Sensing and control of adipocyte function

Obesity has become a global epidemic. Approximately 15% of the world population is either overweight or obese. This figure rises to 75% in many westernised countries including the United Kingdom. Health costs in the UK to treat obesity and associated disease are conservatively estimated at 6% of the National Health Service (NHS) budget equating to 3.33 billion Euros. Excess adiposity, especially in visceral depots, increases the risk of type 2 diabetes, cardiovascular disease, gall stones, hypertension and cancer. Type 2 diabetes mellitus accounts for >90% of all cases of diabetes of which the majority can be attributed to increased adiposity, and approximately 70% of cardiovascular disease has been attributed to obesity in the US. Weight loss reduces risk of these complications and in some cases can eliminate the condition. However, weight loss by conventional non-medicated methods is often unsuccessful or promptly followed by weight regain. This thesis has investigated adipocytes development and adipokine signalling with a view to enhance the understanding of tissue functionality and to identify possible targets or pathways for therapeutic intervention. Adipocyte isolation from human tissue samples was undertaken for these investigative studies, and the methodology was optimised. The resulting isolates of pre-adipocytes and mature adipocytes were characterised and evaluated. Major findings from these studies indicate that mature adipocytes undergo cell division post terminal differentiation. Gene studies indicated that subcutaneous adipose tissue exuded greater concentrations and fluctuations of adipokine levels than visceral adipose tissue, indicating an important adiposensing role of subcutaneous adipose tissue. It was subsequently postulated that the subcutaneous depot may provide the major focus for control of overall energy balance and by extension weight control. One potential therapeutic target, 11ß-hydrosteroid dehydrogenase (11ß-HSD1) was investigated, and prospective inhibitors of its action were considered (BVT1, BVT2 and AZ121). Selective reduction of adiposity of the visceral depot was desired due to its correlation with the detrimental effects of obesity. However, studies indicated that although the visceral depot tissue was not unaffected, the subcutaneous depot was more susceptible to therapeutic inhibition by these compounds. This was determined to be a potentially valuable therapeutic intervention in light of previous postulations regarding long-term energy control via the subcutaneous tissue depot.

Induction of placental heme oxygenase-1 is protective against TNFα-induced cytotoxicity and promotes vessel relaxation

Background: Pregnancy is characterized by an inflammatory-like process and this may be exacerbated in preeclampsia. The heme oxygenase (HO) enzymes generate carbon monoxide (CO) that induces blood vessel relaxation and biliverdin that acts as an endogenous antioxidant. Materials and Methods: We examined the expression and localization of HO-1 and HO-2 in normal and preeclamptic placenta using reverse transcription polymerase chain reaction (RT-PCR), RNase protection assay, immunoblotting and immunohistochemistry. In addition, the effect of HO activation on tumor necrosis factor-alpha (TNF) induced placental damage and on feto-placental circulation was studied. Results: We provide the first evidence for the role of HO as an endogenous placental factor involved with cytoprotection and placental blood vessel relaxation. HO-1 was significantly higher at term, compared with first trimester placentae indicating its role in placental vascular development and regulation. HO-1 predominantly localized in the extravascular connective tissue that forms the perivascular contractile sheath around the developing blood vessels. HO-2 was localized in the capillaries, as well as the villous stroma, with weak staining of trophoblast. Induction of HO-1 caused a significant attenuation of TNF-mediated cellular damage in placental villous explants, as assessed by lactate dehydrogenase leakage (p 0.01). HO-1 protein was significantly reduced in placentae from pregnancies complicated with preeclampsia, compared with gestationally matched normal pregnancies. This suggests that the impairment of HO-1 activation may compromise the compensatory mechanism and predispose the placenta to cellular injury and subsequent maternal endothelial cell activation. Isometric contractility studies showed that hemin reduced vascular tension by 61% in U46619-preconstricted placental arteries. Hemininduced vessel relaxation and CO production was inhibited by HO inhibitor, tin protoporphyrin IX. Conclusions: Our findings establish HO-1 as an endogenous system that offers protection against cytotoxic damage in the placenta, identifies the HO-CO pathway to regulate feto-placental circulation and provides a new approach to study the disease of preeclampsia.

