We aimed to outline the early risk factors for adult bipolar disorder (BPD) in adolescents with mood disorders.Adolescents (16–17 years old) with mood disorders  were identified from a community sample. Fifteen years later (at 30–33 years of age), mood episodes were assessed (n = 194). The risk of developing BPD (n = 22), compared with MDD (n = 104) or no mood episodes in adulthood (n = 68), was estimated via logistic regression. Adolescent mood symptoms, non-mood disorders, and family characteristics were assessed as potential risk factors.Among the adolescents with mood disorders, a family history of BPD was the strongest predictor of developing BPD compared with having no mood episodes in adulthood , whereas disruptive disorders significantly increased the risk of developing BPD compared with developing MDD . The risk that adolescents with MDD would develop adult BPD, versus having no mood episodes in adulthood, was elevated among those with an early disruptive disorder  or multiple somatic symptoms . Only disruptive disorders significantly predicted adult BPD among adolescents with MDD versus continued MDD in adulthood . Only a few adolescents with hypomania spectrum episodes continued to have BPD as adults, and anxiety disorders appeared to increase this risk.Although most of the identified potential risk factors are likely general predictors of continued mood disorders, disruptive disorders emerged as specific predictors of developing adult BPD among adolescents with MDD.The online version of this article (doi:10.1186/s12888-014-0363-z) contains supplementary material, which is available to authorized users. Numerous studies have shown that adolescents with mood disorders are at an increased risk of continued mood disorders in early adulthood -10]. Ho. Ho10]. BPD is a severe condition associated with substantial impairments in emotional, cognitive, and social functioning -18]. An. An18]. Adolescent BPD is associated with early signs such as mood lability or swings, anxiety, hyperarousal, somatic complaints, behavioral dysregulation, attention difficulties and school problems ,18]-[22-[2218]--28]. Th. Th28]. Still, the best-established early marker of BPD risk remains family history ,36],,-41]. Ho. Ho41]. The clinical usefulness of the early markers/premorbid problems as predictors of subsequent BPD has not been proven. The generally high frequency of pre-morbidities and comorbidities between adolescent mood disorders, externalizing disorders and internalizing disorders raises questions regarding the relevance of these disorders for the continued disease course.st - and/or 2nd - degree family member with BPD, were more likely to have BPD as adults compared with those without this history. Adolescents with MDD and a 1st - and/or 2nd - degree relative with BPD were more likely to develop BPD versus those with MDD and no such history. Similarly, adolescents with hypomania spectrum disorder tended to have (hypo)mania episode(s) in adulthood if they had a 1st - and/or 2nd - degree family member with BPD.To summarize, conclusive findings within this area of research are sparse and additional research is needed. The present study is based on a unique community sample of adolescents with mood disorders, followed up after 15 years. Although previous publications form this cohort have not focused on the potential risk factors of BPD, certain results have indicated that specific factors might be important. We have shown that long-term adolescent depression strongly predicts both continued MDD and BPD in adulthood . In anotadult BPD among individuals with previous mood episodes (either MDD or hypomania spectrum episodes) during adolescence;the development of adult BPD among those with adolescent hypomania spectrum episodes; andthe development of adult BPD among those with adolescent MDD.The present study includes a range of potential child and adolescent risk factors for developing BPD. Our overarching aim was to identify the early risk factors of adult BPD (compared with MDD or no mood episodes in adulthood) among individuals with adolescent mood episodes. We investigated the potential risk factors for the following:This study examined the early risk factors for BPD in a high-risk community sample of adolescents with mood disorders. The data were prospectively collected in two waves, with a baseline assessment at age 16–17 years of age and a blinded follow-up assessment at 30–33 years of age , a hypomania spectrum episode (n = 90), or both at the first evaluation  were included. A hypomania spectrum episode was defined as having an “elevated mood”, “grandiosity” or both and at least 1–3 additional manic symptoms or irritability as the only core symptom and at least 4 additional manic symptoms. The participants either met the criteria for full syndromal hypomania (n = 40) or brief-episode hypomania  or subsyndromal hypomania  (n = 32). The majority had also experienced a major depressive episode (n = 68); 10 participants had subthreshold depression and twelve had no depression.To ensure that the symptoms were not better explained by ADHD, we determined that the 12 participants in the hypomania group without depression did not meet the criteria for ADHD.At baseline, the participants were assessed using the DICA-R-A. The participants also completed numerous self-rating scales, including the Somatic Checklist Instrument (SCI) . A psychst - and/or 2nd - degree relatives were collected at the follow-up assessment. The five interviewers, trained in clinical psychology or psychiatry, were blinded to the information from the baseline evaluation. To enhance inter-rater reliability, each interviewer was video-recorded once, and the recorded interviews were rated by all interviewers. These recordings yielded an overall free-marginal kappa value of 0.93. To further increase reliability, and to ensure the clinical validity of the diagnoses, uncertainties were regularly discussed with senior psychiatrists during sessions of group supervision.A follow-up assessment was conducted after 15 years, when the participants were 30–33 years of age. A blinded assessment of adult mental disorders was conducted with the Mini International Neuropsychiatric Interview Plus . EpisodeAll participants (n = 194) with an adolescent mood disorder who participated in the follow-up evaluation were included in the analyses. The participants with a diagnosis of bipolar I or II disorder in adulthood were compared with those with MDD and those with no mood episodes in adulthood with regard to potential risk factors.st - and/or 2nd - degree relatives.Several risk factors with potential relevance for the continued course of mood disorder were considered in the analyses, including child and adolescent mental disorders, adolescent mood symptoms, somatic symptoms, adverse life events during childhood and adolescence, and a family history of mood disorders in 1Previous and current child and adolescent mental disorders as well as psychotic and affective symptoms were recorded using the DICA-R-A. The following diagnoses were included in the analyses: separation anxiety; avoidant disorder ; overanxiousness (GAD); panic disorder; obsessive-compulsive disorder (OCD); posttraumatic stress disorder (PTSD); eating disorders ; disruptive disorders ; and substance abuse .In addition, long-term depression among adolescents was included as a predictor in the analyses because previous analyses showed that this variable strongly predicts continued mood disorders . Long-teChildhood psychotic symptoms, other than schizophrenia, concerned present or previous delusional symptoms or hallucinations that were not due to the direct physiological effects of a substance  were included in the analyses.The included adolescent hypomanic symptoms were elevated mood, grandiosity, irritability, distractibility, increased activity, racing thoughts, pressured speech and a decreased need for sleep. The depressive episode symptoms were suicide attempt, suicide ideation, dysphoria, anhedonia, psychomotor inhibition, fatigue, feelings of worthlessness, problems with concentration, and sleep and appetite disturbances. Details regarding the mood symptoms recorded in this cohort have been published previously .The presence of multiple somatic symptoms was included as a potential risk factor because previous analyses have shown that these symptoms predict continued mood episodes ,44]. Th. Th44]. The DICA-R-A  also incst - or 2nd - degree relatives .At the follow-up assessment, the participants reported their family histories of depressive episodes or manic/hypomanic episodes among their 1Antidepressant medication has been reported to trigger (hypo)manic episodes in some patients. We used information from both the baseline assessment and the follow-up interview in order to ascertain that the (hypo)manic episodes reported were not attributable to medication: Treatments during childhood and adolescence were assessed with the DICA-R-A, and no participant reported psychotropic medication. At follow-up, the MINI interview was used to identify mood episodes and a life-chart was used to indicate when mood episodes had occurred and when the individual had received treatment for the mood episodes. Of the 22 participants reporting bipolar disorder in adulthood, 14 reported treatment with antidepressants. However, all these 14 participants reported that the first (hypo)manic episode had occurred before the antidepressant treatment was introduced.The participation rate at the follow-up evaluation was 66% (130/197) among those with adolescent MDD and 71% (64/90) among those with adolescent hypomania spectrum episodes. No major differences were identified between those who participated and those who were lost to follow up. Details regarding the follow-up attrition have been published previously .In the first set of analyses, adolescents with MDD or hypomania spectrum episodes were divided into three groups: those who developed BPD in adulthood; those who developed MDD in adulthood; or those who did not developed mood episodes in adulthood Table . DiffereThe risk factors that differed significantly between those who developed adult BPD and those who did not have mood episodes in adulthood were used to calculate a receiver operating characteristic (ROC) curve to evaluate the sensitivity and specificity for numerous risk factors. The calculation of a ROC curve for the risk factors of BPD versus MDD in adulthood was not possible because of the low number of significant risk factors.All analyses were first adjustment