in the television series were infected with a vírus, and clinical picture was similar to that presented by young people in real life. For the first time, a fictional illness on television triggered an illness in real life.

Conclusions

More studies should be carried out on these phenomena as their early recognition can have a tremendous impact on the ease of identification, diagnosis and treatment.

Disclosure

No significant relationships.

Folie à deux: contagious mental illness? Report of a clinical case

Introduction

Folie à deux is a clinical condition that was first described in 19th century. It is a psychotic disorder in which two closely associated individuals share a similar delusional system. However, folie à deux is still a matter of study and debate today as it remains a challenge for psychiatrists.

Objectives

The aim of this article is to report a clinical case of folie à deux, between na inducer son and an induced mother. Review the nosological significance of folie à deux and to explore the disorder among patients with psychosis.

Methods

Search in the PubMed/MedLine and Medscape databases with the following key words: folie à deux; shared psychosis; shared delusion.

Results

We presente a case of folie à deux between na inducer son 28 years old and the induced, his mother. They were found to be sharing similiar delusional beliefs. The patient has assumed the role of “man of the house” since his father’s death.

Conclusions

Many years after it was first described, folie à deux is still an interesting and challenging disorder to psychiatrists. Its recognition and correct referral for a rare diagnosis, such as folie a deux, are extremely important.

Disclosure

No significant relationships.

Prospective international validation of the predisposition, infection, response and organ dysfunction (PIRO) clinical staging system among intensive care and general ward patients

Background

Stratifying patients with sepsis was the basis of the predisposition, infection, response and organ dysfunction (PIRO) concept, an attempt to resolve the heterogeneity in treatment response. The purpose of this study is to perform an independent validation of the PIRO staging system in an international cohort and explore its utility in the identification of patients in whom time to antibiotic treatment is particularly important.

Methods

Prospective international cohort study, conducted over a 6-month period in five Portuguese hospitals and one Australian institution. All consecutive adult patients admitted to selected wards or the intensive care, with infections that met the CDC criteria for lower respiratory tract, urinary, intra-abdominal and bloodstream infections were included.

Results

There were 1638 patients included in the study. Patients who died in hospital presented with a higher PIRO score (10 ± 3 vs 8 ± 4, p < 0.001). The observed mortality was 3%, 15%, 24% and 34% in stage I, II, III and IV, respectively, which was within the predicted intervals of the original model, except for stage IV patients that presented a lower mortality. The hospital survival rate was 84%. The application of the PIRO staging system to the validation cohort resulted in a positive predictive value of 97% for stage I, 91% for stage II, 85% for stage III and 66% for stage IV. The area under the receiver operating characteristics curve (AUROC) was 0.75 for the all cohort and 0.70 if only patients with bacteremia were considered. Patients in stage III and IV who did not have antibiotic therapy administered within the desired time frame had higher mortality rate than those who have timely administration of antibiotic.

Conclusions

To our knowledge, this is the first external validation of this PIRO staging system and it performed well on different patient wards within the hospital and in different types of hospitals. Future studies could apply the PIRO system to decision-making about specific therapeutic interventions and enrollment in clinical trials based on disease stage.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13613-021-00966-7.

Improving the preparedness against an oil spill: Evaluation of the influence of environmental parameters on the operability of unmanned vehicles

When an oil spill occurs, a prompt response reduces significantly the impact. The preparedness and contingency plans are essential to identify the most appropriate technologies. Unmanned and autonomous vehicles (UAVs) is emerging as a powerful tool of strategic potential in the observation, oil tracking and damage assessment of an oil spill. The SpilLess project explored the suitability of these devices to be the first-line response to an oil spill. This work analyses the operational requirements related to environmental parameters following a two steps approach: 1) Environmental characterization from long wind and waves time series and modelling; 2) Definition of the optimal periods for operating each UAVs. We have defined the periods in which each of these facilities acts best, confirming that the operational limits of UAVs are not significantly more restrictive than the traditional operations. UAVs should be included in contingency plans as available tools to fight against oil spills.

TAVI via alternative access routes: patient selection and 10-year center experience

Background

Femoral access is considered the gold standard for transcatheter aortic valve implantation (TAVI). However, this route might be precluded due to the presence of tortuosity, small vessel diameter and/or peripheral artery disease. We aimed to investigate TAVI through an alternative access (AA), focusing on the selection criteria and clinical outcomes compared to the femoral route (TF).

Methods

We conducted an all-comers longitudinal single-centre prospective registry in whom a TAVI was performed. The feasibility, safety and efficacy of TAVI by means of an access route other than standard TF was assessed, according to the VARC-2 criteria. The prospective surgical criteria used at our institution to accept an AA route were: a) TF deemed inappropriate; b) acceptable haemorrhagic risk; c) acceptable general anaesthesia risk; and d) adequate anatomy and diameter within acceptable range (subclavian, axillar, transaortic) or e) age &lt;85 years and non-frail patient (transapical). The primary endpoint was all-cause death at 1-year.

Results

From 2008 to 2018, there were 548 patients submitted to TAVI [median age 84 (79–87) years, males 45.4%]. An AA route was used in 100 patients (79 trans-apical, 9 trans-aortic, and 12 trans-subclavian), with a decreasing rate over follow-up (−11% per year). Compared to TF, these patients were younger [80 (77–84) vs. 85 (80–87) years; p&lt;0.001) with a similar baseline surgical risk as per EuroSCORE II [5.1 (3.3–9.0) vs. 4.7 (3.3–7.0); p=0.410). AA patients presented a higher burden of atherosclerotic disease, namely coronary (54.0 vs. 41.3%; p&lt;0.001) and peripheral artery disease (35.0 vs. 16.5%, p&lt;0.001) despite a lower number of other comorbidities (e.g. glomerular filtration rate &lt;50mL/min: 53.1 vs. 64.8%; p=0.030). Left ventricular ejection fraction (56±13 vs 55±12%; p=0.203) and aortic stenosis severity (e.g. valve area: 0.70±0.19 vs. 0.67±0.18cm2; p=0.302) were similar between groups. Haemorrhagic events (minor or major) following TAVI were less often documented in the AA group (11.0 vs 21.7%; p=0.015), contrasting with de novo atrial fibrillation (18.5 vs 7.6%; p=0.048). Overall, 67 patients met the primary endpoint (18.8 vs 16.2%; p=0.584). After adjusted multivariate analysis, the independent predictors of one-year mortality did not include the TAVI access route.

