Anterior segment glaucoma clinical care and research has recently gained new focus because of novel imaging modalities and the advent of angle-based surgical treatments. Traditional investigation drawn to the trabecular meshwork now emphasizes the entire conventional aqueous humor outflow (AHO) pathway from the anterior chamber to the episcleral vein. AHO investigation can be divided into structural and functional assessments using different methods. The historical basis for studying the anterior segment of the eye and AHO in glaucoma is discussed. Structural studies of AHO are reviewed and include traditional pathological approaches to modern tools such as multi-model two-photon microscopy and optical coherence tomography. Functional assessment focuses on visualizing AHO itself through a variety of non-real-time and real-time techniques such as aqueous angiography. Implications of distal outflow resistance and segmental AHO are discussed with an emphasis on melding bench-side research to viable clinical applications. Through the development of an improved structure: function relationship for AHO in the anterior segment of the normal and diseased eye, a better understanding of the eye with improved therapeutics may be developed. Glaucoma can result in irreversible vision loss. At this time, the only proven treatment is lowering intraocular pressure (IOP) ,2. IOP iTo understand the full AHO outflow pathways, one has to understand how it was discovered. Historically, one of the earliest clues for AHO came from Lauber’s dogs. Taking blood from ciliary veins, it was noted that the ciliary vein blood hematocrit was less than the peripheral vein hematocrit . This reTo figure out the physical structures that carried aqueous, outflow pathway mapping was done via casting experiments. Polymerizing agents such as neoprene latex or vulcanizing silicone were injected retrogradely into distal outflow structures identified either by direct visualization or anterior filling with trypan blue ,17. EnzyTo complement structural studies, seminal aqueous humor dynamic physiological experiments were conducted by Morton Grant and others . Using aHowever, careful examination of the AHO resistance measurements resulted in two more observations. First, even after TM removal, some level of resistance was still recorded implying potential sources of resistance distal to the TM  and their results from the last decade have re-invigorated glaucoma anterior segment thought and research. Trabecular MIGS moved from basic goniotomies/trabeculotomies ,27 to usThis review surveys AHO research with an emphasis on the entire conventional outflow pathway, trabecular and post-trabecular. Research will be roughly organized into balancing the study of AHO structure (anatomy) and function (physiology of fluid flow) . GlaucomToday, understanding AHO structure is more sophisticated than traditional casting methods. Initially, pathological/histological and electron microscopic methods were used . TM, SC,Recently, structural assessments, particularly of the TM, have occurred in a more native three-dimensional context with two-photon multimodal imaging. Two photon-microscopy (TPM) enabled high-resolution deep tissue optical sectioning in whole fixed or live tissue . DiffereTo evaluate post-TM AHO structures, multiple approaches have been used. Three-dimensional micro-computed tomography (3D micro-CT) in enucleated eyes identified AHO pathways as lumens of low radiographic signal . SC, colin silico casts of small segments of distal AHO pathways in normal individuals [To study AHO structure in living subjects, anterior segment optical coherence tomography (OCT) has been indispensable. Like 3D micro-CT, AHO lumens appeared as regions of low reflectivity on OCT scans . Spectraividuals . Pilocarividuals ,37. AutoPhase-based OCT (ph-OCT) has shown pulse-dependent TM motion in enucleated non-human primate and live human eyes ,39. In lWhile illuminating, current imaging-based structural analyses of AHO pathways were limited by understanding the relevance of the anatomy observed. It was unclear if large lumens necessarily represent increased or decreased AHO. The trabecular meshwork itself, oft described as a hypo-reflective interface shadow could connect to SC and be confusingly included as a portion of the AHO pathways . StructuAlso, most OCT studies have focused on sampling portions of the outflow anatomy . While sSince the structure of a physiologic system often controls and predicts its function, without an exact working relationship between the two, the meaning of structural variations can on its own be unclear. Thus, functional assessment sometimes takes the primary role in patient care especially because it is usually the function of the organ that is what's clinically relevant. Glaucoma physicians are accustomed to this for posterior segment evaluation. Visual fields are a functional assessment of the structure . Visual fields and defects therein are what a glaucoma patient actually experiences, as opposed to the absolute number of ganglion cells or thickness of the retinal nerve fiber layer on an OCT scan. Thus for glaucoma diagnosis and management, functional assessment of vision with visual fields historically preceded that of more structural evaluations that eventually became prominent today. Recent improvements in posterior segment structure and function relationship was required for this to happen –43.For AHO, functional assessment is equal to assessing the flow itself. This can be determined experimentally with outflow facility measurements in enucleated eyes or calculated from clinically measured variables with help from the Goldmann equation . SimultaNon-real time methods to visualize AHO means adding a tracer to the eye, waiting a set period of time, and then capturing this information, typically in an enucleated eye after fixation for histological or whole mount study. Labeled tracers can include gold particles, fluorescent microspheres, or quantum dots (Qdots) among others.Gold particles or cationic ferritin were initially used with electron microscopic analyses –46. SegmFor a more global AHO assessment, larger and fluorescently tagged tracers were delivered into either live or enucleated eyes in several species. Fluorescent microspheres ranged in size from 0.2 to 20 microns ,44,47–51To probe the underlying biology associated with segmental AHO, biochemical and genetic studies were performed. Regions of high and low tracer accumulation could be isolated in mouse and probed by immunofluorescence . RT-PCR Taken together, non-real time imaging techniques have emphasized the segmental nature of physiologic AHO and a potential relevance for treating ocular hypertension. Particularly exciting is the link of the segmental patterns to possible protein differences that might subserve the segmentalization. Note though that emphasis was on the TM here. Some of this was due to the use of larger particles. Larger particles allowed better maintained intraluminal presence without leakage so that tracers stayed within the AHO pathways during the processing time necessary for the non-real time assessment. However, larger particles may have also had a harder time passing through the TM easily. Thus, while clearly important for understanding AHO biology in model systems, non-real-time approaches using tagged beads or tracers may have a more limited clinical use in live human subjects and patient care.Real-Time AHO imaging refers to visualizing tracer movement without the requirement to stop and process the tissue. The potential advantage here is that the variable of time between tracer introduction and tissue processing for non-real-time assessment is avoided. For the most part, real-time techniques have focused on small and clinically available tracers , or trypan blue) using more clinical and surgical techniques. This is likely because clinical assessment of AHO in patient care would be better real-time since non-real-time methods rely so much upon pathological and histological methods.Channelography and canalography are essentially the same technique that relies on unroofing Schlemm’s canal (SC) with introduction of the tracer  –59. The Searching for clear episcleral fluid waves represented another clever approach to identifying AHO pathways by looking for negative signal in the form of disappearance of blood in surface epislceral veins ,62. CondMore recently, combining different aspects of the above approaches, aqueous angiography was a method that delivered fluorescent tracers into the anterior chamber with external imaging using an experimental microscopic setup  or a cliAqueous angiography was so termed to distinguish it from canalograms because the approach and information provided was different. This is analogous to the difference between classical congenital glaucoma surgeries: goniotomies and trabeculotomies ,27. For This difference in information also parallels the techniques of percutaneous transhepatic cholangiography (PTC) and endoscopic retrograde cholangiopancreatography (ERCP) where, as the names imply, both can visualize the biliary system but ERCP provides easier images of the exocrine pancreatic ducts to detect pancreatic pathologies ,65. AddiUsing enucleated pig and human eyes, aqueous angiography demonstrated segmental AHO patterns that mimicked non-real-time methods. Angiographic signal was validated as representing true AHO using anterior segment OCT and fluorescent dextrans studies . AngiogrThe meaning of any tracer study in any system is only as good as how close the tracer models the native substance of interest. The use of multiple tracers above with similar results of segmental AHO patterns in multiple species has been very reassuring. For AHO, aqueous humor is actually made up of many components . PredomiClinically, aqueous humor outflow and its segmental nature may play a role in normal versus glaucomatous physiology and response to glaucoma therapy . From a pharmacological standpoint, creating more uniform AHO may be beneficial ,44,67.From a surgical standpoint, AHO imaging may help guide and customize MIGS in the individual patient for optimized IOP lowering. However, even with segmental aqueous angiographic information, a common clinical question is whether trabecular MIGS should be targeted to regions of greater flow to take advantage of known AHO pathways. The downside is that if flow is good, potential improvement there may be limited. Alternatively, should surgery be performed where flow is bad with the hopes of recruiting additional and increased AHO? This would be analogous to surgically improved AHO uniformity. The potential disadvantage is that maybe flow in initially poor regions may have been low because the anatomy didn’t support AHO in the first place. Now, tools for structural and functional assessment are available to ask these questions. Early experiments suggested that regions of initially poor flow could be recruited with TM bypass using a trabecular bypass stent .In patient care, combining many of the above techniques will be important. Ideally, clinical angiographic AHO assessment is real-time, includes contributions from the entire AHO pathways, allows for circumferential testing to fairly assess segmentalization and be conducted at physiologic pressures. For surgeries, real-world considerations must be had. While aqueous humor perfusion rigs have become ever sophisticated, patient safety, surgeon comfort, avoidance of unnecessary additional wounds, and time under anesthesia are factors. For example, most surgeons would not be willing to place a sharp needle in the sulcus space of a phakic patient to deliver the tracer there just because it is in a more physiologic starting point compared to the anterior chamber. Like the episcleral fluid wave approach, something familiar and comfortable to the ophthalmic surgeon will be important ,62.In conclusion, for glaucoma, creating posterior segment structure: function relationships have been underway and are already quite developed –43. In t