Efeitos da terapia fotodinâmica com aluminio – cloro ftalocianina sobre a peroxidação lipídica e produtos antioxidantes em tecidos inflamados animais

Photodynamic therapy (PDT) consists of a non-toxic photosensitizing agent (FS) administration followed by a laser source resulting in a sequence of photochemical and photobiological processes that generate reactive oxygen species (ROS) that damaging cells. The present work evaluated the effects of PDT nanoemulsion-aluminum chloride phthalocyanine (AlClFc) mediated on malondialdehyde (MDA), glutathione (GSH), superoxide dismutase (SOD) and glutathione peroxidase (GPx) levels, which represent indicators involved in oxidative stress and antioxidant defenses. For this purpose, this study used 120 female rats of the Rattus norvegicus species, Wistar race, divided into 5 groups: Healthy (H), with periodontal disease (PD), with periodontal disease and treatment with FS (F), with periodontal disease and treatment with the laser (L); and periodontal disease and treatment with PDT (FL). An experimental model for represent periodontal disease (PD) was induced by ligature (split-mouth). Seven days later the induction of PD, the treatments were instituted according to the groups. In the group treated with PDT was applied 40μl FS (5μM) followed by laser irradiation diode InGaAlP (660nm, 100J / cm2). The rats were sacrificed on the 7th and 28th day after treatment and tissue specimens were removed and subjected to histological, immunohistochemical methods and enzymatic colorimetric measurements with detection by UV / VIS spectroscopy. Inflammatory changes, connective tissue disorganization and alveolar bone loss were displaying in groups with PD induced. The enzyme dosages showed that MDA levels were higher in PD induced groups, with no statistically significant differences (p> 0.05). High levels of GSH were found in groups L (p = 0.028) and FL (p = 0.028) compared with PD group, with statistically significant differences. Immunohistochemistry for SOD showed higher immunostaining in L and FL groups, compared to the PD group without statistically significant differences (p> 0.05). GPx showed lower immunoreactivity in the DP group when compared to the other groups and statistically significant differences were observed between the DPxL groups (p <0.05). TFD administered in this experiment did not induce elevation of MDA levels significantly increased the GSH levels and showed intense immunostaining pada SOD and GPx, showing that this therapy does not accentuated lipid peroxidation, however, it was able to induce effects on the antioxidant defenses processes. The LBI therapy appeared to show photomodulatory promoting effects reduction of the MDA levels, increasing GSH levels and with intense immunostaining for SOD and GPx, demonstrating that laser therapy induced antioxidant effects.

Inter-relação entre lesão cervical não cariosa e comprometimento periodontal: diagnóstico, tratamento e previsibilidade - estudo clínico prospectivo e laboratorial

The coexistence of gingival recession (GR) with root coverage indication and non-carious cervical lesions (LCNC) generates the need for a protocol that respects and promotes health of dental and periodontal tissues and allows treatment predictability. The main objectives of this theses were: (1) verify, through clinical evaluations, the connective tissue graft for root coverage on direct and indirect restorations made of ceramic resin; (2) analyze the influence of the battery level of the LED curing unit in the composite resin characteristics; (3) assess the influence of restorative materials, composite resin and ceramics, on the viability of gingival fibroblasts from primary culture. Nine patients with good oral hygiene and occlusal stability diagnosed with LCNCs the anterior teeth including premolars associated with gingival recession (class I and II of Miller) and only gingival recession were selected. After initial clinical examination, occlusal adjustment was performed and the patients had their teeth randomized allocated on direct composite resin restoration of LCNC, polishing and GR treatment with connective tissue graft and advanced coronally flap CR group (n = 15); and indirect ceramic restoration of the LCNC's and GR treatment (CTG+CAF) Group C (n = 15). The GR presented teeth with no clinically formed LCNCs cavity were treated using (CTG+CAF) being the control group (n = 15). Sorption and solubility tests, analysis of the degree of conversion and diametral tensile strength were performed in composite resin samples (n = 10) photoactivated by 100, 50 and 10% battery charge LED unit. The viability of fibroblasts on composite resin, ceramics and dentin disks (n = 3) was examined. Clinical follow-up was performed for three months. The data obtained at different stages were tabulated and subjected to analysis for detection of normal distribution and homogeneity. The results showed that: the LED unit with 10% battery affects the characteristics of the composite resin; restorative materials present biocompatibility with gingival fibroblasts; and the association of surgical and restorative treatment of teeth affected by NCCL and GR presents successful results at 3-month follow-up.

