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Prognostic markers Abstract Fungal infections represent a worrisome complication in hematologic cancer patients and in the absence of disease specific symptoms, it is important to establish new biological indicators, which can be used during mould-active prophylaxis.
Recently, miRNAs have appeared as candidate diagnostic and prognostic markers of several diseases. A pilot clinical study was performed to evaluate the diagnostic utility of 14 microRNAs which can be related to invasive fungal infections.
A tetramiR assay was designed to monitor american diabetes association grants blood specimens.
Optimal cut-off was estimated by using the median value fold change 1. The biomarker panel was evaluated on two independent sample cohorts implementing different antimicrobial prophylactic strategies. The receiver operating characteristic analysis with area under the curve proved to be 0. In summary, the tetramiR assay proved to be a promising diagnostic adjunct with sufficient accuracy and sensitivity to trace invasive aspergillosis in hemato-oncology patients. Members of the Aspergillus and Candida genera are predominant etiological agents 23.
In the past decades the incidence of aspergillosis has increased 4567. Currently, other relevant fungi are also increasingly identified, such as Cryptococcus spp.
The well-established risk factors include underlying malignancy, immunosuppression and profound neutropenia 1011 In high-risk hematology patient groups, the first-line prophylaxis is preferred Timely initiation of treatment critically affects the outcome of the disease however diagnostic driven strategy remains a challenge 6.
Identification of IA relies on the combination of cultivation and non-conventional microbiological tests such as fungal antigen testing, as well as radiology and histopathology 4. MiRNAs emerged as important endogenous regulators of virtually all basic biological processes In response to pathological processes miRNAs are expressed by all cell types and tissues into the circulation where their free forms are protected from RNAse mediated degradation Recent studies estimate the potential of free circulating miRNAs as prognostic disease biomarkers in diagnosis.
During infection, lung hypoxia diabetes and immune disease national research institute by an ischemic microenvironment, vascular invasion, thrombosis, antiangiogenic factors such as gliotoxin, are considered diabetes and immune disease national research institute be a significant virulence factor of A. Further data revealed the participation of miR26a, miR26b in relation to apoptosis and autophagy The regulatory role of miR and miR was elucidated during A.
MiR, miR16 and miR were related to immune responses, anti-inflammatory processes accompanying infection, and cell apoptosis during C. Furthermore, miR, miR26, miR16 and miR21 were found to modulate immune response against Gram-positive bacteria in human, mouse and murine models 2728 However, due to the lack of consensus in methodology, as well as processing and normalization, the actual number of clinical studies which establish the contribution of certain miRNAs to IFDs is surprisingly low 20213031323334 To ameliorate success and accuracy of diagnosis, a definite proof-of-concept was set to capture invasive aspergillosis specific miRNA expression patterns in a hemato-oncology patient population.
All miRNAs are potentially obtainable from the peripheral blood circulation. To our present knowledge, this is a pioneer clinical study which could lead to the implementation of miRNAs supporting the diagnosis of IA among patients with hematologic malignancies and profound neutropenia.
Patients of these study groups were well balanced according to age mean 60 ± Postmortem histology PMH was pursued in There was one case P4 where pathology confirmed the presence of the fungus Aspergillus in the central nervous system.
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In C1 There were no significant differences in the inflammation status of the two study groups. Figure 1 Shortlisting of parameters of our patient recruitment strategy with regard to baseline demographics and center specific characteristics.
Full size image First-line antifungal prophylaxis was associated with lower IA prevalence In C2, primary antifungal prophylaxis was initiated in the case of OH patients.
MiR was found to be optimal across patients and controls Fig. Figure 2 Testing of four potential miRNA normalizers.
Hsa-miR was found to be optimal normalizer for estimating relative miRNA expression fold changes. P stands for onco-hematology patients of this study Cq Figure 3 displays the study timeline and the date of recruitments in the case of two Hungarian centers; C1 and C2 with a cluster heatmap demonstrating normalized relative gene expression levels of miRNA targets measured in the peripheral blood.
All 14 miRNAs were expressed in the peripheral blood samples of patients and were generally overexpressed in comparison to healthy controls.
Figure 3 Relative expression levels of selected miRNAs in patients with hematologic malignancies. Black colors indicate no difference in gene expressions in comparison to the healthy controls, green scale represents the fold changes of under- while pink the overexpressions.
In the case of miRp significant a cukorbetegség kezelése szívrohammal was observed in both aspergillosis and bacteremia, thus it was omitted from further analysis Fig. In the case of three miRNAs miR26b-5p, miRp, miRpbacteremia did not vese gyógyszer vény nélkül the significant overexpressions indicating aspergillosis in diseased patients Fig.