To describe a case of Valsalva-related subretinal hemorrhage as a presenting symptom of polypoidal choroidal vasculopathy (PCV). The patient refrained from treatment against our best advice, and thus this is also a rare case of the natural course of an untreated PCV. Case report. A 66-year-old female with a respiratory infection coughed intensely until exhaustion, after which she developed visual symptoms on the right eye. Primary care ophthalmologist examined the patient on the same day of the onset of symptoms and referred her to our tertiary medical retinal service for detailed retinal diagnosis including fluorescein and indocyanine green angiography. The right eye had a large subretinal hemorrhage and pigment epithelium detachment in the lower temporal arcade with foveal involvement. Against our best advice, the patient refused treatment. In the following 9 months, the BCVA decreased from 68 to 55 ETDRS letters, the subretinal hemorrhage almost regressed, pigment epithelium detachments persisted, and macular edema, intraretinal cysts, and subretinal fibrosis developed. Although classic Valsalva retinopathy with preretinal hemorrhage in most cases can be managed by careful observation and no treatment, this case demonstrates that Valsalva-related subretinal hemorrhage needs different attention and approach. Coughing induces a Valsalva-like situation: a deep breath in, the glottis shuts, the diaphragm presses against the lungs, and the glottis opens blasting out air. The change in intrathoracic pressure is 100–250 mmHg depending on the violence of the cough –5. Here,A 66-year-old female with a respiratory infection decided to “get rid of it the phlegm once for all” by coughing strongly and intensely until exhaustion. During the following hour, the patient acutely developed blurred vision and light flashes on the right eye. Primary care ophthalmologist examined the patient on the same day of the onset of symptoms and referred her to our tertiary medical retinal service. Our examination included slit-lamp biomicroscopy, fluorescein and indocyanine green (ICG) angiography, spectral-domain optical coherence tomography, and B-scan ultrasound. Best-corrected visual acuity (BCVA) of each eye was measured using the Early Treatment of Diabetic Retinopathy Study (ETDRS) chart. The patient did not have any comorbidities. Only relevant family history was a now deceased father, who had received intravitreal injection treatments for a disease unknown to the patient.The right eye had subretinal hemorrhage and pigment epithelium detachment in the lower temporal arcade with foveal involvement, and the retinal angiography showed two hyperfluorescent spots on early-phase ICG but the images were somewhat blurred due to the large subretinal hemorrhage . IntraocAgainst our best advice, the patient initially refused commencement of intravitreal anti-VEGF treatment. Photodynamic therapy was not possible due to risk of hemorrhage. We invited the patient for follow-ups with 3-month intervals. During the total follow-up of 9 months, the BCVA decreased to 55 ETDRS letters (Snellen = 6/24); the subretinal hemorrhage almost regressed; pigment epithelium detachments persisted; and macular edema, intraretinal cysts, and subretinal fibrosis developed .Valsalva-related preretinal hemorrhages are commonly caused by macroaneurisms, and subretinal hemorrhages are commonly seen in choroidal neovascularizations and especially in cases with retinal angiomatous proliferation. We here describe a case report of PCV that present with Valsalva-induced acutely developed subretinal hemorrhage. Although classic Valsalva retinopathy with preretinal hemorrhage in most cases can be managed by careful observation, this case demonstrates that subretinal hemorrhages need different attention and approach.PCV is similar to neovascular age-related macular degeneration (AMD) in being a disease of the posterior section with a significant choroidal component. It differs from neovascular AMD in being characterized by polypoidal vascular dilations with or without an associated branching choroidal network, by not being associated with drusen maculopathy, and by often presenting with hemorrhage , 7. ThisSince the diagnosis of PCV is dependent on retinal angiography, population-based studies on PCV epidemiology are rare. In Asians, PCV accounts for approximately half of all patients with neovascular AMD , while iThe natural history of untreated PCV is vision loss and scarring with hemorrhage as a main reason . Hemorrh


Obesity is a risk factor for stroke and is consequently one of the most common co-morbidities found in patients. There is therefore an identified need to model co-morbidities preclinically to allow better translation from bench to bedside. In preclinical studies, both diet-induced and genetically obese rodents have worse stroke outcome, characterised by increased ischaemic damage and an altered inflammatory response. However, clinical studies have reported an ‘obesity paradox’ in stroke, characterised by reduced mortality and morbidity in obese patients. We discuss the potential reasons why the preclinical and clinical studies may not agree, and review the mechanisms identified in preclinical studies through which obesity may affects stroke outcome. We suggest inflammation plays a central role in this relationship, as obesity features increases in inflammatory mediators such as C-reactive protein and interleukin-6, and chronic inflammation has been linked to worse stroke risk and outcome. Stroke is already the leading cause of adult disability, accounting for 7% of the total disability-adjusted life years lost and 12% of total deaths in Europe.4 As most people affected by a stroke are over the age of 65, its prevalence and associated disabilities will likely increase due to the population living longer. As well as an ageing population, worldwide obesity has more than doubled since 1980, and in 2014, over 600 million adults were classified as obese  2015).The detrimental effects of obesity on overall health are well understood, including an increased risk of developing hypertension and cardiovascular disease, and higher all-cause mortality.2 as overweight and a BMI ≥ 30 kg/m2 as obese. Obesity can then further divided based on BMI into class 1 (30–34.9), class 2 (35–39.0) or class 3 (≥40) obesity. Several studies have identified that obesity is a risk factor for both ischaemic and haemorrhagic stroke in several ethnic populations and in both sexes.6 A linear relationship between increasing BMI and stroke risk has been reported for ischaemic stroke, though a J-shaped or no correlation is often reported for haemorrhagic stroke.714 Obesity is also a strong risk factor for the development of other risk factors for stroke including hypertension, diabetes and dyslipidaemia. However, even after adjustment for these potential co-founding factors, obesity has been found to be an independent risk factor for stroke.5Obesity is usually defined by body mass index , with the WHO classifying adults with a BMI ≥ 25 kg/m15 Furthermore, clinical evidence suggests that recanalisation of cerebral arteries after tPA therapy is reduced in obese stroke patients, suggesting a reduced efficacy of tPA.16 Similar resistance to thrombolysis has been reported in patients with the metabolic syndrome,18 of which obesity is a part. A potential explanation is that patients weighing over 100 kg may be underdosed, as the maximum recommended dose of tPA is 0.9 mg/kg (Guidelines for Management of Ischaemic Stroke and Transient Ischaemic Attack 2008).19 Indeed, worse outcome at 3 months in tPA-treated patients has been reported in patients who were >100 kg compared with patients who were <100 kg.21Currently, the only treatment for stroke is thrombolysis using tissue plasminogen activator (tPA) or by mechanical retrieval. However, since tPA can only be given up to 4.5 h post-stroke due to reduced efficacy and increased risk of haemorrhage, only a minority of stroke suffers benefit from tPA treatment.In both obese and non-obese stroke patients, there is therefore an urgent need for new stroke treatments. Unfortunately, despite hundreds of stroke treatments showing efficacy in preclinical trials, most have been unsuccessful in the clinic. It is now believed that a key factor for this lack of translation from ‘bench to bedside’ is the failure of preclinical studies to consider fully the underlying status of a typical stroke patient. As age is the strongest risk factor for stroke, patients are usually elderly, and present with co-morbid diseases such as hypertension, vascular disease (e.g. atherosclerosis), diabetes, infection or metabolic syndrome/obesity. Several of these co-morbidities may co-exist in the same patient, and it is rare for a stroke to occur in an otherwise healthy individual .Figure 23 Obesity has classically been associated with disruption of pathways controlling lipid and glucose metabolism, however recent evidence has shown that obesity also has an inflammatory component ,29 monocyte chemoattractant protein 1 (MCP-1/CCL2),30 interleukin-8 (IL-8)30 and soluble intracellular adhesion molecule 1 (ICAM-1).31 This positive correlation between makers of inflammation and adiposity has led to suggestions that obesity is an inflammatory condition. However, the profile of immune activation found in obesity is quite different to that found in infection or injury, where the immune system is acutely activated to remove harmful stimuli. In obesity, the concentrations of proinflammatory markers are relatively low by comparison, but are maintained over long periods. Consequently, obesity has been described as resulting in “low-grade chronic inflammation”. This peripheral inflammatory response is thought to originate within adipose tissue, which becomes dysfunctional and inflamed during obesity.32 The important endocrine role of adipose tissue is highlighted by the growing family of adipose tissue-derived protein factors, collectively called adipokines (e.g. leptin and adiponectin). Besides having an established role in immune regulation and energy balance, adipokines have been found to regulate an expanding array of physiological functions, including haemostasis, lipid and glucose metabolism, blood pressure, insulin sensitivity and angiogenesis.33 The inflammation associated with obesity may lead to progressively increased stroke risk, since elevated concentrations of IL-6 and CRP in the plasma are both risk factors for stroke.3437 In support of this, in obese and overweight patients, the BMI-associated cardiovascular disease (combined stroke and ischaemic heart disease) risk decreases substantially when adjusted for CRP, suggesting that inflammation is important in mediating the risk of stroke associated with obesity.38Inflammation and immune mechanisms are well established factors in stroke risk and outcome, in both patients and animals.omponent . Measure3947 Furthermore, increased BMI has also been associated with other improved outcomes post-stroke, including a reduced risk of recurrent stroke,48 reduced morbidity,42 improved functional recovery49 and reduced short-term mortality.50Despite obesity being a risk factor for stroke, several studies have reported a protective effect of obesity on stroke outcome in patients. In these studies, patients are grouped by BMI on admission, and the