Vesicoureteral reflux and the extracellular matrix connection.

Primary vesicoureteral reflux (VUR) is a common pediatric condition due to a developmental defect in the ureterovesical junction. The prevalence of VUR among individuals with connective tissue disorders, as well as the importance of the ureter and bladder wall musculature for the anti-reflux mechanism, suggest that defects in the extracellular matrix (ECM) within the ureterovesical junction may result in VUR. This review will discuss the function of the smooth muscle and its supporting ECM microenvironment with respect to VUR, and explore the association of VUR with mutations in ECM-related genes.

Feasibility of MR-Based Body Composition Analysis in Large Scale Population Studies

Introduction Quantitative and accurate measurements of fat and muscle in the body are important for prevention and diagnosis of diseases related to obesity and muscle degeneration. Manually segmenting muscle and fat compartments in MR body-images is laborious and time-consuming, hindering implementation in large cohorts. In the present study, the feasibility and success-rate of a Dixon-based MR scan followed by an intensity-normalised, non-rigid, multi-atlas based segmentation was investigated in a cohort of 3,000 subjects. Materials and Methods 3,000 participants in the in-depth phenotyping arm of the UK Biobank imaging study underwent a comprehensive MR examination. All subjects were scanned using a 1.5 T MR-scanner with the dual-echo Dixon Vibe protocol, covering neck to knees. Subjects were scanned with six slabs in supine position, without localizer. Automated body composition analysis was performed using the AMRA Profiler™ system, to segment and quantify visceral adipose tissue (VAT), abdominal subcutaneous adipose tissue (ASAT) and thigh muscles. Technical quality assurance was performed and a standard set of acceptance/rejection criteria was established. Descriptive statistics were calculated for all volume measurements and quality assurance metrics. Results Of the 3,000 subjects, 2,995 (99.83%) were analysable for body fat, 2,828 (94.27%) were analysable when body fat and one thigh was included, and 2,775 (92.50%) were fully analysable for body fat and both thigh muscles. Reasons for not being able to analyse datasets were mainly due to missing slabs in the acquisition, or patient positioned so that large parts of the volume was outside of the field-of-view. Discussion and Conclusions In conclusion, this study showed that the rapid UK Biobank MR-protocol was well tolerated by most subjects and sufficiently robust to achieve very high success-rate for body composition analysis. This research has been conducted using the UK Biobank Resource.

Extracellular matrix sub-types and mechanical stretch impact human cardiac fibroblast responses to transforming growth factor beta

Understanding the impact of extracellular matrix sub-types and mechanical stretch on cardiac fibroblast activity is required to help unravel the pathophysiology of myocardial fibrotic diseases. Therefore, the purpose of this study was to investigate pro-fibrotic responses of primary human cardiac fibroblast cells exposed to different extracellular matrix components, including collagen sub-types I, III, IV, VI and laminin. The impact of mechanical cyclical stretch and treatment with transforming growth factor beta 1 (TGFβ1) on collagen 1, collagen 3 and alpha smooth muscle actin mRNA expression on different matrices was assessed using quantitative real-time PCR. Our results revealed that all of the matrices studied not only affected the expression of pro-fibrotic genes in primary human cardiac fibroblast cells at rest but also affected their response to TGFβ1. In addition, differential cellular responses to mechanical cyclical stretch were observed depending on the type of matrix the cells were adhered to. These findings may give insight into the impact of selective pathological deposition of extracellular matrix proteins within different disease states and how these could impact the fibrotic environment.