Conclusion

In the first 10 years of experience, 1 in every 6 patients was treated with a TAVI by means of an AA, most often trans-apically initially and, nowadays, via a trans-subclavian approach. The use of meticulous prospective selection criteria seems to explain the one-year similar results, regardless of the access route.

Funding Acknowledgement

Type of funding sources: None.

Incremental prognostic value of worsening renal function parameters in addition to the GRACE score in patients with acute coronary syndrome

Background

Baseline renal function, one of the parameters included in the GRACE score, has prognostic relevance in patients admitted for acute coronary syndrome (ACS).

Purpose

The aim of this study was to compare different worsening renal function (WRF) parameters during hospitalization for ACS and their impact on all-cause mortality. Furthermore, we aimed to assess if these parameters had any incremental prognostic value in addition to the GRACE score.

Methods

We conducted a single-center retrospective study enrolling consecutive patients admitted for ACS from January 2016 to December 2018. Estimation of glomerular filtration rate (eGFR) for each patient was calculated based on the CKD-EPI formula. WRF during hospitalization was assessed by means of: serum creatinine (sCr) elevation ≥0,3mg/dL, duplication of the sCr value or maximum sCr value ≥2,0mg/dL.

Results

A total of 555 patients were included (65±13 years old, 72% male). Overall, 402 (72%) had hypertension, 167 (30%) were diabetic, 88 (16%) had left ventricular ejection fraction &lt;40%. Mean GRACE score was 102.7±29.1 and median sCr at baseline was 0.83 mg/dL [0.70; 0.97]. Median length of hospitalization was 4 days [2; 10] and the mean follow-up of 963 days.

Baseline eGFR showed significant correlation with mortality during follow-up (HR 0.742 [95% CI 0.691–0.797] per 10 mL/min/1.73m2 increase in eGRF). Moreover, all WRF parameters showed significant association with all-cause mortality during follow-up on a univariate analysis - p&lt;0,001 (Table 1). Elevation of sCr ≥0,3 mg/dL during hospitalization was the most frequent WRF parameter (210 patients - 38%) and the most sensitive parameter to predict our endpoint, occurring in 56 patients who died during follow-up (sensitivity 66.7%). Both duplication of sCr and absolute sCr ≥2,0mg/dL during hospitalization showed a lower prevalence; however, the majority of patients with one of these findings died during follow-up (51,4% and 68,5%, respectively).

On a multivariate Cox regression analysis, adjusted for the GRACE score, all individual WRF parameters remained independently associated with all-cause mortality during follow up (Table 2).

Conclusion

Worsening renal function has significant prognostic impact in patients admitted for ACS. Identification of these parameters during hospitalization adds significant value to the prognostic stratification of the GRACE score.

Funding Acknowledgement

Type of funding sources: None.

Impact of COVID-19 pandemic on ST-elevation myocardial infarction: data from two Portuguese centers

Introduction

Recently during the COVID-19 pandemic there was a general belief in a reduction of hospital admissions due to non-infectious causes, namely cardiovascular diseases.

Objectives

To evaluate the impact of the pandemic in the admissions by ST elevation acute myocardial infarction (STEMI), during the first pandemic wave.

Methods

Multicentric and retrospective analysis of consecutive patients presenting in two Portuguese hospital centers with STEMI in two sequential periods – P1 (1st March to 30th April) and P2 (1st May to 30th June). A comparison of patient's clinical and hospital outcomes data was performed between the year 2020 and 2017 to 2019 for both periods.

Results

A total of 347 consecutive STEMI patients were included in this study. The patient's baseline characteristics and cardiovascular risk factors were similar across the considered periods. During P1 of 2020, in comparison with previous years, a reduction in the number of STEMI patients was observed (26.0±4.2 vs 16.5±4.9 cases per month; p=0.033), contrary to what was observed during P2 (19.5±0.7 vs 20.5±0.7 cases per month; p=0.500). Percutaneous coronary interventions in the setting of failed thrombolysis were more frequent (1.9% vs 9.1%; p=0.033). A global trend in longer delays in time-key bundles of STEMI care was noted, namely pain to first medical contact, door to needle, door to wire crossing and symptoms to wire crossing times, however without statistical significance. Mortality rate was six-fold higher during P1 comparing to previous years (1.9% vs 12.1%; p=0.005), and also an increase in the number of mechanical complications (0.0% vs 3.0%; p=0.029) was observed.

Conclusions

During the first COVID-19 pandemic wave there were fewer patients presenting with STEMI at catheterization laboratory for coronary angioplasty. These patients presented more mechanical complications and higher mortality rates.

Funding Acknowledgement

Type of funding sources: None.

Prognostic impact of the presence and management of coronary artery disease in patients undergoing TAVI

Introduction

Approximately half of transcatheter aortic valve implantaton (TAVI) candidates have coronary artery disease (CAD). Controversial results have been reported regarding the effect of the presence/severity of CAD and its management on clinical outcomes post-TAVI.

Aim

To describe the presence, extension, severityand management of CAD pre-TAVIand to evaluate its impact on 2-yearmortality in areal world all comers population.

Methods and population

Single centre retrospective analysis from a prospectively collected institutional registry (VCROSS) including 517 patients that underwent TAVI for severe aortic stenosis between January 2009 and December 2018. Patients who underwent pre TAVI CA in the context of ACS or at other institution were excluded n=138. Ultimately 380 entered the analysis. Obstructive CAD was defined as stenosis &gt;50% in in major epicardial vessels (&gt;2.5 mm). The total number of major epicardial with obstructive CAD was reported as was assessed the number of those left untreated. Univariate analysis was performed to assess 1) differences between patients with or without CAD and between those with significant CAD who have or have not undergone PCI, 2) variables associated with 2-year mortality. Binary logistic regression was performed to identify independent predictors of 2-year mortality including the presence of significant CAD and the type of management.

Results

A total of 380 patients were included, 55.3% male with an average age of 83YO (±6.3), mean Euroscore II of 4.35. 76 had previous coronary artery bypassgrafting (CABG) and 136 had previous PCI (43 had both). 55 patients (14.4%) presented with normal coronary arteries, 120 (31.6%) with non-obstructive CAD and 205 (54%) with obstructive CAD. Out of the latter, 112 (29.5%) underwent PCI. Statistically significant differences were found between obstructive CAD vs non-obstructive patients in terms of age, previous history of ICP and CABG. In the subgroup population with obstructive CAD, no statistically significant differences was found in the PCI vs non PCI group, apart from previous history of ICP and CABG – Figure 1. Diabetes mellitus, previous history of percutaneous coronary intervention (PCI) and reduced ejection fraction (rEF – defined has &lt;50% echocardiographically) had a negative prognosticimpact in the 2 year mortality of the 380 patients. 2-year mortality was 14,5% (55 patients).The presence and management of CAD pre TAVI had no impact in 2-year mortality, when accounting for the differences in previous ICP history, CABG, age, and rEF.