presence of other stroke risk factors assessed. As would be expected, obese and overweight BMI groups have higher incidence of other risk factors including (but not limited to) hypertension, diabetes and dyslipidaemias. The relative impact of each factor on functional outcome is then assessed using multivariate statistics. When the contribution of other factors is adjusted for, higher BMI has been associated with reduced long-term all-cause mortality after stroke when compared with normal BMI groups in several populations.51 Kim et al. found that higher BMI was associated with milder strokes on admission, and so when initial stroke severity was adjusted for there was no evidence of an obesity paradox in their cohort.52 In a study in patients receiving intravenous thrombolysis, body weight >100 kg was associated with increased mortality at 3 months post-stroke.21 The common use of long-term all-cause mortality as an end-point has also been criticised, for example when the Danish Stroke Register was reanalysed to only include deaths confirmed as occurring acutely due to the index stroke, there was no evidence of an obesity paradox.53 There is therefore still a lack of consensus about the obesity paradox in the literature; whether it predicts a currently unclear biological phenomenon, or is instead due to sampling or other methodological bias. A full discussion of these arguments is beyond the scope of this review, and have been previously discussed elsewhere.5456 Overall, the clinical studies investigating stroke outcome in obese patients have focused on whether obesity has a positive or negative effect on long-term morbidity and mortality. However, the actual mechanisms through which obesity is proposed to have a beneficial or detrimental effect have undergone little to no investigation in clinical studies.However, not all studies have confirmed the existence of an obesity paradox in stroke. For example, Ryu et al. found no association between increased BMI and long-term mortality after ischaemic stroke.ob/ob mouse,8688db/db mouse92 and Zucker rat,83 which all become obese due to a deficiency in the satiety hormone leptin or a defective leptin receptor. Since leptin usually acts on the hypothalamus to limit feeding, these animals  rapidly gain weight because they are hyperphagic. The appearance of ischaemic damage is also more rapid in ob/ob mice.57 Worse stroke outcome has also been confirmed in diet-induced models in which animals become obese due to being fed a high-fat diet. These detrimental effects of a high-fat diet have been observed in rat,93 mouse88 and gerbil94 models of diet-induced obesity. A variety of models of cerebral ischaemia have also been used in these studies, including transient and permanent occlusion of the middle cerebral artery, common carotid artery ligation and exposure to a low-oxygen environment. In mice, it has recently been shown that the negative impact of diet-induced obesity on stroke outcome in mice is dependent on how long the obese phenotype is present and the severity of the initial stroke insult (length of ischaemia).60 It is also unclear whether the detrimental effects of obesity on outcome in these preclinical studies are permanent, or reversible with weight loss.In contrast with the clinical outlook, there is clear consensus in preclinical studies that obesity worsens stroke outcome. This detrimental effect of obesity on outcome has primarily been demonstrated in obese rodents undergoing experimental cerebral ischaemia. In both mouse and rat models of obesity, obese rodents suffer increased ischaemic brain damage and have worse behavioural outcomes in comparison with control animals . This un93 although the latter is not always observed in diet-induced rodents.60 This enhanced microvascular damage in obese animals likely contributes to their worse ischaemic damage due to the neurotoxic effects of both BBB breakdown and haemorrhagic transformation. Perhaps owing to the important role of the BBB in brain ion and water homoeostasis, an increase cerebral oedema is seen in obese rodents.92 White matter damage is also increased in obese rodents post-stroke.77 Importantly, cerebral oedema, BBB breakdown and haemorrhagic transformation are all indicators of poor prognosis in patients.9598Besides an increase in ischaemic damage, obese rodents often show an increase in blood–brain barrier (BBB) permeability and an increased incidence of haemorrhagic transformation,2830 Circulating cytokines may access the brain parenchyma directly, or transduce the inflammatory signal over the BBB indirectly via receptors on the endothelial cells of the cerebrovasculature or by stimulation of afferent nerve fibres. However, the systemic elevation of inflammatory mediators in obesity is likely not great enough to cause an overt inflammatory response in the CNS. Instead, the low-level systemic inflammation found in obesity may prime cells to subsequent inflammatory stimuli, for example leukocytes and platelets in the circulation.99 Mice that become obese after being fed a high-fat diet show increased activation of astrocytes and microglia, and increases in inflammatory mediators in the brain, principally due to NF-κB activation.100104 However, these responses could be due to dietary fats, rather than the resulting obesity. Increases in basal inflammation may therefore alter the reactivity of cells within the CNS to subsequent ischaemic stimuli, changing the subsequent inflammatory response.The chronic low-grade inflammation resulting from obesity may affect stroke outcome by modulating central nervous system (CNS) inflammation prior to stroke. Obese patients often show increased levels of pro-inflammatory cytokines in the plasma, including CRP, IL-6, TNFα and CCL2/MCP-1.db/db, ob/ob and high-fat fed mice after cerebral ischemia.91 This may represent a failure to mount an appropriate inflammatory response, which may prevent the appropriate transition from acute inflammation to repair and recovery. Indeed, db/db mice show delayed and diminished expression of growth factor and other markers of repair in the brain after stroke.90 In contrast, other studies have shown cytokine and chemokine expression levels are increased in ischaemic brain tissue of obese rats and mice.76 This heightened central inflammatory response could be due to the increased damage in the obese rodents, although elevated expression of inflammatory mediators is observed as early as 2.5 h after reperfusion.76Despite showing increased ischaemic damage, less microglial reactivity and reduced expression of inflammatory cytokines have been reported in the brains of both obese 105107 Since this post-stroke peripheral response occurs as central damage is evolving, this process is thought to amplify the post-ischaemic inflammatory reaction and resulting damage. In obesity, the post-stroke peripheral immune response appears to be increased, as plasma IL-6, CCL2/MCP-1 and CXCL-1 (KC) significantly increase post-stroke in obese mice.86 Inhibition of CCL2/MCP-1 using a blocking antibody reduces the damage in ob/ob mice, suggesting the peripheral inflammatory response may contribute to damage in obesity.86 Similarly, both rosuvastatin (a statin) and darglitazone (a PPAR-γ agonist) were shown to be anti-inflammatory and neuroprotective in ob/ob, but not ob/− mice.87Stroke triggers a peripheral immune response by both humoural and neural routes, featuring lymphocyte release from immune organs , release of acute-phase proteins from the liver, increased inflammatory mediators in several organs, and sustained increases in other circulating markers of inflammation.57 Vascular complications occurring later after reperfusion may be mediated by an upregulation of the matrix metalloproteinase (MMP) family of proteases. Increases in expression of both MMP-2 and MMP-9 have been found in the ischaemic hemispheres of obese rodents,82 and greater BBB breakdown, haemorrhagic transformation and ischaemic damage are absent in high-fat fed MMP-9 knock out mice64 suggesting a causative role of MMP-9 in the detrimental effects of obesity. MMP-9 is expressed by cerebral vessels after stroke in ob/ob mice,80 but MMP-9 may also originate from adherent leukocytes, particularly neutrophils that release large quantities of MMP-9 upon degranulation.108 In support of this, increased adhesion of neutrophils and other leukocytes are found in cerebral vessels of obese rodents post-stroke,86 as well as increased neutrophil recruitment in the parenchyma.74 Furthermore, the total number of circulating leukocytes is increased in obese people, including increases in monocyte and neutrophil abundance and oxidative burst activity109114 and also in obese mice.115 Obese mice also show increased vascular inflammation after stroke, characterised by increased vascular ICAM-1 expression, which may mediate neutrophil recruitment.76 These data suggest that obesity exacerbates inflammatory processes converging at the brain microvasculature endothelium, resulting in leukocyte recruitment and BBB breakdown. However, it is currently unclear whether these effects are mediated by changes within or external to the vasculature. For example, obesity may result in changes to the vasculature that subsequently worsens the vascular response to stroke. Alternatively, they may be caused by the convergence of other non-vascular causes at the BBB.Evidence from rodent studies suggests that obesity exacerbates inflammatory disruption of cerebral microvessels, worsening stroke outcome. This is seen experimentally as an increase in BBB permeability, increased incidence of haemorrhagic transformation and worse cerebral oedema. This increase in BBB permeability in obese mice is seen within 4 h of reperfusion, where it appears to be mediated by an increase in transcytotic endothelial vesicles, rather than a loss of tight junction integrity.2).116 Furthermore, in patients receiving intravenous thrombolysis after stroke, obesity had no effect on the development of haemorrhagic transformation.118 This is in contrast to genetically obese mice deficient in leptin (ob/ob) or its receptor (db/db), and diet-induced obese mice, which show an increased incidence of haemorrhagic transformation after experimental stroke.80Whether stroke leads to enhanced microvascular disruption in obese humans is much less clear. No study has yet compared BBB leakage in obese versus non-obese patients, or in patients with similar co-morbidities. However, in patients followed up within a week of ischaemic stroke, the risk of risk of haemorrhagic transformation was decreased in obese patients , potassium chloride (KCl) and endothelin-1 (ET-1), and reduced vasodilation in response to acetylcholine.119 However, other authors reported no effect of high-fat diet on vascular responsiveness, or attributed it to co-morbid hypertension.82 These changes may have a functional impact on cerebral blood flow, for example obese mice show an altered response in cerebral blood flow after whisker stimulation.120Obesity has effects on the structure and responsiveness of the cerebral vasculature that are likely to negatively affect stroke outcome. In high-fat fed and genetically obese rodents the middle cerebral arteries undergo remodelling that features a decrease in the lumen diameter and an increase in the thickness of the vascular wall, increasing vascular resistance.121124 Although these observations have not been made directly in cerebral vessels, obese patients show other hallmarks indicative of cerebrovascular dysfunction. For example, increasing BMI is associated with lower cerebral blood flow velocity, increased cerebrovascular resistance and decreased cerebral blood flow.125127 