Loss of Angiotensin-Converting Enzyme 2 Exacerbates Diabetic Retinopathy by Promoting Bone Marrow Dysfunction.

Angiotensin-converting enzyme 2 (ACE2) is the primary enzyme of the vasoprotective axis of the renin angiotensin system (RAS). We tested the hypothesis that loss of ACE2 would exacerbate diabetic retinopathy by promoting bone marrow dysfunction. ACE2-/y were crossed with Akita mice, a model of type 1 diabetes. When comparing the bone marrow of the ACE2-/y -Akita mice to that of Akita mice, we observed a reduction of both short-term and long-term repopulating hematopoietic stem cells, a shift of hematopoiesis toward myelopoiesis, and an impairment of lineage- c-kit+ hematopoietic stem/progenitor cell (HS/PC) migration and proliferation. Migratory and proliferative dysfunction of these cells was corrected by exposure to angiotensin-1-7 (Ang-1-7), the protective peptide generated by ACE2. Over the duration of diabetes examined, ACE2 deficiency led to progressive reduction in electrical responses assessed by electroretinography and to increases in neural infarcts observed by fundus photography. Compared with Akita mice, ACE2-/y -Akita at 9-months of diabetes showed an increased number of acellular capillaries indicative of more severe diabetic retinopathy. In diabetic and control human subjects, CD34+ cells, a key bone marrow HS/PC population, were assessed for changes in mRNA levels for MAS, the receptor for Ang-1-7. Levels were highest in CD34+ cells from diabetics without retinopathy. Higher serum Ang-1-7 levels predicted protection from development of retinopathy in diabetics. Treatment with Ang-1-7 or alamandine restored the impaired migration function of CD34+ cells from subjects with retinopathy. These data support that activation of the protective RAS within HS/PCs may represents a therapeutic strategy for prevention of diabetic retinopathy. Stem Cells 2018;36:1430-1440.

Conditional Deletion of Bmal1 Accentuates Microvascular and Macrovascular Injury.

The brain and muscle aryl hydrocarbon receptor nuclear translocator-like protein (BMAL)-1 constitutes a major transcriptional regulator of the circadian clock. Here, we explored the impact of conditional deletion of Bmal1 in endothelium and hematopoietic cells in murine models of microvascular and macrovascular injury. We used two models of Bmal1fx/fx;Tek-Cre mice, a retinal ischemia/reperfusion model and a neointimal hyperplasia model of the femoral artery. Eyes were enumerated for acellular capillaries and were stained for oxidative damage markers using nitrotyrosine immunohistochemistry. LSK (lineage-negative, stem cell antigen-1-positive, c-Kit-positive) cells were quantified and proliferation assessed. Hematopoiesis is influenced by innervation to the bone marrow, which we assessed using IHC analysis. The number of acellular capillaries increased threefold, and nitrotyrosine staining increased 1.5-fold, in the retinas of Bmal1fx/fx;Tek-Cre mice. The number of LSK cells from the Bmal1fx/fx;Tek-Cre mice decreased by 1.5-fold and was accompanied by a profound decrease in proliferative potential. Bmal1fx/fx;Tek-Cre mice also exhibited evidence of bone marrow denervation, demonstrating a loss of neurofilament-200 staining. Injured femoral arteries showed a 20% increase in neointimal hyperplasia compared with similarly injured wild-type controls. Our study highlights the importance of the circadian clock in maintaining vascular homeostasis and demonstrates that specific deletion of BMAL1 in endothelial and hematopoietic cells results in phenotypic features similar to those of diabetes.

Electroacupuncture Promotes Central Nervous System-Dependent Release of Mesenchymal Stem Cells.

Electroacupuncture (EA) performed in rats and humans using limb acupuncture sites, LI-4 and LI-11, and GV-14 and GV-20 (humans) and Bai-hui (rats) increased functional connectivity between the anterior hypothalamus and the amygdala and mobilized mesenchymal stem cells (MSCs) into the systemic circulation. In human subjects, the source of the MSC was found to be primarily adipose tissue, whereas in rodents the tissue sources were considered more heterogeneous. Pharmacological disinhibition of rat hypothalamus enhanced sympathetic nervous system (SNS) activation and similarly resulted in a release of MSC into the circulation. EA-mediated SNS activation was further supported by browning of white adipose tissue in rats. EA treatment of rats undergoing partial rupture of the Achilles tendon resulted in reduced mechanical hyperalgesia, increased serum interleukin-10 levels and tendon remodeling, effects blocked in propranolol-treated rodents. To distinguish the afferent role of the peripheral nervous system, phosphoinositide-interacting regulator of transient receptor potential channels (Pirt)-GCaMP3 (genetically encoded calcium sensor) mice were treated with EA acupuncture points, ST-36 and LIV-3, and GV-14 and Bai-hui and resulted in a rapid activation of primary sensory neurons. EA activated sensory ganglia and SNS centers to mediate the release of MSC that can enhance tissue repair, increase anti-inflammatory cytokine production and provide pronounced analgesic relief. Stem Cells 2017;35:1303-1315.

