A systematic review of randomized controlled trials of endovascular therapy for stroke on mortality and disability.

BACKGROUND: Endovascular treatment (EVT) has become standard of care for patients with anterior circulation large vessel occlusion (LVO) stroke, with indications having recently expanded to late time-window and large ischemic core patients. There is conflicting evidence on whether EVT reduces mortality or only disability. We performed a meta-analysis of randomized controlled trials (RCTs) to assess the effect of EVT on mortality and severe disability. METHODS: We systematically searched PubMed, Web of Science, Scopus, and Embase on November 15, 2023, to identify phase 3 RCTs comparing EVT to best medical treatment (BMT) in patients with anterior circulation LVO stroke in a common effects meta-analysis. The primary outcome was mortality at 3 months. Secondary outcomes were moderately severe or severe disability (modified Rankin Scale (mRS) score 4-5) at 3 months. RESULTS: 18 studies comparing EVT to BMT were included, with a total of 4309 patients; 2159 that were treated with EVT, and 2150 treated with BMT. Mortality was significantly lower in the EVT group than in the BMT group (odds ratio (OR): 0.81, 95% CI: 0.70-0.94). Proportions of moderately severe or severe disability (OR: 0.55, 95% CI: 0.48-0.62) were also significantly lower in patients treated with EVT. CONCLUSIONS: This meta-analysis suggests that EVT reduces both mortality and moderately severe or severe disability in patients with anterior circulation LVO stroke.

Neural signatures of indirect pathway activity during subthalamic stimulation in Parkinson's disease.

Deep brain stimulation (DBS) of the subthalamic nucleus (STN) produces an electrophysiological signature called evoked resonant neural activity (ERNA); a high-frequency oscillation that has been linked to treatment efficacy. However, the single-neuron and synaptic bases of ERNA are unsubstantiated. This study proposes that ERNA is a subcortical neuronal circuit signature of DBS-mediated engagement of the basal ganglia indirect pathway network. In people with Parkinson's disease, we: (i) showed that each peak of the ERNA waveform is associated with temporally-locked neuronal inhibition in the STN; (ii) characterized the temporal dynamics of ERNA; (iii) identified a putative mesocircuit architecture, embedded with empirically-derived synaptic dynamics, that is necessary for the emergence of ERNA in silico; (iv) localized ERNA to the dorsal STN in electrophysiological and normative anatomical space; (v) used patient-wise hotspot locations to assess spatial relevance of ERNA with respect to DBS outcome; and (vi) characterized the local fiber activation profile associated with the derived group-level ERNA hotspot.

Long-Term Clinical Implications of High-Risk Cardiac Computed Tomography Findings in Patients With Acute Ischemic Stroke.

BACKGROUND: Cardiac computed tomography (CT) acquired during the initial acute stroke imaging protocol (acute cardiac CT) is increasingly used to screen for cardioembolism, but information on the long-term clinical implications of its findings is lacking. METHODS AND RESULTS: We performed a prospective, single-center cohort study in which consecutive patients with ischemic stroke underwent ECG-gated acute cardiac CT and were followed up for 2 years. The primary outcome was functional outcome assessed using the modified Rankin Scale. Secondary outcomes were death and occurrence of major adverse cardiovascular events (composite of recurrent ischemic stroke, myocardial infarction, and cardiovascular death). We compared patients with and without a high-risk structural source of embolism on acute cardiac CT. Of 452 included patients, 55 (12.2%) had a high-risk source of embolism, predominantly cardiac thrombi (38 patients) and signs of endocarditis (8 patients). Follow-up at 2 years was complete for 430 (95.1%) patients. Patients with a high-risk source of embolism had a worse functional outcome (median modified Rankin Scale, 6 [IQR, 2-6] versus 2 [IQR, 1-5]; adjusted common odds ratio, 2.92 [95% CI, 1.62-5.25]), increased mortality rate (52.7% versus 23.7%; adjusted hazard ratio [HR], 3.28 [95% CI, 1.94-5.52]), and major adverse cardiovascular events (38.9% versus 17.5%; adjusted HR, 3.20 [95% CI, 1.80-5.69]). A high-risk source of embolism was not associated with recurrent ischemic stroke (11.1% versus 9.6%; adjusted HR, 1.30 [95% CI, 0.49-3.44]). CONCLUSIONS: Structural high-risk sources of embolism on acute cardiac CT in patients with ischemic stroke were associated with poor long-term functional outcome and occurrence of major adverse cardiovascular events but not with recurrent stroke.