for sex. This adjustment did not change the results and was not included in the final analyses presented in the results section. In the second set of analyses, univariate logistic regressions were used to identify the risk factors for adult BPD separately for the adolescents with MDD and the adolescents with hypomania spectrum episodes. Multivariate analyses were not conducted because of the smaller sample sizes of these groups. P-values below 0.05 were considered statistically significant for all statistical analyses. IBM SPSS Statistics version 22.0 for Macintosh was used.The Regional Ethical Vetting Board of Uppsala, Sweden approved this study, which was conducted in accordance with the ethical standards established in the Declaration of Helsinki. Both written and verbal information about the study was offered to the students (16–17 years). Informed consent to be contacted for a future follow-up evaluation was also collected. At age 30–33 years, the participants who had given their consent to be contacted were sent written information about the follow-up evaluation. Before consenting to take part, the participants were also informed about the study verbally via telephone. The Regional Ethical Vetting Board approved the verbal consent procedure used in the study.st - and/or 2nd - degree family histories of BPD significantly increased the risk of adult BPD compared with having MDD  or no mood episodes in adulthood .Of the 194 participants with adolescent mood disorders who were followed up after 15 years, 22 were diagnosed with bipolar I or II, 104 had MDD and 68 had no mood episodes in adulthood. The results of the univariate logistic regression analyses of the risk factors for BPD in adulthood (versus having MDD or no mood episodes) are presented in Table The feeling of worthlessness was the single affective symptom from the DICA-interview that significantly increased the risk of BPD compared with not having a mood episode. The other significant risk factors for adult BPD (compared with no mood episodes in adulthood) included multiple somatic symptoms , and long-term depression . A history of child and adolescent panic disorder was not a significant risk factor . Similarly, a history of any anxiety disorder  in childhood and adolescence did not reach statistical significance as a risk factor for adult bipolar disorder compared with having no mood episodes  or MDD  in adulthood.st - and/or 2nd - degree family histories of BPD. In this model, three risk factors remained significant for adult BPD compared with no mood episodes: feelings of worthlessness ; 1st - and/or 2nd - degree family histories of BPD ; and multiple somatic symptoms . The same five risk factors for adult BPD (compared with no mood episodes) were evaluated using an ROC curve .Of the 64 adolescents with hypomania spectrum episodes during childhood, 6 had developed adult hypomania or mania, 32 developed MDD and 26 reported no mood episodes in adulthood.st - and/or 2nd - degree family histories of BPD  and the 1st - and/or 2nd - degree family histories of MDD .The continuity between adolescent hypomania spectrum and adult BPD (compared with no mood episode) was associated with panic disorder , GAD  and long-term depression . When these three factors were entered simultaneously into a logistic regression analysis, panic disorder and GAD predicted an increased risk of adult BPD, whereas long-term depression did not remain as significant  was associated with psychotic symptoms in adolescence .Out of the 130 adolescents with MDD during adolescence, 72 developed adult MDD, 16 developed hypomania or mania and 42 reported no mood episodes in adulthood. The transition from adolescent MDD to adult BPD (compared with no mood episodes in adulthood) was associated with the presence of disruptive disorders  and multiple somatic symptoms  was only significantly associated with adolescent disruptive disorders . Several longitudinal studies have found an association between early disruptive disorders and the bipolar spectrum ,31],,. Both diDifferent types of risk factors predominated among adolescents with MDD who developed adult BPD and those with hypomania spectrum episodes who developed adult BPD. Disruptive disorders, multiple somatic symptoms (somatic complaints), or both precede adolescent MDD before developing adult BPD. Furthermore, panic disorder, GAD or both were associated with adolescent hypomania before developing adult BPD. It is possible that these two predictor groups might represent different developmental trajectories of adult BPD. The first subtype, which is preceded by disruptive disorders, somatic symptoms (somatic complaints) or both, appears to overlap with characteristics of irritability, explosive anger, aggression, mood lability and somatic complaints, which are criteria for the cyclothymic temperament ,83],,. On the Psychotic symptoms might play a similar role. Among adolescents with a hypomania spectrum disorder, early psychotic symptoms appeared to increase the risk of BPD in adulthood. However, psychotic symptoms only occurred in a few individuals, and these results should be interpreted with caution. Early psychotic symptoms that lead to later mood disorders are more clearly aligned with BPD than unipolar depressive disorders -93]. Th. Th93]. Thus, psychotic symptoms in childhood and adolescence probably have diagnostic and prognostic values. Progressive brain changes might occur after the first psychotic/depressive episode, resulting in the inadequate maturation of the cortex -108] an an108] aAlthough no predictor of high sensitivity or specificity was identified, the results may still have important implications for clinical practice. In the present study, 11.3% of the participants developed adult BPD. This rate was substantially higher in subsamples with the major identified risk factors, including 31.3% of participants with family histories of BPD, 20.6% of participants with disruptive disorders, and 19.2% of participants with panic disorder. However, none of the studied predictors had specificity or sensitivity values high enough to be used in routine clinical practice with regard to informing patients and their families of the supposed long-term course of the disorder or facilitating decisions on the long-term use of mood stabilizers. However, given the serious nature of BPD and recurrent MDD, adolescents with mood disorders and, in particular, those with early indications of an increased risk for future BPD should be followed up with carefully, preferably in specialized affective disorder subunits, where the long-term results are best ,114]..114].This study has numerous strengths. The study was based on a large, well-defined community sample, and it focused on the natural development of mood disorders. Participants were assessed during adolescence and followed up 15 years later by clinically trained interviewers blinded to the adolescent interviews. We had access to extensive data about mood episodes, other mental disorders, and treatment. Of note, no case of suspected antidepressant induced switch was identified in this sample, although we had data on the timing of mood episodes and antidepressant treatment.Certain limitations of this study must also be considered. First, the participants lost to follow-up might have more severe mood disorders. However, separate analyses demonstrated that those lost to follow-up and those who participated did not differ substantially with regard to adolescent psychopathology ,45],,. FurtherSecond, although we included both adolescents with MDD and hypomania spectrum episodes, the original community study was designed to screen for only depression and not for hypomania. No hypomania screening measurement was used at the baseline evaluation, and therefore some individuals with ongoing hypomania might not have been identified. A fully representative sample of adolescents with hypomania spectrum episodes might show a slightly different result. However, 317 controls with negative screening results were also diagnostically interviewed. In addition, numerous studies have demonstrated that the early onset of depressive disorders in children or adolescents typically precedes BPD ,24],,,117],,. It shouThird, there are some potential limitations regarding to the validity of our data. All information was self-reported. Further, we did not include potential predictors such as socioeconomic status and gender. Finally, a general risk of type II errors exists, because of the relatively small number of participants. Larger samples are needed in future studies.The current results provide an overview of a range of potential clinical risk factors of adult BPD among adolescents with mood disorders. No risk factor of high sensitivity or specificity was identified. Because of the severity of BPD, however, adolescents with mood disorders should be followed carefully into adulthood. Characteristics such as family histories, disruptive disorders, anxiety disorders, somatic symptoms, and family histories of mood disorders warrant particular attention. In order to make progress, it is likely that future studies need to include larger samples and account for both genetic factors and psychosocial exposure during critical periods.


