ST-segment elevation in patients with cocaine abuse and chest pain

Use of cocaine may complicate the diagnosis of myocardial infarction (MI) and may influence treatment strategy. Patients with symptoms suggestive of acute coronary syndrome (ACS) should be questioned about the use of cocaine. Initial management of cocaine users presenting with chest pain and ST segment elevation should include administration of glyceryl trinitrate (GTN). Assessment for resolution of chest discomfort and ECG changes should be undertaken before fibrinolytic therapy or angiography is considered. We present a case of patient with chest pain (CP) and ST elevation after cocaine use, whose symptoms and ST changes promptly resolved after medical therapy. Our case highlights the importance of medical therapy in patient with CP and ST elevation after cocaine abuse, before activating cardiac catheterization laboratory for emergent angiography.

Abstract P5-01-07: Select neutrophils inhibit breast cancer metastases in patients via chemokine-mediated mechanisms

Background: In both breast cancer patients and healthy women, we have previously demonstrated that select neutrophils found in breast cancer patients as opposed to healthy women are cytotoxic to breast cancer cell lines. (Granot Z et al. Cancer Cell. 2010) This work stemmed from our prior research in murine breast cancer models indicating that primary breast tumors can mobilize select neutrophils, termed Tumor Entrained Neutrophils (“TENS”); these entrained neutrophils have the unique capacity to inhibit metastatic seeding in the lung through cell-kill mechanisms. (Granot Z et al. Cancer Cell. 2010) In this study, we evaluated the relationship between select chemokines and neutrophil cytotoxicity in breast cancer patients versus healthy volunteers.

Methods: Neutrophils were purified from the blood of 75 randomly selected newly diagnosed pre-operative breast cancer patients without evidence of metastatic disease, and 47 healthy female volunteers with no history of cancer. Cytotoxicity was evaluated by incubating neutrophils with luciferase labeled MDA-MB-231 cells. Luciferase activity was measured as a reflection of% cytotoxicity. Serum was also isolated from breast cancer patients and healthy volunteers. Based on prior experiments, we used the Millipore® Milliplex Human Cytokine Plex Kit to evaluate Il-1Ra, MCP-1 and TNFa in our serum samples in 50/75 of the cancer patients and 25/47 controls. We used multiple linear regression to develop a model to predict cytotoxicity as a function of the chemokines.

Results: In comparison to healthy volunteers whose mean neutrophil cytotoxicity to MDA-MB-231 cells was 6.5%, pre-operative breast cancer patients demonstrated a mean neutrophil cytotoxicity of 12.7%, p<0.0001. We then evaluated the serum chemokine levels of 50 of the breast cancer patients; 31/50 had high neutrophil cytotoxicity (>10%), and 19/50 had low neutrophil cytotoxicity (<10%). We compared the serum chemokine levels in the patients to the levels found in the 25 controls. Using a multiple linear regression model, we found that the levels of these three chemokines are associated with cytotoxicity (R2 = 0.126, p = 0.022). An ANOVA decomposition of the model suggested that Il.1RA was the most predictive (p = 0.018) followed by MCP.1 (p = 0.088) and TNF.alpha (p = 0.245).

Conclusion: Our work demonstrates the cytotoxic role of select neutrophils in the peripheral blood of breast cancer patients as contrasted with neutrophils from healthy women. We further demonstrate that select chemokines appear to be correlated with neutrophil cytotoxicity. We are currently evaluating the prognostic and therapeutic roles of cytotoxic neutrophils and their related chemokines in breast cancer patients.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-01-07.

Randomized clinical trial of intraoperative superficial cervical plexus block versus incisional local anaesthesia in thyroid and parathyroid surgery

Background

Moderate wound pain and opiate analgesia requirement is reported following thyroid and parathyroid surgery. A randomized clinical trial was performed to investigate whether intraoperative superficial cervical plexus block (SCPB) would decrease postoperative pain and analgesia use.

