Vascular dysfunction as a target for adjuvant therapy in cerebral malaria

Cerebral malaria (CM) is a life-threatening complication of Plasmodium falciparum malaria that continues to be a major global health problem. Brain vascular dysfunction is a main factor underlying the pathogenesis of CM and can be a target for the development of adjuvant therapies for the disease. Vascular occlusion by parasitised red blood cells and vasoconstriction/vascular dysfunction results in impaired cerebral blood flow, ischaemia, hypoxia, acidosis and death. In this review, we discuss the mechanisms of vascular dysfunction in CM and the roles of low nitric oxide bioavailability, high levels of endothelin-1 and dysfunction of the angiopoietin-Tie2 axis. We also discuss the usefulness and relevance of the murine experimental model of CM by Plasmodium berghei ANKA to identify mechanisms of disease and to screen potential therapeutic interventions.

Anti-vascular endothelial growth factor acts on retinal microglia/macrophage activation in a rat model of ocular inflammation.

PURPOSE: To evaluate whether anti-vascular endothelial growth factor (VEGF) neutralizing antibodies injected in the vitreous of rat eyes influence retinal microglia and macrophage activation. To dissociate the effect of anti-VEGF on microglia and macrophages subsequent to its antiangiogenic effect, we chose a model of acute intraocular inflammation. METHODS: Lewis rats were challenged with systemic lipopolysaccharide (LPS) injection and concomitantly received 5 µl of rat anti-VEGF-neutralizing antibody (1.5 mg/ml) in the vitreous. Rat immunoglobulin G (IgG) isotype was used as the control. The effect of anti-VEGF was evaluated at 24 and 48 h clinically (uveitis scores), biologically (cytokine multiplex analysis in ocular media), and histologically (inflammatory cell counts on eye sections). Microglia and macrophages were immunodetected with ionized calcium-binding adaptor molecule 1 (IBA1) staining and counted based on their differential shapes (round amoeboid or ramified dendritiform) on sections and flatmounted retinas using confocal imaging and automatic quantification. Activation of microglia was also evaluated with inducible nitric oxide synthase (iNOS) and IBA1 coimmunostaining. Coimmunolocalization of VEGF receptor 1 and 2 (VEGF-R1 and R2) with IBA1 was performed on eye sections with or without anti-VEGF treatment. RESULTS: Neutralizing rat anti-VEGF antibodies significantly decreased ocular VEGF levels but did not decrease the endotoxin-induced uveitis (EIU) clinical score or the number of infiltrating cells and cytokines in ocular media (interleukin [IL]-1β, IL-6, tumor necrosis factor [TNF]-α, and monocyte chemoattractant protein [MCP]-1). Eyes treated with anti-VEGF showed a significantly decreased number of activated microglia and macrophages in the retina and the choroid and decreased iNOS-positive microglia. IBA1-positive cells expressed VEGF-R1 and R2 in the inflamed retina. CONCLUSIONS: Microglia and macrophages expressed VEGF receptors, and intravitreous anti-VEGF influenced the microglia and macrophage activation state. Taking into account that anti-VEGF drugs are repeatedly injected in the vitreous of patients with retinal diseases, part of their effects could result from unsuspected modulation of the microglia activation state. This should be further studied in other ocular pathogenic conditions and human pathology.

Maladies vasculaires: quels dépistages au cabinet du praticien [Vascular diseases: what screening could be done in the office?]

The screening of vascular pathologies in physician offices starts with precise medical history and clinical exam. Tools like the Edinburgh Claudication Questionnaire for the peripheral artery disease or the Wells score for the probability of a thromboembolic event are useful. The measure of the ankle brachial index, the D-dimers or any other biological screening are complementary. In the presence of pathological features, it is recommended to organise a specialised consultation in order to precise diagnosis, treatment and follow-up. The screening of a vascular disease is interesting not only for the management of local symptoms, but also for the associated systemic pathologies to provide a preventive medicine of good quality.

Placental growth factor contributes to micro-vascular abnormalization and blood-retinal barrier breakdown in diabetic retinopathy.