Stem cell therapy is being investigated as an innovative and promising strategy to restore cardiac function in patients with heart failure. Several stem cell populations, including adult (multipotent) stem cells from developed organs and tissues, have been tested for cardiac repair with encouraging clinical and pre-clinical results. The heart has been traditionally considered a post-mitotic organ, however, this view has recently changed with the identification of stem/progenitor cells residing within the adult heart. Given their cardiac developmental origins, these endogenous cardiac progenitor cells (CPCs) may represent better candidates for cardiac cell therapy compared with stem cells from other organs such as the bone marrow and adipose tissue. This brief review will outline current research into CPC populations and their cardiac repair/regenerative potential. The adult heart is capable of limited cardiomyocyte turn over, enhanced directly or indirectly by endogenous cardiac progenitor cells.The specific biological roles of cardiac progenitor cell populations in the injured heart still remains elusive.Favourable effects of cardiac progenitor cells after transplantation into injured myocardium is likely due to multiple mechanisms including neovascularisation and favourable remodelling of cardiac scar.Which cardiac progenitor cell populations  play a predominant role in repairing the damaged heart?What is the overlap between the several cardiac progenitor cell populations listed above?Do cardiac progenitor cells contribute directly to new adult cardiomyocytes lost after myocardial injury?Cardiovascular disease continues to be a major cause of morbidity and mortality worldwide. Despite considerable progress in revascularisation techniques and pharmacotherapy, many patients progress to heart failure after acute myocardial infarction (MI). Current therapies are unable to replace dead cardiomyocytes (CMs) and largely irreversible cardiac dysfunction ensues. The discovery of multiple classes of stem cells has generated hope for their use as therapeutic agents in heart failure. This may involve the transplantation of pluripotent stem cells or multipotent adult progenitor cells into the area of the infarcted myocardium, to promote regeneration of new functioning myocytes and vascular cells, thus improving heart function.2 In a genetic fate-mapping study, it was shown that CPCs contribute to the replenishment of adult mammalian CMs lost after injury, throughout the adult life.4 Numerous other studies have also identified and isolated endogenous CPC populations in the hearts from multiple species including rodents, dogs, pigs and humans.5–10 These studies suggest that CPCs are capable of differentiating into multiple cell types, such as CMs, vascular smooth muscle cells and endothelial cells (ECs). Intra-myocardial transplantation of CPCs after induced MI, resulted in reduction of scar size and improvement in left ventricular (LV) function, have been demonstrated in pre-clinical models. These findings promised a paradigm shift in cardiac biology and new opportunities for future treatment. However, 15 years after these initial reports, a consensus on the biological role of these populations still remains elusive. In this review, we provide a brief overview of the CPCs currently being considered for cardiac repair and the potential mechanisms of action of CPCs in the damaged heart.The adult mammalian heart was previously considered a post-mitotic organ without the capacity for self-renewal. However, recent evidence suggests that the adult heart is capable of CM turn over, possible from endogenous cardiac stem cells/cardiac progenitor cells (CPCs).4 After injury, however, CPCs can be activated and may differentiate into new myocytes or vascular cells.4 Unlike other adult cell types such as bone marrow cells (BMCs), for which surface markers have been extensively characterised, resident CPCs show mixed and overlapping expression of stem cell markers ; epicardium derived cells; cardiac side population cells (identified by their ability to exclude Hoechst dye from nuclei8); stem cell antigen-1 (Sca-1+) CPCs; Islet-1 (Isl-1+) expressing CPCs and platelet derived growth factor receptor-alpha (PDGFRα+) expressing CPCs (interested readers are directed to other reviews for further detail12). A timeline for major events in studies of cardiac stem/progenitor cells is shown in CPCs are a heterogeneous group of cells distributed throughout the heart, . Under normal physiological conditions, CPCs are thought to be quiescent and do not contribute significantly to CM renewal. markers . Several13 c-Kit+ cardiac cells possess prolonged self-renewing, clonogenic and multipotent characteristics. Encouraging results whereby c-Kit+ CPCs improved LV dysfunction and remodelling in various pre-clinical models of post-MI cardiomyopathy have paved the way for Cardiac Stem cell Infusion in Patients with Ischemic Cardiomyopathy (SCIPIO), the first clinical trial of CPCs. In SCIPIO, c-Kit+ cells were isolated from the right atrial appendage of patients undergoing open heart surgery for coronary artery bypass grafting. Harvested CPCs underwent expansion in vitro and were then infused back into the donor heart via the coronary arterial circulation. Although the SCIPIO results appeared to support pre-clinical work by the same group  in the adult mammalian heart.17 From these cardiospheres, millions of proliferative cells that express markers of mesenchymal, and progenitor cell-related antigens can be harvested.17In vitro CDCs are clonogenic and have multilineage potential. The safety and efficacy of CDC transplantation has also been demonstrated in pre-clinical studies.10 In a murine model of MI, the functional outcome of CDC transplantation was superior  to the transplantation of bone marrow mesenchymal stromal cells and adipose-derived regenerative cells.18 In the cardiosphere derived autologous stem cells to reverse ventricular dysfunction (CADUCEUS) study, patients with acute MI were randomised to receive standard medical therapy or autologous CDCs.19 This phase I randomised clinical trial showed no difference in LV ejection fraction after 6 months.19 However, infarct size was significantly reduced in the cell treated group. Patients treated with CDCs showed a reduction in scar mass, increased viable heart mass and improved regional contractility.19Another well-characterised CPC population is the CDC population. CDCs are a mixture of stromal, mesenchymal and progenitor cells that are derived from cultures of atrial or ventricular biopsy specimens. When cloned in suspension, they develop multicellular clusters known as cardiospheres.in vitro and in vivo. They express several markers characteristic of stem cells  and have significant regenerative potential in vivo. However, recent evidence has suggested that Isl-1 is not a marker of endogenous CPCs.20 Furthermore, using genetic fate-mapping approaches, Isl-1 has been shown to mark not only progenitors from the second heart field, but also from the cardiac neural crest.21 Recent reports suggest that resident cardiac c-Kit+ cells in the mouse are not a source of myocytes but are predominantly a source of ECs after cardiac injury.23 Therefore, as previously mentioned, the exact biological role of these various progenitor populations in the injured heart remains unknown.Several other CPC populations have also been identified and characterised using different membrane markers  and transcription factors  in the embryonic and adult heart . Again, + identifies a resident cardiac progenitor population  in the murine6 and human heart24 , rather than the formation of new CMs. Direct transdifferentiation into CMs (as robustly seen in current pluripotent stem cell differentiation protocols) is considered unlikely.Implantation of CPCs in the injured heart may lead to myocardial repair via direct and indirect mechanisms . These i+ cells as the primary source of cardiac regeneration after injury and a more recent study has used powerful genetic fate-mapping experiments to show CM formation from c-Kit+ progenitors in a rodent catecholamine-induced injury model.26 However, van Berlo et al.22 have also used genetic fate-mapping experiments to arrive at a contrary conclusion, that minimal CMs are generated from c-Kit+ cells in vivo. In contrast, abundant cardiac ECs appeared to be derived from c-Kit+ CPCs.23 Taken together, these new findings suggest that improvements in cardiac function after injury may be due to c-Kit+ CPC vascularisation of the injured heart and subsequent favourable effects on hibernating myocardium rather than the generation of new CMs.Many of the pre-clinical studies and the SCIPIO clinical trial (discussed above) have used c-Kit27Despite publication of many studies in multiple different species, the physiological and pathophysiological functions of the various CPC populations in the heart remain unclear. Utilisation of CPCs (either exogenously delivered or harnessing CPCs residing within the injured heart) has repeatedly been shown to induce favourable reparative or regenerative effects. Nevertheless the molecular mechanisms underpinning such changes are also not completely understood. Thus, the application of CPCs as a clinical treatment for cardiovascular disease will remain difficult until these limitations are appropriately addressed. In addition, attention should be focused on gaining a better understanding of the cardiac fibroblast population, which is known to aid repair and regeneration of CMs in addition to producing cardiac scar. Currently, what defines the cardiac fibroblast pool is poorly understood.


Prions are a unique group of proteinaceous pathogens which cause neurodegenerative disease and can be transmitted by a variety of exposure routes. After peripheral exposure, the accumulation and replication of prions within secondary lymphoid organs are obligatory for their efficient spread from the periphery to the brain where they ultimately cause neurodegeneration and death. Mononuclear phagocytes (MNP) are a heterogeneous population of dendritic cells (DC) and macrophages. These cells are abundant throughout the body and display a diverse range of roles based on their anatomical locations. For example, some MNP are strategically situated to provide a first line of defence against pathogens by phagocytosing and destroying them. Conventional DC are potent antigen presenting cells and migrate via the lymphatics to the draining lymphoid tissue where they present the antigens to lymphocytes. The diverse roles of MNP are also reflected in various ways in which they interact with prions and in doing so impact on disease pathogenesis. Indeed, some studies suggest that prions exploit conventional DC to infect the host. Here we review our current understanding of the influence of MNP in the pathogenesis of the acquired prion diseases with particular emphasis on the role of conventional DC. Sc, abnormally folded isoforms of the cellular prion protein (PrPC), in affected tissues. Although the precise nature of the infectious prion is still the subject of intense debate, prion infectivity copurifies with PrPSc which is considered to constitute the major component of the infectious agent [Sc in the central nervous system (CNS) of prion-infected hosts is accompanied by neuronal loss, spongiosis, and reactive glial responses ( PRNP gene (which encodes PrPC) which some consider predisposes the prion protein to abnormally fold into the disease-specific isoform (such as Gerstmann-Straussler-Scheinker syndrome). Many other prion diseases, including natural sheep scrapie, bovine spongiform encephalopathy, and chronic wasting disease in cervids and kuru and variant Creutzfeldt-Jakob disease (vCJD) in humans, are acquired following exposure to prions, for example, by oral consumption