Mobilisation des dépôts ectopiques de tissu adipeux : ses implications dans la résolution des comorbidités associées à l'obésité sévère suivant une chirurgie bariatrique

La prévalence de l’obésité sévère ne cesse d’augmenter. La problématique associée à l’obésité sévère est la présence possible de nombreuses comorbidités qui peuvent coexister et altérer le système cardiovasculaire, pulmonaire, endocrinien, articulaire et même favoriser le développement de certains cancers. L’excès de poids, plus particulièrement l’excès de tissu adipeux, sont tous deux liés au développement de ces comorbidités. Aucune donnée n’est disponible quant au rôle de la déposition ectopique du tissu adipeux. Considérant le caractère morbide de l’obésité sévère, la mortalité de toute cause augmentée et l’espérance de vie réduite, à ce jour le seul traitement dit efficace à long terme pour le traitement de l’obésité sévère est la chirurgie bariatrique. L’efficacité est définie par la perte de poids, le maintien à long terme de cette perte de poids ainsi que par l’amélioration ou la résolution des comorbidités. L’intérêt clinique et scientifique pour la chirurgie bariatrique est grandissant. Un nombre important d’études s’intéresse aux mécanismes sous-jacents de la résolution des comorbidités. Le diabète de type 2 est la comorbidité la plus étudiée et peu d’études se sont intéressées aux déterm meil.inants de la résolution de l’hypertension artérielle et de l’apnée obstructive du som Comme premier objectif, cette thèse visait à caractériser les différences de la composition corporelle et de la distribution du tissu adipeux de patients obèses sévères avec ou sans diagnostic de diabète de type 2, d’hypertension artérielle et d’apnée obstructive du sommeil. Le deuxième objectif de cette thèse visait à comparer l’évolution postopératoire suite à une chirurgie bariatrique sur les changements de la composition corporelle et de la distribution du tissu adipeux selon le statut de résolution du diabète de type 2, de l’hypertension artérielle et de l’apnée obstructive du sommeil. De plus, considérant le peu d’évidences dans la littérature au sujet des déterminants de la résolution de l’hypertension artérielle et de l’apnée obstructive du sommeil, l’évaluation du profil inflammatoire, des adipokines et de l’activité du système nerveux autonome ont aussi été caractérisés. Premièrement, nous avons documenté qu’en présence d’obésité sévère, la déposition ectopique du tissu adipeux était plus importante chez les patients avec un diabète de type 2, une hypertension artérielle et une apnée obstructive du sommeil comparativement à ceux n’ayant pas ces comorbidités. Nous avons par la suite montré que la résolution du diabète de type 2 et de l’hypertension artérielle était caractérisée par une réduction plus importante du tissu adipeux viscéral. Au contraire, la résolution de l’apnée obstructive du sommeil était plutôt caractérisée par une réduction plus importante du tissu adipeux sous-cutané à la mi-cuisse et par une tendance à une perte de poids plus élevée. De plus, nous avons observé que chez les patients qui n’avaient pas résolu leur diabète de type 2, leur hypertension artérielle et leur apnée obstructive du sommeil, la quantité de tissu adipeux viscéral, à 12 mois suivant la chirurgie bariatrique, était plus importante comparativement à celle mesurée chez les patients n’ayant pas résolu ces comorbidités. Spécifiquement à l’évaluation du profil inflammatoire et des adipokines, nous avons observé que chez les patients obèses sévères, la présence de l’hypertension artérielle et de l’apnée obstructive du sommeil n’était pas caractérisée par un profil altéré au niveau des marqueurs inflammatoires et des adipokines. Également, nous n’avons pas observé de changements majeurs qui pouvaient expliquer, en partie, la résolution de l’hypertension artérielle et de l’apnée obstructive du sommeil. Quant à l’activité du système nerveux autonome, nous avons observé une faible activité du système nerveux parasympathique chez les patients obèses sévères avec hypertension artérielle et apnée obstructive du sommeil. Nous avons également documenté que la résolution de l’hypertension artérielle et de l’apnée obstructive du sommeil était associée à une tendance à une augmentation plus importante de l’activité parasympathique du système nerveux autonome. Les résultats obtenus au cours de ce doctorat supportent l’importance de la déposition ectopique du tissu adipeux en situation d’obésité sévère, particulièrement le rôle du tissu adipeux viscéral, dans le développement du diabète de type 2, de l’hypertension artérielle et de l’apnée obstructive du sommeil ainsi que dans la résolution de ces comorbidités suivant une chirurgie bariatrique. D’autres recherches devront davantage s’intéresser à la mobilisation des dépôts ectopiques de tissu adipeux comme un déterminant important dans la résolution à plus long terme de ces comorbidités.