Therefore, both preclinical and clinical data suggest that cerebrovascular dysfunction characterised by increased vascular resistance and impaired autoregulation may contribute to worsened stroke outcome or risk in obesity.Similar findings have also been made in the peripheral blood vessels of obese patients. Obesity is associated with increased intima-media thickness and decreased elasticity in arteries, impaired endothelium-mediated vasodilation and increased endothelin-1 activity.129 Adiponectin has a variety of anti-inflammatory actions, and has recently been shown to be neuroprotective in stroke.131 In humans, increased levels of plasma adiponectin correlate with decreased ischaemic stroke damage, and conversely, low levels are associated with increased mortality after stroke.132 Similar observations have been made in rodent models of transient focal ischaemia, with adiponectin administration decreasing infarct size and neurological deficit,131 and adiponectin-deficiency increasing damage.133 The neuroprotective effects of adiponectin appear to be primarily mediated via the ischaemic cerebrovascular endothelium where adiponectin selectively localises post-stroke. The mechanisms of this localisation are not fully understood since adiponectin is not synthesised locally and does not permeate an intact BBB,134 but may involve adhesion to collagens of the injured endothelium and passage over the ischaemically damaged endothelial barrier.133 The resulting accumulation of adiponectin may have a variety of beneficial effects. Adiponectin appears to promote BBB integrity by reducing BBB permeability, microvascular MMP-9 expression and parenchymal leukocyte accumulation.131 Furthermore, adiponectin induces endothelial nitric oxide synthase (eNOS) activation and consequentially increases cerebral blood flow during ischaemia.130 Finally, adiponectin has been shown to decrease expression of pro-inflammatory cytokines, purportedly by inhibiting NF-κB, possibly due to activation of adiponectin receptors.134 A similar decrease in inflammatory cytokine expression was found in cultured brain endothelial cells treated with adiponectin.134 Through these actions, adiponectin has been extensively shown to protect the vascular endothelium in the periphery.135 Therefore, a loss of these protective effects may explain increases in stroke damage and microvascular complications in obese mice where adiponectin levels are chronically decreased. In support, recent data demonstrate that obesity exacerbates experimental ischaemia by increasing apoptosis of adiponectin-expressing neurones.61Plasma levels of adiponectin are high in healthy adults, but reduce in correlation with increasing adiposity.136 Using lean mice, Zhang et al.137 reported that leptin dose-dependently reduced infarct volume and neurological deficits after transient focal ischaemia, suggesting leptin was neuroprotective. Furthermore, in leptin-deficient obese ob/ob mice administration of leptin was protective in permanent focal ischaemia84 but detrimental in transient focal ischaemia.86 In addition, a lack of any significant effect of leptin was reported in both lean and obese ob/ob mice.80 No conclusive explanation has been given for these conflicting reports, however differences in dose regimes, adiposity and reperfusion may be involved, suggesting that leptin’s role is more complicated than being merely pro- or anti-inflammatory.The adipokine leptin has also been investigated for its role in stroke outcome, with several authors reporting seemingly conflicting conclusions. Since leptin circulates at levels proportional to body fat, obesity results in an increase in plasma leptin concentration. However, because these high concentrations are sustained, obesity may result in desensitisation to central leptin signalling.138 with acute hyperglycaemia resulting in greater infarcts and an increased risk of HT in rodents.139 Hypertension is the most important modifiable risk factor for stroke, and itself increases HT risk.140 Importantly, the pathological evolution of these conditions is intimately linked to obesity,141 so that disassociating the specific impact of obesity on health outcomes is difficult. This is the case in patients, but also in preclinical models of obesity that often develop different aspects of the metabolic syndrome dependent on their age, diet and genetic background  does not mean their causative pathologies are not present and developing. This means that although animal models of obesity mimic the situation in obese people, the possible contribution from other co-morbidities should be considered when attempting to study specifically the effects of obesity on stroke. This is especially important when considering effects of obesity on the cerebral microvasculature where the deleterious effects on stroke outcome of both diabetes and hypertension are focused.144 However, similar considerations must be made for studies that have previously attributed poor outcome in animal models solely to the presence of diabetes or hypertension, when animals are often also obese.Obesity is a component of the metabolic syndrome, and so is often accompanied by hyperglycaemia, hypertension and dyslipidaemia in patients that may all affect stroke outcome . Type-2 ckground . For exaDespite the well-established link between obesity and stroke risk, several clinical studies have reported that obese and overweight stroke patients have improved mortality and morbidity. This is in stark contrast to the consensus of preclinical studies, which have clearly shown that obesity worsens stroke outcome in rodents. There are many potential reasons for this disparity, which will be discussed, including differences in experimental design, models, aims and outcomes between preclinical and clinical studies.145 The metabolic consequences of stroke have been poorly studied pre-clinically in general, and even less so in the context of obesity. In preclinical studies, stroke is usually surgically induced in obese mice, rather than waiting for spontaneous strokes to occur. Therefore, if the obesity paradox is primarily due to the effects of obesity on risk, for example increasing the risk of a stroke earlier in life, then this would not be detectable in current animal studies. A further problem is that animals are almost all young and male. This tight control of variables, such as sex and age, is useful in establishing causal links in experimental studies, but does not reflect the clinical situation. A final disadvantage of preclinical studies is their exclusive use of rodents, and whether rodent physiology can accurately model human stroke. This question has been discussed in detail elsewhere.147The preclinical studies assessing the effects of obesity on stroke outcome are all experimental, and have several limitations in common. Whereas the clinical studies typically assess outcome in terms of functional recovery or mortality at weeks or years post-stroke, the majority of preclinical studies have focused on the evolution of the ischaemic lesion within 48 h of reperfusion. This focus on short-term outcomes may explain why no obesity paradox is found in preclinical studies. For example, a hypothesised reason that obesity is protective in stroke patients is that the metabolic reserves present in obesity protects against post-stroke weight loss, and associated muscle wasting.424650 However, due to the presence of these other co-morbidities, it becomes difficult to attribute the worse outcome in rodent models as being solely due to obesity. This is in contrast to clinical studies that can quantify the specific contribution of obesity to stroke outcome by applying multivariate statistics to large, heterogeneous patient populations. By this reasoning, worse stroke outcome in obese rodents may not be due to their adiposity, but their development of dyslipidaemia, diabetes or vascular disease. However, the same may be true of the individual stroke patient, whose outcome will be determined by a constellation of common co-morbidities.Worse stroke outcome has been reported in both genetically obese and diet-induced obese rodents, yet both models also develop other pathologies alongside their increased adiposity . As disc149 In diet-induced obesity, the constitution of the diet  can affect the resulting phenotype. Use of an altered diet also adds an extra variable to consider, as effects on outcome may be due to the diet per se, rather the resulting obesity. Preclinical studies also use animals that are more homogenously and robustly obese than the patient population. Although this homogeneity makes interpretation of the contribution of obesity easier in experimental studies, it ignores the potentially protective effects of mild obesity (e.g. overweight). For example, mice fed a high-fat diet for 4 months show an average body weight increase of 60%.60 Assuming mice fed a control diet have a healthy BMI of 20–25, this translates to an increase in ‘mouse BMI’ to 32–40. In both mice and rats, the harmful effects of obesity on stroke outcome are not observed until a threshold level of obesity is obtained.73Although both genetic and diet-induced obese models replicate the clinical situation found in obese patients, both have other drawbacks. Monogenic mutations leading to obesity are actually very rare in the general population and leptin has other immunological roles beyond regulation of energy balance.The clinical studies assessing the impact of obesity on stroke outcome are almost universally observational – experimental studies in this setting are not possible as they would require purposefully exposing patients to either stroke and obesity. For similar reasons, observational studies are limited in their potential outcomes as non-invasive techniques are preferred. Furthermore, very acute events after the onset of ischaemia are difficult to study clinically as patients may not arrive at hospital until hours after symptom onset, and even then their care must be prioritised. Therefore, such findings of faster evolution of damage in obese rodents would be difficult to replicate in patients.151 This results in non-causal relationships or associations between effects (factors that can affect the risk of stroke), for example between obesity and age. For this reason, the average age of patients in the obese groups is lower than in the non-obese groups of several studies reporting on the obesity paradox, with age often decreasing inversely with BMI and reaching a difference of 10 years in the most obese groups.4753 This problem is not insurmountable, as in the case of known and commonly measured effects, such as age and traditional cardiovascular risk factors, their impact can be adjusted for statistically. However, there are many potential factors that may affect stroke incidence that are not commonly measured, so-called unmeasured effects. Similarly to age, stratification based on the presence of stroke will also create non-causal relationship between these unmeasured effects and obesity due to collider-stratification bias. As we cannot statistically adjust or account for the presence of unmeasured effects, they can distort the relationship between obesity and stroke outcome. This confounding of the stroke-mortality relationship by unmeasured confounding effects has been hypothesised to account for all of,151 or at least part of,152 the obesity paradox.A further potential problem with observational studies is their potential for selection bias. A typical epidemiological study assessing how obesity affects stroke outcome will include all patients in their cohort that present with ischaemic stroke on hospital admittance. However, stratifying based on the presence