Methods

Patients were randomized to incisional local anaesthesia (control) or incisional local anaesthesia plus intraoperative SCPB. The primary outcome measure was pain, assessed by a visual analogue scale (VAS). Secondary outcome measures were analgesia use (strong opiates defined as having potency at least as strong as that of oral morphine), respiratory rate and sedation score. Primary outcome measures were analysed with non-parametric tests, as well as with receiver operating characteristic (ROC) curves calculated as area under the curve (AUC) to discriminate between trial limbs.

Results

Twenty-nine patients were randomized to each group. Pain (VAS) scores were lower in patients who received intraoperative SCPB than in controls 30 min after surgery and subsequently (P < 0·020 at all time points), with a median pain score of zero on the day of operation in the SCPB group. Corresponding analysis of ROC curves showed differences between groups at 30 min (AUC = 0·722, P = 0·012), 90 min (AUC = 0·747, P = 0·005), 150 min (AUC = 0·803, P < 0·001) and 210 min (AUC = 0·849, P < 0·001) after surgery, and at 07.00 hours on postoperative day 1 (AUC = 0·710, P = 0·017). Fewer patients in the SCPB group required strong opiates (5 of 29 versus 16 of 29 in the control group; P = 0·003) and rescue opiates (6 of 29 versus 20 of 29; P < 0·001).

Conclusion

Intraoperative SCPB reduces pain scores following thyroid and parathyroid surgery, and reduces the requirement for strong and rescue opiates. Registration number: 2009-012671-98 (https://www.clinicaltrialsregister.eu).

Cell cytoskeletal changes effected by static compressive stress lead to changes in the contractile properties of tissue regenerative collagen membranes

Static compressive stress can influence the matrix, which subsequently affects cell behaviour and the cell's ability to further transform the matrix. This study aimed to assess response to static compressive stress at different stages of osteoblast differentiation and assess the cell cytoskeleton's role as a conduit of matrix-derived stimuli. Mouse bone marrow mesenchymal stem cells (MSCs) (D1 ORL UVA), osteoblastic cells (MC3T3-E1) and post-osteoblast/pre-osteocyte-like cells (MLO-A5) were seeded in hydrated and compressed collagen gels. Contraction was quantified macroscopically, and cell morphology, survival, differentiation and mineralisation assessed using confocal microscopy, alamarBlue® assay, real-time quantitative reverse transcription polymerase chain reaction (RT-qPCR) and histological stains, respectively. Confocal microscopy demonstrated cell shape changes and favourable microfilament organisation with static compressive stress of the collagen matrix; furthermore, cell survival was greater compared to the hydrated gels. The stage of osteoblast differentiation determined the degree of matrix contraction, with MSCs demonstrating the greatest amount. Introduction of microfilament disrupting inhibitors confirmed that pre-stress and tensegrity forces were under the influence of gel density, and there was increased survival and differentiation of the cells within the compressed collagen compared to the hydrated collagen. There was also relative stiffening and differentiation with time of the compressed cell-seeded collagen, allowing for greater manipulation. In conclusion, the combined collagen chemistry and increased density of the microenvironment can promote upregulation of osteogenic genes and mineralisation; MSCs can facilitate matrix contraction to form an engineered membrane with the potential to serve as a 'pseudo-periosteum' in the regeneration of bone defects.

Intracerebral haemorrhage, anticoagulation and mechanical heart valves: what should I do next?

Life-long oral anticoagulant therapy is recommended to all patients with mechanical heart valves to reduce the incidence of thromboembolic events. However, intracerebral haemorrhage is the fatal complication associated with anticoagulation, with an estimated 6-month mortality of 67%. (1) The incidence of cerebral bleeding while on anticoagulation is 0.3-0.7%/year, with as many as 85% of survivors left with permanent neurological deficits. (2) Difficulties in management arise when anticoagulation is temporarily discontinued as mechanical valves, particularly mitral, are exposed to significant thromboembolic and valve dysfunction risk. The decision on when to appropriately restart anticoagulation needs to be balanced with the risk of precipitating further cerebral haemorrhage. There are currently no guidelines on the optimal time to start anticoagulation. We describe a case of the management approach implemented in a patient with a mechanical valve presenting to the emergency department with an acute intracerebral haemorrhage.