Surgical technique to avoid bladder flap formation during cesarean section

Cesarean section (CS) is now the most common major surgical procedure performed on women worldwide. A CS can be performed by either suturing or not suturing of the visceral peritoneum. Creation of the bladder flap is an integral step of the standard cesarean section. The bladder flap is made by superficially incising and dissecting the peritoneal lining to separate the urinary bladder from the lower uterine segment. It’s still debated whether the formation of bladder flap is advantageous or not. If the uterine incision is made slightly above the vesicouterine peritoneal fold, the loose connective tissue between the uterus and the urinary bladder allows spontaneous descent of the bladder. Evidence on the role of the bladder flap in cesarean section is very limited. At present, it remains to be established whether there is any advantage in dissecting the bladder from the lower uterine segment during cesarean section.

Ischemic necrosis with sigma perforation in a patient with Systemic Lupus Erythematosus (SLE): case report

Systemic Lupus Erythematosus (SLE) is a chronic inflammatory rheumatic disease which affects the connective tissue. Its etiology is as yet unknown, while its pathogenesis involves the immune system. Both genetic and environmental and hormonal factors play a key role in the impaired immune regulation. A correlation with estrogens is demonstrated by the fact that the greatest incidence is found in young women, when estrogen secretion is at its highest. The disease is also reported to worsen in women taking oral contraceptives. It is therefore believed that the components of oral contraceptives, estrogens (ethinyl estradiol) and progestins, can affect the immune profile. Of the various complications attributed to systemic lupus erythematosus, gastrointestinal disorders are less common but potentially by far the most serious. We report a case of ischemic necrosis with sigma perforation in a patient with SLE. Signs and symptoms of acute abdomen in patients with SLE are rare (0.2%), but serious. Most patients require an exploratory laparotomy, as the causes are often linked with vasculitis.

O efeito agudo da terapia Bowen no limiar de dor e controlo postural em indivíduos saudáveis

Introdução: A fáscia é tecido conjuntivo inervado por terminações nervosas livres e por mecanoretores, tendo um papel importante na dor e na proprioceção. Acredita-se que a Terapia Bowen estimule os mecanorecetores e as terminações nervosas livres presentes na fáscia. Objetivos: Determinar o efeito imediato da Terapia Bowen no limiar de dor à pressão mecânica e no controlo postural em indivíduos saudáveis. Métodos: Este foi um estudo cruzado de amostras emparelhadas, duplamente cego, constituído por duas sessões para cada indivíduo: numa foi aplicado Terapia Bowen e noutra placebo. Em ambas as sessões, cada indivíduo foi avaliado quanto ao controlo postural, com plataforma de forças, e ao limiar de dor à pressão mecânica, com algómetro de pressão eletrónico, antes e depois da aplicação da intervenção/placebo. Resultados: A amostra foi constituída por 34 participantes, 17 receberam Bowen na primeira sessão e os restantes receberam placebo, distribuídos aleatoriamente. Os resultados mostraram uma diferença significativa para a deslocação ântero-posterior e velocidade de excursão do centro de pressão e limiar de dor à pressão mecânica em C1 bilateralmente (p <0,05). Discussão/Conclusão: A diferença significativa entre Terapia Bowen e placebo para apenas 4 de 14 variáveis sugere que a primeira tenha um efeito imediato reduzido no controlo postural e limiar de dor em indivíduos saudáveis. Estes resultados estão em consonância com estudos anteriores sobre o efeito imediato da terapia manual em indivíduos saudáveis.