of ischaemic stroke introduces collider-stratification bias, a type of selection bias.154 In support of this, obesity has a beneficial effect on vascular disease survival in obese diabetic patients when obesity is classified by BMI, but not when classified by waist circumference.155 Furthermore, people with elevated BMI are not always obese (i.e. have increased adiposity) and conversely people within normal body weight by BMI can still show a high percentage of body fat that is associated with higher risk of disease.156 The usefulness of BMI as a measure of adiposity may also decrease with age. In a cohort of patients with chronic heart failure with mean age 62–66, BMI misclassified body fat status 41% of the time, and was a better indicator of lean body mass than adiposity.157The existing clinical studies have primarily used BMI as a measure of obesity, but BMI may not always be the best indicator of adiposity. This is primarily because BMI does not discriminate between lean body mass and fat mass, and obesity is associated with an increase in both lean and fat mass. Other measures of obesity may more accurately reflect harmful adiposity, for example visceral/abdominal obesity rather than BMI is more strongly correlated with metabolic health.Preclinical research has clearly shown that obesity worsens stroke outcome in rodents, suggesting a central role of pathological changes in the cerebrovasculature, including vascular inflammation and remodelling. In comparison, it is still unclear whether obesity worsens outcome in patients, and many preclinical findings cannot be replicated in the clinic. Future unification of preclinical and clinical findings will rely upon better alignment of research goals, with common outcomes that can be assessed in both fields. For example, studies assessing longer term functional outcomes in obese rodents could give insights into the obesity paradox in patients.In this approach, preclinical studies should aim to make findings, which are verifiable in the clinic, and thereby give more confidence in translation potential of preclinical research.Despite this disparity between the preclinical and clinical outlooks, several key mechanisms that may mediate the interaction between stroke and obesity have been identified , though At least in the preclinical data, there is strong evidence that altered inflammatory processes are central in mediating the worse stroke outcome found in obese rodents. Furthermore, there is a clinically established role of inflammation in both stroke and obesity. Further work is therefore required to reconcile the preclinical and clinical outlooks and allow identification of mechanisms important in both rodents and men, hopefully translating into better care for obese stroke patients.


Overall Abstract: Smartphone and internet based applications that promote symptom tracking, treatment engagement, and self-management have the potential to improve mental health outcomes and reduce cost of care. This is especially important in the treatment of psychosis, as long-term clinical outcomes to commonly available treatments remain poor and financial costs are high. The speakers in this symposium will present novel approaches using mobile health technology to promote rapid identification and referral (Dr. Niendam), access to treatment , treatment engagement and symptom tracking (Dr. Tully), and functional recovery (Dr. Alvarez-Jimenez) for individuals experiencing psychosis.Dr. Niendam will present initial results of a community-based cluster-randomized controlled trial aiming to increase identification rates of individuals with psychosis and reduce Duration of Untreated Psychosis. Twenty-two school, community, and primary care sites in Sacramento, California were randomized to either standard community education and clinician-based referral versus standard education plus electronic (tablet) screening for psychosis symptoms. Results show electronic screening is feasible across various community settings and significantly increases identification rates compared to clinician-based identification alone.Dr. Hidalgo-Mazzei will present data examining the feasibility of delivering a psychoeducational treatment program that promotes self-management in bipolar disorder. The SIMPLe platform is accessible from any internet enabled device and provides symptom monitoring and personalized psychoeducation content in Spanish, Italian, and French. Data from a large open trial with over 300 participants from across the globe demonstrate how mobile technologies can increase access to care by extending effective interventions to many people at low cost.Dr. Tully will present data on the feasibility, validity, and predictive utility of a consumer smartphone application (“app”) plus provider web-based Dashboard as an add-on treatment tool in Early Psychosis outpatient programs in Northern California. Data demonstrate that consumers and providers in community-based outpatient clinics are responsive to integrating smartphone technology into treatment services. Consumers willingly use the app to track their symptoms; symptom data gathered via the app appears to be a valid reflection of symptoms experienced over time and can predict symptom exacerbations two weeks later.Dr. Alvarez-Jimenez will present data demonstrating the feasibility, acceptability, and efficacy of two novel online social media based platforms designed to promote functional recovery in Ultra High Risk and First Episode Individuals. Results indicate online social media platforms are safe, engaging, and improve social functioning in both populations – a domain that is often neglected in most treatment approaches.Chantel Garrett is the founder of Strong365.org, a website providing consumer and family-focused psychoeducation materials related to psychosis in 103 languages. She also has lived experience as a family member of a loved one with schizophrenia. As discussant, she will speak from her expertise as both a developer and consumer of internet-based and mobile technologies to elucidate how mobile health materials can impact provision of mental health care, and facilitate discussion of the barriers and future directions for the field. Implementation of technology-based care across diverse cultures and languages will also be discussed.


We report on the increasingly important need to diagnose and care for the elderly with sepsis as a distinct patient population. We share an overview of age-related changes in sepsis physiology and the potential role of exercise.https://ccforum.biomedcentral.com/articles/10.1186/s13054-017-1783-1See related research by Tyml et al.,  For all the supposed benefits attributable to moderate exercise in the elderly population  –3, improSepsis is a critical issue in old age and is among the top causes for intensive care unit (ICU) admission in the elderly . The incThe mechanism(s) underpinning the disproportionate susceptibility to sepsis in the elderly is not yet fully understood. Elderly patients are at higher risk for sepsis likely related to the higher rates of comorbidities, including dementia, poor dentition, and diabetes. With age, intact integument and physiologic reflexes  that contribute to the body’s physical defense mechanisms to infection can degrade. Additionally, institutionalization, implanted devices, and surgical procedures can predispose patients to infection .All mammals age over their lifetime, manifest by gradual development of telomere shortening of chromosomes, degenerative arthritis, loss of hair, inactivity, atherosclerosis, impaired T- and B-cell responses, and age-related malignancies , 8. MiceElderly septic patients often do not have typical clinical responses to sepsis, making diagnosis by the Sepsis-3 quick Sepsis-Related Organ Failure Assessment (qSOFA) criteria difficult. Older patients may present with inverse signs and symptoms , or nonspecific signs of infection . AccepteOnce infected, older patients experience a disadvantaged host immune response with defects in humoral and cellular immune function . The patElderly mice experience many of the same age-related defects in immune function and increased risk of infection as observed in the older adult human patients . Aged miA recent report now directly challenges the potential role of exercise in an isolated, controlled setting where other variables were minimized . These iIntriguingly, consistent upregulation of endogenous endothelial nitric oxide synthase (eNOS) was observed in exercised mice compared to nonexercised mice . Nitric Like many innovative investigations, the results of this study pose more questions than they answer. Would the advantageous effects of exercise work as well in outbred mice, females , and how long does the protective effect of exercise last in aged mice after exercise succession? How much exercise is enough, when should it start, and is there a dose-response effect to exercise conditioning? Does exercise work better in obese or nonobese subjects? The most critical question is, of course, how well do these study findings in mice translate to improved outcomes in human sepsis? The data collected thus far in older humans indicate that while the effects of exercise on inflammatory biomarkers is measurable, the effect size is rather small and often confounded by obesity indices –3.Should future surviving sepsis campaigns recommend daily exercise for older patients to stave off the risk of death from sepsis potentially lurking in their future? Should octogenarians be encouraged to do some daily exercise? Based on this study, one of the purported benefits might be a more constrained and appropriate host response to systemic infection.Additional animal models would likely be needed to confirm these findings as retrospective, observational studies in humans would be susceptible to selection bias and randomized trials would be very difficult to organize. Randomly assigning people to the nonexercise group would pose an ethical challenge considering the many common benefits of light physical activity in aging populations . If conf