of prion-contaminated food. For the efficient transmission of prions to the CNS after peripheral exposure (a process termed neuroinvasion), the replication of prions within secondary lymphoid tissues is crucial [Prion diseases, or transmissible spongiform encephalopathies, are subacute neurodegenerative diseases affecting humans and certain domestic and free-ranging animal species. These diseases are characterized by the presence of aggregations of PrPus agent , 2. The esponses . Some pr crucial . Within  crucial –6  arise from haematopoietic precursor cells within the bone marrow and are a heterogeneous population of monocytes, macrophages, and dendritic cells –13. Thes+ DC at the time of peripheral exposure, the early accumulation of prions in the draining lymphoid tissue was blocked and disease susceptibility reduced [Viable commensal bacteria can be recovered from DC migrating from the intestine  and some reduced –24. ThesC; (iii) activate acquired immune responses and induce a specific immune response to prions as conventional DC are potent antigen-presenting cells; (iv) be conveyed from the site of exposure to sites of prion replication within the draining lymphoid tissue. The sections below describe the many studies which have attempted to address the potential contribution of these roles to prion disease pathogenesis.MNP such as conventional DC exhibit a diverse array of functions in the mammalian innate immune system. This is reflected in the various ways in which they may interact with prions, and, by doing so, impact on prion disease pathogenesis . Followi in vitro cultivated DC-like cells can readily acquire and degrade prions [Sc appears to be preferentially degraded by cysteine proteases [ in vitro exposure [ in vivo is uncertain since these cells can retain high levels of infectious prions in infected rodents [ in vivo in prion-infected hosts, higher concentrations of prions are recovered from their lymphoid tissues [+ cells impedes the early accumulation of prions in the draining lymphoid tissue [“Immature” conventional DC are highly phagocytic cells and have the potential to sequester and destroy prions in a similar manner to that in which they process peptide antigens for presentation to T cells in association with MHC class II. Data from several independent studies support this hypothesis and have shown thate prions –28. Withroteases . These dexposure , 31. Whe rodents –36. Furt tissues , 38. In d tissue –24, 39  gene rather than the absence of PrPC expression [C accumulates at contact sites between T cells and antigen-loaded conventional DC implying a role in the immune synapse between these cell populations. Consistent with this, the absence of PrPC in antigen-presenting cells impacted on their ability to stimulate T cells [The cellular prion protein, PrPfunction –44. Howeturation . Some stpression . Microsc T cells .C may regulate human monocyte migration by modulating cell adhesion dynamics [C regulates β1-integrin-mediated adhesion by modulating the remodelling of the actin cytoskeleton through the RhoA-cofilin pathway.A separate study has proposed that PrPdynamics . The autC throughout the body. This prevents the induction of specific cell-mediated and antibody-mediated immune responses to PrPSc, the major component of infectious prions [Although conventional DC are potent antigen-presenting cells and play an important role in the induction of antigen-specific immune responses, these cells are unlikely to play a role in the induction of specific immunity against prions. The prion protein is tolerated by the host immune system due to the widespread expression of PrPs prions . Despites prions .Sc following its injection into the gut lumen [+ cells (using CD11c-DTR-eGFP-tg mice) dramatically impedes oral prion pathogenesis [+CD11c+ cells (using CD11c-N17Rac1-tg mice) does not [+ langerin− dermal DC but was not affected in the absence of epidermal Langerhans cells or langerin+ dermal DC [Some DC populations have been shown to have the ability to capture and retain unprocessed antigens in their native states and transfer them intactly to naïve B cells to initiate a specific antibody response . Viable ut lumen . Subsequut lumen –24, 39. ogenesis , specifi plt mice which lack CCL19 and CCL21 [Chemokines help to attract lymphocytes and DC to lymphoid tissues and control their positioning within them. For example, the chemokines CCL19 and CCL21 are constitutively expressed by stromal cells within the T cell zones and mediate the homing of chemokine receptor CCR7-expressing naïve T cells and mature DC towards them . The posnd CCL21 . This obnd CCL21 , are thend CCL21 , 60. Prind CCL21 .Sc-containing DC within the villous lacteals and submucosal lymphatics in the intestines of sheep soon after exposure to prions by oral infection or by injection into ligated gut loops implies a similar role [ in vivo [The demonstration that the accumulation of prions upon FDC in the draining lymphoid tissues was prevented in the absence of DC at the time of exposure –24, 39 ilar role –64. Dist in vivo , 65, 66. in vivo , 68. The in vivo , 70. Dur in vivo . FurtherAlthough several studies suggest that DC may play an important role in the initial delivery of prions to and within the draining lymphoid tissues, the possibility that some of the prions may enter these tissues in a cell-free manner should not be excluded , 72, 73.106–126 is a chemoattractant for monocyte-derived DC [C highly which may itself act as a receptor for prion-specific PrPSc [C-dependent manner, it does not play a major role in disease pathogenesis. The propagation of prions from various peripheral sites of exposure to FDC and their subsequent neuroinvasion are not influenced by a lack of PrPC expression by haematopoietic cells [C that they may use to acquire prions.Whether DC acquire and endocytose prions via a specific receptor or receptors is uncertain, but the neurotoxic prion protein fragment PrPrived DC . Some MNic PrPSc –44. Howeic cells –48. ThesThe FDC within the B cell follicles are considered to acquire prions in the form of complement-opsonized complexes , 76. Conα/β) in response to foreign nucleic acids such as during virus infection [C, even after activation, so like classical DC they are unlikely to be important sources of prion replication [The plasmacytoid DC are a distinct subset of MNP which rapidly secrete large amounts of type I interferon , thin membrane-bound cylinders of cytoplasm which can connect neighbouring cells, might represent a novel method through which the intracellular exchange of prions between these cells may occur [Sc appears to travel in endolysosomal vesicles [ in vivo remains to be determined. However, the analysis of lymphoid tissues from HIV patients shows intercellular transfer via a similar mechanism is possible. Xu and colleagues revealed that HIV-1-infected macrophages were able to establish long range intercellular connections (consistent with TNT) with B cells [Data from2a cells –93. Effi2a cells , 93. Fur2a cells . Data fray occur . Within vesicles . Whether B cells . These iPrions have also been proposed to be released from infected cells in the form of small endosomal-derived vesicles termed exosomes . Therefo in vivo study has suggested that prion-infected DC alone are potentially sufficient to transfer infection directly to the nervous system. Immunodeficient Rag1−/− mice lack T and B cells and are indirectly deficient in FDC. As a consequence these mice are refractory to peripheral infection with prions [ Rag1−/− mice [ Tnfr1−/− mice was unable to demonstrate significant direct infection of the nervous system by prion-infected DC [ Rag1−/− mice when compared to Tnfr1−/− mice [ in vivo.Anh prions . Despite−/− mice . Since tected DC . The pre−/− mice . ClearlySc have been described in vascular-associated DC [+ (DEC-205) expressing DC may also migrate into the murine brain during prion disease [β protein [Sc in the brains of prion-infected mice [A subset of MNP with apparent conventional DC characteristics has been described in the mouse brain . Within iated DC , and ano disease . Under c protein . The posted mice , raisingted mice , 77.The detection of prion-specific PrP within the circumventricular organs of the brain has been reported to be an early feature in scrapie-affected sheep . Due to As described above, DC have been proposed to exert a diverse range of contrasting effects on prion disease pathogenesis which may have a significant outcome on the spread of infection to the CNS. Some studies have suggested that DC may help to protect the host against infection by attempting to sequester and destroy the prions. Others suggest that prions may exploit the migratory characteristics of prions to facilitate their efficient propagation from the site of exposure to the lymphoid tissues. DC may also play an important role in the subsequent transfer of prions to the CNS by bridging the gap between the immune and peripheral nervous systems . in vitro following the treatment of bone marrow cells or monocytes with GM-CSF and IL-4. The cells obtained from these preparations do share many typical characteristics of conventional DC, such as expression of high levels of CD11c and potent antigen-presenting activity, but macrophages can also share these characteristics [ in vitro bone marrow-derived or monocyte-derived DC prepared from mice and humans are indistinguishable from macrophages and do not cluster with conventional DC enriched from tissues [While it is evident from data described above that the actions of certain MNP populations may significantly influence the outcome of a peripheral prion infection, it is uncertain whether the cells involved actually are DC. Indeed there is much controversy over whether DC and macrophages can be separated based on either their functions or transcriptomes , 104. Moeristics , 104. Fu tissues , 105 (FiC and impede peripheral prion disease pathogenesis [+ cells at the time of exposure [+ MNP may reveal novel targets for therapeutic intervention in the initial phase of infection with these invariably fatal neurodegenerative diseases.As well as playing an important role in the establishment of a peripherally acquired prion infection, current data suggest that conventional DC may potentially be manipulated in order to provide immunotherapeutic protection against peripherally acquired prion diseases. As proof-of-principal studies have shown, a conventional DC-based immunotherapy approach can overcome host tolerance towards PrPogenesis , 107. Fiexposure –24, 39.