OBJECTIVE: There are controversies regarding the pro-angiogenic activity of placental growth factor (PGF) in diabetic retinopathy (DR). For a better understanding of its role on the retina, we have evaluated the effect of a sustained PGF over-expression in rat ocular media, using ciliary muscle electrotransfer (ET) of a plasmid encoding rat PGF-1 (pVAX2-rPGF-1). MATERIALS AND METHODS: pVAX2-rPGF-1 ET in the ciliary muscle (200 V/cm) was achieved in non diabetic and diabetic rat eyes. Control eyes received saline or naked plasmid ET. Clinical follow up was carried out over three months using slit lamp examination and fluorescein angiography. After the control of rPGF-1 expression, PGF-induced effects on retinal vasculature and on the blood-external barrier were evaluated respectively by lectin and occludin staining on flat-mounts. Ocular structures were visualized through histological analysis. RESULTS: After fifteen days of rPGF-1 over-expression in normal eyes, tortuous and dilated capillaries were observed. At one month, microaneurysms and moderate vascular sprouts were detected in mid retinal periphery in vivo and on retinal flat-mounts. At later stages, retinal pigmented epithelial cells demonstrated morphological abnormalities and junction ruptures. In diabetic retinas, PGF expression rose between 2 and 5 months, and, one month after ET, rPGF-1 over-expression induced glial activation and proliferation. CONCLUSION: This is the first demonstration that sustained intraocular PGF production induces vascular and retinal changes similar to those observed in the early stages of diabetic retinopathy. PGF and its receptor Flt-1 may therefore be looked upon as a potential regulatory target at this stage of the disease.

Lack of correlation between the optimal glycaemic control and coronary micro vascular dysfunction in patients with diabetes mellitus: a cross sectional study.

Background Coronary microvascular dysfunction (CMD) is associated with cardiovascular events in type 2 diabetes mellitus (T2DM). Optimal glycaemic control does not always preclude future events. We sought to assess the effect of the current target of HBA1c level on the coronary microcirculatory function and identify predictive factors for CMD in T2DM patients. Methods We studied 100 patients with T2DM and 214 patients without T2DM. All of them with a history of chest pain, non-obstructive angiograms and a direct assessment of coronary blood flow increase in response to adenosine and acetylcholine coronary infusion, for evaluation of endothelial independent and dependent CMD. Patients with T2DM were categorized as having optimal (HbA1c < 7 %) vs. suboptimal (HbA1c ≥ 7 %) glycaemic control at the time of catheterization. Results Baseline characteristics and coronary endothelial function parameters differed significantly between T2DM patients and control group. The prevalence of endothelial independent CMD (29.8 vs. 39.6 %, p = 0.40) and dependent CMD (61.7 vs. 62.2 %, p = 1.00) were similar in patients with optimal vs. suboptimal glycaemic control. Age (OR 1.10; CI 95 % 1.04–1.18; p < 0.001) and female gender (OR 3.87; CI 95 % 1.45–11.4; p < 0.01) were significantly associated with endothelial independent CMD whereas glomerular filtrate (OR 0.97; CI 95 % 0.95–0.99; p < 0.05) was significantly associated with endothelial dependent CMD. The optimal glycaemic control was not associated with endothelial independent (OR 0.60, CI 95 % 0.23–1.46; p 0.26) or dependent CMD (OR 0.99, CI 95 % 0.43–2.24; p = 0.98). Conclusions The current target of HBA1c level does not predict a better coronary microcirculatory function in T2DM patients. The appropriate strategy for prevention of CMD in T2DM patients remains to be addressed. Keywords: Endothelial dysfunction; Diabetes mellitus; Coronary microcirculation

Edge vascular response after polymer-free vs. polymer-based paclitaxel-eluting stent implantation.