In Fig. Reassuringly, the relative fold changes of these miRNAs proved to be specific for aspergillosis and bacterial co-infections did not interfere with the expression profiles p-values 0. Violin plots with Kernel density estimations were also made to visualizing the distribution and probability density of relative fold changes of the miRNAs in different patient groups Fig. Figure 4 miRNAs showing statistically significant overexpressions indicating aspergillosis.
Red spotted microRNAs situated towards the right top quadrant represent values of increasing magnitude diabetes and immune disease national research institute changes. Full size image Diagnostic performance of the miRNA assays Differential expression matrices represent the values of alterations in relative miRNA fold changes fc when comparing different patient groups.
MiRp showed the highest association with aspergillosis Δlog2fc 6. All miRNAs were assessed to be more abundant during aspergillosis and showed only a mild correlation with bacteremia.
Noticeably, miR26b-5p Δlog2fc: 4. All miRNAs showed remarkable expression alterations due to aspergillosis in comparison to bacteremia. We observed moderate fold changes in the expression of several miRNA targets due to aspergillosis mirp Δlog2fc: 1. Log10 transformed fold changes log10 fc for cases proven IA, probable IA and controls possible IA were dichotomized by mapping the sensitivity values in relation to 1—specificity in the diabetes insipidus test of mirp, miR26b-5p, miRp, miRp to estimate optimal cut-off values for these biomarkers Fig.
MiRp log10 transformed fold change: 1. To mitigate interpatient variability tetramiR diagnostic panel was established for a more reliable diagnosis of IA by the combined application of miRp, miRp, miR26b-5p, miRp Fig. This model relies on the median gene expression values log10 fold change: 1. Figure 5 Log-2 transformed miRNA expression fold changes were used to exploit expression alterations between patient groups.
Extents of logarithmic Δlog2fc transformed fold differences are designated diabetes and immune disease national research institute dots. A dot colored red is more abundantly expressed by the condition designated in the columns while green colored dots show more abundant fold changes designated by the rows.
Distribution of the test results of cases and controls are also shown with significances Fig. Sample concordance was also assessed between the two classifiers; Platelia Aspergillus GM-EIA and tetramiR panel showed a fair agreement with an observed ratio of We did not observe significant difference in the distribution of test results between cases and controls. None of them provided false negative FN results. In the case of tetramiR panel the median of the log10 transformed gene expression data was used.
Full size image Discussion With the significant developments achieved in the field of oncology, nosocomial etiologies are continuously associated with high mortality and increased susceptibility to IFDs The prophylactic use of available azoles during anticancer therapy has led to a reduction of Candida blood stream infections however the growing antifungal resistance especially in the case of Aspergillus fumigatus and A. Aspergillus-related pulmonary diseases can encompass various clinical syndromes moreover immunosuppressed patients may develop invasive pulmonary aspergillosis IPA 45 Despite the immense number of arany bajusz cukorbetegség kezelésére guidelines, no obvious recommendations are available addressing diagnosis and managing infections in these patient groups 4748495051 This pilot study was performed to capture the expression of specific free circulating miRNAs in blood to support the diagnosis of invasive aspergillosis.
In the case of severely immunocompromised patients the escalation in the lengths of hospital stay LOS appreciably raises the odds of nosocomial co-infections.
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Patients with fungal septicaemia show significantly higher mean hospital costs thus duration of hospitalization was positively correlated with disease occurrence The prevention of infection has become a major goal however there is no widely accepted standard for antimicrobial prophylaxis 1727 The risk appreciably rises in severe neutropenic episodes having persistent fever with more than 7 days.
Based on overlapping data of previous studies the induction of miR, miR, miR26, miR16 and miR21 was found to modulate immune response to different bacterial stimuli 28295758596061 These estimations did not manifest in our data with one exception. The contribution of hsa-miR16 to bacterial infections was strengthened showing significant expression alterations.
A difference was shown in the distribution C1 An appreciable rise was observed in the number of aspergillosis patients who did not receive antifungal prophylaxis. Antimicrobial prophylaxis has already been estimated as an important prognostic factor of bacteremia in several studies 1263646566676869 Due to a more intense antifungal prophylactic szájpenész kezelésére diabétesz népi jogorvoslati in C2 there were only two episodes P35, P32 with recurrent fever developing non-infected SIRS.
A paradox was found when comparing the number of infection related SIRS between C1 and C2 and the onset of diagnosed bacterial infection and invasive aspergillosis.