To investigate the association between complications during pregnancy and premature coronary heart disease in adult offspring.We conducted a population-based case-control study of 153 Indonesian patients with a first acute coronary syndrome (ACS) (age ≤55 years) and 153 age-matched and sex-matched controls. Data on complications during pregnancy  and maternal infections in pregnancy were obtained, together with sociodemographic data, clinical profiles, laboratory measurements and adulthood cardiovascular disease (CVD) risk factors at hospital admission or enrolment. Conditional logistic regression was performed to assess the association between overall pregnancy complications, and specific groupings of complications and premature ACS.adjusted 4.5, 1.1 to 18.1, p=0.036). In subgroup analyses, pregnancy-related high blood pressure  and maternal infections  were associated with offspring ACS.Pregnancy-related hypertension and infection were more common in mothers of cases than controls. Pregnancy complications were associated with premature offspring ACS , and the association persisted in fully adjusted analyses (OROffspring of mothers with complications during pregnancy have an increased risk for premature ACS in adulthood, which may be of particular relevance in populations in transition, where the incidence of both pregnancy-related morbidity and CVD are high. Increasing evidence indicates that in utero exposures contribute to adult disease, in addition to childhood and adulthood exposures.WHO has reported that 99% of all global maternal deaths due to pregnancy complications occur in the low-income and middle-income countries.We hypothesised that complications in pregnancy may contribute to the increased incidence of premature CVD in this setting. Therefore, we conducted a population-based case-control study of a first acute coronary syndrome (ACS) episode in Indonesia to investigate the association between complicated pregnancy and the occurrence of early coronary heart disease (CHD) in adult offspring.This study was conducted between February 2013 and December 2014 in Makassar Cardiac Center, Wahidin Sudirohusodo Hospital, the general academic and referral hospital in East Indonesia.Cases were defined as patients with a first ACS event occurring at age ≤55 years. After obtaining written informed consent, we enrolled 153 consecutive new patients, who were admitted to the cardiovascular care unit with ACS, defined as unstable angina (UA), non-ST segment elevation myocardial infarction (NSTEMI) and ST segment elevation myocardial infarction (STEMI).17Cardiologists made a diagnosis of ACS in patients with acute cardiac chest pain based on clinical presentations, ECG, and elevated biomarker of cardiomyocyte injury (cardiac troponin (cTn) and/or creatine kinase muscle and brain (CKMB)). Patients were diagnosed with STEMI if they had new or presumed new significant ST segment T wave (ST-T) changes or new left bundle branch block, and/or development of pathological Q waves on ECG, with an increase of cardiac troponin T (cTn-T) and/or CKMB, at least one value above the 99th centile of a normal reference population (upper reference limit).We enrolled young adult controls from the general population in equal numbers to cases. We matched the cases and controls for age (±3 years) and sex. Controls were sampled from the same residential neighbourhood as the cases and were invited to visit a primary healthcare centre for clinical examination, laboratory measurements and a questionnaire interview. To ensure incidence-density sampling, a control was recruited in the same week as a case was enrolled. Controls were excluded if they had any previous diagnosis of CVD, had current clinical features of a cardiovascular event or were unable to give written informed consent.A detailed questionnaire was administered to all cases and controls. In the cases group, we obtained baseline data from medical records, physical examination and interview, including age, sex, occupation, monthly income, education level, dietary pattern, physical activity, smoking status, parental history of CVD, as well as previous history of hypertension and diabetes , genitourinary tract infections, dengue fever, malaria, varicella, measles and unspecified infections ). Reliable medical records in hospital and primary healthcare in Indonesia did not exist at the time of pregnancy. Therefore data on pregnancy complications were obtained using take-home questionnaires filled by participants (cases and controls), enabling information to be sourced from their mothers or other family members who were present throughout the pregnancy. We collected the questionnaire by visiting participants' houses. We subsequently verified the data by a further interview to minimise missing data and resolve ambiguities.There are several possible confounders that may be relevant to analysis of an association between pregnancy complications and premature ACS in adult offspring. The following variables were therefore included in the regression analyses: adulthood lifestyle (current smoking status); dietary pattern  intake, and high fatty food intake); socioeconomic status (monthly income and college education); parental history of CVD; childhood infections,In the present study, we included childhood infections (yes/no) as a confounding variable, as we20Crude=Univariable (matched for age and sex)Model 1=Crude+adulthood lifestyle+dietary pattern+socioeconomic statusModel 2=Model 1+parental history of CVDModel 3=Model 2+childhood infectionsModel 4=Model 3+adulthood cardiovascular risk factorsThe selection of confounders in this study is crucial. As pregnancy complication is a broad categorisation encompassing various conditions during pregnancy, there are several extraneous factors that potentially act either as a confounding or as an intermediate variable. Maternal infections during pregnancy may be related with offspring childhood infections, while maternal high blood pressure in pregnancy is related with offspring hypertension in adult life.2 tests were applied. We reported median and IQR for skewed data. Main results were expressed as crude and adjusted ORs from univariable and multivariable conditional logistic regressions, with their 95% CI, corresponding to two-sided p values <0.05.Baseline characteristics of cases and controls were first tabulated for descriptive purposes and confounder assessment. To assess group differences, paired t-tests were performed with normal distributions and non-parametrical Wilcoxon signed-rank tests for skewed distributions. For categorical variables, McNemar's χWe initially performed the overall analyses dichotomising the presence of pregnancy complications as the exposure. We then performed complication-specific analyses for two subgroups: (1) high blood pressure, and (2) maternal infections. We did not apply further subgroup analyses for preterm delivery as this complication showed very low numbers among cases and controls. In subgroup analyses, we restricted the analyses to the subset group of interest as ‘exposed’ group, while other pregnancy complications and those without any pregnancy complications were classified as ‘unexposed’ group. Statistical analyses were performed with IBM SPSS V.23.0.Baseline characteristics of cases and controls are shown in adjusted 4.5, 95% CI 1.1 to 18.1, p=0.036). In subgroup analyses, maternal high blood pressure  and maternal infections  during pregnancy were related with offspring premature ACS.In this case-control study of Indonesian adults, complications during pregnancy were associated with premature ACS in adult offspring. These associations were independent of adulthood cardiovascular risk factors, dietary pattern, socioeconomic status, parental history of CVD and childhood infections. In subgroup analyses, those born following pregnancies complicated by infection were significantly at increased risk of premature ACS. To the best of our knowledge, this is the first report of an association between maternal infections in pregnancy and CVD in the offspring.Although CVD risk factors burden has transited from rich to poor populations in Indonesia,It is generally accepted that maternal problems such as hypertension and infections during pregnancy, and preterm delivery may directly affect birth outcomes in the newborns. There is also increasing evidence relating these exposures to later outcomes in childhood23This is the first study to address the relationship between maternal infections during pregnancy and clinical CVD in adult offspring. The mechanisms are unclear, as the absolute number of mothers reporting infection in pregnancy is modest, the diagnoses were by maternal recall, and antibiotic and other treatments are largely unknown. Further longitudinal studies are warranted to confirm this finding, interrogate mechanisms and provide a platform for translation. Previous studies and meta-analyses on pregnancies complicated by maternal infection have reported increased risk of adverse neurodevelopmental outcomes in the offspring, including autism spectrum disorder,27Mounting evidence suggests that impaired fetal growth is associated with increased risk of adult CHD.The longitudinal Helsinki Birth Cohort Study reported a relationship between pre-eclampsia and pregnancy hypertension with the occurrence of stroke in adult offspring, but not with CHD.Interpretation of these novel but preliminary data should be considered within the limitations of longitudinal data in this setting. The potential mechanisms that underlie the association between pregnancy complications and premature ACS in adult offspring may involve fetal growth impairment,Finally, we could not consistently detect the association between maternal high blood pressure and offspring CHD. The associations were unstable, but the ORs were increased, and therefore this may reflect limited power from our sample size to perform subgroup analysis. Our study was a formal and planned case-control study as apparent from prospective (new) ACS cases collection and incidence density sampling of controls. We did not perform a pre hoc power calculation. Instead, we planned for inclusion of as many cases as possible within a reasonable time frame and managed to include one control for every included case, as described. Notably, ours is one of the biggest case-control studies performed on this subject, certainly in Indonesia. We did attempt to avoid overfitting our models, and therefore we carefully performed stepwise analyses in four adjustment models. Although clear rules of thumb for multivariable  logistic regression are currently not available,Our findings contribute to the understanding of the relationship between pregnancy complications and the clinically manifest CVD in adult offspring. However, further studies—ideally larger, prospective and longitudinal—are required to confirm the specific associations and to investigate the underlying mechanisms. In terms of clinical implications, optimising maternal health and nutrition during pregnancy may reduce or delay the development of CVD in the offspring. Vaccination and adequate treatment of pregnant women with infectious diseases is of importance, especially in settings where the burden of infection is high. In addition, the necessity of standardised data and management of pregnancy complications is essential, particularly in low-income and middle-income countries in South-East Asia where the infrastructure, financial and human resources are limited.Maternal complications during pregnancy have long been associated with increased risk factors for cardiovascular disease (CVD) in the offspring. However, it is unclear if these complications are also related to the development of clinically manifest CVD in the offspring, particularly at a younger age.Both maternal pregnancy complications and premature CVD are currently major health issues in South-East Asia.We found that pregnancy complications were associated with an increased risk of clinically manifest acute coronary syndrome in young adult offspring. This is the first report of an association between the common pregnancy complications  and offspring premature coronary heart disease in a low-income and middle-income population of South-East Asia.Our study adds to the existing knowledge on maternal pregnancy complications and cardiovascular risk factors, notably that such exposures may partly contribute to the increase of premature CVD in countries with epidemiological transition.From our findings, we suggest that optimising maternal health and nutrition during pregnancy may reduce or delay the development of CVD in the offspring.Vaccination and adequate treatment of pregnant women with infectious diseases is of importance, especially in settings where the burden of infection is high.The necessity of standardised data and management of pregnancy complications is essential, particularly in the low-income and middle-income countries in South-East Asia where the infrastructure, financial and human resources are limited.In conclusion, offspring of mothers with complicated pregnancies are at increased risk of premature ACS in young adulthood. Our finding may be of particular relevance in populations with epidemiological transition, where the incidence of both pregnancy-related morbidity and CVD are high.