Conclusion

The presence and type of management of obstructive CAD in this real world all comers registry did not impact the prognosis at 2 years.

Funding Acknowledgement

Type of funding sources: None.

Does the Aged Simulation Suit help nursing students provide better care? - A phenomenological study

BACKGROUND

The use of simulation in the training of nurses has increased in the last decades, allowing the acquisition and development of several competencies.

OBJECTIVE

Understand the experiences of nursing students who used the aged simulation suit.

METHODOLOGY

Qualitative study of a phenomenological nature. The participants were nursing students, who used the aged simulation suit. Data collection was made through the interview, and the data analysis was performed following the Giorgi phenomenological method.

RESULTS

Three themes reflect the essence of the experience: Wear the skin of the elderly; Confrontation with their own ageing process; Skills development.

CONCLUSION

If, on the one hand, the students who used the aged simulation suit experienced sensory and motor impairment and consequent confrontation with their own ageing process, on the other hand, they experienced the development of scientific, relational and citizenship skills. It is expected that the results of this work will foster the use of the aged simulation suit as a complementary methodology, with potential impact on the quality of care and health gains.

Gold(iii) bis(dithiolene) complexes: from molecular conductors to prospective anticancer, antimicrobial and antiplasmodial agents

The anticancer, antimicrobial and antiplasmodial activities of six gold(iii) bis(dithiolene) complexes were studied. Complexes 1-6 showed relevant anticancer properties against A2780/A2780cisR ovarian cancer cells (IC50 values of 0.08-2 μM), also being able to overcome cisplatin resistance in A2780cisR cells. Complex 1 also exhibited significant antimicrobial activity against Staphylococcus aureus (minimum inhibitory concentration (MIC) values of 12.1 ± 3.9 μg mL-1) and both Candida glabrata and Candida albicans (MICs of 9.7 ± 2.7 and 19.9 ± 2.4 μg mL-1, respectively). In addition, all complexes displayed antiplasmodial activity against the Plasmodium berghei parasite liver stages, even exhibiting better results than the ones obtained using primaquine, an anti-malarial drug. Mechanistic studies support the idea that thioredoxin reductase, but not DNA, is a possible target of these complexes. Complex 1 is stable under biological conditions, which would be important if this compound is ever to be considered as a drug. Overall, the results obtained evidenced the promising biological activity of complex 1, which might have potential as a novel anticancer, antimicrobial and antiplasmodial agent to be used as an alternative to current therapeutics.

P–569 Woman with CYP19A1 TC/CC genotype have increased susceptibility to infertility development, independently of the cause

Study question

Is TC/CC genotype of codon 39 at CYP19A1 gene associated with the development of female infertility?

Summary answer

Yes, CYP19A1 codon 39 TC/CC genotype is associated with increased susceptibility to infertility development in women, regardless of associated cause.

What is known already

Aromatase protein is responsible for the aromatization of androgens into estrogens. This protein that catalyzes the final step in biosynthesis of estrogens is encoded by the gene CYP19A1. The CYP19A1 gene is located on chromosome 15q21.1. It is a member of the cytochrome P450 superfamily which are monooxygenases that catalyze many reactions involved in steroidogenesis. TC/CC genotype of codon 39 at CYP19A1 gene results in an increase of aromatase activity and thus affect the hormone levels which can lead to the development of various diseases, including infertility.

Study design, size, duration

A case-control study was designed to investigate the association of CYP19A1 gene polymorphism with female infertility. Case subjects, 201 women with infertility established as women under 39 years of age, that failed to establish a clinical pregnancy after 12 months of regular, unprotected sexual intercourse. 161 fertile female controls, with no previous history of infertility, no previous history of gynecological pathologies compatible with infertility, and no history of IVF treatments, were selected.

Participants/materials, setting, methods

Blood was collected by venous puncture and genomic DNA was extracted. CYP19A1 genotyping was performed by polymerase chain reaction-based methods with confronting two-pair primers. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated by unconditional logistic regression.

Main results and the role of chance

Significant statistical association of the TC/CC genotype combined with endometriosis risk was found, with reference to TT genotype (OR 4.554; 95% CI 2.209–9.386; p &lt; 0.001). We also found an increased risk of developing polycystic ovary syndrome (PCOS) associated with TC/CC genotype (OR 5.317; 95% CI 2.767–10.215; p &lt; 0.001). We also observed an increased prevalence of premature ovarian failure associated with TC/CC genotype (OR 3.376; 95% CI 1.672–6.815; p = 0.001) and verified an increased prevalence of tubal pathology in carriers of TC/CC genotype (OR 3.231; 95% CI 1.653–6.314; p = 0.001). Finally, a strong association of TC/CC genotype with female infertility, regardless of the cause was found (OR 4.232; 95% CI 2.710–6.609; p &lt; 0.001). In conclusion, TC/CC genotype is associated with increased susceptibility to infertility development in women.

Limitations, reasons for caution

The sample size may eventually be considered small, despite the strong significance found.

Wider implications of the findings: There are not many studies in this area and the few existing exhibit disparate results. The association of TC/CC genotype with endometriosis was observed in a few studies, but some disagree. This difference could be attributed to the notable heterogeneity across the different studies.

Trial registration number

Not applicable

Neutralization of oxidized phospholipids attenuates age-associated bone loss in mice

Oxidized phospholipids (OxPLs) are pro‐inflammatory molecules that affect bone remodeling under physiological conditions. Transgenic expression of a single‐chain variable fragment (scFv) of the antigen‐binding domain of E06, an IgM natural antibody that recognizes the phosphocholine (PC) moiety of OxPLs, increases trabecular and cortical bone in adult male and female mice by increasing bone formation. OxPLs increase with age, while natural antibodies decrease. Age‐related bone loss is associated with increased oxidative stress and lipid peroxidation and is characterized by a decline in osteoblast number and bone formation, raising the possibility that increased OxPLs, together with the decline of natural antibodies, contribute to age‐related bone loss. We show here that transgenic expression of E06‐scFv attenuated the age‐associated loss of spinal, femoral, and total bone mineral density in both female and male mice aged up to 22 and 24 months, respectively. E06‐scFv attenuated the age‐associated decline in trabecular bone, but not cortical bone, and this effect was associated with an increase in osteoblasts and a decrease in osteoclasts. Furthermore, RNA‐seq analysis showed that E06‐scFv increased Wnt10b expression in vertebral bone in aged mice, indicating that blocking OxPLs increases Wnt signaling. Unlike age‐related bone loss, E06‐scFv did not attenuate the bone loss caused by estrogen deficiency or unloading in adult mice. These results demonstrate that OxPLs contribute to age‐associated bone loss. Neutralization of OxPLs, therefore, is a promising therapeutic target for senile osteoporosis, as well as atherosclerosis and non‐alcoholic steatohepatitis (NASH), two other conditions shown to be attenuated by E06‐scFv in mice.

