Heterogeneity of treatment effects by risk in pulmonary arterial hypertension.

BACKGROUND: It is currently unknown if disease severity modifies response to therapy in pulmonary arterial hypertension (PAH). We aimed to explore if disease severity, as defined by established risk-prediction algorithms, modified response to therapy in randomised clinical trials in PAH. METHODS: We performed a meta-analysis using individual participant data from 18 randomised clinical trials of therapy for PAH submitted to the United States Food and Drug Administration to determine if predicted risk of 1-year mortality at randomisation modified the treatment effect on three outcomes: change in 6-min walk distance (6MWD), clinical worsening at 12 weeks and time to clinical worsening. RESULTS: Of 6561 patients with a baseline US Registry to Evaluate Early and Long-Term PAH Disease Management (REVEAL 2.0) score, we found that individuals with higher baseline risk had higher probabilities of clinical worsening but no difference in change in 6MWD. We detected a significant interaction of REVEAL 2.0 risk and treatment assignment on change in 6MWD. For every 3-point increase in REVEAL 2.0 score, there was a 12.49 m (95% CI 5.86-19.12 m; p=0.001) greater treatment effect in change in 6MWD. We did not detect a significant risk by treatment interaction on clinical worsening with most of the risk-prediction algorithms. CONCLUSIONS: We found that predicted risk of 1-year mortality in PAH modified treatment effect as measured by 6MWD, but not clinical worsening. Our findings highlight the importance of identifying sources of treatment heterogeneity by predicted risk to tailor studies to patients most likely to have the greatest treatment response.

Thoracic Visceral Adipose Tissue Area and Pulmonary Hypertension in Lung Transplant Candidates. The Lung Transplant Body Composition Study.

Rationale: Obesity is associated with an increased risk of pulmonary hypertension (PH); however, regional adipose tissue deposition is heterogeneous with distinct cardiovascular phenotypes.Objectives: To determine the association of body mass index (BMI) and thoracic visceral and subcutaneous adipose tissue areas (VAT and SAT, respectively) with PH in patients with advanced lung disease referred for lung transplantation.Methods: We studied patients undergoing evaluation for lung transplantation at three centers from the Lung Transplant Body Composition Study. PH was defined as mean pulmonary artery pressure >20 mm Hg and pulmonary vascular resistance ≥3 Wood units. VAT and SAT were measured on chest computed tomography and normalized to height squared.Results: One hundred thirty-seven (34%) of 399 patients included in our study had PH. Doubling of thoracic VAT was associated with significantly lower pulmonary vascular resistance (ß, -0.24; 95% confidence interval [95% CI], -0.46 to -0.02; P = 0.04), higher pulmonary arterial wedge pressure (ß, 0.79; 95% CI, 0.32 to 1.26; P = 0.001), and decreased risk of PH (relative risk, 0.86; 95% CI, 0.74 to 0.99; P = 0.04) after multivariate adjustment. Vaspin levels were higher in patients without PH (median, 101.8 vs. 92.0 pg/ml; P < 0.001) but did not mediate the association between VAT and the risk of PH. SAT and BMI were not independently associated with risk of PH.Conclusions: Lower thoracic VAT was associated with a higher risk of PH in patients with advanced lung disease undergoing evaluation for lung transplantation. The role of adipokines in the pulmonary vascular disease remains to be evaluated.

Molecular determinants of Ca2+ sensitivity at the intersubunit interface of the BK channel gating ring.

The large-conductance calcium-activated K+ (BK) channel contains two intracellular tandem Ca2+-sensing RCK domains (RCK1 and RCK2), which tetramerize into a Ca2+ gating ring that regulates channel opening by conformational expansion in response to Ca2+ binding. Interestingly, the gating ring's intersubunit assembly interface harbors the RCK2 Ca2+-binding site, known as the Ca2+ bowl. The gating ring's assembly interface is made in part by intersubunit coordination of a Ca2+ ion between the Ca2+ bowl and an RCK1 Asn residue, N449, and by apparent intersubunit electrostatic interactions between E955 in RCK2 and R786 and R790 in the RCK2 of the adjacent subunit. To understand the role of the intersubunit assembly interface in Ca2+ gating, we performed mutational analyses of these putative interacting residues in human BK channels. We found that N449, despite its role in Ca2+ coordination, does not set the channel's Ca2+ sensitivity, whereas E955 is a determinant of Ca2+ sensitivity, likely through intersubunit electrostatic interactions. Our findings provide evidence that the intersubunit assembly interface contains molecular determinants of Ca2+-sensitivity in BK channels.