BACKGROUND It is unknown if lack of polymer can provoke a different edge response in drug-eluting stents. The aim of this study was to compare edge vascular response between polymer-free paclitaxel-eluting stent (PF-PES) and polymer-based paclitaxel-eluting stents (PB-PES). METHODS AND RESULTS: A total of 165 eligible patients undergoing percutaneous coronary intervention were prospectively randomized 1:1 to receive either PF-PES or PB-PES. Those patients with paired intravascular ultrasound (IVUS) after procedure and at 9-month follow-up were included in this analysis.Seventy-six patients with 84 lesions, divided into PB-PES (38 patients, 41 lesions) and PF-PES groups (38 patients, 43 lesions) had paired post-procedure and 9-month follow-up IVUS and were therefore included in this substudy. There was a significant lumen decrease at the proximal edge of PF-PES (from 9.02±3.06 mm(2)to 8.47±3.05 mm(2); P=0.040), and a significant plaque increase at the distal edges of PF-PES (from 4.39±2.73 mm(2)to 4.78±2.63 mm(2); P=0.004). At the distal edge there was a significant plaque increase in the PF-PES compared to PB-PES (+8.0% vs. -0.6%, respectively; P=0.015) with subsequent lumen reduction (-5.2% vs. +6.0%, respectively; P=0.024). CONCLUSIONS PF-PES had significant plaque increase and lumen reduction at the distal edge as compared to PB-PES, probably due to difference in polymer-based drug-release kinetics between the 2 platforms.

Infarto cerebral secundario a trombosis de la carótida interna por traumatismo cervical

In this paper, a case of post-traumatic thrombosis in the internal carotid artery after a blow with a ball in the neck of a 33-year-old male is presented. The death came 10 days after the coup as a result of intracranial hypertension and cerebral herniation secondary to ischemic infarction affecting the entire territory of the middle right cerebral artery, both superficial and profound. Macroscopic and microscopic findings that largely explain the mechanism of vascular injury with intimal dissection in the proximity of an atheroma plaque located above the carotid bifurcation are discussed.

Identificació i caracterització funcional dels complexes proteics dels receptors BRL1 i BRL3 en el teixit vascular d’Arabidopsis Thaliana

Els esteroids juguen papers clau en el creixement I el desenvolupament d’eucariotes multicel•lulars. En plantes, aquestes hormones, anomenades Brassinosteroides (BRs), estan involucrades en una gran varietat de processos biològics essencials per a les plantes. S’han descrit anteriorment dos receptors de BRs del tipus Leucine Rich Repeat Receptor Like Kinase LRR-RLK, BRASSINOSTEROID RECEPTOR LIKE 1 i 3 (BRL1 i BRL3 respectivalemt) que són homòlegs al receptor principal BRI1 i són necessaris pel desenvolupament vascular. Tot i que els principals components de la senyal ja han estat identificats pel seu homòleg més pròxim, el receptor BRI1, els complexes de BRL1 i BRL3 juntament amb els candidats co-receptors així com els components de la ruta de senyalització encara no han sigut identificats. Per tal d’entendre millor la funció molecular d’aquests receptors de BRs en la planta aquesta tesis doctoral planteja dues aproximacions: com a primera aproximació, vaig realitzar un estudi fenotípic del desenvolupament del teixit vascular a la planta model Arabidopsis thaliana (Arabidopsis). Disposant d'una amplia bateria de mutants de síntesis de la hormona i senyalització del receptor BRI1, vam analitzar quantitativament el seu patró vascular a la tija d'Arabidopsis. Vam establir els paràmetres en les plantes silvestres [Col-0 wild type, (WT)] i els vam analitzar a tots i cadascun dels mutants. Això conjuntament amb una col•laboració amb la Dr. Marta Ibañes, física de la Universitat de Barcelona que va construir un model matemàtic per simular la formació del patró vascular ens va permetre el•laborar una hipòtesis que vam demostrar experimentalment i va ser publicada a la revista PNAS. Posteriorment vam observar que les plantes knock-out d'aquests dos receptors BRL1 y BRL3 a diferència de BRI1, no tenien cap fenotip obvi en el teixit vascular de la planta adulta. Així, a continuació, per entendre quina necessitat té la planta de disposar de tres receptors tant altament homòlegs que poden percebre la mateixa hormona, vam utilitzar una aproximació bioquímica en col•laboració amb el Prof. de Vries de la Universitat de Wageningen (Holanda) per tal de purificar els complexes dels receptors in vivo i els seus interactors. Això ens ha permès entendre millor el paper funcional d'aquests receptors en la planta. Els resultats d’aquests experiments estan resumits en un article en preparació que aviat estarà en revisió.