CNS inflammation and bone marrow neuropathy in type 1 diabetes.

By using pseudorabies virus expressing green fluorescence protein, we found that efferent bone marrow-neural connections trace to sympathetic centers of the central nervous system in normal mice. However, this was markedly reduced in type 1 diabetes, suggesting a significant loss of bone marrow innervation. This loss of innervation was associated with a change in hematopoiesis toward generation of more monocytes and an altered diurnal release of monocytes in rodents and patients with type 1 diabetes. In the hypothalamus and granular insular cortex of mice with type 1 diabetes, bone marrow-derived microglia/macrophages were activated and found at a greater density than in controls. Infiltration of CD45(+)/CCR2(+)/GR-1(+)/Iba-1(+) bone marrow-derived monocytes into the hypothalamus could be mitigated by treatment with minocycline, an anti-inflammatory agent capable of crossing the blood-brain barrier. Our studies suggest that targeting central inflammation may facilitate management of microvascular complications.

A Fatal Cause of Rapidly Progressive Heart Failure in a Middle-Aged Woman.

Primary cardiac neoplasms are rare, with 3/4 cases being benign. Most malignant neoplasms are sarcomas. Clinically, they present as pseudovalvular obstruction or remote embolism and rarely as a paraneoplastic syndrome. Median survival depends on complete resection rather than histologic type. We describe the case of a 65-year-old woman who presented to the hospital with a three-month history of asthenia, anorexia, weight loss, and progressive worsening of exertional dyspnea. Transthoracic echocardiogram showed a bulky mass in the auricles with significant transvalvular obstruction of the mitral valve. The CT scan showed a voluminous mass in the interauricular septum with the invasion of both atria and restriction of flow in both pulmonary veins. A transvenous biopsy was performed and histology revealed a primary intimal sarcoma. The patient was not eligible for surgery and was proposed for palliative chemotherapy, but she succumbed to her illness in less than two weeks. This report describes this rare and rapidly fatal disease and reviews the literature.

An Uncommon Presentation of Cryptococcal Meningoencephalitis.

Cryptococcal meningoencephalitis (CM) remains a common cause of central nervous system infections. Patients usually present with headache, fever, malaise, and altered mental status over several weeks. Signs are often absent, but they may include meningism, papilledema, cranial nerve palsies, and depressed level of consciousness. Individuals with CM can occasionally present with small vessel vasculitis causing cerebral lesions. The literature regarding patterns of cerebrovascular injury in CM is scarce. We describe a case of CM in which an unusual presentation was observed: transient focal neurological symptoms initially with absence of fever that led to a misleading primary diagnosis of transient ischemic attack. Since neurological symptoms may be a manifestation of a cryptococcal infection, it is necessary to have a high degree of suspicion for this pathology in the presence of focal neurological deficits, even in patients with vascular risk factors, requiring a thorough etiological investigation.

Hulk-Like Urine: A Case of Green Urine Caused by Flupirtine Intoxication.

Acute intoxications are common causes of admission to the Emergency Department (ED). Flupirtine is a non-opioid analgesic, originally used for acute and chronic pain. Because of several reports of severe liver toxicity, its use was limited to acute pain in 2013 by the European Medicines Agency. Although withdrawn from the European market in March 2018, there are still flupirtine tablets in many households, and most people are unaware of the hazards they might be facing. A 58-year-old man was admitted to the ED after a suicide attempt with 1 g of flupirtine. He was lethargic and confused but presented no focal neurological deficits or other symptoms, and the rest of his clinical examination was unremarkable. His cerebral CAT and blood chemistry showed no alterations. The only remarkable feature was that he had green urine. After a careful literature search, a similar case was found caused by flupirtine intoxication. After 24 hours of vigilance in the ED, he improved his neurological status and his urine lost part of its greenish color. He was then transferred to the Psychiatric Department, where he presented a complete remission of the clinical alterations. A follow-up check-up showed no permanent deficits.

When Alice Took Sertraline: A Case of Sertraline-Induced Alice in Wonderland Syndrome.

