OBJECTIVES:Stroke after thoracic aortic surgery is a complication that is associated with poor outcomes. The aim is to characterize the intraoperative risk factors for stroke development.DESIGN:A retrospective analysis.SETTING:Tertiary, high-volume cardiac surgery center.PARTICIPANTS:Patients who had surgical repair of thoracic aortic diseases from January 1, 2017, through December 31, 2021.INTERVENTIONS:None.MEASUREMENTS AND MAIN RESULTS:A total of 704 patients were included, of whom 533 had ascending aortic aneurysms, and 171 had type A aortic dissection. The incidence of postoperative stroke was 4.5% (95% CI 2.9%-6.6%) for ascending aortic aneurysms compared with 12.3% (95% CI 7.8%-18.16%) in type-A aortic dissections. Patients who developed postoperative strokes had significantly lower intraoperative hemoglobin median (7.5 gm/dL [IQR 6.8-8.6] v 8.55 gm/dL [IQR 7.3-10.0]; p < 0.001). The median cardiopulmonary bypass time was 185 minutes (IQR 136-328) in the stroke group versus 156 minutes (IQR 113-206) in the nonstroke group (p = 0.014). Circulatory arrest was used in 57.8% versus 38.5% of the nonstroke patients (p = 0.017). The initial temperature after leaving the operating room was lower, with a median of 35.0°C (IQR 34-35.92) in the stroke group versus 35.5°C (IQR 35-36) in the nonstroke cohort (p = 0.021).CONCLUSIONS:This single-center study highlighted the potential importance of intra-operative factors in preventing stroke. Lower hemoglobin, longer duration of cardiopulmonary bypass, deep hypothermic circulatory arrest, and postoperative hypothermia are potential risk factors for postoperative stroke. Further studies are needed to prevent this significant complication in patients with thoracic aortic diseases.

Background: During wound healing, ensuring cellular coordination and adhesion involves a variety of intracellular and intercellular signaling processes.Ca 2+ release-activated Ca 2+ channel protein Orai1 contributes to cell transwell migration, number of focal adhesions per cell, cell spreading area, and migration speed.Orai1 favors Ca 2+ permeation and limits Na + permeation.However, Orai1-related cytosolic Ca 2+ and Na + changes in response to scratch and the role of these changes in endothelial wound healing remain unclear, and thus, are the focus of this study.Method: Pulmonary arterial endothelial cells (PAECs) were seeded and grew to confluent monolayers in 4-5 days.Monolayers were loaded with intracellular Ca 2+ dye Cal-590 AM and Na + dye Ion NaTRIUM Green-2 AM.Orai1 inhibitor GSK-7975A (10 μM) was added for 15 minutes prior to scratch.Fluorescence images were taken immediately after scratch every 5 seconds for 30 minutes.Fluorescent signals were quantified.Scratch wound healing assay was conducted in the presence and absence of GSK-7975A and Orai1, respectively.Collective migration was triggered by barrier removal in the presence and absence of Orai1.Migration distances were quantified.Results: In the spatial manner, scratch injury immediately increased both cytosolic Ca 2+ and Na + fluorescence intensity at the wound edge.Cytosolic Ca 2+ and Na + quickly decreased within 50 µm from the wound edge.However, only cytosolic Ca 2+ but not Na + in cells between 50 and 200 µm from the wound edge increased to form a second peak.In the temporal manner, the increases in cytosolic Ca 2+ and Na + at the wound edge reduced in 30 minutes.These reductions were faster within 50 µm than those beyond 50 µm from the wound edge, respectively.The second Ca 2+ increase was much short-lived and reduced within 6 minutes.Beyond 200 µm from the wound edge, both cytosolic Ca 2+ and Na + increased again after 30 minutes.Orai1 inhibition abolished neither the onset nor the decline of scratch-triggered Ca 2+ increase at the wound edge but fully eliminated the second Ca 2+ increase.Orai1 inhibition did not fully abolish the Na + increase or decline at the wound edge either.In the remaining monolayer, Orai1 inhibition appeared to attenuate changes in both cytosolic Ca 2+ and Na + signals.Orai1 expression, but not acute Orai1 activation, contributes to scratch wound closure.Conclusions: Scratch not only evokes acute cytosolic Ca 2+ and Na + increases at the wound edge but also causes transient Ca 2+ entry through Orai1 near the wound edge.