In Situ Accumulation of CaOx Crystals in C. quitensis Leaves and Its Relationship with Anatomy and Gas Exchange.

The accumulation of crystal calcium oxalate (CaOx) in plants is linked to a type of stress-induced photosynthesis termed 'alarm photosynthesis', serving as a carbon reservoir when carbon dioxide (CO2) exchange is constrained. Colobanthus quitensis is an extremophyte found from southern Mexico to Antarctica, which thrives in high-altitude Andean regions. Growing under common garden conditions, C. quitensis from different latitudinal provenances display significant variations in CaOx crystal accumulation. This raises the following questions: are these differences maintained under natural conditions? And is the CaOx accumulation related to mesophyll conductance (gm) and net photosynthesis (AN) performed in situ? It is hypothesized that in provenances with lower gm, C. quitensis will exhibit an increase in the use of CaOx crystals, resulting in reduced crystal leaf abundance. Plants from Central Chile (33°), Patagonia (51°), and Antarctica (62°) were measured in situ and sampled to determine gas exchange and CaOx crystal accumulation, respectively. Both AN and gm decrease towards higher latitudes, correlating with increases in leaf mass area and leaf density. The crystal accumulation decreases at higher latitudes, correlating positively with AN and gm. Thus, in provenances where environmental conditions induce more xeric traits, the CO2 availability for photosynthesis decreases, making the activation of alarm photosynthesis feasible as an internal source of CO2.

Efectividad de la entrevista motivacional en la atención fisioterápica de los trastornos musculoesqueléticos de la espalda / Effectiveness of the motivational interview in the physiotherapy care of musculoskeletal disorders of the back: A quasi-experimental study

Objetivo: Evaluar la efectividad de la entrevista motivacional (EM) junto al tratamiento fisioterapéutico habitual en pacientes con trastornos musculoesqueléticos (TME) de la espalda en atención primaria (AP). Métodos: Estudio cuasiexperimental en pacientes que iniciaron su tratamiento en el año 2020 en una unidad de fisioterapia tras diagnóstico médico de TME en la espalda, con seguimiento prospectivo de 2grupos con actuación terapéutica: grupo experimental (GE) y grupo de control (GC). Se empleó la EM solo en el GE. A ambos grupos se les entrevistó telefónicamente a los 3y 6meses de finalizar el tratamiento fisioterápico, preguntando por el cumplimiento de pautas domiciliarias y por la percepción subjetiva del estado de salud (escala de Barthel). Se ajustaron modelos de regresión lineales (coeficiente de regresión, IC del 95%) y logísticos (OR, IC del 95%). Resultados: La población de estudio fue de 154 personas (76,6% mujeres). La salud percibida fue significativamente mejor (p<0,001) en el GE que en el GC, tanto a los 3meses de seguimiento (7,4 versus 5,0, respectivamente) como a los 6(7,1 versus 4,6, respectivamente). Hubo una fuerte asociación entre percepción de salud y cumplimiento (coeficiente de regresión 3,0 [IC del 95%=2,5-3,4]). La asociación entre la EM y el cumplimiento terapéutico se mantuvo tras ajustes multivariados (OR a 6meses=383,6 [IC del 95% = 31,0-4.742,4]). Conclusiones: la incorporación de la EM como complemento de los tratamientos de fisioterapia es una herramienta factible y efectiva para mejorar el cumplimiento de las pautas domiciliarias y la percepción subjetiva de salud. (AU)