Heart failure in young adults

Heart failure (HF) is a major health concern affecting 15 million people in Europe and around 900 000 people in the U.K. HF predominantly affects the elderly, with the mean age of patients with a diagnosis of HF between 70 and 80 years. Most previous HF studies have accordingly focused on older patients. Although HF is less common in younger adults (<65 years), 15% to 20% of patients hospitalised with HF are younger than 60 years of age. Very few studies have described the characteristics of younger adults with HF and its outcome. The aims of this thesis are to describe the clinical characteristics of younger adults with HF, explore the epidemiology of HF in younger adults and determine their short- and long-term outcomes. This was made possible by access multiple databases consisting of large patient cohorts with HF. The first chapter is a systematic literature review of younger adults with HF. Gaps in the current literature were identified and the thesis focused on some of these. The CHARM study allows detail characterisations of younger adults with HF. It recorded characteristics of patients with HF, including symptoms and signs of HF, electrocardiographic changes, chest radiographic findings, and also left ventricular ejection fraction. HF hospitalisations and its precipitating factors were also recorded systematically. Younger adults were more likely to have a third heart sound and hepatomegaly, but less likely to have pulmonary crackles and peripheral oedema. Similarly, radiological findings in younger adults were less likely to show interstitial pulmonary oedema or pleural effusion. Interestingly, younger adults aged <40 years not only have similar HF hospitalisation rate to older patients, however during their presentation with decompensated HF, they were less likely to have clinical pulmonary oedema and radiological signs of HF. Physicians managing younger adults with HF need to be aware of this. Younger adults were also less compliant with medications and lifestyle restriction resulting in hospitalisation with decompensated HF. Fortunately, despite these challenges, mortality rates in younger adults with HF were lower compared to older patients. To further substantiate the findings from the CHARM study, the MAGGIC study, a meta-analysis consists of over 40 000 patients with HF from large observational studies and randomised controlled trials, was examined. In both databases, the commonest aetiology of HF in younger adults was dilated cardiomyopathy. The ejection fraction was the lowest in younger adults. Similar to the CHARM study, mortality rates in younger adults were lower compared to older patients. However, in the MAGGIC study, by stratifying mortality into patients with preserved ejection fraction and with reduced ejection fraction, younger patients with preserved ejection fraction have a much lower mortality rate compared to patients with reduced ejection fraction. Findings from clinical trials are not always reflective of the real life clinical practice. The U.K. Clinical Practice Research Datalink (CPRD), a large and well-validated primary care database with 654 practices contributing information into the database representing approximated 8% of the U.K. population, is a rich dataset offering a unique opportunity to examine the characteristics, treatments, and outcomes of younger adults with HF in the community. In contrast to the CHARM and MAGGIC studies, younger adults aged <40 years were stratified into 20-29 and 30-39 years in the CPRD analysis. This is possible due to the larger number of younger adults with HF. Further stratifying the younger age groups demonstrated heterogeneity among younger adults with HF. In contrast to previous data showing younger adults have lower co-morbidities, the proportions of depression, chronic kidney disease, asthma, and any connective tissue disease were high among patients aged 20-29 years in the analysis from the CPRD. Surprisingly, the treatment rates for angiotensin converting enzyme (ACE) inhibitor, and aldosterone antagonist were the lowest in patients aged 20-29 years. With the exception of patients aged ≥80 years, treatment rate with beta-blocker was also the lowest in patients aged 20-29 years. With over two decades of follow up, long-term mortality rates in younger adults with HF can be determined. The mortality rates continued to decline from 1988 to 2011. Physicians managing younger adults with HF can now use this contemporary data to provide prognostic information to patients and their family. A hospital administrative database is the logical next platform to explore younger adults with HF. The Alberta Ministry of Health database links an outpatient database to a hospitalisation database providing ample data to examine the relationship between outpatient clinic visits and hospital admissions in younger adults with HF. Following a diagnosis of HF in the outpatient setting, younger adults were admitted to the hospital with decompensated HF much sooner than older patients. Younger adults also presented to emergency department more frequently following their first hospitalisation for HF. In conclusion, this thesis presented the characteristics and outcomes of younger adults with HF, and helped to extend our current understanding on this important topic. I hope the data presented here will benefit not only physicians looking after younger adults with HF, but also patients and their family.