Late-phase clinical trials investigating metformin as a cancer therapy are underway. However, there remains controversy as to the mode of action of metformin in tumors at clinical doses. We conducted a clinical study integrating measurement of markers of systemic metabolism, dynamic FDG-PET-CT, transcriptomics, and metabolomics at paired time points to profile the bioactivity of metformin in primary breast cancer. We show metformin reduces the levels of mitochondrial metabolites, activates multiple mitochondrial metabolic pathways, and increases 18-FDG flux in tumors. Two tumor groups are identified with distinct metabolic responses, an OXPHOS transcriptional response (OTR) group for which there is an increase in OXPHOS gene transcription and an FDG response group with increased 18-FDG uptake. Increase in proliferation, as measured by a validated proliferation signature, suggested that patients in the OTR group were resistant to metformin treatment. We conclude that mitochondrial response to metformin in primary breast cancer may define anti-tumor effect.

Background Timely initiation of weaning from mechanical ventilation (MV) is important. Non-validated screening criteria may delay weaning if too prescriptive. This study observed physician-led utilisation of pressure support ventilation (PSV), referenced to four reported conventional screening criteria hypothesising that these criteria would have delayed the weaning progress. Methods A prospective observational cohort study of adult patients receiving MV in a 30-bed university hospital intensive care unit (ICU). Logistic regression analysis identified factors associated with PSV failure. Outcome is reported according to adherence to the screening criteria. Results 209 patients were included (age 62.6±15.9 years, male:female 115:94, Acute Physiology and Chronic Health Evaluation (APACHE) II 16.7±6.1). Median (IQR) time to initiate PSV was 11.0 (5.0–22.0) h, and duration of weaning to extubation was 43.0 (13.0–121.5) h. PSV weaning was initiated despite significant hypoxia (partial pressure of arterial oxygen to fraction of inspired oxygen ratio (PaO2:FiO2) 35.8±15.9 kPa), moderate positive end-expiratory pressure levels (7.5±2.5 cm H2O), deep sedation (44% Richmond Agitation and Sedation Scale (RASS) ≤−3) and cardiovascular instability (48.8%). At PSV initiation, 85% of patients violated at least one screening criterion, yet 74.6% of patients remained stable for 24 h and 25.4% of patients were successfully extubated within 12 h. There was no association between individual screening criteria and PSV failure. Failure to sustain a PSV trial was associated with ventilation >7 days (RR=2.12 (1.33 to 3.38), p=0.002) and ICU mortality (RR=2.94 (1.46 to 5.94), p=0.002). Conclusions Physician-led transition to PSV and weaning was often initiated early and successfully before patients fulfilled conventional screening criteria. Failure to sustain a PSV trial could be an early indicator of prolonged MV and ICU mortality and warrants further investigation. These data support the view that current screening criteria may delay initiation of weaning.

Autoimmune lymphoproliferative syndrome (ALPS) is a disorder of dysregulated lymphocyte homeostasis. Biomarkers including elevated CD3+TCRαβ+CD4−CD8− double negative T cells (TCRαβ+ DNT), IL-10, sCD95L and vitamin B12 can be used to differentiate between ALPS and common variable immunodeficiency (CVID) patients with an overlapping clinical phenotype. We investigated the utility of ALPS biomarkers in 13 CVID patients with lymphoproliferation and/or autoimmune cytopaenia with comparison to 33 healthy controls. Vitamin B12 (P<0.01) and IL-10 (P<0.0001), but not sCD95L or TCRαβ+ DNT, were increased in CVID compared to controls. The 95th percentile for TCRαβ+ DNT in healthy controls was used to define a normal range up to 2.3% of total lymphocytes or 3.4% of T cells. These frequencies lie markedly beyond the cut offs used in current ALPS diagnostic criteria (⩾1.5% of total lymphocytes or 2.5% of CD3+ lymphocytes), suggesting these limits may have poor specificity for ALPS.