Global plant trait studies have revealed fundamental trade-offs in plant resource economics. We evaluated such trait trade-offs during secondary succession in two species-rich tropical ecosystems that contrast in precipitation: dry deciduous and wet evergreen forests of Mexico. Species turnover with succession in dry forest largely relates to increasing water availability and in wet forest to decreasing light availability. We hypothesized that while functional trait trade-offs are similar in the two forest systems, the successful plant strategies in these communities will be different, as contrasting filters affect species turnover. Research was carried out in 15 dry secondary forest sites (5-63 years after abandonment) and in 17 wet secondary forest sites (<1-25 years after abandonment). We used 11 functional traits measured on 132 species to make species-trait PCA biplots for dry and wet forest and compare trait trade-offs. We evaluated whether multivariate plant strategies changed during succession, by calculating a ‘Community-Weighted Mean’ plant strategy, based on species scores on the first two PCA-axes. Trait spectra reflected two main trade-off axes that were similar for dry and wet forest species: acquisitive versus conservative species, and drought avoiding species versus evergreen species with large animal-dispersed seeds. These trait associations were consistent when accounting for evolutionary history. Successional changes in the most successful plant strategies reflected different functional trait spectra depending on the forest type. In dry forest the community changed from having drought avoiding strategies early in succession to increased abundance of evergreen strategies with larger seeds late in succession. In wet forest the community changed from species having mainly acquisitive strategies to those with more conservative strategies during succession. These strategy changes were explained by increasing water availability during dry forest succession and increasing light scarcity during wet forest succession. Although similar trait spectra were observed among dry and wet secondary forest species, the consequences for succession were different resulting from contrasting environmental filters. Trade-offs in plant traits and resource economics are consistent at the global scale –3. Thesecommunity-level, the community-weighted mean (CWM) of individual functional traits changed with tropical forest succession in Mexico  when we used the Phi coefficient, a measure of association between binary variables whose interpretation is similar to correlation coefficients.We also examined whether the trait associations found were influenced by evolutionary histories. To this end, we recovered phylogenetic trees for the dry forest species and the wet forest species using Phylomatic , scalingwi is the relative basal area of the ith species and xi is the score on the PCA axis of the ith species. Relative basal area is a measure of species’ relative contributions to the total basal area represented by functional trait measurements in each plot . The relative basal area was used for weighting, rather than the abundance, because it reflects the species’ biomass, an indicator of plant performance and adaptation to local conditions. These community weighted mean scores on the PCA axes reflect the average multivariate plant strategy in the community, and were regressed against stand basal area (m2/ha) (including cacti in the case of dry forest). Stand basal area is a structural variable of succession and logarithmically relates to forest age in both forest types [see supplementary material in Species scores on the first two principal components of the PCA were scaled up to community level using the Community Weighted Mean (CWM) ,33, whicThe first two component axes of the PCAs for dry and wet forest species captured more than half of the variation in species trait values , Table 1There were also some differences between forest types. For example, plants with large leaf laminas and petioles (high LA and PL) had an acquisitive strategy in dry forest (as they were associated with high SLA), whereas such plants rather coincided with a drought avoiding strategy in wet forest  face similar functional trait trade-offs, thus confirming the existence of universal trait spectra. The functional turnover with succession in the two forest types, however, reflected different trait spectra, and hence, the changing dominance of different plant strategies. During dry forest succession, species strategies shifted from high importance of deciduousness early in succession towards increased reproductive effort late in succession, whereas during wet forest succession species strategies changed from acquisitive towards conservative strategies. This indicated that dry and wet forest species face different filters during forest succession.Associations between traits may be influenced by evolutionary history, where the presence of particular clades with contrasting characteristics could confound their ecological interpretation . Phylogeduration of leaf retention during the dry season reflects this variation better and correlates with resource economics, where conservative species retain their leaves longer during the dry season.We hypothesized the existence of two major trade-off axes underlying trait variation in dry and wet forest species, namely the acquisitive-conservative spectrum, and the seed size spectrum, with the spectra reflecting multivariate strategy axes. Our results largely confirmed this hypothesis. The first principal component reflected variation from a deciduous strategy with abiotically (mainly wind-) dispersed species towards evergreen species that invested in biotic seed dispersal, in the dry forest biotic seed dispersal also coincided with an increased seed size . DeciduoBiotically dispersed, evergreen species, having large seeds (in dry forest) and thick leaves marked the other end of the deciduousness/reproductive effort strategy axis. The positive correlation between seed size and biotic dispersal in dry forest has been widely found . The lacThe second trade-off axis reflected the strategy axis of resource acquisition versus conservation, in line with the leaf-, stem- and plant economics spectrum, and the growth-survival trade-off –3,5,7,49We used the community-weighted means of species scores on the two PCA axes to quantify the position of secondary forest communities along these spectra (or multivariate strategy axes) of trait variation. Doing so, we found that in both dry and wet forest, directional changes in the dominance of plant strategies took place with secondary succession . HoweverIn dry forest the main axis of variation was not the acquisitive conservative trade-off, as we anticipated, but the axis that described seed size and drought avoidance strategies. Dry forest changes in functional composition were characterized by the gradient of compound- leaved, deciduous species early in succession towards larger-seeded species that were more often animal dispersed and had thicker leaves later in succession. This finding confirms previous studies showing that deciduousness and leaf compoundness are particularly important during the extra dry environments in early-successional stages, cf. ,37,64. TIn wet forest, the main axis of variation was described by changes in functional composition from acquisitive to conservative trait values , a resulWe investigated a dry (900 mm/yr) and a wet forest (3000 mm/yr) chronosequence and showed that tree species are constrained by similar trade-offs, though this had different consequences for the success of plant strategies during succession. This confirms that dry and wet forest species face different filters during succession. A challenging issue is how the relative strength of these different filters (light and water) changes along the large precipitation gradient found across tropical regions and the consequences thereof for functional composition of successional communities. This is relevant because throughout the tropics the importance of secondary and degraded forests is increasing  and therThis study showed that similar trait spectra were observed among dry and wet secondary forest species, but with different consequences for succession. In dry forest succession the dominant plant strategies changed from drought avoiding species towards species that invest in large biotically dispersed seeds, which can be explained by water limitations in early succession. In wet forest succession the dominant plant strategies changed from species having acquisitive towards species with conservative strategies, which can be explained by decreasing light availability as the main driver of wet forest succession.S1 DatasetData are presented per forest type, the first two sheets containing the data from the Principal Components Analyses . Present(XLSX)Click here for additional data file.S1 Fig2, * P < 0.05; ** P < 0.01.Functional composition was calculated using the community-weighted mean of species scores on the principal component axes . Dry for(TIFF)Click here for additional data file.S1 TableThese species represent at least 80% of the basal area of each secondary forest plot. All species except Aragebortia sp. (wet forest) were used in the phylogenetic analysis, as for this species the family was unknown.(DOCX)Click here for additional data file.S2 TableGiven are Blomberg’s K , the var(DOCX)Click here for additional data file.S3 Table§Traits were ln-transformed prior to PIC calculation. Lower-left half of the matrix corresponds to dry forest species (n = 51), Upper-right half corresponds to wet forest species (n = 80). * P < 0.05, ** P < 0.01, *** P < 0.001. These values are very similar to the original pairwise trait-correlations  are Phi coefficients. elations , as resu(DOCX)Click here for additional data file.


Triple-negative breast cancer (TNBC) has been demonstrated to carry poor prognosis, but whether or not there exists any age-related variation in TNBC outcomes has yet to be elucidated. The current population-based study investigated the early survival pattern of elderly women with TNBC and identified outcome-correlated factors.We searched the Surveillance, Epidemiology, and End Results (SEER) database and enrolled female primary non-metastatic TNBC cases. The patients were subdivided into elderly (≥70 years) and young groups (<70 years). The survival status of elderly patients was compared to that of the younger women. The primary and secondary endpoints were cancer-specific survival (CSS) and overall survival (OS) respectively.9908 female TNBC patients diagnosed from 2010 to 2011 were included in the current study (20.4% elderly). Elderly patients with relatively advanced diseases exhibited distinctly worse cancer-specific  and overall survival  than their young counterparts. Advanced age at diagnosis (≥70 years) was significantly predictive of poor outcome in terms of CSS (hazard ratio (HR), 2.125; 95% confidence interval (CI), 1.664 to 2.713; p<0.001) and OS . Underuse of curative treatment especially radiotherapy was more prevalent in elderly women with stage II or III diseases than in younger patients.Elderly patients with TNBC displayed elevated early mortality within the first two years of diagnosis compared to the younger individuals. The observed lower rate of loco-regional treatment might be associated with worse cancer-specific outcome for these patients. As the most common incident form of female cancer worldwide, breast cancer has constituted a considerable disease burden to public health . Triple-It has been well established that TNBC carries poor prognosis with an early peak of recurrence at 2–3 years after initial surgical excision and compromised 5-year survival rate when compared to other subtypes , 11, butGiven the well-known fact that the majority of TNBC recurrence cases occur within the first 2–3 years of diagnosis and inadequate