Alice in Wonderland syndrome (AIWS) is a rare disorder that refers to episodic body image distortions, sometimes associated with altered perception of external space and time. AIWS is mainly associated with viral disease in children as well as migraines and epileptic seizures in adults. Its pathogenesis is still very much unknown and there are not many reported drug-associated cases in medical literature. We describe a case of a 67-year-old woman, with a relevant history of depressive disorder, nontoxic goiter, and dyslipidemia that presented short episodes of altered body perception associated with altered external space perception for a period of one week. Her physical examination was unremarkable and her cerebral computerized axial tomography (cerebral CAT) and blood tests showed no alterations. She had been medicated with sertraline till the previous year and had restarted it in the previous month. She reported similar episodes of body image distortions in the first weeks of initiating sertraline for the first time. The current episode lasted for two weeks and in one year follow-up she reported no recurrence. The patient was diagnosed with AIWS probably induced by sertraline, being the first reported case of the kind.

Exuberant Hand-Foot-Mouth Disease: An Immunocompetent Adult with Atypical Findings.

Non-polio enteroviruses are ubiquitous viruses responsible for a wide spectrum of disease in people of all ages, although infection and illness disproportionately affect infants and young children. Hand-foot-mouth disease (HFMD) is an enteroviral clinical syndrome most frequently caused by coxsackievirus-A16 and enterovirus-A71. Since 2008, a novel coxsackievirus-A6 genotype has been associated with more severe HFMD in both children and adults, presenting with a unique constellation of findings, and whose prevalence has been increasing over the last few years. In this case report, an atypical clinical picture of confirmed enterovirus HFMD is described in an immunocompetent adult, with exuberant clinical findings, clinically consistent with coxsackievirus-A6 infection. This case report highlights the importance of awareness of the clinical presentation of this increasingly common infection in adults. LEARNING POINTS: Hand-foot-mouth disease (HFMD) caused by coxsackievirus-A6 is associated with more severe illness in adults, and presents with a peculiar constellation of findings that include delayed-onset skin desquamation and nail dystrophy.The prevalence of coxsackievirus-A6 HFMD has been increasing over the last few years.Dactylitis-like inflammatory signs on the distal extremities of the fingers can be a manifestation during the viral illness and may precede nail dystrophy.

Epigastric Pain and Weight Loss - A Case of Wilkie's Syndrome.

Superior mesenteric artery syndrome (SMA syndrome) or Wilkie's syndrome is a rare etiology of duodenal obstruction due to compression of the third portion of the duodenum between the superior mesenteric artery and the aorta. Physical and laboratory findings are often non-specific but imaging methods are useful for diagnosing the condition. A 46-year-old female patient presented to the outpatient clinic of our internal medicine department with a 2-year history of epigastric pain, nausea, early satiety and weight loss of 15 kg. Previous studies were inconclusive. The patient underwent computed tomography enterography and its findings were consistent with SMA syndrome. Currently the patient is being followed by General Surgery and Nutrition and is under nutritional measures in order to optimize her body mass index to decrease possible surgical complications. This case report emphasizes the importance of clinical suspicion and careful investigation when considering less common etiologies for frequent gastrointestinal symptoms. LEARNING POINTS: Superior mesenteric artery syndrome is a rare cause of upper gastrointestinal system obstruction and its diagnosis is often delayed.This syndrome should be suspected in the differential diagnosis of patients with persistent nausea, abdominal pain and significant weight loss.

Peripheral blood-derived mesenchymal stem cells demonstrate immunomodulatory potential for therapeutic use in horses.

Previously, we showed that mesenchymal stem cells (MSC) can be mobilized into peripheral blood using electroacupuncture (EA) at acupoints, LI-4, LI-11, GV-14, and GV-20. The purpose of this study was to determine whether EA-mobilized MSC could be harvested and expanded in vitro to be used as an autologous cell therapy in horses. Peripheral blood mononuclear cells (PBMC) isolated from young and aged lame horses (n = 29) showed a marked enrichment for MSCs. MSC were expanded in vitro (n = 25) and administered intravenously at a dose of 50 x 106 (n = 24). Treatment resulted in significant improvement in lameness as assessed by the American Association of Equine Practitioners (AAEP) lameness scale (n = 23). MSCs exhibited immunomodulatory function by inhibition of lymphocyte proliferation and induction of IL-10. Intradermal testing showed no immediate or delayed immune reactions to MSC (1 x 106 to 1 x 104). In this study, we demonstrated an efficient, safe and reproducible method to mobilize and expand, in vitro, MSCs in sufficiently high concentrations for therapeutic administration. We confirm the immunomodulatory function of these cells in vitro. This non-pharmacological and non-surgical strategy for stem cell harvest has a broad range of biomedical applications and represents an improved clinically translatable and economical cell source for humans.