Objective: To evaluate the effectiveness of motivational interviewing (MI) combined with the usual physiotherapy treatment in patients with back musculoskeletal disorders (MSD) in primary care (PC). Methods: Quasi-experimental study with 2groups with therapeutic action (control group and experimental group) and prospective follow-up, in a physiotherapy unit in PC, in patients who began their treatment in 2020, with a medical diagnosis of MSD in the back. MI was used only in the face-to-face visits of the experimental group. Both groups were interviewed by telephone about 3and 6months after finishing the physiotherapy treatment. For this purpose, the Barthel scale was used for the subjective perception of the state of health, and the scale of compliance with home guidelines. Linear (regression coefficient, 95% CI) and logistic (OR, 95% CI) regression models were fitted. Results: The study population was 154 people (76.6% women). Perceived health was significantly better (P<.001) in the experimental group than in the control group, both at 3(7.4 versus 5.0, respectively) and at 6months of follow-up (7.1 versus 4.6, respectively). There was a strong association between perceived health and compliance (regression coefficient 3.0 [95% CI=2.5–3.4]). The strong association between MI and treatment adherence was maintained after multivariate adjustments (6-month OR=383.6 [95% CI 31.0–4742.4]). Conclusions: MI is a feasible and effective complement to physiotherapy treatments to improve compliance with home recommendations and subjective perception of health. (AU)

What Is a Meaningful Difference When Using Infarct Volume as the Primary Outcome?: Results From the HERMES Database.

BACKGROUND: Ischemic stroke lesion volume at follow-up is an important surrogate outcome for acute stroke trials. We aimed to assess which differences in 48-hour lesion volume translate into meaningful clinical differences. METHODS: We used pooled data from 7 trials investigating the efficacy of endovascular treatment for anterior circulation large vessel occlusion in acute ischemic stroke. We assessed 48-hour lesion volume follow-up computed tomography or magnetic resonance imaging. The primary outcome was a good functional outcome, defined as modified Rankin Scale (mRS) scores of 0 to 2. We performed multivariable logistic regression to predict the probability of achieving mRS scores of 0 to 2 and determined the differences in 48-hour lesion volume that correspond to a change of 1%, 5%, and 10% in the adjusted probability of achieving mRS scores of 0 to 2. RESULTS: In total, 1665/1766 (94.2%) patients (median age, 68 [interquartile range, 57-76] years, 781 [46.9%] female) had information on follow-up ischemic lesion volume. Computed tomography was used for follow-up imaging in 83% of patients. The median 48-hour lesion volume was 41 (interquartile range, 14-120) mL. We observed a linear relationship between 48-hour lesion volume and mRS scores of 0 to 2 for adjusted probabilities between 65% and 20%/volumes <80 mL, although the curve sloped off for lower mRS scores of 0-2 probabilities/higher volumes. The median differences in 48-hour lesion volume associated with a 1%, 5%, and 10% increase in the probability of mRS scores of 0 to 2 for volumes <80 mL were 2 (interquartile range, 2-3), 10 (9-11), and 20 (18-23) mL, respectively. We found comparable associations when assessing computed tomography and magnetic resonance imaging separately. CONCLUSIONS: A difference of 2, 10, and 20 mL in 48-hour lesion volume, respectively, is associated with a 1%, 5%, and 10% absolute increase in the probability of achieving good functional outcome. These results can inform the design of future stroke trials that use 48-hour lesion volume as the primary outcome.

Four decades of region- and species-specific trends in lowland stream Ephemeroptera abundance.

