Comparison between sitagliptin as add-on therapy to insulin and insulin dose-increase therapy in uncontrolled Korean type 2 diabetes: CSI study

AIM

Individuals requiring insulin therapy for type 2 diabetes often require escalation of their regimen to achieve glycaemic control. Optimal management strategies for uncontrolled type 2 diabetes would improve glycaemic control without hypoglycaemia and weight gain. This study compared the efficacy and tolerability of adding sitagliptin, an oral dipeptidyl peptidase-4 inhibitor, and an up to 20% increase in insulin dose in patients with uncontrolled type 2 diabetes on insulin therapy.

METHODS

We conducted a 24-week, randomized, active-competitor, parallel-group study in subjects with uncontrolled type 2 diabetes [haemoglobin A1c (HbA1c) = 7.5-11%] currently using insulin therapy. Subjects were randomly assigned to either the sitagliptin adding (100 mg daily, n = 70) or an insulin-increasing arm (≥ 10% at week 12 and ≥ 10% at week 24, n = 70) while continuing other medications.

RESULTS

Average baseline HbA1c was 9.2% in both groups. HbA1c decreased more at 24 weeks in the sitagliptin adding than the insulin-increasing arm (-0.6 ± 0.1% vs. -0.2 ± 0.1%, p < 0.01). Insulin was increased by 25% at 24 weeks in the insulin-increasing group. Hypoglycaemic events were less common and less severe in sitagliptin adding arm than insulin-increasing arm (7.0 vs. 14.3 events per patient-year, p < 0.05). Weight was stable in the sitagliptin adding subjects (68.6 ± 11.6 vs. 68.1 ± 11.4 kg) but increased in the insulin-increasing subjects (66.2 ± 10.6 vs. 67.4 ± 9.7 kg, p < 0.05). Other adverse events occurred at similar rates in both arms.

CONCLUSIONS

Compared to a 25% increase in insulin dose, adding sitagliptin to an insulin-based regimen was more effective at lowering HbA1c and associated with less hypoglycaemia and weight gain over 24 weeks.

CLINICAL TRIAL NUMBER

NCT01100125.

Factors leading to under-reporting of tuberculosis in the private sector in Korea

OBJECTIVE

To identify factors associated with under-reporting of tuberculosis (TB) in the private sector in Korea.

DESIGN

A cross-sectional study of 37,820 cases in whom treatment was initiated between January and December 2008 using data from the Nationwide Medical Records Survey of Patients with TB. Adjusted odds ratios (aOR) for under-reporting with respect to socio-demographic and clinical factors were estimated.

RESULTS

Among the 37,820 identified cases, 21,611 (57.1%) were reported to the Korean TB Surveillance System. Factors associated with under-reporting on univariate analysis included young children, foreign-born persons, non-multidrug-resistant TB, persons prescribed fewer than four anti-tuberculosis drugs, non-performance of or negative result on sputum smear and extra-pulmonary TB (particularly abdominal or genitourinary TB). For pulmonary TB, cases with no sputum smear results vs. smear-positive patients (aOR 2.23, P < 0.001) and those prescribed <4 drugs vs. those who were prescribed ≥4 drugs (aOR 1.60, P < 0.001) were strongly related to under-reporting on multivariate analysis.

CONCLUSION

The extent of under-reporting was greater among young children, persons who had not received sputum smear testing and those who had been prescribed fewer than four drugs. Furthermore, TB diagnostic investigations were often inadequate. Education on reporting requirements, including the importance of following guidelines on TB management, and a stricter enforcement of the existing TB Prevention Law, are needed.

Comparison of peripheral nerve damages according to glucose control timing in experimental diabetes

OBJECTIVE

In addition to tight glucose control, early intensive therapy has been reported to be more important for the prevention of diabetic micro- and macro-vascular complications. What is not known exactly is the quantitative difference according to timing delay in glucose control and whether early period control is really better than late control in terms of diabetic peripheral neuropathy. In this study, we investigated the effect of timing differences in glucose control on the peripheral nerves in an experimental diabetic model.

METHODS

5 groups (6-8 rats in each group) were comprised of normal glucose rats (designated control), rats with hyperglycemia (designated DM), rats with glucose control for the entire 28-week study period (designated DM + INS [W0-28]), rats with glucose control for the early 14-week period followed by hyperglycemia for the late 14-week period (designated DM + INS [W0-14]), and rats with hyperglycemia for the early 14-week period followed by glucose control in the late 14-week period (designated DM + INS [W15-28]).