Interstitial lung disease (ILD) comprises a heterogeneous group of diffuse parenchymal lung processes with overlapping clinical, radiographic, and histopathologic features. Among the most common and deadly ILDs are idiopathic pulmonary fibrosis (IPF) and chronic hypersensitivity pneumonitis (CHP). As the name implies, the cause of IPF remains elusive, but a variety of genetic and infectious risk factors have been identified. CHP results from chronic inhalation of an organic antigen, usually of avian or mold origin, and may occur in patients with a genetic predisposition. While IPF is treated with anti-fibrotic compounds, CHP is generally treated by suppression of the immune system and elimination of the causative antigen. Despite advances in our understanding of IPF and CHP, there exists substantial variability in the diagnosis and treatment of these disease processes. Furthermore, IPF and CHP natural history and treatment response remain far from uniform, leaving it unclear which patients derive the most benefit from disease-specific therapy. While clinical prediction models have improved our understanding of outcome risk in patients with various forms of ILD, recent advances in genomic technology provides a valuable opportunity to begin understanding the basis for outcome variability. Such advances will ultimately allow for the incorporation of genomic markers into risk stratification and clinical decision-making. In this piece, we highlight recent advances in our understanding of the genomic factors that influence susceptibility and outcome risk among patients with IPF and CHP. Genomic modalities used to identify these genomic markers include genome-wide association studies, analyses of gene expression, drug–gene interaction testing, telomere length determination, telomerase mutation analysis, and studies of the lung microbiome. We then identify gaps in knowledge that should be addressed to help facilitate the incorporation of these genomic technologies into ILD clinical practice. The interstitial lung diseases (ILDs) are comprised of a heterogeneous group of diffuse parenchymal lung processes with overlapping clinical, radiographic, and histopathologic features . Among tIdiopathic pulmonary fibrosis is now treated with compounds targeting fibrotic mediators after phase III clinical trials demonstrated efficacy in slowing pulmonary function decline –14. ProsIn this review, we highlight recently identified genomic factors influencing susceptibility and outcomes of patients with IPF and CHP. These include single-nucleotide polymorphisms (SNPs) identified by targeted sequencing and genome-wide association studies (GWAS), gene expression profiling, telomere length testing, and lung microbiome bacterial DNA profiling. We then identify gaps in knowledge that should be addressed to help facilitate the incorporation of these genomic technologies into ILD clinical practice.MUC5B (rs35705950) and an intronic SNP near TOLLIP (rs5743890). MUC5B encodes one of several mucin-producing genes, which facilitate airway clearance and function to maintain immune homeostasis  among the general population  trial (TOLLIP (rs3750920) was associated with a favorable responsive to N-acetylcysteine (NAC)  trial , 27, invne (NAC) . Comparene (NAC) . Those wNo GWAS have been performed in patients with CHP to date, but studies employing targeted genotyping have identified gene variants linked to disease susceptibility and outcomes. Camarena and colleagues conducted targeted genotyping of SNPs within the major histocompatibility complex (MHC) II region and found that SNPs within HLA-DRB1 were disproportionately present in patients with avian antigen-associated CHP compared to control subjects . SubsequWhile GWAS have identified gene polymorphisms that may influence IPF susceptibility, transcriptomic analyses of RNA isolated from lung tissue and peripheral blood have shed important light on gene expression pathways involved in IPF and CHP pathogenesis and outcomes. Selman and colleagues conducted a microarray analysis of RNA obtained from lung tissue in patients with IPF and CHP to determine whether gene expression profiles could differentiate these disease processes. These investigators showed that while patients with IPF had upregulation of genes involved in tissue remodeling, apoptosis and fibroblast signaling, those with CHP displayed upregulation of genes critical to immunologic function, including those T cell signaling and others related to MHC function .Subsequent transcriptomic investigations using lung and peripheral blood specimens from patients with IPF supported the role of genes involved in alveolar epithelial injury and remodeling in IPF pathogenesis , 32. YanIn addition to differentiating IPF from other forms of ILD, investigators have utilized transcriptomic analysis to develop a peripheral blood-based genomic prediction tool to predict IPF survival. Using a two-stage, multi-center derivation and validation approach, Herazo-Maya and colleagues identified a gene signature composed of 52 differentially expressed genes could effectively categorize patients with high versus low mortality risk over a 4-year follow-up period . This geTERT, TERC, RTEL1, PARN, NAF1, TINF2, DKC1)  and improved our understanding of the genetic underpinnings of ILD. To date, there have been seven telomere-related genes that have been implicated in adult-onset FPF  –43. Path2, DKC1) , 45.TERT is the most commonly affected gene and accounts for ~20% of FPF  from patients diagnosed with a variety of idiopathic interstitial pneumonias using 16S-rRNA gene PCR and degenerating gel electrophoresis . This wagression . The retVeillonella, Neisseria, Streptococcus, and Haemophilus spp. in patients with IPF compared to controls. The most striking differences, however, were observed in the bacterial burden, which was increased twofold in IPF patients compared to control subjects. Within the IPF cohort, bacterial burden correlated with disease progression. When stratifying the cohort by this metric, the authors demonstrated a clear increase in mortality risk with increasing bacterial burden (Figure A subsequent prospective study of the lung microbiome compared IPF cases to healthy control subjects and controls with COPD, allowing for direct compassions between health and disease . This inn Figure .MUC5B promoter polymorphism, with individuals carrying the minor allele of this SNP having a lower bacterial burden. Driven by these tantalizing interactions between host and environment, authors of both microbiome studies have attempted to advance the studies of the lung microbiome from merely descriptive and observational to functional (Streptococcus and Pseudomonas and worse survival.These authors also showed few differences in the microbiome between IPF subjects with progressive or stable disease, suggesting bacterial load itself might be more important in driving disease progression. The authors hypothesized a mechanistic link between host and environment and demonstrated an association with bacterial burden and the nctional , 64. IntMUC5B and TOLLIP, influence both susceptibility and mortality risk, few others have demonstrated significant outcome association (While some SNPs associated with IPF susceptibility, notably those within ociation , 28. Givociation , 65, it ociation , 66.The development of a transcriptomic signature to predict mortality has greatly improved our understanding of IPF pathobiology. Now that IPF has two currently approved therapies, it will be important to assess the test performance characteristics of this signature in those treated with prolonged anti-fibrotic therapy and in those without prior exposure to immunosuppressive therapy, as was common practice prior to completion of the PANTHER trial . In addiTERT and TERC suggest that immunosuppression after lung transplant for ILD may be associated with high rates of side effects including bone marrow failure, liver toxicity, and infections (TERT carriers (The presence of telomere-related rare variants or short telomere length predispose to rapid disease progression in both IPF and CHP, however, there is very little data regarding response to specific treatments. The therapeutic strategies for IPF and CHP differ substantially. Immune suppression is often employed for patients with CHP and progressive disease, while immunosuppression is detrimental in IPF . To our fections –69. Thisfections –14, but carriers  but largIdiopathic pulmonary fibrosis is characterized by a distinct respiratory microbiome, with a higher bacterial burden than in health. This is further disturbed during exacerbations of disease . DespiteThe majority of genomic data generated to date has been in patients with IPF, leaving CHP ripe for similar investigation. However, standardization of diagnostic criteria through international consensus is first needed. Once that occurs, GWAS to identify SNPs linked to disease susceptibility and survival would advance our understanding of disease underpinnings and potentially identify novel therapeutic targets for this devastating disease without proven therapy. In addition, determining whether outcome-related transcriptomic signatures derived in patients with IPF informs outcomes in patients with CHP will be of immense clinical value. Finally, determining whether the microbiota makeup of patients with CHP influences disease susceptibility and outcomes has the potential to guide therapy in these patients.In this review, we highlight the most developed genomic technologies informing susceptibility and outcome risk in patients with IPF and CHP. There remain critical questions to be answered to characterize the extent to which these technologies will improve risk stratification. In addition, a cost benefit analysis will be necessary to determine whether individual technologies make sense from a cost utilization perspective. The field of ILD has advanced rapidly over the last 10 years and will continue to do so into the foreseeable future. Clinical genetics represents the logical next step for the field and holds great potential to be a cornerstone of personalized medicine in the field.CN, PM, and JO contributed to the conception and writing of this review. All authors have reviewed and approved the submitted work.CN, PM, and JO have no relevant conflicts to disclose related to the submitted work.