Patients undergoing invasive coronary angiography after a positive single-photon emission computed tomography or a positive stress cardiac magnetic resonance - What to expect at the cath lab

Funding Acknowledgements

Type of funding sources: None.

Background

 Randomized controlled trials comparing stress cardiac magnetic resonance (CMR) and single-photon emission computed tomography (SPECT) suggest similar diagnostic accuracy for detecting obstructive coronary artery disease (CAD). However, there are few data on whether or not this remains true in routine clinical practice.

The aim of this study was to assess the clinical and angiographic characteristics of patients undergoing invasive coronary angiography (ICA) after a positive stress CMR or positive SPECT, and to compare their positive predictive value with published results from the CE-MARC trial.

Methods

In this retrospective tertiary-center analysis, we included 429 patients (mean age 67 ± 10 years, 28% women, 42% diabetic) undergoing ICA between January 2016 and December 2020, after a positive stress CMR or positive SPECT. Regarding stress test, an adenosine protocol was performed in all stress CMR and in 76.4% (n = 272) of stress SPECT. 

Stress test results, including ischemia location and severity, were classified as reported by their primary readers. Patients with missing data on key variables, and those in whom microvascular disease was considered likely in the original stress test report were excluded. Obstructive CAD was defined as any coronary artery stenosis ≥ 50% in a vessel compatible with the ischemic territory on stress testing.

Results

Out of the total 429 patients, 356 (83%) were referred after a positive SPECT, and 73 (17%) after a positive stress CMR. Patients did not differ regarding age, cardiovascular risk factors, previous revascularization or left ventricular dysfunction, but patients with SPECT were more frequently male (p = 0.046). Overall, 320 patients (75%) had obstructive CAD on ICA. The prevalence of obstructive CAD was similar in patients with positive SPECT vs. positive stress CMR (76.1% vs. 80.8%, respectively, p = 0.385). There were also no significant differences in the prevalence of left main or 3-vessel disease (9.0% vs. 9.6%, p = 0.871, and 19.7% vs. 23.3% p = 0.483, respectively). Revascularization was performed or planned in 59.3% of patients in the SPECT group, and 52.1% of those in the stress CMR group (p = 0.255). The positive predictive values of both techniques were similar to those reported in the CE-MARC trial (Figure), and would increase to 88.1% and 89.4% for SPECT and stress CMR, respectively, if patients reported as having only mild ischemia were excluded.

Conclusion

In this tertiary center analysis, stress CMR and SPECT showed similar positive predictive values, comparable to those reported in the CE-MARC trial.

Mitochondrial Sirt3 contributes to the bone loss caused by aging or estrogen deficiency

Altered mitochondria activity in osteoblasts and osteoclasts has been implicated in the loss of bone mass associated with aging and estrogen deficiency — the 2 most common causes of osteoporosis. However, the mechanisms that control mitochondrial metabolism in bone cells during health or disease remain unknown. The mitochondrial deacetylase sirtuin-3 (Sirt3) has been earlier implicated in age-related diseases. Here, we show that deletion of Sirt3 had no effect on the skeleton of young mice but attenuated the age-related loss of bone mass in both sexes. This effect was associated with impaired bone resorption. Osteoclast progenitors from aged Sirt3-null mice were able to differentiate into osteoclasts, though the differentiated cells exhibited impaired polykaryon formation and resorptive activity, as well as decreased oxidative phosphorylation and mitophagy. The Sirt3 inhibitor LC-0296 recapitulated the effects of Sirt3 deletion in osteoclast formation and mitochondrial function, and its administration to aging mice increased bone mass. Deletion of Sirt3 also attenuated the increase in bone resorption and loss of bone mass caused by estrogen deficiency. These findings suggest that Sirt3 inhibition and the resulting impairment of osteoclast mitochondrial function could be a novel therapeutic intervention for the 2 most important causes of osteoporosis.

Effects of caregiver-provided individual cognitive interventions on cognition, social functioning and quality of life in older adults with major neurocognitive disorders: a systematic review

OBJECTIVE

The objective of this review was to investigate the effectiveness of caregiver-provided individual cognitive interventions for improving cognition, social functioning and quality of life in older adults with major neurocognitive disorders.

INTRODUCTION

A large number of people with major neurocognitive disorders live in their homes, requiring ongoing community care. Different individual cognitive intervention programs have been explored as a potential approach for implementation by caregivers on a one-to-one basis. These programs have the advantage of being implemented in a home setting and in the real-life context of the older adult, in a society that is increasingly aging and where aging in place is being fostered.

INCLUSION CRITERIA

This review considered experimental studies that included older adults aged 60 years and over with major neurocognitive disorders who were receiving individual cognitive interventions (e.g. cognitive stimulation, cognitive training or cognitive rehabilitation) provided by their caregivers. The comparator was usual care, wait-list control or alternative therapeutic intervention. The primary outcomes of interest included cognition, social functioning and quality of life. Additionally, behavior, mood and activities of daily living were considered.

METHODS

A comprehensive search strategy was used to identify relevant published and unpublished studies from January 1995 to March 2018, written in English, Spanish and Portuguese. Studies meeting the inclusion criteria were retrieved and their methodological quality was assessed by two independent reviewers using the JBI critical appraisal checklists for randomized controlled trials and quasi-experimental studies. Quantitative data were extracted using the standardized data extraction tool from the JBI System for the Unified Management, Assessment and Review of Information. Due to the clinical and methodological heterogeneity in the included studies, statistical pooling was not possible. Therefore, findings are presented in a narrative format.