Identification of an invasion-predictive biomarker that identifies oral epithelial dysplasia (OED) lesions with a high transformation potential could have clinical implications by helping to target chemoprevention. Insulin-like growth factor II mRNA–binding protein 3 (IMP3), which is a recently identified oncofetal protein essential for mRNA binding, trafficking, and stabilization, is overexpressed in many cancers, including oral squamous cell carcinoma (OSCC). Clinical studies have shown that IMP3 expression in biopsies correlates with the presence of carcinoma in excised cervical epithelium. The objective of this case-control retrospective pilot study was to determine whether or not patterns of IMP3 expression are associated with OED progression to OSCC. Immunohistochemically stained archival tissues (2 groups, age- and site-matched, ≥4 biopsies followed for ≥4 years, transformed [n = 5] and nontransformed [n = 4] to OSCC) were analyzed by light microscopy and with TissueStudio 3.5 image analysis software (Definiens, Munich, Germany). Statistics confirmed comparable initial clinical and histologic features between the transformed and nontransformed groups. Microscopic evaluation revealed greater distribution of moderate to intense IMP3 staining in OED lesions that transformed. Image-analyzed samples revealed that intense IMP3 staining increased over time in those OED lesions that transformed to OSCC (Pearson r; P = .002; all patients combined). In contrast, no such association was noted in nontransformed OED lesions (P = .105). Pearson r values (intense IMP3 expression over time) for each individual patient were: transformed group, 0.82, 0.37, 0.99*, 0.92, and 0.72* (*P = .015); nontransformed group, 0.11, 0.53, −0.70, and 0.57. These data, which show increasing levels of intense IMP3 expression in progressive OED lesions, suggest that high sustained levels of intracellular IMP3 contribute to development of an invasive phenotype.

Granulomas that occur in sarcoidosis are histologically identical to those found in a subset of Common Variable Immunodeficiency (CVID) patients where they are associated with a reduction in class switched memory B lymphocytes. The aim of this study was to investigate whether the abnormalities in peripheral blood lymphocyte populations associated with granulomatous variant CVID (gvCVID) are also present in individuals with sarcoidosis. We examined B lymphocyte populations using flow cytometry and found that the reduction of class switched memory (CSM: CD19+CD27+IgM-IgD-) and unswitched memory (CD19+CD27+IgM+IgD+) B cells in our sarcoidosis cohort was similar to that previously reported in gvCVID patients. The reduction of class switched memory B cells in sarcoidosis patients indicated a possible defect in the T cell repertoire as antibody class switching requires T cell help. We subsequently explored the peripheral blood T cell compartment of our sarcoidosis patients. The results identified a population of terminally differentiated effector CD8 + T cells (CCR7 - CD45RA - CD127 - CD27 - CD28 - ) that were significantly expanded in the peripheral blood of sarcoidosis patients. Terminally differentiated effector CD8 + T cells have been defined as cytolytic, inflammatory cells with reduced replicative capacity. The discovery of abnormal peripheral blood B and T cells compartments in sarcoidosis may be of value in clinical diagnosis and could be relevant to the pathogenic process. Patients with Chronic Sarcoidosis have Reduced CD27 + IgM + IgD +

Common variable immunodeficiency disorders (CVID) are a group of heterogeneous conditions that have in common primary failure of B cell function, although numerous T cell abnormalities have been described, including reduced proliferative response and reduced regulatory T cells. This study compared the T cell phenotype of CVID patients subdivided into clinical phenotypes as well as patients with partial antibody deficiencies [immunoglobulin (Ig)G subclass deficiency and selective IgA deficiency], X-linked agammaglobulinaemia (XLA) and healthy and disease controls. Absolute numbers of T cell subpopulations were measured by four-colour flow cytometry: naive T cells, central and effector memory and terminally differentiated (TEM) T cells, using CD45RA and CCR7 expression. Early, intermediate and late differentiation status of T cells was measured by CD27/CD28 expression. Putative follicular T cells, recent thymic emigrants and regulatory T cells were also assessed. Significant reduction in naive CD4 T cells, with reduced total CD4 and recent thymic emigrant numbers, was observed in CVID patients, most pronounced in those with autoimmune cytopenias or polyclonal lymphoproliferation. These findings suggest a lack of replenishment by new thymically derived cells. CD8 naive T cells were reduced in CVID patients, most significantly in the autoimmune cytopenia subgroup. There was a reduction in early differentiated CD4 and CD8 T cells and increased CD8 TEM in the CVID patients, particularly autoimmune cytopenia and polyclonal lymphoproliferation subgroups, suggesting a more activated T cell phenotype, due perhaps to an antigen-driven process. XLA patients had significantly reduced putative follicular T cells, which may depend on B cells for survival, while no significant alterations were observed in the T cells of those with IgG subclass deficiency or selective IgA deficiency.