attention has been paid to the immediate survival of TNBC patients following disease relapse, it’s justified to focus on the short-term survival status after primary diagnosis. In the current population-based research, we sought to investigate the early survival pattern of elderly women with TNBC within two years of initial diagnosis and identify any outcome-correlated factors.The Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute (NCI) collects cancer incidence and survival data from US population-based cancer registries. The SEER 18 registries which consist of the SEER 17  plus Greater Georgia and cover cases diagnosed from 1973 to 2011 were included in our research [We enrolled female primary breast cancer patients who were classified as having TNBC at diagnosis based on local reporting. Stage IV cases and those who were complicated by multiple malignancies were excluded from the present analysis. Inflammatory breast cancer and cases that recorded unknown ER, PR and/or HER2 status were further rejected. Statistics about HER2 status were not available in SEER database until 2010, and the most recent release of SEER research data on April 15, 2014 has been updated to cover cases diagnosed from 1973 to 2011. Therefore the study population only encompassed TNBC patients who were diagnosed with malignancy from January 2010 through December 2011 and whose tumors had been evaluated for the 3 relevant markers.Survival data and relevant case-specific information such as age at diagnosis, histological grade, tumor size, lymph node metastasis, AJCC stage, surgery and radiotherapy were retrospectively gathered and compiled. Patients were subdivided into the young (<70 years) and old-aged (≥70 years) groups according to age at diagnosis. Follow-up data were available monthly until December 31, 2011. SEER database released research data about survival status and cause of death but failed to specify any information about local/distant relapse. As a consequence, the primary endpoint was cancer-specific survival (CSS), which was defined as the duration from initial diagnosis to breast cancer-related death. OS was set as the secondary outcome.Since the present study is a database-dependent analysis rather than experimental research on humans, approval of ethics committees and consent from participating patients are not needed. Patient records/information was anonymized and de-identified prior to analysis. Our access to SEER cancer registries was granted by SEER program after we signed Data-Use Agreement for the SEER 1973–2011 Research Data File.The clinical and pathological characteristics of incorporated cases were compared between the two age groups using Chi square test. In survival analysis Kaplan-Meier method was adopted to depict the survival curves, with log-rank test being performed to detect any significant difference in survival distribution. Univariate and multivariate analyses by Cox proportional hazards regression and logistic regression were carried out in order to determine the outcome-related elements. Two-sided p-values were reported and p<0.05 was considered statistically significant. All analyses were done utilizing SPSS version 20.0 software package .v 36.2%; p<0.001), earlier TNM stage  and better differentiation . Therapy-concerning indexes such as the proportion of surgery and radiation generated cues as to the present situation of clinical management of elderly TNBC cases. 94.6% of patients less than 70 years old underwent some form of surgical excision while 92.8% of older women underwent surgery (p = 0.002). As for radiation a similar trend was observed, with less than a half of old patients being given radiotherapy .In all, 9908 female TNBC patients were enrolled in the current study, with 2017 cases older than 70 years of age accounting for 20.4% of total records, which corroborated previous finding about the proportion of elderly patients in overall breast cancer burden (21%) . The medv 2.7%; p<0.001).As showcased in To better understand the impact of age on outcomes of patients with TNBC, further survival analysis was performed stratified by stage of disease and histological grade. It was demonstrated that in subgroups with stage II or III diseases, elderly women displayed inferior CSS  and OS  comparedThe records of the older-aged patients (n = 2017) were reviewed for survival analysis. As shown in Since preliminary exploration disclosed therapy as a prognosis-indicative element, we accomplished further analysis based on the loco-regional treatment status. In the subset of patients who didn’t receive surgical intervention or radiotherapy (n = 460), a statistically different CSS was found between the older and younger TNBC patients . Logistic regression method was adopted in order to disclose any potential factors that might influence the decision of surgery and radiotherapy. In comparison to their younger peers, old-aged TNBC patients were less likely to receive radiation (odds ratio (OR), 0.678; 95%CI, 0.609 to 0.754; p<0.001) and showed a tendency for less surgery .Consensus has been reached that TNBC is commonly associated with early age at diagnosis –7. AccorBRCA mutations were more prevalent in young breast cancer patients and predicted poor prognosis [Older-aged individuals make up nearly 20% of TNBC cases . Till norognosis , 19. YetIn the present study, older-aged women with TNBC displayed reduced OS compared with the younger individuals, which is consistent with previous finding that the risk of mortality increases with age. Naturally enough elderly patients tend to die of comorbidities such as cardiovascular diseases in addition to malignancy. There are two major aspects concerning the compromised CSS observed in older-aged TNBC. To start with, advanced age itself remained as an unfavorable prognostic element after ruling out potential interaction of confounders, even though old-aged tumors tended to be less biologically aggressive. Generally speaking, senility is usually connected with ill health condition and comorbidities that require additional care and monitoring, which will definitely complicate the clinical management of such cases and result in an increased risk of therapy-relevant adverse events. Moreover, it was found that compared with the younger women elderly individuals were less likely to receive loco-regional therapy, which was exemplified by a reduced proportion of patients undergoing surgery and radiotherapy. Surgery and radiotherapy were both indispensable treatment modalities especially in TNBC, a subtype naturally lacking molecular targets of endocrine therapy and chemotherapeutics. A remarkable finding derived from our study was that among patients with relatively advanced diseases (stage II or III) for whom surgery and postoperative radiotherapy should be indicated, use of loco-regional intervention especially radiotherapy was inadequate in elderly women, which coincided with the reduced CSS observed in this subgroup. Furthermore, surgery and radiation were demonstrated to be independent prognostic factors in both total TNBC population and the subset of elderly TNBC patients. Nevertheless we failed to eliminate the influence of confounding factors such as personal health status and receipt of systemic chemotherapy which are not recorded in SEER registries. Given the cohort nature of our study, we could only infer a possible association rather than establish a causal relationship between loco-regional undertreatment and poor immediate prognosis of elderly TNBC from the derived results. The driving elements that contribute to elevated early cancer-specific mortality in elderly patients with TNBC warrant further study.Already known is that undertreatment in elderly breast cancer patients produced an eminent negative effect on survival –22. AparPotential reasons that might preclude the application of loco-regional treatment in older-aged individuals with TNBC are speculated. First, the study revealed that elderly patients were slightly more likely to have node-negative disease and T1 tumors, which may account for an appropriately lower rate of adjuvant radiotherapy. Furthermore, the decisions to forgo surgery or radiotherapy in older patients could be driven by valid concerns over post-therapy complications and even mortality. In a study evaluating surgery in older breast cancer patients (n = 449), Rocco et al concluded that advanced age (≥85 years) was associated with evidently higher risk of postoperative complications , which then had an undesirable bearing on OS  . One proThe present study has several limitations. Above all, since crucial information concerning competing comorbidities and receipt of adjuvant chemotherapy is unavailable in SEER database, the observed association between loco-regional undertreatment and inferior outcome in elderly patients with TNBC could be confounded by external factors that are not recorded and thus cannot be established by the current cohort study. In order to solve this problem we set CSS as the primary outcome of our study considering that comorbidities such as cardiovascular diseases and hypertension exert a much more profound influence on OS than CSS. Admitting that the results of OS analysis  were lesAdmitting that geriatric patients are more vulnerable to the adverse impact of post-treatment complications due to comorbidities and functional deficiency of vital organs, denying standard anti-cancer treatment to this cohort merely based on age is not fully justified. However this dilemma still awaits more evidence from prospective clinical trials to be resolved since existing findings concerning the treatment of geriatric TNBC patients were all too limited and conflicting. Ongoing are clinical trials and studies that are designed to establish old-aged TNBC-specific treatment approaches. For instance, great efforts are made to identify subtypes of TNBC that require modified radical mastectomy with or without adjuvant radiation or BCS followed by radiation. Besides, the appropriate choice of chemotherapeutics and molecularly targeted agents in adjuvant settings among elderly TNBC women is being investigated.In our population-based analysis of 9908 women with TNBC, we found that elderly patients with TNBC had increased early mortality compared to the younger cases although they tended to develop tumors of lower grade and TNM stage. Advanced age at diagnosis (≥70 years) was significantly predictive of worse OS and CSS. These older patients with TNBC were less likely to receive loco-regional treatment encompassing surgery and radiation, which might be associated with the compromised cancer-specific survival observed in elderly TNBC.S1 Filen, number of patients; O, observed events.(TIF)Click here for additional data file.S2 FilePatients underwent neither surgery nor radiotherapy . Patients underwent surgery irrespective of radiation history . Patients underwent surgery without radiotherapy . Patients underwent both surgery and radiotherapy . n, number of patients; O, observed events.(TIF)Click here for additional data file.S1 TableCox proportional hazards regression model was used. Two-sided p-values were reported with p<0.05 considered statistically significant. Abbreviations: HR, hazard ratio.(DOCX)Click here for additional data file.