RESULTS

Eight randomized controlled trials and two quasi-experimental studies were included, with a total sample of 844 dyads (older adults and caregivers). The number of dyads included in the studies ranged from 16 to 356. Beneficial effects of the caregiver-provided individual cognitive interventions were observed in various cognitive domains, including memory, attention, verbal fluency and problem-solving. Two studies additionally reported the positive impact of the intervention of interest on general cognitive functioning. None of the reviewed studies revealed significant changes in quality of life. Social functioning was not analyzed in any of the included studies. Beneficial effects were also reported in relation to behavior and activities of daily living, despite the low level of evidence.

CONCLUSIONS

This review responds to a gap in current international literature on the synthesis of evidence on the use of caregiver-provided individual cognitive interventions. The intervention of interest is associated with improvement in cognitive performance, revealing some benefits for the stabilization of neuropsychiatric symptoms and an increase in autonomy in activities of daily living. Further research on the impact of sociodemographic and clinical factors on the intervention effects is needed, as these factors seem to interfere with successful intervention implementation. To reinforce current evidence, the methodological quality of future studies should be improved.

First psychotic episode as first manifestation of lyme disease: Case report

Introduction

Lyme disease (LD) is caused by the spirochete Borrelia burgdorferi (Bb) and has been reported to be associated with various psychiatric presentations.

Objectives

To report a case with LD and to highlight the importance of differential diagnosis in a first psychotic episode.

Methods

Case report and non-systematic review of the literature.

Results

A woman aged 31 was admitted to the psychiatric department, after a car accident with a mortal victim, due to a first psychotic episode with visual hallucinations, disorientation in time and space, persecutory and grandiosity delusions. She had a personal psychiatric history of obsessive-compulsive disorder and no previous admission to an inpatient Unit. On psychotropic drugs the condition failed to improve, and subsequently neurological symptoms developed. EEG abnormalities prompted a lumbar puncture. In the CSF a strong plasma cell reaction with atypical cells was observed. The enzyme immunoassay for Borrelia burgdorferi was positive and after treatment with penicillin the psychiatric and neurological signs and symptoms remitted. Screening assessment followed by a thorough history, comprehensive psychiatric clinical exam, review of systems, mental status exam, neurological exam and physical exam relevant to the patient’s complaints and findings with clinical judgment, pattern recognition and knowledgeable interpretation of laboratory findings facilitates diagnosis. Psychotropics and antibiotics may help improve functioning and prevent further disease progression.

Conclusions

LD is relatively rare, but awareness of the association between LD and neuropsychiatric presentations can improve understanding of the causes of mental illness and result in more effective prevention, diagnosis and treatment.

Disclosure

No significant relationships.

Attention deficit hyperactivity disorder in adulthood and the heritability of this condition

Introduction

Attention Deficit Hyperactivity Disorder (ADHD) is a common neurodevelopmental disorder characterized by inattention and/or hyperactivity-impulsivity resulting from the interaction of genetic and environmental risk factors. Family studies shows that persistent ADHD is very familial.

Objectives

We aim to review the literature on this condition and its heritability and describe the implications that a possible misdiagnosis can have during life.

Methods

Bibliography review was performed using the databases PubMed and Cochrane, using the following keywords: “ADHD”; “Adults”; “Heretability”; “Family” and “Rater effect”.

Results

Childhood ADHD persists into adolescence and adulthood substantially, identified in some studies, as going up to 78%. The prevalence of ADHD in children and adults is between 2.5% and 5% worldwide. Family studies have shown that children of adults with ADHD are at higher risk of having ADHD. Some large-scale twin studies of adult ADHD, used self-report assessments of ADHD symptoms and estimated the heritability of this condition to be between 30 to 40%, which differs from other studies that analyse parents and teachers responses and estimates heritability to be between 60 and 90%.

Conclusions

Since there is a direct influence of the evaluators in estimating the extent of ADHD heritability, future studies need to clarify and describe in detail all the related characteristics of the raters. Although ADHD is widely studied, there is still a lot to learn about its etiology. The diagnosis of ADHD is clinical and complex and must be considered both in childhood and adolescence and in adulthood, with special emphasis on the family antecedents.

Disclosure

No significant relationships.

A decrease in NAD+ contributes to the loss of osteoprogenitors and bone mass with aging

Age-related osteoporosis is caused by a deficit in osteoblasts, the cells that secrete bone matrix. The number of osteoblast progenitors also declines with age associated with increased markers of cell senescence. The forkhead box O (FoxO) transcription factors attenuate Wnt/β-catenin signaling and the proliferation of osteoprogenitors, thereby decreasing bone formation. The NAD⁺-dependent Sirtuin1 (Sirt1) deacetylates FoxOs and β-catenin in osteoblast progenitors and, thereby, increases bone mass. However, it remains unknown whether the Sirt1/FoxO/β-catenin pathway is dysregulated with age in osteoblast progenitors. We found decreased levels of NAD⁺ in osteoblast progenitor cultures from old mice, associated with increased acetylation of FoxO1 and markers of cell senescence. The NAD⁺ precursor nicotinamide riboside (NR) abrogated FoxO1 and β-catenin acetylation and several marker of cellular senescence, and increased the osteoblastogenic capacity of cells from old mice. Consistent with these effects, NR administration to C57BL/6 mice counteracted the loss of bone mass with aging. Attenuation of NAD⁺ levels in osteoprogenitor cultures from young mice inhibited osteoblastogenesis in a FoxO-dependent manner. In addition, mice with decreased NAD⁺ in cells of the osteoblast lineage lost bone mass at a young age. Together, these findings suggest that the decrease in bone formation with old age is due, at least in part, to a decrease in NAD⁺ and dysregulated Sirt1/FoxO/β-catenin pathway in osteoblast progenitors. NAD⁺ repletion, therefore, represents a rational therapeutic approach to skeletal involution.

Lithium in severe affective disorders: Balancing safety with efficacy

Introduction

Lithium has been one of the oldest substances used in psychiatric treatments and remains the first-line treatment for prevention of manic and depressive episodes of bipolar disorder (BD), but it has also a wide spectrum of side-effects.

Objectives

The goal is to review efficacy, and clinical use of lithium, such as its side effects, and its benefit-to-risk ratio.

Methods

Non-systematic literature review based on scientific databases such as PubMed.

Results

The first modern use of lithium was for the treatment of mania. Lithium has also proven useful in major depression, particularly for augmentation of antidepressants, for aggressive behavior and it has a specific antisuicide effect. Lithium’s prophylactic and antisuicidal effects are most unique. However, the use of lithium became problematic due to the serious toxicity since lithium also a narrow therapeutic index, with therapeutic levels between 0.6 and 1.5 mEq/L.