Small vascular and Alzheimer disease-related pathologic determinants of dementia in the oldest-old.

The relative contributions of Alzheimer disease (AD) and vascular lesion burden to the occurrence of cognitive decline are more difficult to define in the oldest-old than they are in younger cohorts. To address this issue, we examined 93 prospectively documented autopsy cases from 90 to 103 years with various degrees of AD lesions, lacunes, and microvascular pathology. Cognitive assessment was performed prospectively using the Clinical Dementia Rating scale. Neuropathologic evaluation included the Braak neurofibrillary tangle (NFT) and β-amyloid (Aβ) protein deposition staging and bilateral semiquantitative assessment of vascular lesions. Statistics included regression models and receiver operating characteristic analyses. Braak NFTs, Aβ deposition, and cortical microinfarcts (CMIs) predicted 30% of Clinical Dementia Rating variability and 49% of the presence of dementia. Braak NFT and CMI thresholds yielded 0.82 sensitivity, 0.91 specificity, and 0.84 correct classification rates for dementia. Using these threshold values, we could distinguish 3 groups of demented cases and propose criteria for neuropathologic definition of mixed dementia, pure vascular dementia, and AD in very old age. Braak NFT staging and severity of CMI allow for defining most of demented cases in the oldest-old. Most importantly, single cutoff scores for these variables that could be used in the future to formulate neuropathologic criteria for mixed dementia in this age group were identified.

Decreased acute vascular remodeling, anaphylaxis and delayed type hypersensitivity in PPARβ/δ-deficient mice