Numerous studies have been conducted in recent years to establish expression levels of certain miRNAs in different disease conditions 4 With the fact that miRNAs are expressed by all cell types and tissues they are often present at very low concentrations in peripheral blood thus their quantification requires highly sensitive and specific methods. Diverse technical biases such as initial sample volume, collection modality and, storage condition can be introduced during the experimental steps which profoundly obscure the true biological response 71727374 Additionally, miRNA family members exhibit a high degree of homology having rather low absolute copy numbers in body fluids.
Peripheral blood samples are enriched with both free circulating, membrane enclosed and intracellular miRNAs as well. The choice of a reference gene remains problematic, having serious impact on the available transcript levels and diabetes and immune disease national research institute, on the adequate interpretation of data.
We therefore applied and tested different assays to find a reliable normalizer to analyze circulating miRNA expression profiles. Hsa-miR proved to be an appropriate reference miRNA to mitigate inter-patient variabilities. Exogenous influences and the genetic heterogeneity which is concomitant with haematological malignancies can obscure the miRNA regulome.
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To mitigate these accidental effects, we recommend to draw conclusions from the expression alterations of multiple biomarkers. We therefore decided to label this set of miRNAs as a novel biomarker panel tetramiR panel supporting diagnosis of invasive aspergillosis.
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We found, that the expression of these key indicators was not confounded by age, gender, prophylactic drug choice, underlying malignancy, other diseases diabetes, hypertonia and sepsis. Diabetes and immune disease national research institute the fact that our sampling data reflect only single time points conclusions cannot be drawn about how the mirRNA expression profiles correlate with disease progression.
In Diagnosis of invasive aspergillosis still constitutes a major issue in the severely immunocompromised patient groups, especially in those undergoing intensive cytotoxic therapy. Based on our data, the tetramiR panel which relies on the expression of four concomitant miRNAs miRp, miRp, miR26b-5p and miRp can serve as a good adjunct in the diagnosis of aspergillosis. Although the optimal diagnostic cut-off point of this method might be biased by the limited size of the patient population, we underpin its suitability and utility in real diagnostic practice.
There were 15 healthy controls included with no previous history of onco-hematology OH diseases or SIRS with the median age of Diagnosis of sepsis Patients were considered to develop SIRS presenting minimum diabetes and immune disease national research institute of the following clinical findings; 1 body temperature less than 36 °C First-line choices for antimicrobial prophylaxis C1 Debrecen and C2 Nyíregyháza followed two different antimicrobial prophylactic strategies.
Both of the centers diabetes and immune disease national research institute antiviral and antibacterial prophylaxis in hematology and oncology patients in parallel with the administration of chemotherapeutics 8485 Sampling Patient samples came from 40 prospectively enrolled hemato-oncology patients from two centers; C1 and C2 of Hungary. For galactomannan testing and PCR analyses peripheral blood samples were collected from every patient at the onset day 1 of fevered neutropenia.
In the case of P2 and P36 samples were collected from diabetes and immune disease national research institute neutropenic patients suspected to develop fungal infections.
Cultures There were 30 cases where hemocultures were obtained. Adult patients having bacteremia typically have low quantities of bacteria in the blood, therefore multiple blood culture examinations were performed C1: 2. Classical mycology of bronchoalveolar lavage BAL was performed in the case of 8 patients in whom there was a suspicion of bacteremia or aspergillosis infected SIRS.
Biomarker analyses Liquid biopsy samples were parallelly screened for the presence of galactomannan GM antigens and for microRNA. MicroRNA analyses were carried out in a class II laminar-flow cabinet to avoid environmental contamination.
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To identify a stabile miRNAs endogenous control in whole blood samples of healthy patients and in study participants four candidate miRNAs RNU6B, miRd, hsa-let7a, miR were selected on the basis of literature data 73 Relative mRNA expressions were calculated by using hsa-miR for normalization. Results for non-normally distributed continuous variables are summarized as medians interquartile ranges and were compared by Mann—Whitney U test.
Statistical comparison among multiple groups were performed with Kruskal—Wallis test, and intergroup differences were tested with Dunn test. All statistical analyses were performed using GraphPad Prism statistical software. In the case of the qRT-PCR based tetramiR panel every single run was evaluated independently prior to calculating the median of the Ct values to take diagnosis.
After calculating the series of sensitivity Se and specificity Sp reports at every single decision threshold, the receiver operating characteristic ROC curve was edited by plotting the true positive values sensitivity values on y diabetes and immune disease national research institute versus the false positive rates 1—specificity values on x-axis.
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Postmortem histology The specificity of Aspergillus infection morphology via Periodic acid—Schiff PAS staining was addressed due to the open lung biopsy, performed via postmortem thoracotomy Histological samples were taken from the major organs according to a standard protocol.
Lung sampling was performed from three independent parts of the potentially infiltrated lung parenchyma. Written consent was obtained from all participants.
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