The natural history of recoverable vocal fold paralysis: Implications for kinetics of reinnervation.

OBJECTIVES/HYPOTHESIS: Patients with unilateral vocal fold paralysis (UVFP) are commonly told to wait 12 months for spontaneous recovery. This study aims to 1) determine the time to vocal recovery in UVFP, 2) use that data to develop a neurophysiologically plausible model for recovery, and 3) use the model to generate meaningful predictions for patient counseling. STUDY DESIGN: Case series with de novo mathematical modeling. METHODS: Patients with UVFP who could pinpoint a discrete onset of vocal improvement were identified. The time-to-recovery data were modeled by assuming an "early" recovery group with neuropraxia and a "late" recovery group with more severe nerve injury. For the late group, a two-stage model was developed to explain the time to recovery: regenerating axons must cross the site of injury in stage 1 (probabilistic), followed by unimpeded regrowth to the larynx in stage 2 (deterministic). RESULTS: Of 727 cases of UVFP over a 7-year period, 44 reported spontaneous recovery with a discrete onset of vocal improvement. A hybrid distribution incorporating the two stages (exponentially modified Gaussian) accurately modeled the time-to-recovery data (R2 = 0.918). The model predicts 86% of patients with recoverable UVFP will recover within 6 months, with 96% recovering within 9 months. Earlier vocal recovery is associated with recovery of vocal fold motion and younger age. CONCLUSIONS: Waiting 12 months for spontaneous recovery is probably too conservative. Repair across the site of injury, and not regrowth to larynx, is likely the rate-determining step in reinnervation, consistent with other works on peripheral nerve regeneration. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:2585-2590, 2017.

Design and synthesis of a novel series of N-alkyl isatin acylhydrazone derivatives that act as selective cannabinoid receptor 2 agonists for the treatment of neuropathic pain.

There is growing interest in using cannabinoid receptor 2 (CB2) agonists for the treatment of neuropathic pain. We have synthesized a novel series of N-alkyl isatin acylhydrazone derivatives and have identified and characterized several of them as novel analogues with high functional activity and selectivity at human CB2 receptors using [(35)S]GTP-gamma-S assays. Binding affinities at human CB2 and CB1 were determined for compounds 28, 33, 40, 48, and 58. Structure-activity relationship studies of this novel series led to optimization of our lead compound, compound 33 (MDA19). Compound 33 possessed potent antiallodynic effects in a rat model of neuropathic pain but did not affect rat locomotor activity. More potent and more CB2-receptor-selective compounds, including compounds 37, 40, and 48, were also discovered.

Plasticity of pre- and postsynaptic GABAB receptor function in the paraventricular nucleus in spontaneously hypertensive rats.

GABA(B) receptor function is upregulated in the paraventricular nucleus (PVN) of the hypothalamus in spontaneously hypertensive rats (SHR), but it is unclear whether this upregulation occurs pre- or postsynaptically. We therefore determined pre- and postsynaptic GABA(B) receptor function in retrogradely labeled spinally projecting PVN neurons using whole cell patch-clamp recording in brain slices in SHR and Wistar-Kyoto (WKY) rats. Bath application of the GABA(B) receptor agonist baclofen significantly decreased the spontaneous firing activity of labeled PVN neurons in both SHR and WKY rats. However, the magnitude of reduction in the firing rate was significantly greater in SHR than in WKY rats. Furthermore, baclofen produced larger membrane hyperpolarization and outward currents in labeled PVN neurons in SHR than in WKY rats. The baclofen-induced current was abolished by either including G protein inhibitor GDPbetaS in the pipette solution or bath application of the GABA(B) receptor antagonist in both SHR and WKY rats. Blocking N-methyl-d-aspartic acid receptors had no significant effect on baclofen-elicited outward currents in SHR. In addition, baclofen caused significantly greater inhibition of glutamatergic excitatory postsynaptic currents (EPSCs) in labeled PVN neurons in brain slices from SHR than WKY rats. By contrast, baclofen produced significantly less inhibition of GABAergic inhibitory postsynaptic currents (IPSCs) in labeled PVN neurons in SHR than in WKY rats. Although microinjection of the GABA(B) antagonist into the PVN increases sympathetic vasomotor tone in SHR, the GABA(B) antagonist did not affect EPSCs and IPSCs of the PVN neurons in vitro. These findings suggest that postsynaptic GABA(B) receptor function is upregulated in PVN presympathetic neurons in SHR. Whereas presynaptic GABA(B) receptor control of glutamatergic synaptic inputs is enhanced, presynaptic GABA(B) receptor control of GABAergic inputs in the PVN is attenuated in SHR. Changes in both pre- and postsynaptic GABA(B) receptors in the PVN may contribute to the control of sympathetic outflow in hypertension.