Endothelial cells form a semi-permeable barrier that participates in the exchange of plasma fluids, proteins and cells, and helps to maintain the physiological functions of organs as well as circulatory homeostasis. Vascular permeability and vasodilatation are increased during acute and chronic inflammation, cancer and wound healing. This is mediated by exposure to certain vascular permeability increasing factors, such as vascular endothelial growth factor (VEGF). The peroxisome proliferator-activated receptors (PPAR) belong to the nuclear hormone receptor (NHRs) family of ligand-activated transcription factors. Three isotypes, PPARa, PPARp/5 and PPARy have been identified. They are all expressed in endothelial cells (ECs). Recent data have demonstrated their involvement in important mechanisms for vasculogenesis and angiogenesis, such as cell proliferation/differentiation, directional sensing/migration, and survival. PPARs were reported to modulate the expression of pro-angiogenic soluble factors, such as VEGF-A and may also participate in the regulation of expression of VEGF receptors. The aim of the present work was to elucidate the role of PPARp/δ in endothelial cell functions important for angiogenesis as well as in vascular permeability and vasodilatation. Using organ culture models of mouse aorta expiants, cultures of human umbilical vein endothelial cells (HUVECs) and genetically modified mouse models, we studied the consequences of loss and gain of PPARp/5 activity on endothelial cell functions. In the first part of this study, we show that the activation of PPARp/δ promotes EC outgrowth in murine aorta expiants. In vivo we observed that dermal vessel acute permeability in response to VEGF-A stimulation is strongly impaired in PPARfi/δ -I- animals. Additionally, observation of the dermal vessel morphology showed a clear enlargement of the wild-type dermal vessels upon VEGF-A injection, whereas vessels of PPARp/5 -/- animals showed almost no enlargement. The impaired response to VEGF stimulation in the knock-out animals was not due to structural or morphological abnormalities. Based on this data, we suggest that PPARp/5 may act on intracellular signaling cascades in ECs, downstream of the VEGF-A receptor. In the second part of this study, we address the relevance of PPARβ/δ vascular functions in pathophysiological inflammatory conditions, such as delayed- type hypersensitivity (DTH) reaction and anaphylaxis in mice. The DTH reaction is a cell-mediated immune reaction to protein, bacterial and viral antigens, whereas anaphylaxis is the most severe form of allergic reaction. In these in vivo models, we demonstrated that the absence of PPARβ/δ in ECs prevents the formation of severe edema in the DTH reaction, and that Ρ PARβ/δ accelerates recovery following systemic anaphylaxis, at least partially through the control of vascular permeability. Our data not only describe a novel function of PPARβ/δ in vessel permeability and vasodilatation, but also open new routes of research for the development of vessel permeability/vasodilatation regulating agents. - Les cellules endothéliales qui bordent la face interne des vaisseaux sanguins forment l'endothélium, une barrière semi-perméable qui régule les échanges de fluides, de protéines et de cellules immunes entre la circulation et les organes. L'endothélium participe également au maintien de la fonction des organes et de l'homéostasie circulatoire. La perméabilité vasculaire augmente dans des situations inflammatoires aigties ou chroniques, dans les tumeurs, et pendant la réparation de blessures. Cette augmentation de perméabilité est due à la production de facteurs sécrétés, tels que le Vascular Endothelial Growth Factor (VEGF-A), la thrombine ou I'histamine. Lès récepteurs nucléaires Peroxisome Proliferator-Activated Receptors (PPAR) sont des facteurs de transcription mis en activité par des ligands. Trois isotypes de PPARs, PPARa, ΡΡΑΡβ/δ and PPARy ont été caractérisés. Ils sont exprimés dans les cellules endothéliales, et des travaux récents ont montré qu'ils régulent des comportements cellulaires importants pour la vasculogenèse et l'angiogenèse, tels que la prolifération, la différenciation, la migration, et la survie des cellules. Ils régulent également la production de VEGF-A par divers types cellulaires. Le but de ce travail était d'élucider le rôle de PPARβ/δ dans la régulation de la perméabilité vasculaire, plus particulièrement dans les cellules endothéliales. Grâce à des cultures d'expiants d'aortes de souris, à la culture d'une lignée endothéliale humaine (HUVECs) et de souris génétiquement modifiées, nous avons étudié le rôle de PPARβ/δ dans les cellules endothéliales, dans des situations gain et perte de fonction du récepteur. Dans la première partie de ce travail, nous avons montré les propriétés pro-angiogéniques de PPARβ/δ dans des explants d'aortes. In vivo, nous avons observé l'absence d'hyperperméabilité aiguë induite par le VEGF-A, la thrombine et I'histamine chez les souris PPARβ/δ -/-. De plus, l'analyse morphologique des vaisseaux dans le derme des souris après stimulation par VEGF- A a confirmé l'absence de réponse à la stimulation. Ces analyses morphologiques nous ont également permis de montrer que l'absence de réponse aiguë n'était pas due à un défaut de structure des vaisseaux dermiques chez les souris PPARp/δ -/-. Sur la base de ces résultats, nous proposons que PPARp/δ régule des voies de signalisation intracellulaires dans les cellules endothéliales, voie de signalisation impliquées dans la régulation de la perméabilité vasculaire: Dans la seconde partie du travail, nous avons étudié l'importance de la régulation de la perméabilité vasculaire par PPARβ/δ dans des situations pathophysiologiques impliquant une hyperperméabilité aiguë des vaisseaux : une réaction d'hypersensibilité cutanée retardée d'une part (delayed-type hypersensitivity, DTH), et un choc anaphylactique d'autre part. Dans ces deux modèles induits expérimentalement chez la souris, l'absence de PPARβ/δ prévient en partie la formation de l'oedème inflammatoire local (DTH), et accélère la récupération (anaphylaxie), au moins partiellement en réglant la perméabilité vasculaire. Ces résultats ouvrent un nouveau champs d'étude quant au rôle de PPARβ/δ dans les vaisseaux et à d'éventuelles applications thérapeutiques dans des pathologies inflammatoires.

The role of the vascular endothelium in arenavirus haemorrhagic fevers.