Complementary Embryonic and Adult Cell Populations Enhance Myocardial Repair in Rat Myocardial Injury Model.

We compared the functional outcome of Isl-1+ cardiac progenitors, CD90+ bone marrow-derived progenitor cells, and the combination of the two in a rat myocardial infarction (MI) model. Isl-1+ cells were isolated from embryonic day 12.5 (E12.5) rat hearts and expanded in vitro. Thy-1+/CD90+ cells were isolated from the bone marrow of adult Sprague-Dawley rats by immunomagnetic cell sorting. Six-week-old female Sprague-Dawley rats underwent permanent left anterior descending (LAD) coronary artery ligation and received intramyocardial injection of either saline, Isl-1+ cells, CD90+ cells, or a combination of Isl-1+ and CD90+ cells, at the time of infarction. Cells were delivered transepicardially to the peri-infarct zone. Left ventricular function was assessed by transthoracic echocardiography at 1- and 4-week post-MI and by Millar catheterization (-dP/dt and +dP/dt) at 4-week post-MI. Fluorescence in situ hybridization (Isl-1+cells) and monochrystalline iron oxide nanoparticles labeling (MION; CD90+ cells) were performed to assess biodistribution of transplanted cells. Only the combination of cells demonstrated a significant improvement of cardiac function as assessed by anterior wall contractility, dP/dt (max), and dP/dt (min), compared to Isl-1+ or CD90+ cell monotherapies. In the combination cell group, viable cells were detected at week 4 when anterior wall motion was completely restored. In conclusion, the combination of Isl-1+ cardiac progenitors and adult bone marrow-derived CD90+ cells shows prolonged and robust myocardial tissue repair and provides support for the use of complementary cell populations to enhance myocardial repair.

Increase in acid sphingomyelinase level in human retinal endothelial cells and CD34+ circulating angiogenic cells isolated from diabetic individuals is associated with dysfunctional retinal vasculature and vascular repair process in diabetes.

BACKGROUND: Diabetic retinopathy is a microvascular disease that results from retinal vascular degeneration and defective repair due to diabetes-induced endothelial progenitor dysfunction. OBJECTIVE: Understanding key molecular factors involved in vascular degeneration and repair is paramount for developing effective diabetic retinopathy treatment strategies. We propose that diabetes-induced activation of acid sphingomyelinase (ASM) plays essential role in retinal endothelial and CD34+ circulating angiogenic cell (CAC) dysfunction in diabetes. METHODS: Human retinal endothelial cells (HRECs) isolated from control and diabetic donor tissue and human CD34+ CACs from control and diabetic patients were used in this study. ASM messenger RNA and protein expression were assessed by quantitative polymerase chain reaction and enzyme-linked immunosorbent assay, respectively. To evaluate the effect of diabetes-induced ASM on HRECs and CD34+ CACs function, tube formation, CAC incorporation into endothelial tubes, and diurnal release of CD34+ CACs in diabetic individuals were determined. RESULTS: ASM expression level was significantly increased in HRECs isolated from diabetic compared with control donor tissue, as well as CD34+ CACs and plasma of diabetic patients. A significant decrease in tube area was observed in HRECs from diabetic donors compared with control HRECs. The tube formation deficiency was associated with increased expression of ASM in diabetic HRECs. Moreover, diabetic CD34+ CACs with high ASM showed defective incorporation into endothelial tubes. Diurnal release of CD34+ CACs was disrupted with the rhythmicity lost in diabetic patients. CONCLUSION: Collectively, these findings support that diabetes-induced ASM upregulation has a marked detrimental effect on both retinal endothelial cells and CACs.

CX3CR1 deficiency accelerates the development of retinopathy in a rodent model of type 1 diabetes.