Lowland stream ecosystems are under threat from climate change, industrialization, urbanization, and intensive agriculture. Since the 1980s, improvements in water quality have led to an increase in lowland stream biodiversity. Despite restoration efforts, however, further recovery is often hampered by the presence of region-specific (combinations of) stressors, and species-specific stressor responses. Identification of these stressors may not be achieved by the analysis of abundance data over large areas for entire communities or species assemblages. Therefore, our study introduces an alternative in-depth approach, selecting Ephemeroptera as a model organism group and analyzing 41 years of species abundance data across distinct geographical regions. Our findings revealed that 15 Ephemeroptera species had already disappeared before 1985, emphasizing the importance of evaluating an extended historical period when analyzing biodiversity trends. While biodiversity was generally characterized by an initial recovery that stagnated over time, the analysis of the past 41 years of Ephemeroptera abundance data revealed strong differences in species' abundance trends between periods, regions, and species. Certain species were likely to have benefitted from local restoration measures in specific geographical regions, while others may have declined due to the presence of region-specific stressors. Our approach underscores the importance of studying the development of region- and species-specific stream biodiversity trends over time to aid the selection of the appropriate restoration measures to recover lowland stream biodiversity.

The First Comprehensive Chemical Profiling of Vachellia gummifera (Willd.) Kyal. & Boatwr., a Plant with Medicinal Value.

Vachellia gummifera (Willd.) Kyal. & Boatwr. is a medicinal plant endemic to Morocco that has no documented studies on its chemical composition. In this study, the chemical composition of the water/methanol (4 : 1) extracts of air-dried leaf and stem samples of Moroccan V. gummifera was determined using UHPLC-MS and NMR. In total, over 100 metabolites were identified in our study. Pinitol was the major compound in both the leaf and stem extracts, being significantly more abundant in the former. Asparagine and 3-hydroxyheteroendrin were the second most abundant compounds in the stem and leaf extracts, respectively, though both compounds were present in each tissue. The other compounds included flavonoids based on quercetin, and phenolic derivatives. Eucomic acid, only identified in the stems and was the major aromatic compound distinguishing the leaf and stem profiles. Quercetin 3-O-(6''-O-malonyl)-ß-D-glucopyranoside was identified as the major flavonoid in the leaves but was also present in the stems. Other malonylated derivatives that were all flavonol glycosides based on myricetin, kaempferol, and isorhamnetin in addition to quercetin were also identified. This is the first report of eucomic acid and malonylated compounds in Vachellia species. This report provides valuable insights into the chemotaxonomic significance of the Vachellia genus.

Identification of prognostic factors for survival in patients with metastatic gastric adenocarcinoma in a Mexican population.

INTRODUCTION AND AIMS: Gastric adenocarcinoma is among the high-ranking tumors, with respect to frequency and mortality, worldwide. The inflammatory process and immune system activity are associated with oncologic control. Our aim was to identify whether the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and other variables are prognostic factors for survival in patients with metastatic gastric cancer in a Mexican population. MATERIAL AND METHODS: Patients diagnosed with metastatic gastric adenocarcinoma, hospitalized within the time frame of December 2011 to 2021, were analyzed. The NLR, PLR, and albumin and hemoglobin levels obtained from blood samples were calculated. Functional status (ECOG and Karnofsky), sex, histology, and the presence of signet ring cells were also considered possible prognostic factors. Each factor's prognostic value for overall survival was determined through univariate and multivariate analyses. RESULTS: The study included 956 patients diagnosed with metastatic gastric cancer, of whom 494 (51.7%) were men and 462 (48.3%) were women. The main histologic finding was diffuse adenocarcinoma (n = 619, 64.7%), followed by intestinal adenocarcinoma (n = 293, 30.6%), and the presence of signet ring cells was found in 659 (68.9%) patients. Diagnostic laparoscopy was performed on 238 patients (24.9%) to confirm peritoneal carcinomatosis. The multivariate analysis showed that an NLR above 3.2 (HR 1.51, 95% CI 1.27-1.8; p < 0.001), albumin below 3.5 g/dl (HR 1.25, CI 1.06-1.47; p = 0.006), and an ECOG performance status of 2 or higher (HR 1.39, CI 1.10-1.76; p = 0.005) were independent factors that predicted a lower survival rate, whereas a Karnofsky score above 70% (HR 0.69, CI 0.53-0.91; p = 0.008) was associated with a better survival rate. Lastly, the PLR was not statistically significant in the multivariate analysis. CONCLUSIONS: The NLR, nutritional status assessed through albumin measurement, and functional status can act as independent prognostic survival factors in hospitalized Mexican patients diagnosed with metastatic gastric adenocarcinoma and be taken into account during therapeutic decision-making.