Introduction A significant minority of patients do not experience clinical benefit following cardiac resynchronisation therapy (CRT). Haemodynamically-guided adjustment of the intervals between chambers paced (“optimisation” of atrio-ventricular (AV) and left-right ventricular (VV) delays) may be undertaken to improve the chance of response to CRT. However, data to support this approach as standard management are lacking and many institutions programme CRT devices to deliver “out-of-the-box” intervals, only undertaking optimisation when clinical response is lacking. We sought to determine how often the “out-of-the-box” settings are optimal or acceptable and how often CRT optimisation results in significant alteration of the pre-programmed pacing intervals. Methods Data were collected from 180 consecutive patients who underwent CRT followed by optimisation within 24 h. Optimisation was performed with serial adjustment of AV and VV intervals. Haemodynamic assessment was undertaken using either echocardiography or Non-Invasive Cardiac Output Measurement. The optimal pacing intervals were considered to be those which resulted in greatest acute augmentation of cardiac output and the device was programmed accordingly. The final settings were compared with the pre-programmed settings for that device and the difference (AV or VV Adjustment) derived, taking into account the preset paced or sensed AV delay. An AV or VV Adjustment of more than 40 ms was considered to be clinically significant. Data are presented as mean (SD). Results Optimal AV delay ranged from 60 to 200 ms (mean 124 ms (30)), VV delay ranged from 0 to 100 ms (mean 23 ms (19)). With the pre-set pacing parameters, cardiac output was acutely augmented by 13.1 (34)%. Optimised CRT produced further improvement of cardiac output, to 24.9 (32)% augmentation. “Out-of-the-box” settings were found to be optimal in 11 (6.1%), or requiring only minor alteration in 120 (66.7%). A clinically significant alteration in AV delay was made in 40 (22.2%), in VV delay in 12 (6.7%) or in either parameter in 49 (27.2%). Conclusions Significant adjustment of AV or VV delay is required in over a quarter of patients receiving CRT. Optimisation of pacing intervals provides augmentation of cardiac output over and above the “out-of-the-box” settings. The findings suggest that optimisation is an important component of resynchronisation therapy.

Tapasin edits the peptide repertoire presented to CD8(+) T cells by favoring loading of slow off-rate peptides on MHC I molecules. To investigate the role of tapasin on T cell immunodominance we used poxvirus viral vectors expressing a polytope of lymphocytic choriomeningitis virus epitopes with different off-rates. In tapasin-deficient mice, responses to subdominant fast off-rate peptides were clearly favored. This alteration of the CD8(+) T cell hierarchy was a consequence of tapasin editing and not a consequence of the alteration of the T cell repertoire in tapasin-deficient mice, because bone marrow chimeric mice (wild-type recipients reconstituted with tapasin knockout bone marrow) showed the same hierarchy as the tapasin knockout mice. Tapasin editing is therefore a contributing factor to the phenomenon of immunodominance. Although tapasin knockout cells have low MHC I surface expression, Ag presentation was efficient and resulted in strong T cell responses involving T cells with increased functional avidity. Therefore, in this model, tapasin-deficient mice do not have a reduced but rather have an altered immune response.

Moderate-severe obstructive sleep apnoea (OSA) has been associated with several pro-atherogenic mechanisms and increased cardiovascular risk, but it is not known if minimally symptomatic OSA has similar effects. Circulating cell-derived microparticles have been shown to have pro-inflammatory, pro-coagulant and endothelial function-impairing effects, as well as to predict subclinical atherosclerosis and cardiovascular risk. In 57 patients with minimally symptomatic OSA, and 15 closely matched control subjects without OSA, AnnexinV-positive, platelet-, leukocyte- and endothelial cell-derived microparticles were measured by flow cytometry. In patients with OSA, median (interquartile range) levels of AnnexinV-positive microparticles were significantly elevated compared with control subjects: 2,586 (1,566-3,964) microL(-1) versus 1,206 (474-2,501) microL(-1), respectively. Levels of platelet-derived and leukocyte-derived microparticles were also significantly higher in patients with OSA (2,267 (1,102-3,592) microL(-1) and 20 (14-31) microL(-1), respectively) compared with control subjects (925 (328-2,068) microL(-1) and 15 (5-23) microL(-1), respectively). Endothelial cell-derived microparticle levels were similar in patients with OSA compared with control subjects (13 (8-25) microL(-1) versus 11 (6-17) microL(-1)). In patients with minimally symptomatic obstructive sleep apnoea, levels of AnnexinV-positive, platelet- and leukocyte-derived microparticles are elevated when compared with closely matched control subjects without obstructive sleep apnoea. These findings suggest that these patients may be at increased cardiovascular risk, despite being minimally symptomatic.