Expiratory muscle strength training for radiation-associated aspiration after head and neck cancer: A case series.

OBJECTIVE/HYPOTHESIS: Expiratory muscle strength training (EMST) is a simple, inexpensive, device-driven exercise therapy. Therapeutic potential of EMST was examined among head and neck cancer survivors with chronic radiation-associated aspiration. STUDY DESIGN: Retrospective case series. METHODS: Maximum expiratory pressures (MEPs) were examined among n = 64 radiation-associated aspirators (per penetration-aspiration scale score ≥ 6 on modified barium swallow). Pre-post EMST outcomes were examined in a nested subgroup of patients (n = 26) who enrolled in 8 weeks of EMST (25 repetitions, 5 days/week, 75% load). Nonparametric analyses examined effects of EMST on the primary endpoint MEPs. Secondary measures included swallowing safety (Dynamic Imaging Grade of Swallowing Toxicity [DIGEST]), perceived dysphagia (M.D. Anderson Dysphagia Inventory [MDADI]), and diet (performance status scale for head and neck cancer patients [PSSHN]). RESULTS: Compared to sex-matched published normative data, MEPs were reduced in 91% (58 of 64) of aspirators (mean ± standard deviation: 89 ± 37). Twenty-six patients enrolled in EMST and three patients withdrew. MEPs improved on average 57% (87 ± 29 to 137 ± 44 cm H2 O, P < 0.001) among 23 who completed EMST. Swallowing safety (per DIGEST) improved significantly (P = 0.03). Composite MDADI scores improved post-EMST (pre-EMST: 59.9 ± 17.1, post-EMST: 62.7 ± 13.9, P = 0.13). PSSHN diet scores did not significantly change. CONCLUSION: MEPs were reduced in chronic radiation-associated aspirators relative to normative data, suggesting that expiratory strengthening could be a novel therapeutic target to improve airway protection in this population. Similar to findings in neurogenic populations, these data also suggest improved expiratory pressure-generating capabilities after EMST and translation to functional improvements in swallowing safety in chronic radiation-associated aspirators. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:1044-1051, 2018.

Protection by endogenous FGF-2 against isoproterenol-induced cardiac dysfunction is attenuated by cyclosporine A.

Fibroblast growth factor-2 (FGF-2) is implicated in cardioprotection. However, previously we found that chronic elevation in cardiac FGF-2 levels in transgenic mice was associated with exaggerated, cyclosporine A-preventable, cellular infiltration after isoproterenol-induced injury, suggestive of an adverse outcome, although this was not examined with functional studies. We have now used highly sensitive tissue Doppler imaging (TDI) to evaluate cardiac functional parameters after isoproterenol administration in transgenic mice overexpressing the 18 kDa FGF-2 in the heart in vivo. Cardiac function was assessed in conscious FGF-2 transgenic and non-transgenic mice at 24 h as well as 2 and 4 weeks after isoproterenol administration, and in the absence or presence of either cyclosporine A or anti-CD3ε treatments. Isoproterenol decreased left ventricular endocardial velocity and strain rate by 47-51% at 24 h in non-transgenic mice, but to a significantly lesser extent (by 24%) in transgenic mice. While additional decreases were seen in non-transgenic mice at 2 weeks, there was no further reduction in ventricular endocardial velocity or strain rate up to 4 weeks post-treatment in FGF-2 transgenic mice. Functional improvement at 2 and 4 weeks post-isoproterenol was reduced significantly by treatment with cyclosporine A but not anti-CD3ε; the latter targets T lymphocyte activation more specifically. TDI values in the presence of chronic FGF-2 overexpression are prognostic of an improved cardiac outcome and protection from isoproterenol induced cardiac dysfunction in vivo. Our data also suggest that cyclosporine A-sensitive infiltrating cell population(s) may contribute to the sustained beneficial effect of FGF-2 in vivo.

A single bout of exercise promotes sustained left ventricular function improvement after isoproterenol-induced injury in mice.

We have investigated whether acute (swimming) exercise is sufficient to have sustained beneficial effects against cardiac functional decline observed after high-dose isoproterenol administration. Mice were subjected to one bout of swimming for 30 min ("swim" group). Twenty-four hours later, they were given isoproterenol (160 mg/kg) to cause injury. Two control groups were included, a shallow "water" group, for which no swimming took place, and a "cage" group; they were both given isoproterenol as in the "swim" group. Cardiac function was assessed by tissue Doppler imaging (TDI) 24 h, 2 weeks, and 4 weeks post-isoproterenol. Left ventricular (LV) systolic function including endocardial velocity and radial strain rate declined significantly in all groups at all time points after isoproterenol, compared with their pre-isoproterenol treatment values. The "swim" group, however, had significantly higher LV systolic function compared with either of the control groups at 24 h, and this improvement persisted 2 and 4 weeks post-treatment. There were no significant differences between the control groups at any time point. In conclusion, a single bout of swimming has sustained beneficial effects against injury, as measured by TDI, after administration of isoproterenol.

Fibroblast growth factor-2 and cardioprotection.