In this study, the role of CX3CR1 in the progression of diabetic retinopathy (DR) was investigated. The retinas of wild-type (WT), CX3CR1 null (CX3CR1gfp/gfp, KO), and heterozygous (CX3CR1+/gfp, Het) mice were compared in the presence and absence of streptozotocin (STZ)-induced diabetes. CX3CR1 deficiency in STZ-KO increased vascular pathology at 4 months of diabetes, as a significant increase in acellular capillaries was observed only in the STZ-KO group. CX3CR1 deficiency and diabetes had similar effects on retinal neurodegeneration measured by an increase in DNA fragmentation. Retinal vascular pathology in STZ-KO mice was associated with increased numbers of monocyte-derived macrophages in the retina. Furthermore, compared to STZ-WT, STZ-KO mice exhibited increased numbers of inflammatory monocytes in the bone marrow and impaired homing of monocytes to the spleen. The induction of retinal IL-10 expression by diabetes was significantly less in KO mice, and when bone marrow-derived macrophages from KO mice were maintained in high glucose, they expressed significantly less IL-10 and more TNF-α in response to LPS stimulation. These findings support that CX3CR1 deficiency accelerates the development of vascular pathology in DR through increased recruitment of proinflammatory myeloid cells that demonstrate reduced expression of anti-inflammatory IL-10. KEY MESSAGES: • CX3CR1 deletion in STZ-diabetic mice accelerated the onset of diabetic retinopathy (DR). • The early onset of DR was associated with increased retinal cell apoptosis. • The early onset of DR was associated with increased recruitment of bone marrow-derived macrophages to the retina. • Bone marrow-derived macrophages from CX3CR1 KO diabetic mice expressed more TNF-α and less IL-10. • The role of IL-10 in protection from progression of DR is highlighted.

Dicer expression exhibits a tissue-specific diurnal pattern that is lost during aging and in diabetes.

Dysregulation of circadian rhythmicity is identified as a key factor in disease pathogenesis. Circadian rhythmicity is controlled at both a transcriptional and post-transcriptional level suggesting the role of microRNA (miRNA) and double-stranded RNA (dsRNA) in this process. Endonuclease Dicer controls miRNA and dsRNA processing, however the role of Dicer in circadian regulation is not known. Here we demonstrate robust diurnal oscillations of Dicer expression in central and peripheral clock control systems including suprachiasmatic nucleolus (SCN), retina, liver, and bone marrow (BM). The Dicer oscillations were either reduced or phase shifted with aging and Type 2 diabetes. The decrease and phase shift of Dicer expression was associated with a similar decrease and phase shift of miRNAs 146a and 125a-5p and with an increase in toxic Alu RNA. Restoring Dicer levels and the diurnal patterns of Dicer-controlled miRNA and RNA expression may provide new therapeutic strategies for metabolic disease and aging-associated complications.

Porcentaje de mamografías de tamizaje con resultado BIRADS 4 y 5 en las que se diagnosticó cancer por biopsia en el Instituto Salvadoreño del Seguro Social de enero 2013 a diciembre 2014 / Percentage of screening mammograms with BIRADS 4 and 5 results in which cancer was diagnosed by biopsy at the "Instituto Salvadoreño del Seguro Social" from January 2013 to December 2014

El cáncer de mama en las mujeres representa en frecuencia el primer lugar debido a que anualmente a nivel mundial se diagnostican un promedio de 1.67 millones de nuevos casos con una incidencia que va de 27 (en África) a 92 (en Norteamérica) por 100,000 mujeres. La mamografía es la primera herramienta de imagen para la detección precoz del cáncer de mama, debido a que ha probado ser un método que ha logrado disminuir la mortalidad por dicha neoplasia. Existen varios sistemas de clasificación para la interpretación de las imágenes en mamografía, de estas BI-RADS® (Breast Imaging Reporting and Data System: Sistema de informes y registro de datos de imagen de la Mama) es la más utilizada, siendo el resultado BI-RADS® 4 y 5 sugestivas de malignidad, y por tanto ameritan confirmación histológica. Con el presente estudio se determinó el porcentaje de lesiones sospechosas de malignidad por hallazgo en mamografía de tamizaje en las cuales se diagnosticó cáncer de mama en mujeres del Instituto Salvadoreño del Seguro Social de enero 2013 a diciembre de 2014, mediante un estudio descriptivo, transversal. Tomando como población a todas las mujeres tamizadas para cáncer de mama mediante mamografía entre los 40 y 69 años en periodo ya mencionado con resultado BI-RADS® 4 o BI-RADS® 5. Con los datos obtenidos se concluyó que la edad media de las pacientes con BI-RADS® 4 y 5 es de 51.17 años; en su mayoría beneficiarias, la composición de la mama en su mayor porcentaje fue de tipo B. Las biopsia negativa a malignidad fueron 74.23% que correspondió en su mayoría a cambios fibroquisticos. Las biopsias positivas a malignidad fueron de 25.77% de las cuales se diagnosticaron en un estadio 0= 12%, IA= 16%; IIA=12%; IIB= 16%; IIIA= 12%; siendo el Carcinoma Canalicular Infiltrante el más común. IIIB, IIIC y IV no se diagnosticaron. Con dicho estudio se reconoció la importancia de este método de tamizaje para la detección temprana de cáncer de mama