The potentialities to apply mesenchymal stem cells (MSCs) in regenerative medicine have been extensively studied over the last decades. In the cardiovascular disease (CVD) field, MSCs-based therapy is the subject of great expectations. Its therapeutic potential has been already shown in several preclinical models and both the safety and efficacy of MSCs-based therapy are being evaluated in humans. It is now clear that the predominant mechanism by which MSCs participate in heart tissue repair is through a paracrine activity. Via the production of a multitude of trophic factors endowed with different properties, MSCs can reduce tissue injury, protect tissue from further adverse effects, and enhance tissue repair. The present review discusses the current understanding of the MSCs secretome as a therapy for treatment of CVD. We provide insights into the possible employment of the MSCs secretome and their released extracellular vesicles as novel approaches for cardiac regeneration that would have certain advantages over injection of living cells. Cardiovascular diseases (CVD), which are the leading cause of morbidity and mortality worldwide, account for approximately 30% of all deaths, with nearly half resulting from myocardial infarction (MI) . Unlike  in vitro culture expansion, they are positive for the cell surface markers CD73, CD90, and CD105 and negative for CD11b, CD14, CD34, CD45, and human leukocyte antigen- (HLA-) DR [Adult mesenchymal stem or stromal cells (MSCs) are nonhematopoietic cells capable of self-renewal and multilineage differentiation into various tissues of mesodermal origin. They could reside in virtually all postnatal organs and vascularized tissues , but theIn the present review we will discuss the literature regarding application of MSCs for cardiac regeneration, presenting a concise summary about cell-based therapy followed by a deeper analysis of MSCs paracrine effects via secreted factors and extracellular vesicle release.+ and Sca1+ cells [Cell-based cardiac repair offers the promise of rebuilding the injured heart . Mobiliz1+ cells . In gene1+ cells . The sea1+ cells .Meanwhile, regenerative therapy using bone marrow-derived mononuclear cells (BM-MNCs) and MSCs has shown considerable promise. Between 2002 and 2005 the first stem-cell-based clinical trials for MI initiated using unfractionated and highly heterogeneous adult BM-MNCs. Despite initial positive results indicating safety of BM-MNCs transplantation and some beneficial effects on heart function, subsequent overall analysis of these first-generation trials revealed several inconsistencies possibly due to the differences in trial design, outcome evaluation, and cell isolation, thereby preventing general conclusions  and send in vitro expanded MSCs can act through different mechanisms. MSCs can transdifferentiate into cardiomyocytes, as seen in a study employing female pigs which underwent experimental acute MI and 3 days later received transendocardial injections of allogeneic male bone marrow-derived MSCs; cell engraftment and differentiation into cardiomyocytes and vascular structures were documented [In order to contribute to cardiovascular repair,cumented . Howevercumented . Accordicumented . In conccumented  and to ocumented –18.Another possible mechanism is fusion of MSCs with native cells, even though this phenomenon was very infrequently observed, ruling out any substantial involvement in MSCs-mediated cardiomyocyte regeneration , 19. in situ. However, the ischemic microenvironment is characterized by oxidative stress and inflammation, hostile conditions that pose a serious problem for MSCs survival. Experiments in small animals have shown that MSCs do not persist well inside the graft environment and if there is or no incorporation into the host tissue, most of the cells are lost within a month [MSCs-induced stimulation of endogenous CSCs via direct cell-cell interaction  and MSCs a month . Failure a month , an evenThus, a more likely explanation for MSCs-mediated cardiovascular repair is via exocytosis of a complex secretome made up of growth factors, cytokines, and other signaling molecules in the form of both released factors and extracellular vesicles , which mThe proposal that the paracrine activity of MSCs would be central for their therapeutic efficacy is supported by recent preclinical studies demonstrating improved cardiac function upon infusion of cytokines or conditioned medium (CM) in the absence of cell transplantation. The first studies implying paracrine activity of MSCs as central to their cardiac therapeutic efficacy date back almost ten years ago and evidenced trophic, prosurvival, and antiapoptotic effects .+ bone marrow stem cells recently being evaluated as a candidate cell population for treating MI in patients [+ cells [Among other studies, Takahashi and colleagues assessed that MSCs-derived cytokines were able to preserve myocardial contractile capacity, inhibit apoptosis of cardiomyocytes, and allow the formation of new vessels in damaged tissues . Gnecchipatients . To clarpatients . Results[+ cells . In part[+ cells . Overall[+ cells .ε signaling by blocking activation of mitochondrial death channels [Follow-up functional genomics studies then revealed that Secreted Frizzled Related Protein 2 (Sfrp2), a member of the Wnt signaling pathway, was significantly upregulated in Akt-MSCs-CM compared to control MSCs and its attenuation by siRNA silencing abrogated Akt-MSCs-mediated cytoprotective effects . Furtherchannels .α. Based on this evidence it was postulated that MSCs paracrine effects and associated cardioprotection are likely mediated by TNFR2 [In another study it was shown that ablation of TNF receptor 1 (TNFR1) but not TNFR2 in mouse MSCs enhanced protection following their infusion in the injured myocardium and correlated with reduced levels of ventricular TNF-by TNFR2 . Furtherby TNFR2 .Transplanted MSCs can release soluble factors contributing to neoangiogenesis inside the heart . AccordiThe functional ability of MSCs to modulate the immune system seems to play a role in almost all the effects attributed to these cells via three major mechanisms: cell-to-cell contact, production of inhibitory molecules, and induction of regulatory T-cells . MSCs haα-induced protein 6 (TNAIP6 or TSG-6); in particular, this molecule was associated with suppression of the excessive inflammatory response consequent to permanent ligation of the anterior descending coronary artery (LAD), decrease of the proteolytic damage to the heart and the subsequent fibrotic scarring, and increase in cardiac function [In a mouse model of acute MI inflammation was suppressed through MSCs-dependent production of the anti-inflammatory factor TNF-function .Another recognized effect of MSCs secretome is the promotion of a regenerative microenvironment inside the injured tissue , with di in vitro proliferation of endogenous CPCs. For example, Nakanishi et al. highlighted that rMSCs-CM promoted proliferation and migration of isolated CPCs and prevented their apoptosis when subjected to hypoxia and serum starvation. Furthermore, conditioned CPCs also showed upregulated expression of cardiomyocyte-related genes such as beta-myosin heavy chain (beta-MHC) and atrial natriuretic peptide (ANP) [+, CD31+, and CD133+ progenitor cells and a subsequent increase in myocardial c-Kit+ cells [In the CVD concern, there is strong evidence that MSCs secrete trophic factors that inducede (ANP) . Anotherde (ANP) . Intramut+ cells . In addit+ cells .μm and derive from the detachment of cytoplasmic protrusions with a process that depends on the increase of intracellular calcium concentration and subsequent enzyme activation  and cytoskeleton reorganization. MVs expose high amounts of phosphatidylserine and specific protein markers, such as integrins, selectins, or CD40 ligand [Extracellular vesicles (EVs) is a term recently proposed by György et al.  to descr0 ligand . On the 0 ligand  by most 0 ligand , 70, can0 ligand , and MSC0 ligand . Their mβ signaling and apoptosis [β phosphorylation and reduction of oxidative stress, phosphorylation of c-Jun, and inflammatory response in the reperfused myocardium [A recent systematic review on animal studies of various kinds of injury highlighted that MSC-derived MVs are strongly associated with improved organ function . Initialpoptosis . Furtherpoptosis . Subsequpoptosis . Notablyocardium .Besides promising results, however these works do not underline the precise effectors that mediate protection in the heart. In this concern, it has been shown that exosomes can also deliver nucleic acids, like microRNAs (miRNAs). A recent study showed that preconditioned murine BM-MSCs released exosomes enriched with miR-22. These vesicles were highly internalized by cocultured cardiomyocytes and prevented their apoptosis via interaction of miR-22 with methyl CpG binding protein 2 (Mecp2). Finally, delivery of these enriched exosomes into mice subjected to MI led to marked reduction of fibrosis . FurtherAltogether, these data support the assumption that MSC-dependent paracrine function inside the heart might be due not only to freely released soluble factors, but also to secreted exosomes that can deliver a large amount of peptides or other molecules protecting them from eventual degradation and facilitating their uptake inside cells. According to previous findings correlating exosome internalization with microenvironmental/intracellular acidity , it was  in vivo secretome profiling, relying on the analysis of body fluids or the interstitial solution that directly surrounds the cells, would seem to most accurately reflect cell secretions in their native microenvironment. In such an in vivo approach, capillary microdialysis devices or ultrafiltration probes can be used to collect body fluids [ in vitro conditions via collection of media conditioned by cells mostly for 12–48 h of culture [Due to these encouraging preclinical results, the MSCs-CM has become a subject of intensive proteomic profiling, in order to identify the released factors that might be applicable in regenerative medicine. Analysis of MSCs secretome was recently enabled mainly for the extensive development in protein separation techniques, mass spectrometry, immunological methods, and bioinformatics . The in y fluids . Unfortu culture .Since 2003, when the first proteomic analysis of human BM-MSCs secretory counterpart was undertaken , more thIsolation of EVs relies on their purification from supernatants of cells grown in absence of serum  through EVs from MSCs specifically express CD13, CD29, CD44, CD73, and CD105 , 88, 89 More recently, Lai et al.  focused In some studies the specific exosome-contained molecules able to mediate the protective effects on myocardium were identified: miR-19a promoted the cardioprotective Akt/ERK signaling , miR22 rFinally, MSCs microvesicles were found to improve cardiomyocytes survival through miR221  and to iRegenerative medicine is a subject of great expectations and gives rise to enormous hopes for patients who display severe forms of diseases without effective treatment. In the CVD field, MSCs-based therapy might be an advantageous alternative to current approaches and in the last decade, its potential has been demonstrated in numerous preclinical studies and it is being evaluated in clinics with promising results. Interestingly, the potential of MSCs to contribute to tissue repair has been found largely dependent on their secretory capacity  rather tTherefore, the employment of cell-derived secretome to replace stem cells transplantation is of enormous interest. While MSCs are considered relatively safe, the development of therapeutic strategies that may avoid administration of living stem cells will attenuate the safety concerns relative to cell origin and immunocompatibility issues. A secretome-based approach should also minimise biological variability, allow precise dosing, and thus lead to the development of safe and effective therapeutic strategies with possibly predictable outcomes. Another advantage is the possibility of avoiding the lung barrier, one of the major obstacles for systemic administration of MSCs. Finally, given that patients with HF are at an increased surgical risk, the development of a noninvasive therapeutic approach looks very appealing.In this perspective, the possibility of harnessing the MSCs secretome (both soluble factors and EVs) would have certain advantages over administration of a single factor that cannot mimic the actions of MSCs. Several questions have however to be addressed before clinical use can be considered.