RESULTS

We found that the current perception threshold (CPT) was lower in the DM + INS (W0-28) and DM + INS (W15-28) groups than in the DM + INS (W0-14) or DM groups (P<0.05). The mean myelinated fiber area of the sciatic nerve was significantly greater in the DM + INS (W0-28) and DM + INS (W15-28) groups (63.5±2.32 and 60.1±2.14 um, respectively) than in the DM + INS (W0-14) or DM groups (55.5±2.81 or 51.5±2.64 um, respectively) (P<0.05), and the intraepidermal nerve fiber (IENF) density was significantly higher in the DM + INS (W0-28) and DM + INS (W15-28) groups (6.9±0.46 and 6.8±0.11, respectively) than in the DM + INS (W0-14) or DM groups (59.5±0.32 and 5.3±0.39/mm, respectively) (P<0.05).

CONCLUSION

Our results indicate that continuous glucose control is necessary to alleviate peripheral nerve damage and that glycemic control during the later period may be more important than early period management. The importance of continuous glucose control, including the later period of diabetes, should therefore be emphasized in diabetic peripheral neuropathy.

Nonstructural 5A protein of hepatitis C virus regulates heat shock protein 72 for its own propagation

We identified heat shock protein 72 (Hsp72) as a host factor that was differentially expressed in cells expressing nonstructural 5A (NS5A) protein. To investigate how NS5A modulates Hsp72 in hepatitis C virus (HCV) life cycle, we examined the role of Hsp72 in HCV replication and virus production. NS5A specifically interacted with Hsp72. Both Hsp72 and nuclear factor of activated T cells 5 (NFAT5) levels were increased in cells expressing NS5A protein. Treatments of N-acetylcysteine and glutathione markedly reduced protein levels of both NFAT5 and Hsp72. Knockdown of NFAT5 resulted in decrease in Hsp72 level in cells expressing NS5A. Importantly, silencing of Hsp72 expression resulted in decrease in both RNA replication and virus production in HCV-infected cells. These data indicate that NS5A modulates Hsp72 via NFAT5 and reactive oxygen species activation for HCV propagation.

Decreased risk of graft failure with maternal liver transplantation in patients with biliary atresia

The presence of maternal cells in offspring may promote tolerance to noninherited maternal antigens (NIMAs). Children with biliary atresia (BA) have increased maternal cells in their livers, which may impact tolerance. We hypothesized that patients with BA would have improved outcomes when receiving a maternal liver. We reviewed all pediatric liver transplants recorded in the SRTR database from 1996 to 2010 and compared BA and non-BA recipients of maternal livers with recipients of paternal livers for the incidences of graft failure and retransplantation. Rejection episodes after parental liver transplantation were examined for patients transplanted at our institution. BA patients receiving a maternal graft had lower rates of graft failure compared to those receiving a paternal graft (3.7% vs. 10.5%, p = 0.02) and, consequently, fewer episodes of retransplantation (2.7% vs. 7.5%, p = 0.04). These differences were not seen among non-BA patients or among BA patients who received female deceased donor grafts. In patients transplanted at our institution, paternal liver transplantation was associated with an increased incidence of refractory rejection compared to maternal liver transplantation only in BA. Our data support the concept that maternal cells in BA recipients promote tolerance to NIMAs and may be important in counseling BA patients who require liver transplantation.

Development and in vitro evaluation of a flow-adjustable elastic drug infusion pump

Passive-type drug infusion pumps have several advantages over active-type pumps including a simple drug chamber structure and relatively high operational stability. However, conventional passive-type infusion pumps also have several limitations compared to active ejection pumps, such as a fixed flowrate and monotonic flow pattern. To enhance the clinical feasibility of using passive-type drug infusion pumps, flow readjustment and flow regulation abilities are needed. This paper proposes a new portable elastic drug infusion pump that integrates the advantages of active and passive infusion pumps to improve clinical feasibility. The proposed infusion pump incorporates a passively driven drug chamber and an actively adjusted flow controller, which can adjust and regulate various target flowrates and adjust the flow pattern in accordance with the patient’s time-varying physiological status. The proposed infusion pump uses the contraction force of an expanded elastic membrane to extract the drug from the drug chamber for delivery into the patient’s body through an outlet catheter. It also utilizes a flow sensor, a flow resistor, and a motor-driven flow restrictor that can monitor the real-time flowrate through the outlet catheter and automatically regulate the actual flowrate around the target value. Experiments on the proposed system resulted in actual injection rates of 0.49 ± 0.03 (mean ± standard deviation), 0.98 ± 0.03, 1.49 ± 0.04, and 1.99 ± 0.03 ml/h when the target injection rate was set to 0.5, 1.0, 1.5, and 2.0 ml/h, respectively. During the entire period of operation from the fully filled state to the totally empty state, an inner-chamber pressure of >100 mmHg was maintained, which shows that the proposed infusion pump can stably maintain its target flowrate as the amount of drug remaining to be injected decreases. It appears that the proposed drug infusion pump can be applied to a wide variety of patient treatments that require short-term, accurate, and stable drug delivery.