Cardiac magnetic resonance imaging in the diagnosis and determination of outcome of pulmonary hypertension

Pulmonary hypertension (PH) is a rare but serious condition that causes progressive right ventricular (RV) failure and death. PH may be idiopathic, associated with underlying connective-tissue disease or hypoxic lung disease, and is also increasingly being observed in the setting of heart failure with preserved ejection fraction (HFpEF). The management of PH has been revolutionised by the recent development of new disease-targeted therapies which are beneficial in pulmonary arterial hypertension (PAH), but can be potentially harmful in PH due to left heart disease, so accurate diagnosis and classification of patients is essential. These PAH therapies improve exercise capacity and pulmonary haemodynamics, but their overall effect on the right ventricle remains unclear. Current practice in the UK is to assess treatment response with 6-minute walk test and NYHA functional class, neither of which truly reflects RV function. Cardiac magnetic resonance (CMR) imaging has been established as the gold standard for the evaluation of right ventricular structure and function, but it also allows a non-invasive and accurate study of the left heart. The aims of this thesis were to investigate the use of CMR in the diagnosis of PH, in the assessment of treatment response, and in predicting survival in idiopathic and connective-tissue disease associated PAH. In Chapter 3, a left atrial volume (LAV) threshold of 43 ml/m2 measured with CMR was able to distinguish idiopathic PAH from PH due to HFpEF (sensitivity 97%, specificity 100%). In Chapter 4, disease-targeted PAH therapy resulted in significant improvements in RV and left ventricular ejection fraction (p<0.001 and p=0.0007, respectively), RV stroke volume index (p<0.0001), and left ventricular end-diastolic volume index (p=0.0015). These corresponded to observed improvements in functional class and exercise capacity, although correlation coefficients between Δ 6MWD and Δ RVEF or Δ LVEDV were low. Finally, in Chapter 5, one-year and three-year survival was worse in CTD-PAH (75% and 53%) than in IPAH (83% and 74%), despite similar baseline clinical characteristics, lung function, pulmonary haemodynamics and treatment. Baseline right ventricular stroke volume index was an independent predictor of survival in both conditions. The presence of LV systolic dysfunction was of prognostic significance in CTD-PAH but not IPAH, and a higher LAV was observed in CTD-PAH suggesting a potential contribution from LV diastolic dysfunction in this group.

Spontaneous Dissection of the Renal Artery in Vascular Ehlers-Danlos Syndrome

Ehlers-Danlos syndrome (EDS) is a rare heterogeneous group of connective tissue disorders. The vascular type (vEDS) is an autosomal dominant disorder caused by heterozygous mutations in the COL3A1 gene predisposing to premature arterial, intestinal, or uterine rupture. We report a case of a 38-year-old woman with a recent diagnosis of vEDS admitted in the Emergency Department with a suspicion of a pyelonephritis that evolved to a cardiopulmonary arrest. A fatal retroperitoneal hematoma related with a haemorrhagic dissection of the right renal artery was found after emergency surgery. This case highlights the need to be aware of the particular characteristics of vEDS, such as a severe vascular complication that can lead to a fatal outcome.

A Young Woman with Fever and Cervical Lymphadenopathy

Kikuchi-Fujimoto's disease is a self-limiting and rare disorder of unknown aetiology. The typical presentation includes fever, cervical lymphadenopathy and night sweats. Consequently, it is part of the differential diagnosis of infectious, lymphoproliferative and connective tissue diseases. Histology demonstrates necrotizing histiocytic lymphadenitis. Treatment is symptomatic with non-steroidal antiinflammatory agents, although there are reports of corticosteroid use in complicated cases. We present the case of a 23-year-old woman admitted to hospital for fever and cervical lymphadenopathies, and diagnosed with Kikuchi-Fujimoto's disease.