Viral haemorrhagic fevers (VHF) caused by arenaviruses are among the most devastating emerging human diseases. The most important pathogen among the arenaviruses is Lassa virus (LASV), the causative agent of Lassa fever that is endemic to West Africa. On the South American continent, the New World arenavirus Junin virus (JUNV), Machupo (MACV), Guanarito (GTOV), and Sabia virus (SABV) have emerged as causative agents of severe VHFs. Clinical and experimental studies on arenavirus VHF have revealed a crucial role of the endothelium in their pathogenesis. However, in contrast to other VHFs, haemorrhages are not a salient feature of Lassa fever and fatal cases do not show overt destruction of vascular tissue. The functional alteration of the vascular endothelium that precede shock and death in fatal Lassa fever may be due to more subtle direct or indirect effects of the virus on endothelial cells. Haemorrhagic disease manifestations and vascular involvement are more pronounced in the VHF caused by the South American haemorrhagic fever viruses. Recent studies on JUNV revealed perturbation of specific endothelial cell function, including expression of cell adhesion molecules, coagulation factors, and vasoactive mediators as a consequence of productive viral infection. These studies provided first possible links to some of the vascular abnormalities observed in patients, however, their relevance in vivo remains to be investigated.

Cuidar de pessoa incapacitada por acidente vascular cerebral no domicílio: o fazer do cuidador familiar

Estudo exploratório, descritivo e quantitativo que busca identificar e descrever as atividades do familiar que cuida de pessoas incapacitadas por AVC no domicílio. A amostra constituiu-se de 35 cuidadores familiares, predominantemente mulheres, esposas ou filhas. Os cuidados realizados relacionam-se ao grau de incapacidade do familiar. As orientações recebidas denotam falta de compromisso dos profissionais com a continuidade do cuidado. O cuidador aprende a cuidar no cotidiano, com base na observação e auxílio à enfermagem na internação. As dificuldades pautam-se no esforço físico, na desinformação e no medo, no constrangimento e na vergonha em lidar com o corpo do outro. O estudo enfoca a necessidade do preparo para a alta hospitalar, salienta a família como espaço concreto para o cuidado; o aumento da expectativa de vida é uma constatação.

Intraoperative assessment of vascular access.

PURPOSE: The intraoperative quality assessment of the arteriovenous fistula for hemodialysis is an essential process to limit early failure due to technical problems or inadequate vascular quality. This step is not clearly defined in the literature with no recommendations. METHODS: We selected published articles related to the topic of intraoperative quality control of the vascular access for hemodialysis. RESULTS: The intraoperative blood flow measurement greater than 120 ml/min in autologous fistula and less than 320 ml/min in arteriovenous graft was described as predictive factors for early failure. CONCLUSIONS: The blood flow measurement should be performed after the confection of the anastomosis. When blood flow is limited, fistulography is an essential step to assess patency.

Vascular dysfunction in children conceived by assisted reproductive technologies: underlying mechanisms and future implications.

Epidemiological studies in humans have demonstrated a relationship between pathological events during fetal development and increased cardiovascular risk later in life and have led to the so called "Fetal programming of cardiovascular disease hypothesis". The recent observation of generalised vascular dysfunction in young apparently healthy children conceived by assisted reproductive technologies (ART) provides a novel and potentially very important example of this hypothesis. This review summarises recent data in ART children demonstrating premature subclinical atherosclerosis in the systemic circulation and pulmonary vascular dysfunction predisposing to exaggerated hypoxia-induced pulmonary hypertension. These problems appear to be related to the ART procedure per se. Studies in ART mice demonstrating premature vascular aging and arterial hypertension further demonstrate the potential of ART to increase cardiovascular risk and have allowed to unravel epigenetic alterations of the eNOS gene as an underpinning mechanism. The roughly 25% shortening of the life span in ART mice challenged with a western style high-fat-diet demonstrates the potential importance of these alterations for the long-term outcome. Given the young age of the ART population, data on cardiovascular endpoints will not be available before 20 to 30 years from now. However, already now cohort studies of the ART population are needed to early detect cardiovascular alterations with the aim to prevent or at least optimally treat cardiovascular complications. Finally, a debate needs to be engaged on the future of ART and the consequences of its exponential growth for public health.