Pre- and postsynaptic plasticity underlying augmented glutamatergic inputs to hypothalamic presympathetic neurons in spontaneously hypertensive rats.

Increased sympathetic outflow plays an important role in the pathogenesis of hypertension. Glutamatergic inputs in the paraventricular nucleus (PVN) of the hypothalamus maintain resting sympathetic vasomotor tone in spontaneously hypertensive rats (SHR). In this study, we determined the synaptic and cellular mechanisms of increased glutamatergic inputs to PVN presympathetic neurons in SHR. The spinally projecting PVN neurons were retrogradely labelled by fluorescent microspheres injected into the intermediolateral cell column of the spinal cord. Blockade of NMDA and non-NMDA receptors significantly decreased the firing activity of labelled PVN neurons in brain slices in SHR, but not in normotensive Wistar-Kyoto rats (WKY). The basal frequency of glutamatergic spontaneous and miniature excitatory postsynaptic currents (sEPSCs and mEPSCs, respectively) of labelled PVN neurons was significantly greater in SHR than in WKY. But the frequency of neither sEPSCs nor mEPSCs stimulated by 4-aminopyridine or capsaicin differed significantly between WKY and SHR. Furthermore, the amplitude of postsynaptic NMDA currents elicited by either electrical stimulation or puff application in labelled PVN neurons was significantly higher in SHRs than in WKY. However, the evoked AMPA current amplitude in PVN neurons was similar in WKY and SHR. This study provides new evidence of how the glutamatergic synaptic inputs to PVN presympathetic neurons are increased and how they contribute to the elevated firing activity of these neurons in SHR. The augmented glutamatergic tone in the PVN is maintained by an increase in presynaptic glutamate release and an up-regulation of postsynaptic NMDA receptor function in SHR.

Potentiation of spinal alpha(2)-adrenoceptor analgesia in rats deficient in TRPV1-expressing afferent neurons.

The alpha(2)-adrenoceptors (alpha(2)-ARs) are located on primary afferent terminals and on neurons in the spinal cord dorsal horn. However, their relative contribution to the analgesic effect of the alpha(2)-AR agonists is not known. In this study, we determined the role of certain presynaptic alpha(2)-ARs in the antinociceptive effect produced by intrathecal administration of the alpha(2)-AR agonist clonidine. TRPV1-expressing sensory neurons were removed by resiniferatoxin (RTX). The effect of intrathecal injection of clonidine was measured by testing the paw withdrawal response to noxious mechanical or heat stimuli. In RTX-treated rats, the alpha(2A)-AR-immunoreactivity co-expressed with TRPV1-expressing terminals in the spinal cord was eliminated. However, the alpha(2C)-AR-immunoreactivity in the spinal cord was little changed. Surprisingly, intrathecal administration of clonidine produced a much greater increase in the mechanical withdrawal threshold in RTX- than in vehicle-treated rats. The duration of the clonidine effect was also significantly increased in RTX-treated rats. Furthermore, in the vehicle-treated group, although intrathecal injection of clonidine produced a large increase in the thermal withdrawal latency, it only had a small and short-lasting effect on the mechanical withdrawal threshold. This study provides new information that the antinociceptive effect of spinally administered alpha(2)-AR agonists is largely modality-specific. Loss of TRPV1-expressing sensory neurons leads to a reduction in presynaptic alpha(2A)-ARs but paradoxically potentiates the effect of clonidine on mechano-nociception.