Pulmonary arterial hypertension (PAH) is rare, but patients who are diagnosed with this disease still suffer from a lack of satisfactory treatment strategies to prolong survival. While currently approved drugs for PAH have some benefits, these vasodilators only have limited efficacy for eliminating pulmonary vascular remodeling and reducing mortality. Thus, our laboratory has been exploring the use of aggressive drugs, which are capable of causing apoptotic cell death, to treat PAH. We have so far found that three classes of anti-tumor agents, including anthracyclines, taxanes, and proteasome inhibitors, are capable of reducing pulmonary vascular thickness in rats with PAH. These drugs kill cells in remodeled pulmonary vessels without affecting the normal, healthy pulmonary vasculature, revealing that proliferating vascular cells in PAH patients are more sensitive to drug-induced apoptosis compared to the differentiated phenotype that is physiologically important for smooth muscle contraction. Since many apoptosis-inducing drugs cause cardiotoxicity in cancer patients, and because PAH patients already have a weakened heart, we focus on finding biological mechanisms that may reverse pulmonary vascular remodeling without promoting cardiotoxicity. We found two agents, dexrazoxane and pifithrin-α, that selectively inhibit cardiac muscle apoptosis without affecting the drug-induced apoptosis of the proliferating pulmonary vascular cells. Thus, we propose that the addition of apoptosis-inducing drugs and cardioprotectants to PAH therapies may be effective in treating patients and preventing right heart failure. PAH prevalence is two-to-four times higher in women than in men3, and the disease can affect people of any age, even children. The early symptoms of PAH include mild dyspnea, fatigue, and dizziness, which can also be associated with various other diseases. Further, accurate diagnosis of PAH requires an invasive right-heart catheterization2. As a result, PAH diagnosis is often delayed and, by the time patients are diagnosed with PAH, the disease is progressed to the occurrence of pulmonary vascular remodeling and right ventricle (RV) remodeling3.Pulmonary arterial hypertension (PAH) is a rare disease with prevalence estimated between 15 and 50 cases per million people4. The narrowing and occlusion of pulmonary vessels, as well as the elevation of pulmonary vascular resistance are due to multiple factors, including vasoconstriction and the thickening of pulmonary vascular walls. Currently approved drugs for PAH treatment primarily cause vasodilation, but these have limited influence on the structural changes in the vessel walls.In PAH, elevated pulmonary vascular resistance causes stress to the RV, and RV failure is the major cause of death in patients with PAHIncreased pulmonary vascular wall thickness and the narrowing and, in some cases occlusion, of the pulmonary arterial lumens are due to the growth of pulmonary arterial cells such as smooth muscle cells, endothelial cells, and fibroblasts, which form various lesions including medial hypertrophy; eccentric intimal proliferation; concentric, non-laminar intimal thickening; concentric, laminar intimal thickening; fibrinoid necrosis; occlusive intimal proliferation; and plexiform legions. However, as noted above, PAH patients are often diagnosed after developing severe changes in the pulmonary vasculature, suggesting that inhibiting cell growth may have only limited effects in terms of reducing vascular resistance. Thus, our laboratory is exploring the effects of therapeutic agents that are capable of causing the death of pulmonary vascular cells in order to eliminate lesions that contribute to the narrowing and occlusion of the pulmonary vessels . Since i5. Since PAH patients already suffer from RV dysfunctions, the use of such drugs, which could potentially worsen the cardiac problems in PAH patients, poses challenges. In this regard, over the last decade, our laboratory has been investigating: (i) whether pulmonary vascular cells are susceptible to apoptosis; (ii) whether the administration of apoptosis-inducing, anti-tumor drugs reverses pulmonary vascular remodeling; and (iii) what the effects of these drugs are on RVs influenced by PAH.Research in cancer therapy, which also frequently utilizes apoptosis-based approach, has demonstrated that one major problem with using cell death-causing agents is that they can also cause the deaths of cells which we do not want to kill. Notably, many anti-tumor drugs cause the death of cardiac myocytes, exerting cardiotoxicity6. Another important reason was that since anthracyclines have cardiotoxic properties, particularly left ventricle (LV) toxicity, in cancer patients5, such drugs may serve as an excellent model for understanding how normal RVs and RVs affected by PAH may be influenced by anti-tumor drugs. While the RV and LV are generally thought to have identical molecular characteristics, our studies have revealed differential molecular-signaling mechanisms in the two ventricles8. Thus, we thought we might find that the RV is not as susceptible as the LV to the toxic effects of anthracycline administration. Further, our studies using cultured cells revealed that the mechanisms of DNR-induced cell death processes differ between PASMCs and cardiac muscle cells9. We reported that DNR kills cardiac muscle cells via p53-dependent inhibition of the DNA-binding activity of the CBF/NF-Y transcription factor toward the CCAAT box within the promoter region of Gata4 that regulates the gene transcription of anti-apoptotic proteins10. In cardiac muscle cells, a p53 inhibitor, pifithrin-α, suppresses DNR-induced CBF/NF-Y activity and therefore GATA4 downregulation and cell death . DNR is the first member of the anthracycline class of anti-tumor agents and has been used clinically for 50 years. One reason we investigated this drug is that DNR was found to be an effective inducer of apoptosis in cultured human pulmonary artery smooth muscle cells (PASMCs)ll death . By contll death . These r12. Importantly, neither the reduction of vascular wall thickness nor the induction of apoptosis occurred in the pulmonary vessels of normal control rats, suggesting that remodeled pulmonary vasculature is sensitive to DNR-induced cell killing.To determine the effect of DNR in intact animals, Sprague-Dawley rats were exposed to chronic hypoxia for 2 weeks to develop pulmonary hypertension and pulmonary vascular remodeling, characterized by thickening of the smooth muscle mass. After pulmonary hypertension and vascular thickening were developed, DNR was administered. We found that, within 3 days, DNR at a concentration as low as 5-mg/kg body weight significantly reduced pulmonary arterial wall thickness, a reduction associated with increased apoptosis13. Bortezomib has been used to treat multiple myeloma and relapsed mantle cell lymphoma.14 To produce the more severe pulmonary vascular remodeling, resembling the human disease, rats were injected with SU5416  and then subjected to chronic hypoxia for 3 weeks16. Subsequently, maintaining these rats in normoxia for 2 weeks developed medial as well as intimal thickening in the pulmonary vasculature, and proteasome inhibition effectively reduced vascular wall thickness in this model12.We found that proteasome inhibitors -- bortezomib and MG-132 -- also reversed pulmonary vascular remodeling in chronic hypoxia-induced pulmonary hypertensive ratsAs described above, DNR reduced the thickness of remodeled pulmonary arterial walls in rats exposed to chronic hypoxia without affecting the pulmonary vessels of normoxic control rats. Understanding this remarkable mechanism should help in developing improved therapeutic agents for PAH.17, is also expressed in PASMCs and may define the mechanism for the increased susceptibility of remodeled pulmonary vascular walls to DNR-induced cell death. We found that DNR increases the expression of parkin in the pulmonary arteries of normal rats, but not in rats with PAH , considered to be a safe and effective alternative to bortezomib in the treatment of multiple myeloma19. In two rat models of PAH , CFZ reduced pulmonary vascular wall thickness and induced programmed cell death  was administered along with CFZ in rats with PAH. Remarkably, pifithrin-α completely protected the LV against CFZ-induced apoptosis. Moreover, pifithrin-α did not affect the action of CFZ to induce the apoptosis of pulmonary vascular cells or to reduce vascular wall thickness in rats with PAH20. Thus, p53 inhibitors protect the heart against drug-induced toxicity without altering the efficacy of antitumor agents to reverse pulmonary vascular remodeling. While we do not yet understand the mechanism, a clinically used, FDA-approved cardioprotectant against anti-tumor agents, dexrazoxane, also exhibited protective effects against CFZ-induced cardiotoxicity in PAH rats without affecting the efficacy of CFZ to reverse pulmonary vascular remodeling20. Thus, including dexrazoxane or pifithrin-α should be considered during apoptosis-based therapy to treat PAH using anti-tumor drugs.Our study noted no apparent cardiotoxicity, such as the induction of apoptosis by DNR (5 mg/kg body weight), in the hypertrophied RVll death 20. Like 21 may contribute to the restoration of RV myocytes. The inclusion of agents that can activate these mechanisms in the treatment strategies would help repairing the damaged RV in PAH patients.Pulmonary hypertension per se does not kill patients; rather, right heart failure is the major cause of death among PAH patients. In addition to pulmonary vascular remodeling and severe narrowing and occlusion of the pulmonary vascular lumen, by the time patients are diagnosed with PAH, severe RV modifications have already occurred, including the death of RV myocytes as well as the induction of RV fibrosis. Therefore, a treatment that can preferentially kill remodeled pulmonary vascular cells without affecting normal cells and also reduce mechanisms that contribute to these RV dysfunctions would be ideal. As shown in Currently, no therapeutic agents are capable of satisfactorily prolonging the lives of patients who are diagnosed with PAH, perhaps because currently available therapies have only limited effects on the pulmonary vascular remodeling that is an important aspect of this disease. Histologic observations in humans and experimental animals show dramatic narrowing and occlusion of the pulmonary vascular lumens, clearly indicating limited blood flow. Thus therapeutic strategies to reverse the narrowing and occlusion of the pulmonary vascular lumen should be necessary aspects of the treatment of PAH. In rat models of PAH, our laboratory observed that some cell-death-inducing anti-tumor drugs reverse pulmonary vascular remodeling without influencing the normal pulmonary vasculature. Further, the perception that giving these drugs to PAH patients is contraindicated appears to be incorrect, as remodeled RVs were found to be more resistant to damage by these drugs, and we discovered agents that are capable of protecting the heart without reducing the anti-tumor drug’s efficacy in the pulmonary vasculature. Collectively, these data generated using animal models of PAH suggest that combining cell-killing drugs and cardioprotectants with the currently available vasodilator therapies may present optimal therapeutic strategies to treat this lethal disease. Clinical studies to test this concept are warranted. Successfully curing PAH, however, depends on future studies that use experimental models to define exactly which anti-tumor agents  should be given via which route of administration, which doses, and under which timing or duration of treatment. Further, possible unwanted effects of such treatment regimes, such as drug resistance, should also be investigated.