Conclusions

Awareness of the benefits and risks of lithium is essential for the use of this lifesaving agent. Lithium levels must be carefully monitored and lithium dosage adjusted as necessary.

Disclosure

No significant relationships.

Tumor cell and immune cell profiles in primary human glioblastoma: Impact on patient outcome

The distribution and role of tumor-infiltrating leucocytes in glioblastoma (GBM) remain largely unknown. Here, we investigated the cellular composition of 55 primary (adult) GBM samples by flow cytometry and correlated the tumor immune profile with patient features at diagnosis and outcome. GBM single-cell suspensions were stained at diagnosis (n = 44) and recurrence following radiotherapy and chemotherapy (n = 11) with a panel of 8-color monoclonal antibody combinations for the identification and enumeration of (GFAP+ CD45- ) tumor and normal astrocytic cells, infiltrating myeloid cells -i.e. microglial and blood-derived tumor-associated macrophages (TAM), M1-like, and M2-like TAM, neutrophils. and myeloid-derived suppressor cells (MDSC)- and tumor-infiltrating lymphocytes (TIL) -i.e. CD3+ T-cells and their TCD4+ , TCD8+ , TCD4- CD8- , and (CD25+ CD127lo ) regulatory (T-regs) subsets, (CD19+ CD20+ ) B-cells, and (CD16+ ) NK-cells-. Overall, GBM samples consisted of a major population (mean ± 1SD) of tumor and normal astrocytic cells (73% ± 16%) together with a significant but variable fraction of immune cells (24% ± 18%). Within myeloid cells, TAM predominated (13% ± 12%) including both microglial cells (10% ± 11%) and blood-derived macrophages (3% ± 5%), in addition to a smaller proportion of neutrophils (5% ± 9%) and MDSC (4% ± 8%). Lymphocytes were less represented and mostly included TCD4+ (0.5% ± 0.7%) and TCD8+ cells (0.6% ± 0.7%), together with lower numbers of TCD4- CD8- T-cells (0.2% ± 0.4%), T-regs (0.1% ± 0.2%), B-lymphocytes (0.1% ± 0.2%) and NK-cells (0.05% ± 0.05%). Overall, three distinct immune profiles were identified: cases with a minor fraction of leucocytes, tumors with a predominance of TAM and neutrophils, and cases with mixed infiltration by TAM, neutrophils, and T-lymphocytes. Untreated GBM patients with mixed myeloid and lymphoid immune infiltrates showed a significantly shorter patient overall survival versus the other two groups, in the absence of gains of the EGFR gene (p = 0.02). Here we show that immune cell infiltrates are systematically present in GBM, with highly variable levels and immune profiles. Patients with mixed myeloid and T-lymphoid infiltrates showed a worse outcome.

Longitudinal Functional Study of Murine Aging: A Resource for Future Study Designs

Aging is characterized by systemic declines in tissue and organ functions. Interventions that slow these declines represent promising therapeutics to protect against age-related disease and improve the quality of life. In this study, several interventions associated with lifespan extension in invertebrates or improvement of age-related disease were tested in mouse models to determine if they were effective in slowing tissue aging in a broad spectrum of functional assays. Benzoxazole, which extends the lifespan of Caenorhabditis elegans, slowed age-related femoral bone loss in mice. Rates of change were established for clinically significant parameters in untreated mice, including kyphosis, blood glucose, body composition, activity, metabolic measures, and detailed parameters of skeletal aging in bone. These findings have implications for the study of preclinical physiological aging and therapies targeting aging. Finally, an online application was created that includes the calculated rates of change and that enables power and variance to be calculated for many clinically important metrics of aging with an emphasis on bone. This resource will help in future study designs employing novel interventions in aging mice. © 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC. on behalf of American Society for Bone and Mineral Research.

Calcium score of the aortic valve as a predictor of aortic stenosis severity

Funding Acknowledgements

Type of funding sources: None.

Background

The calcium score of the aortic valve (CaScAoV) is now recommended as a supporting tool to assist in the grading of aortic stenosis (AS) severity when echocardiographic assessment is inconclusive. However, the proposed CaScAoV cut-offs for considering severe AS "unlikely", "likely", or "very likely" have never been validated in Portuguese cohorts.

Aim

The purpose of this study was to assess the performance of the proposed CaScAoV cut-offs in identifying patients with severe aortic stenosis.

Methods

A total of 513 consecutive patients (median age 83 years [IQR 79–87], 38% males) evaluated at a single-centre TAVI-programme between Jan/2016 and Nov/2019 were retrospectively identified. Only patients with an ECG-gated cardiac computed tomography (CT) and a transthoracic echocardiography performed within a 6-month time-frame were included. Main exclusion criteria were left ventricular ejection fraction &lt; 50%, indexed stroke volume &lt; 35 ml/m2, previous valve surgery and

bicuspid aortic disease. CaScAoV was measured according to the Agatston method (Agatston units – AU). As previously reported, the likelihood of aortic stenosis as assessed by CT was categorized as: "very likely" (&gt;3000 AU for men, &gt;1600 AU for women); "likely" (&gt;2000 AU for men, &gt;1200 AU for women) ; or unlikely (&lt;1600 AU for men, &lt;800 AU for women). Diagnostic tests performance measures were calculated for each category. Separate analyses were performed for each gender.

Results

Severe AS (mean gradient ≥ 40 mmHg) was present in 422 patients (overall 82.3%: 83.1% in females and 80.8% in males), with a median transvalvular gradient of 49 mmHg (IQR 42 – 60).

Overall, the discriminative ability of the CaScAoV to distinguish severe from non-severe AS was higher in men when compared with women (c-statistic 0.86 [95%CI 0.80 – 0.93] vs. 0.72 [95%CI 0.64 – 0.80], p for comparison &lt; 0.001). In males, the "very likely" cut-off had a sensitivity of 71% (95%CI 63 – 78%), a specificity of 81% (95%CI 65 – 92%), a positive predictive value (PPV) of 94% (95%CI 89 – 97%) and a negative predictive value (NPV) of 40% (95%CI 33 – 46%) for the diagnosis of severe AS. Conversely, in women the sensitivity was 75% (95%CI 69 – 80%), specificity was 57% (95%CI 43 – 71%), PPV was 90% (95%CI 86 – 92%) and NPV was 32% (95%CI 25 – 39%).

On the other end of the spectrum, the "unlikely" cut-off showed poor performance in dismissing severe AS, particularly in females – NPV of 43% (95%CI 25-63%) in women vs. 83% (95%CI 63-93%) in men.