Boosting myocardial resistance to acute as well as chronic ischemic damage would ameliorate the detrimental effects of numerous cardiac pathologies and reduce the probability of transition to heart failure. Experimental cardiology has pointed to ischemic and pharmacological pre- as well as post-conditioning as potent acute cardioprotective manipulations. Additional exciting experimental strategies include the induction of true regenerative and/or angiogenic responses to the damaged heart, resulting in sustained structural and functional beneficial effects. Fibroblast growth factor-2 (FGF-2), an endogenous multifunctional protein with strong affinity for the extracellular matrix and basal lamina and well-documented paracrine, autocrine and intracellular modes of action, has been shown over the years to exert acute and direct pro-survival effects, irrespectively of whether it is administered before, during or after an ischemic insult to the heart. FGF-2 is also a potent angiogenic protein and a crucial agent for the proliferation, expansion, and survival of several cell types including those with stem cell properties. Human clinical trials have pointed to a good safety record for this protein. In this review, we will present a case for the low molecular weight isoform of fibroblast growth factor-2 (lo-FGF-2) as a very promising therapeutic agent to achieve powerful acute as well as sustained benefits for the heart, due to its cytoprotective and regenerative properties.

Fibroblast growth factor 2 isoforms and cardiac hypertrophy.

Fibroblast growth factor 2 (FGF-2), a multifunctional polypeptide that affects cell growth and differentiation and becomes upregulated by stress, is expressed as AUG-initiated 18 kDa FGF-2 or CUG-initiated 21-34 kDa (hi-FGF-2) isoforms. Animal models have provided strong evidence that FGF-2 is essential for the manifestation of overload- and angiotensin-induced cardiac hypertrophy. Nevertheless, studies to-date have not discriminated between the activities of 18 kDa FGF-2 and hi-FGF-2. Our recent work has pointed to a potent pro-hypertrophic effect of added hi-FGF-2, and a pro-apoptotic effect of sustained intracrine hi-FGF-2 signaling. In the future, it will be important to differentiate between the activities of the different FGF-2 isoforms in the context of adaptive and maladaptive myocardial hypertrophy and heart failure. Based on all available evidence, we propose that while the 18-kDa FGF-2 is a component of an adaptive trophic response, a switch to hi-FGF-2 accumulation would exacerbate hypertrophy and contribute to cell death, thus driving the myocardium towards a maladaptive phenotype.

Transcriptional regulation of FGF-2 gene expression in cardiac myocytes.

OBJECTIVE: Fibroblast growth factor-2 (FGF-2) exerts its cardioprotective effect through cell surface receptor signaling and may play a role in the normal maintenance of a healthy myocardium. One mechanism of FGF-2 release from contracting cardiomyocytes is through transient sarcolemmal disruption, with accumulation in the extracellular matrix. Continuous FGF-2 release would require a link to synthesis and, thus, we examined regulation of FGF-2 promoter activity in cardiomyocytes as a potential target for optimizing cardioprotection. METHODS AND RESULTS: To investigate autoregulation, neonatal rat cardiomyocytes, (NRCM), were transfected with approximately 1 or 0.1 kb of rat FGF-2 promoter sequences linked to luciferase, -1058FGF-2p.luc and -110FGF-2p.luc, and treated with or without FGF-2. FGF-2 promoter activity was significantly increased approximately 2.5-fold with both genes. The proximal promoter region of rat FGF-2 contains putative binding sites for the early growth response-1 (Egr-1) and stimulating protein 1 (Sp1) transcription factors. Overexpression of Egr-1 and Sp1 increased -1058FGF-2p.luc expression by 4.4- and 8.7-fold, respectively. Mutation of Egr-1 and overlapping Sp1 sites did not blunt the response of -110FGF-2p.luc to FGF-2 treatment but did significantly reduce basal promoter activity. Transgenic mice expressing -1058FGF-2p.luc were treated with isoproterenol (IsP) to increase heart rate and endogenous FGF-2 release. FGF-2 promoter activity was stimulated significantly at 6 h, and increases in both FGF-2 and its receptor mRNA levels were also detected. In contrast, no effect of IsP was seen on -1058FGF-2p.luc or -110FGF-2p.luc in transfected NRCMs. CONCLUSIONS: FGF-2 released from cardiomyocytes may act to regulate its own synthesis at the transcriptional level. The mechanism does not appear to require an intact Egr-1 site in the proximal promoter region. This may, however, reflect redundancy in the control of FGF-2 promoter activity as our data support a stimulatory role for Egr-1 and Sp1.

Exacerbation of myocardial injury in transgenic mice overexpressing FGF-2 is T cell dependent.

Fibroblast growth factor-2 (FGF-2) is cardioprotective when added exogenously, stimulates cardiac myocyte proliferation, and is a mediator of tissue repair after injury. Furthermore, transgenic (TG) mice overexpressing FGF-2 in cardiac muscle demonstrate increased resistance to injury in an isolated heart model of ischemia-reperfusion. We investigated how increasing the endogenous FGF-2 levels in the heart affects the extent of myocardial damage induced by isoproterenol in vivo. Histopathological evaluation of hearts after intraperitoneal injection of isoproterenol yielded significantly higher scores for myocardial damage in FGF-2 TG lines compared with non-TG mice. After 1 day, FGF-2 TG mouse hearts displayed more cellular infiltration correlating with increased tissue damage. Immunostaining of non-TG and FGF-2 TG mouse hearts showed the presence of leukocytes in the infiltrate, including T cells expressing FGF receptor-1. Treatment of mice with T cell suppressors cyclosporin A and anti-CD3epsilon significantly decreased the level of myocardial injury observed after isoproterenol and equalized the histopathology scores in FGF-2 TG and non-TG hearts. These data demonstrate a direct T cell involvement in the response to isoproterenol-induced injury in vivo. Moreover, the findings indicate that the exacerbation of myocardial damage in FGF-2 TG mice was dependent on T cell infiltration, implicating FGF-2 in the inflammatory response seen in cardiac tissue after injury in vivo.