Novel Apoplastic Antifreeze Proteins of Deschampsia antarctica as Enhancer of Common Cell Freezing Media for Cryobanking of Genetic Resources, a Preliminary Study.

Antifreeze proteins (AFPs) are natural biomolecules found in cold-adapted organisms that lower the freezing point of water, allowing survival in icy conditions. These proteins have the potential to improve cryopreservation techniques by enhancing the quality of genetic material postthaw. Deschampsia antarctica, a freezing-tolerant plant, possesses AFPs and is a promising candidate for cryopreservation applications. In this study, we investigated the cryoprotective properties of AFPs from D. antarctica extracts on Atlantic salmon spermatozoa. Apoplastic extracts were used to determine ice recrystallization inhibition (IRI), thermal hysteresis (TH) activities and ice crystal morphology. Spermatozoa were cryopreserved using a standard cryoprotectant medium (C+) and three alternative media supplemented with apoplastic extracts. Flow cytometry was employed to measure plasma membrane integrity (PMI) and mitochondrial membrane potential (MMP) postthaw. Results showed that a low concentration of AFPs (0.05 mg/mL) provided significant IRI activity. Apoplastic extracts from D. antarctica demonstrated a cryoprotective effect on salmon spermatozoa, with PMI comparable to the standard medium. Moreover, samples treated with apoplastic extracts exhibited a higher percentage of cells with high MMP. These findings represent the first and preliminary report that suggests that AFPs derived from apoplastic extracts of D. antarctica have the potential to serve as cryoprotectants and could allow the development of novel freezing media.

Sustainable cultivation of melon landraces: Effects of grafting on the accumulation of flavor-related compounds.

Melon landraces are highly appreciated by consumers who pay price premiums to compensate for lower yields, enabling on-farm conservation. However, they are highly susceptible to soilborne diseases. This study analyses the impact of Cucurbita and Cucumis rootstocks on the accumulation of flavor-related metabolites in Spanish landraces of the Ibericus melon group, as a strategy to promote their sustainable cultivation. Scion genotype was the main factor conditioning the accumulation of sugars and acids both under standard and saline organic farming conditions. The effects of grafting on organic acid accumulation were negligible, while the effects on sugar content were significant. The latter effects were dependent on specific scion-rootstock combinations, though wild Cucumis (e.g. Fian) rootstocks represent an alternative that should be further studied. The effect on the accumulation of volatiles was limited, and again depended on specific scion-rootstock combinations. The rootstock effect even differed between populations of the same landrace.

Ecophysiology of Antarctic Vascular Plants: An Update on the Extreme Environment Resistance Mechanisms and Their Importance in Facing Climate Change.