Conclusion

In our population, the discriminative power of CaScAoV for identifying patients with severe AS was lower than in previously published cohorts, particularly in females. While very high CaScAoV is strongly supportive of severe AS, caution should be employed when interpreting low CaScAoV values in women, since the recommended cut-off value does not allow the safe exclusion of severe aortic stenosis.

Abstract Figure. Waterfall chart of individuals CaScAoV

Patterns of revascularization in stable ischemic heart disease in the pre-ISCHEMIA era

Introduction

New evidence on the role of myocardial revascularization in stable ischemic heart disease (SIHD), recently presented, showed that revascularization guided by the presence of moderate-to severe ischemia relieves angina more effectively than optimal medical therapy (OMT), without a significant benefit in hard clinical endpoints.

Aim

To assess the representativeness of the ISCHEMIA trial in a real-world population and compare management strategies between patients who fulfill the eligibility criteria of the trial (Group 1, G1) and those who do not (Group 2, G2).

Methods and population

Single centre retrospective analysis including all consecutive patients referred to coronary angiography (CA) for SIHD from January 2018 to December 2019. Patients were stratified in two groups (G1 and G2) according to the ISCHEMIA trial inclusion and exclusion criteria. G1 was compared with G2 and with a subset of G2 with obstructive coronary artery disease (CAD), defined as ≥70% luminal stenosis in at least one coronary artery or &gt;50% for the left main.

Results

A total of 1020 patients underwent CA, of whom only 124 (12.2%) would have been eligible for the ISCHEMIA trial (G1). Overall, there were no significant differences in baseline characteristics between the two groups. G1 patients had more extensive and severe disease, presenting more frequently with proximal left anterior descending (LAD) involvement (26.6% vs 10.4%; p&lt;0.001), two vessel disease without proximal LAD stenosis (23.4% vs 10.3%; p&lt;0.001) and three vessel disease (18.5% vs 5.9%; p&lt;0.001). These patients had higher rates of revascularization, both CABG (25.8% vs 10.8%, p&lt;0.001) and PCI (56.5% vs 39.5%, p&lt;0.001). However, when comparing G1 with the subset of G2 patients with obstructive CAD, G1 patients had higher rates of CABG (26.8% vs 17.8%, p=0.034) but there were no differences on the rates of PCI (58.0% vs 56.9%, p=0.916).

Conclusions

Patients included in the ISCHEMIA trial are underrepresented in a real-world population of SIHD patients referred to coronary angiography. PCI rates were similar among patients with at least one significant coronary artery stenosis, regardless of previous evidence or severity of ischemia. Our findings underline the need for further refinement in criteria for revascularization in SIHD.

Funding Acknowledgement

Type of funding source: None

External validation of a new staging system for severe aortic stenosis in a Portuguese cohort

Background

Recently, a new staging system for severe aortic stenosis (AS) based upon the extent of extra-aortic-valve cardiac damage has been developed (Genereux et al. Eur Heart J 2017). The present study aimed to: 1) determine the prevalence of the different stages of extra-aortic valvular cardiac damage and its impact on prognosis in a real-world Portuguese cohort and; 2) evaluate the distribution of aortic valve calcium score (AV-CaSc) and its prognostic value.

Methods

Consecutive patients evaluated at a single-centre TAVI-programme between Nov/2015 and Nov/2018 were retrospective selected. The extent of extra-aortic valve cardiac damage was defined by echocardiography as stage 0 (no cardiac damage), stage 1 (left ventricular damage), stage 2 (mitral valve or left atrial damage), stage 3 (tricuspid valve or pulmonary artery vasculature damage) or stage 4 (right ventricular damage). AV-CaSc was estimated routinely at CT-angiography as per TAVI-programme protocol. The primary endpoint was 1-year all-cause mortality after CT-angiography. Survival analysis (Cox-regression hazards model and Kaplan-Meier) was performed. To account for the effect of aortic valve replacement (AVR), this variable entered the Cox-regression model as a time-dependent covariate.

Results

A total of 443 patients (mean age 82±7 years, 44% men, median euroSCORE II 4% [IQR 2.4–5.8]) were identified. After Heart Team discussion, 79% (n=349) underwent AVR (TAVI=307; surgical valve repair=42); 9% (n=42) await intervention; 6% (n=25) remain under medical treatment; 4% (n=19) died during the period of evaluation; and 2% (n=8) underwent palliative aortic balloon valvuloplasty.

According to the proposed classification, the distribution of patients from stages 0 through 4 was: 0.2% (n=1), 7.5% (n=34), 67.8% (n=306), 14% (n=63), and 10.4% (n=47). Additionally, for each increasing stage of cardiac damage, the burden of AV-CaSc was higher (from stage 1 through 4: 1776 [IQR 1217–2448]; 2448 [1796–3442]; 2448 [1832–3622]; 2960 [1936–4878] units; p for trend = 0.002).

All-cause mortality at 1-year was 14% (n=63). Mortality increased alongside with increasing extent of cardiac damage (from stage 0 through 4: 0% [n=0], 6% [n=2], 12% [n=36], 20% [n=12], and 30% [n=13]) – Fig. Multivariable analysis revealed chronic renal disease (HR 1.37 per stage [1.15–1.64], p&lt;0.001), AV-CaSc (HR 1.02 per 100 units [1.01–1.03], p=0.007), AVR (HR 0.46 [0.26–0.81], p=0.007) and stage of cardiac damage (HR 1.54 per stage [1.15–2.05], p=0.004) as independent predictors of 1-year mortality.

Conclusion

In a real-world Portuguese cohort of severe AS patients, the extent of cardiac damage was associated with 1-year mortality. AV- CaSc grants additional prognostic information to this classification. Incorporation of this staging system into patient evaluation may be useful in the risk assessment of severe AS.

Survival analysis

Funding Acknowledgement

Type of funding source: None

Predicting pacemaker implantation after TAVR with procedural CT

Background and aim

The need for permanent pacemaker implantation (PPMI) is a burdensome complication of transcatheter aortic valve replacement (TAVR). Calcium distribution in the aortic-valvular complex (AVC) and, more recently, membranous septum (MS) length seem to be surrogate markers for conduction abnormalities after specific last generation balloon and self-expandable expandable valves. We sough to evaluate whether such pre-procedural association remains across the entire device spectrum.