Recent concepts have highlighted the role of the hippocampus and adjacent medial temporal lobe (MTL) in positive symptoms like delusions in schizophrenia. In healthy individuals, the MTL is critically involved in the detection and encoding of novel information. Here, we aimed to investigate whether dysfunctional novelty processing by the MTL might constitute a potential neural mechanism contributing to the pathophysiology of delusions, using functional magnetic resonance imaging (fMRI) in 16 unmedicated patients with paranoid schizophrenia and 20 age-matched healthy controls. All patients experienced positive symptoms at time of participation. Participants performed a visual target detection task with complex scene stimuli in which novel and familiar rare stimuli were presented randomly intermixed with a standard and a target picture. Presentation of novel relative to familiar images was associated with hippocampal activation in both patients and healthy controls, but only healthy controls showed a positive relationship between novelty-related hippocampal activation and recognition memory performance after 24 h. Patients, but not controls, showed a robust neural response in the orbitofrontal cortex (OFC) during presentation of novel stimuli. Functional connectivity analysis in the patients further revealed a novelty-related increase of functional connectivity of both the hippocampus and the OFC with the rostral anterior cingulate cortex (rACC) and the ventral striatum (VS). Notably, delusions correlated positively with the difference of the functional connectivity of the hippocampus vs. the OFC with the rACC. Taken together, our results suggest that alterations of fronto-limbic novelty processing may contribute to the pathophysiology of delusions in patients with acute psychosis. Patients who experience delusional perceptions typically attribute a direct personal relevance to such stimuli. More generally, altered salience attribution is such a characteristic feature of schizophrenia spectrum disorders that re-classification as a “salience syndrome” has been suggested during recent revision processes of DSM and ICD  hallucinations and bizarre delusions. While negative symptoms typically persist chronically, positive symptoms are pronounced during psychotic episodes that last for several weeks or months. Delusions, uncorrectable beliefs not shared by others, are a hallmark positive symptom of schizophrenia Frith, . A commo van Os, . From a  van Os, .An influential model of positive symptoms suggests that developmentally dysfunction of temporal lobe limbic structures leads to impaired interactions between the prefrontal cortex (PFC) and the mesolimbic dopaminergic system, resulting in a cortical dopamine deficit, but also in inadequate subcortical dopamine release. The hyperdopaminergic state in subcortical structures gives rise to a blunted signal-to-noise ratio in prediction error coding, leading to aberrant salience attribution to irrelevant events. Such aberrant salience attributions clinically present as psychotic symptoms such as hallucinations or delusions Heinz, .Multiple brain structures have been implicated in processing of salience, i.e., the propensity of a stimulus to attract attention. A “salience network” consisting primarily of the anterior insula and the dorsal anterior cingulate cortex  study, we sought to circumvent this problem by using a simple target detection task  with acute psychosis were recruited from the Department of Psychiatry and Psychotherapy , Charité Universitätsmedizin Berlin. All patients met ICD-10 and DSM IV diagnostic criteria of paranoid schizophrenia (ICD-10: F20.0) as assessed by at least one consultant psychiatrist. Exclusion criteria were history of neurological disorders, brain abnormalities in T1-weighted MRIs and co-morbid Axis I psychiatric disorders [Note: past depressive episodes were no exclusion criterion]. All patients were free of antipsychotic medication at the time of participation for at least four half-lives of their most recently used antipsychotic and had not used any centrally acting drugs (including benzodiazepines) for at least 12 h before participation. Psychopathological symptoms were assessed using the Scale for the Assessment of Positive Symptoms  matched for age, gender, handedness, educational level  and smoking habits were recruited by public postings at the university and via Internet advertisements. Exclusion criteria in healthy controls were lifetime history of any psychiatric or neurological disorder, systemic medical illness, use of any centrally acting or illicit drugs at the time of participation, or a family history of psychosis or bipolar disorder in first-degree relatives. Patients and healthy controls performed the Brief Assessment of Cognition in Schizophrenia  were presented, randomly intermixed with a standard image and a target image (stimulus duration = 1.25 s), with an interstimulus interval (ISI) jittered between 2.25 s and 6.25 s using a near-exponential distribution, to optimize estimation of the blood oxygen level-dependent (BOLD) response  using a standard head coil. 450 T2*-weighted echo-planar images  were acquired in an ascending order (from bottom to top). Six volumes were acquired at the beginning of each run to allow for magnetic field stabilization and discarded from analysis. A co-planar T1-weighted MPRAGE image was acquired before the functional session and used for optimized normalization (see below).Data were analyzed using Statistical Parametric Mapping . EPIs were corrected for acquisition delay and head motion. The subjects’ individual T1-weighted MPRAGE image was then coregistered to the mean EPI and segmented using the segmentation algorithm implemented in SPM8. EPIs were then normalized into a common stereotactic reference frame (ICBM)p < 0.05, small-volume-corrected for family-wise error (FWE) within the respective ROIs. For illustrative purposes only, figures display activations at p < 0.005, uncorrected. Peak activations (contrasts of parameter estimates) of significant between-group differences in the hippocampus were extracted and submitted to post hoc correlation analyses with memory performance  using robust Shepherd’s pi correlations . The resulting time courses formed the regressors of interest  in a General Linear Model (GLM). The six rigid-body movement parameters determined from motion correction were included as covariates of no interest, plus a single constant representing the mean over scans. GLM parameters were estimated using a restricted maximum likelihood (ReML) fit. To assess the interaction between novelty and diagnosis, single subjects’ contrast images (novel vs. familiar) were submitted to a second level random effects analysis with diagnosis as fixed factor and age as covariate. Regions of interest (ROIs) were defined anatomically for the hippocampus  convolved with the HRF formed further covariates in the GLM design matrices. We also included the regressors of the standard and target pictures and the six movement parameters determined as covariates of no interest, plus a constant representing the mean over scans. At second level, a two-way between-subjects ANOVA  with age and smoking status (Fagerström score) as covariates was computed. A small-volume FWE-corrected significance level of 0.05 was applied, correcting for combined anatomical and probabilistic ROIs of the rACC and of the VS/NAcc. In the patients, peak contrasts of parameter estimates of significant between-group differences in the rACC/mPFC were extracted and submitted to post hoc correlation analyses with SAPS global delusion scores using robust Shepherd’s pi correlations . Patients, however, showed a slightly higher false alarm rate  and a trend for longer reaction times  .Table T18 = 4.91, p < 0.001; patients: T15 = 3.74, p = 0.001). There were no significant between-group differences in adjusted d’ values  .In the delayed memory task, both groups exhibited above-chance recognition performance, with hit rates being significantly higher than false alarm rates in both groups (controls: FWEp = 0.006), and there was no significant difference in novelty-related hippocampal activation between patients and controls .Both, healthy controls and patients exhibited a robust response of the right hippocampus to novel as compared to familiar rare pictures  .To assess the relationship between hippocampal activity during novelty detection and delayed memory performance, correlations were computed between the peak activation in the right hippocampus to novel vs. familiar pictures and recognition performance in the delayed memory test , separately for patients and controls. Because brain-behavior correlations have been criticized for their sensitivity to outliers .In a direct comparison of patients’ and controls’ novelty contrasts, patients showed a robust fMRI response in the right OFC to novel vs. familiar rare pictures that was absent in healthy controls Figure . Similarp = 0.015, FWE-corrected for ROI volume; 2 × 2 random effects ANOVA model, T-test-based comparison of hippocampal and OFC PPI contrasts; see Figure pi correlations of the sum and the difference of their contrasts of parameter estimates and the global delusions subscale of the SAPS. While there was no significant correlation of the sum, the difference , was positively correlated with the global delusions score in the patients . While there was no direct novelty-related functional connectivity increase between the hippocampus and OFC in the patients, both seed regions exhibited increased novelty-related functional connectivity with the rACC in patients when compared to healthy controls .A significant connectivity increase of both the hippocampus and the OFC in the patients was observed in the VS/nucleus accumbens (small-volume FWE-corrected Our results provide further evidence for hippocampal dysfunction in schizophrenia, as evident from the absent relationship between the hippocampal novelty response and long-term memory performance. Moreover, patients exhibited a novelty-related OFC activation that was absent in the controls. Functional connectivity results further suggest that acute psychotic states might be accompanied by an processing of novel stimuli in fronto-limbic structures.per se, it might nevertheless provide further—at least indirect—evidence for the previously suggested role of the hippocampus in the pathophysiology of schizophrenia. As discussed by Lisman et al. (Patients, like healthy controls, exhibited a robust hippocampal response to novel vs. familiar stimuli, suggesting a preserved hippocampal novelty response in acute psychosis. The relationship between novelty-related hippocampal activation and successful memory encoding was, however, disrupted in the patients. While the hippocampal novelty response was positively correlated with later recognition memory performance in the control cohort, no such relationship was observed in patients. Several previous studies in healthy participants (Hariri et al., n et al. , 2010, hn et al. . Notablyn et al. . In the A recent influential model suggests that chronic disinhibition of hippocampal pyramidal cells and resulting overstimulation of mesolimbic dopaminergic nuclei by a polysynaptic pathway originating in the hippocampus might trigger positive symptoms (Lisman et al., One limitation of the present study is that, while we did observe a robust hippocampal signal to novel stimuli in both, controls and patients, no midbrain activation was found in either group. The most likely reason for this is that the study was conducted on a 1.5T MR tomograph, and most studies in which midbrain activity could be reliably detected had employed field strengths of at least 3T, providing an inherently higher signal-to-noise ratio and higher spatial resolution (Bunzeck and Düzel, While novelty-related hippocampal activation in patients did not correlate with later memory performance, the patients showed more pronounced activation and functional connectivity increases to stimulus novelty in fronto-limbic structures, most prominently in the OFC Figure . The humOne apparently straight-forward and plausible explanation of the novelty-related OFC activation in the patient group might therefore be that patients might attribute atypical salience to the novel, but task-irrelevant stimuli, which would be in line with the previously demonstrated attention orienting towards novel stimuli in patients with schizophrenia (Cortiñas et al., When stimulus evaluation in the OFC is impaired, for example as a result of psychosis-related structural alterations (Malla et al., Future studies are warranted to further characterize the functional parcellation of fronto-limbic structures within this network. With respect to the OFC region that was found activated to novel stimuli in the present study, we can thus far only speculate that it could reflect an evaluation process of the stimuli that might to some extent moderate the hippocampal-rACC interactions, possibly by computing stimulus value (Rothkirch et al., Hippocampal novelty processing has previously been linked to stimulation of dopamine release by VTA neurons (Lisman and Grace, The present study suggests that patients in an acute psychotic state exhibit atypical processing of novel information in two ways. First, the hippocampal novelty response is decoupled from successful hippocampus-dependent encoding of the novel information into episodic memory. Second, patients exhibited a specific novelty response in the OFC and increased novelty-related fronto-limbic functional connectivity. With the hippocampal-rACC functional connectivity showing a positive correlation with delusions, our results highlight the possibility that delusions might arise from abnormal processing of novel stimuli in fronto-limbic cortices.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.