Antarctic flowering plants have become enigmatic because of their unique capability to colonize Antarctica. It has been shown that there is not a single trait that makes Colobanthus quitensis and Deschampsia antarctica so special, but rather a set of morphophysiological traits that coordinately confer resistance to one of the harshest environments on the Earth. However, both their capacity to inhabit Antarctica and their uniqueness remain not fully explained from a biological point of view. These aspects have become more relevant due to the climatic changes already impacting Antarctica. This review aims to compile and update the recent advances in the ecophysiology of Antarctic vascular plants, deepen understanding of the mechanisms behind their notable resistance to abiotic stresses, and contribute to understanding their potential responses to environmental changes. The uniqueness of Antarctic plants has prompted research that emphasizes the role of leaf anatomical traits and cell wall properties in controlling water loss and CO2 exchange, the role of Rubisco kinetics traits in facilitating efficient carbon assimilation, and the relevance of metabolomic pathways in elucidating key processes such as gas exchange, nutrient uptake, and photoprotection. Climate change is anticipated to have significant and contrasting effects on the morphophysiological processes of Antarctic species. However, more studies in different locations outside Antarctica and using the latitudinal gradient as a natural laboratory to predict the effects of climate change are needed. Finally, we raise several questions that should be addressed, both to unravel the uniqueness of Antarctic vascular species and to understand their potential responses to climate change.

The future of International Classification of Diseases coding in steatotic liver disease: An expert panel Delphi consensus statement.

BACKGROUND: Following the adoption of new nomenclature for steatotic liver disease, we aimed to build consensus on the use of International Classification of Diseases codes and recommendations for future research and advocacy. METHODS: Through a two-stage Delphi process, a core group (n = 20) reviewed draft statements and recommendations (n = 6), indicating levels of agreement. Following revisions, this process was repeated with a large expert panel (n = 243) from 73 countries. RESULTS: Consensus ranged from 88.8% to 96.9% (mean = 92.3%). CONCLUSIONS: This global consensus statement provides guidance on harmonizing the International Classification of Diseases coding for steatotic liver disease and future directions to advance the field.

Electrical Chain Rearrangement: What Happens When Polymers in Brushes Have a Charge Gradient?

Under the influence of electric fields, the chains in polyelectrolyte brushes can stretch and collapse, which changes the structure of the brush. Copolymer brushes with charged and uncharged monomers display a similar behavior. For pure polyelectrolyte and random copolymer brushes, the field-induced structure changes only the density of the brush and not its local composition, while the latter could be affected if charges are distributed inhomogeneously along the polymer backbone. Therefore, we systematically study the switching behavior of gradient polyelectrolyte brushes in electric fields for different solvent qualities, grafting densities, and charges per chain via coarse-grained molecular dynamics simulations. Similar to random copolymers and pure polyelectrolytes, these brushes show a mixed-phase transition: intermediate states between fully stretched and collapsed are characterized by a bimodal chain-end distribution. Additionally, we find that the total charge of the brush plays a key role in the critical field required for a complete transition. Finally, we find that gradient polyelectrolyte brushes are charge-enriched at the brush-solvent interface under stretched conditions and charge-depleted under collapsed conditions, allowing for control over the local composition and thus the surface charge of the brush due to the inhomogeneous charge along the grafted chains.

A versatile 2A peptide-based strategy for ectopic expression and endogenous gene tagging in Trypanosoma cruzi.

Nearly all expression vectors currently available for Trypanosoma cruzi were conceived to produce a single primary transcript containing the genes of interest along with those that confer antibiotic resistance. However, since each messenger RNA (mRNA) matures separately, drug selection will only guarantee the expression of those derived from the selectable marker. Therefore, commonly a considerable fraction of the cells recovered after selection with these expression vectors, although resistant do not express the protein of interest. Consequently, in order to counteract this disadvantage, we developed vectors with an alternative arrangement in which the gene of interest and antibiotic resistance are fused sharing the same mRNA. To test this configuration, we included the coding sequence for the green fluorescent protein (mEGFP) linked to the one conferring neomycin resistance (Neo). Additionally, to allow for the production of two independent proteins the sequence for a Thosea asigna virus self-cleaving 2A peptide (T2A) was inserted in-between. Cells obtained with these vectors displayed higher mEGFP expression levels with more homogeneous transgenic parasite populations than those transfected with more conventional independent mRNA-based alternatives. Moreover, as determined by Western blot, 2A mediated fusion protein dissociation occurred with high efficiency in all parasite stages. In addition, these vectors could easily be transformed into endogenous tagging constructs that allowed the insertion, by ends-in homologous recombination, of a hemagglutinin tag (HA) fused to the actin gene. The use of 2A self-cleaving peptides in the context of single mRNA vectors represents an interesting strategy capable of improving ectopic transgene expression in T. cruzi as well as providing a simple alternative to more sophisticated methods, such as the one based on CRISPR/Cas9, for the endogenous labeling of genes.