Methods

Single-centre prospective study of 239 consecutive patients (140 women, median age of 84) with severe symptomatic aortic stenosis patients who underwent ECG-gated contrast-enhanced multi-detector computed tomography (MSCT) before TAVR since Jun/2017. Exclusion criteria were those with previous PPMI, previous bioprothesis, congenital bicuspid valve, and poor imaging quality. The J-score with an 850-Hounsfield unit threshold was used to detect areas of calcium in the region of interest. AVC was characterized by leaflet sector and region, using 3mensio Valves software 7.0 TM. An independent team retrospectively measured MS length blindly by determining the thinnest part of the interventricular septum in the coronal view in the better-defined systolic phase (usually at 40% of the R-R interval, Figure). Device selection (75.8% self-expandable devices, 20.1% balloon expandable, 3.1% other) and positioning were performed according to the operator criteria. Final implant depth was assessed based on the pre-release angiogram or final aortography.

Results

Mortality at 30-days was 1.3% and PPMI occurred in 43 patients (18%). Median MS length was 9.59mm (IQR: 3.11mm). After multivariable logistic regression analysis, MS length emerged as the single significant protective predictor for PPMI (OR: 0.14; 95% 95% CI: 0.05–0.42; p&lt;0.001), independently of the device used (p&lt;0.001). MS length showed strong discriminatory ability for PPMI (c-statistic 0.93; 95% CI 0.88–0.99). Sensitivity/specificity decision plots yielded an MS length of 6.9 mm as the optimal cut-off point for predicting the need for PPMI with a positive and negative predictive value of 91% and 93%, respectively (Figure). There wasn't any calcium accumulation within a specific region of AVC that independently predicted the outcome.

Conclusion

In our experience, a short membranous septum was strongly and independently associated with new permanent pacemaker implantation, regardless of the device type.

Our findings suggest that this simple measure should be routinely made to help device selection and implantation technique.

Funding Acknowledgement

Type of funding source: None

Downstream testing after an halted coronary CT angiography due to high coronary artery calcium score

Background and aim

In many centers, coronary artery calcium score (CACS) is performed immediately before coronary CT angiography (CCTA) in order to exclude heavy calcification that could hamper test performance. When high CACS values are found, CCTA is usually aborted and other tests suggested. However, there are no recommendations on which test to pursue, and little data on their diagnostic yield in this setting. The aim of this study was to assess the type and results of downstream testing among patients whose CCTA study was halted due to high CACS.

Methods

Single-centre retrospective study of consecutive patients undergoing CCTA for suspected obstructive coronary artery disease (CAD). A CACS threshold of &gt;400 was generally used to cancel CCTA. Downstream testing and its results were assessed using electronic medical records. A group of consecutive patients with CACS &lt;400 who underwent CCTA was used for comparison.

Results

Of the 795 patients who performed CCTA for suspected CAD, 86 (10.8%), had their test halted due to high CACS (57 men, mean age 71±11 years). In this subgroup, the median pre-test probability for CAD was 27% (interquartile range 25) and the median CACS was 983 (interquartile range 930). Compared to patients who underwent CCTA, those who saw their tests cancelled were older, more frequently male, and had higher prevalence of cardiovascular risk factors and higher pre-test probability for CAD.

Patient's downstream testing is illustrated in Figure. From the 86 patients enrolled, 12 are currently waiting for downstream tests and were excluded from further analysis. Overall, 35 patients ended up performing invasive coronary angiography (ICA, 47.3%) of whom 19 (54.3%) had significant CAD. Among those who underwent non-invasive testing (N=19, 25.7%), 10 (52.6%) had significant ischemia and 4 (21%) underwent additional testing with ICA. In 24 patients (32.4%), no downstream testing was pursued. Finally, 17 (22.3%) patients underwent coronary revascularization, either percutaneous (N=10, 13.5%) or surgical (N=7, 10.8%).

Conclusion

Invasive coronary angiography is the most frequently used downstream test when CCTA is halted due to high CACS values, and shows significant CAD in roughly half of the cases. Considering the high prevalence of significant CAD, direct referral for ICA (with the possibility of invasive functional testing) seems a reasonable approach.

Funding Acknowledgement

Type of funding source: None

Increased marrow adipogenesis does not contribute to age-dependent appendicular bone loss in female mice

Marrow adipocytes and osteoblasts differentiate from common mesenchymal progenitors in a mutually exclusive manner, and diversion of these progenitors toward adipocytes in old age has been proposed to account for the decline in osteoblasts and the development of involutional osteoporosis. This idea has been supported by evidence that thiazolidinedione (TZD)‐induced activation of PPARγ, the transcription factor required for adipocyte differentiation, increases marrow fat and causes bone loss. We functionally tested this hypothesis using C57BL/6J mice with conditional deletion of PPARγ from early mesenchymal progenitors targeted by the Prx1‐Cre transgene. Using a longitudinal littermate‐controlled study design, we observed that PPARγ is indispensable for TZD‐induced increase in marrow adipocytes in 6‐month‐old male mice, and age‐associated increase in marrow adipocytes in 22‐month‐old female mice. In contrast, PPARγ is dispensable for the loss of cortical and trabecular bone caused by TZD or old age. Instead, PPARγ restrains age‐dependent development of cortical porosity. These findings do not support the long‐standing hypothesis that increased marrow adipocyte differentiation contributes to bone loss in old age but reveal a novel role of mesenchymal cell PPARγ in the maintenance of cortical integrity.

Osteocyte RANKL is required for cortical bone loss with age and is induced by senescence

In aging mice, osteoclast number increases in cortical bone but declines in trabecular bone, suggesting that different mechanisms underlie age-associated bone loss in these 2 compartments. Osteocytes produce the osteoclastogenic cytokine RANKL, encoded by Tnfsf11. Tnfsf11 mRNA increases in cortical bone of aged mice, suggesting a mechanism underlying the bone loss. To address this possibility, we aged mice lacking RANKL in osteocytes. Whereas control mice lost cortical bone between 8 and 24 months of age, mice lacking RANKL in osteocytes gained cortical bone during this period. Mice of both genotypes lost trabecular bone with age. Osteoclasts increased with age in cortical bone of control mice but not in RANKL conditional knockout mice. Induction of cellular senescence increased RANKL production in murine and human cell culture models, suggesting an explanation for elevated RANKL levels with age. Overexpression of the senescence-associated transcription factor Gata4 stimulated Tnfsf11 expression in cultured murine osteoblastic cells. Finally, elimination of senescent cells from aged mice using senolytic compounds reduced Tnfsf11 mRNA in cortical bone. Our results demonstrate the requirement of osteocyte-derived RANKL for age-associated cortical bone loss and suggest that increased Tnfsf11 expression with age results from accumulation of senescent cells in cortical bone.