Leaf hydraulic properties of Antarctic plants: effects of growth temperature and its coordination with photosynthesis.

One of the well-documented effects of regional warming in Antarctica is the impact on flora. Warmer conditions modify several leaf anatomical traits of Antarctic vascular plants, increasing photosynthesis and growth. Given that CO2 and water vapor partially share their diffusion pathways through the leaf, changes in leaf anatomy could also affect the hydraulic traits of Antarctic plants. We evaluated the effects of growth temperature on several anatomical and hydraulic parameters of Antarctic plants and assessed the trait co-variation between these parameters and photosynthetic performance. Warmer conditions promoted an increase in leaf and whole plant hydraulic conductivity, correlating with adjustments in carbon assimilation. These adjustments were consistent with changes in leaf vasculature, where Antarctic species displayed different strategies. At higher temperature, Colobanthus quitensis decreased the number of leaf xylem vessels, but increased their diameter. In contrast, in Deschampsia antarctica the diameter did not change, but the number of vessels increased. Despite this contrasting behavior, some traits such as a small leaf diameter of vessels and a high cell wall rigidity were maintained in both species, suggesting a water-conservation response associated with the ability of Antarctic plants to cope with harsh environments.

Distinct Inflammatory Phenotypes are associated with subclinical and clinical Cardiovascular disease in People living with HIV.

Despite inflammation being implicated in cardiovascular disease (CVD) in people with HIV (PWH), considerable heterogeneity within populations of PWH exists. Stratifying CVD risk based on inflammatory phenotype could play an important role. Using principal component analyses and unsupervised hierarchical clustering, we examined 38 biomarkers to identify inflammatory phenotypes in two independent cohorts of PWH. We identified three distinct inflammatory clusters present in both cohorts that associated with altered risk of both subclinical CVD (cohort 1) and prevalent clinical CVD (cohort 2) after adjusting for CVD risk factors. These data support precision medicine approaches to enhance CVD risk assessment in PWH.

The spectrum of thrombotic microangiopathy related to monoclonal gammopathy.

Background: Recent studies showed a high prevalence of monoclonal gammopathy (MG) in patients with thrombotic microangiopathy (TMA) aged over 50 years and suggested that complement dysregulation is pivotal for the disease to develop. Here, we studied this premise in seven patients with TMA and coexisting MG. Methods: Patients with TMA on kidney biopsy and/or peripheral blood were recruited from the prospective COMPETE cohort (NCT04745195) and Limburg Renal Registry. Patients were screened for complement dysregulation, including genetics/factor H autoantibodies (FHAA) and functional ex vivo testing on microvascular endothelial cells. Results: Seven (8%) out of 84 patients with TMA presented with a coexisting MG. MG clustered in patients aged over 50 years (n/N = 6/32, 19%). C4 and/or C3 levels were low in three patients, while four patients presented with normal complement levels. None of the patients carried rare variants in complement genes. Massive ex vivo C5b9 formation on the endothelium was noted in one patient; purified IgG from this patient caused massive ex vivo C5b9 formation via the alternative pathway of complement activation, pointing to complement dysregulation in the fluid phase. Kidney biopsies from other nephropathies linked to MG rarely exhibited concurrent TMA (n/N = 1/27, 4%). Conclusions: MG clustered in patients with TMA aged over 50 years. TMA and coexisting MG represents a heterogeneous disease spectrum, including a small subset of patients who may present with complement dysregulation.