Novel vaccines against influenza viruses

Killed and live attenuated influenza virus vaccines are effective in preventing and curbing the spread of influenza epidemics when the strains present in the vaccines are closely matched with the predicted epidemic strains. These vaccines are primarily targeted to induce immunity to the variable major target antigen, hemagglutinin (HA) of influenza virus. However, current vaccines are not effective in preventing the emergence of new pandemic or highly virulent viruses. New approaches are being investigated to develop universal influenza virus vaccines as well as to apply more effective vaccine delivery methods. Conserved vaccine targets including the influenza M2 ion channel protein and HA stalk domains are being developed using recombinant technologies to improve the level of cross protection. In addition, recent studies provide evidence that vaccine supplements can provide avenues to further improve current vaccies.

Impact of polar ozone depletion on subtropical precipitation

Over the past half-century, the ozone hole has caused a poleward shift of the extratropical westerly jet in the Southern Hemisphere. Here, we argue that these extratropical circulation changes, resulting from ozone depletion, have substantially contributed to subtropical precipitation changes. Specifically, we show that precipitation in the southern subtropics in austral summer increases significantly when climate models are integrated with reduced polar ozone concentrations. Furthermore, the observed patterns of subtropical precipitation change, from 1979 to 2000, are very similar to those in our model integrations, where ozone depletion alone is prescribed. In both climate models and observations, the subtropical moistening is linked to a poleward shift of the extratropical westerly jet. Our results highlight the importance of polar regions for the subtropical hydrological cycle.

Degrading ability of oligocyclic aromates by Phanerochaete sordida selected via screening of white rot fungi

Seventy-nine white rot strains were screened to determine if they had the potential for use in the degradation of oligocyclic aromates (PAHs) by measuring their dye-decoloration rate. Fourteen strains that were selected based on their dye-decoloration rate were then evaluated for the ability to tolerate various levels of PAHs spiked in agar medium. The ability of white rot fungi to degrade 3- or 4-ring PAHs (anthracene, phenanthrene, fluoranthene, pyrene) was determined. Two strains of Phanerochaete sordida (KUC8369, KUC8370) were possible PAHs degraders, degrading a significantly greater amount of phenanthrene and fluoranthene than the culture collection strain P. chrysosporium (a known PAHs degrader). The production of manganese peroxidase, the only extracellular ligninolytic enzyme detected during the cultivation, was evaluated.

The Tcl1 oncogene defines secondary hair germ cells differentiation at catagen-telogen transition and affects stem-cell marker CD34 expression

Overexpression of the TCL1 gene family plays a role in the onset of T-cell leukemias in mice and in humans. The Tcl1 gene is tightly regulated during early embryogenesis in which it participates in embryonic stem (ES)-cells proliferation and during lymphoid differentiation. Here, we provide evidences that Tcl1 is also important in mouse hair follicle (HF) and skin homeostasis. We found that Tcl1(-/-) adult mice exhibit hair loss, leading to alopecia with extensive skin lesions. By analysing Tcl1 expression in the wild-type (wt) skin through different stages of hair differentiation, we observe high levels in the secondary hair germ (HG) cells and hair bulges, during early anagen and catagen-telogen transition phases. The loss of Tcl1 does not result in apparent skin morphological defects during embryonic development and at birth, but its absence causes a reduction of proliferation in anagen HFs. Importantly, we show the that absence of Tcl1 induces a significant loss of the stem-cell marker CD34 (but not alpha6-integrin) expression in the bulge cells, which is necessary to maintain stem-cell characteristics. Therefore, our findings indicate that Tcl1 gene(s) might have important roles in hair formation, by its involvement in cycling and self-renewal of transient amplifying (TA) and stem-cell (SC) populations.

Controllable dimension of ZnO nanowalls on GaN/c-Al2O3 substrate by vapor phase epitaxy method

Vertically well-aligned ZnO nanowalls were successfully synthesized at 950-1050 degrees C. Ar gas was introduced into the furnace at a flow rate of 2000-2500 sccm. An Au thin film with a thickness of 3 nm was used as a catalyst. The ZnO nanowalls were successfully grown on the substrate and most of them had nearly the same thickness and were oriented perpendicular to the substrate. The morphology and chemical composition of the ZnO nanowalls were examined as a function of the growth conditions examined. It was found that the grown ZnO nanowalls have a single-crystalline hexagonal structure and preferred c-axis growth orientation based on the X-ray diffraction and high-resolution transmission electron microscope measurements. The room temperature photoluminescence showed a strong free-exciton emission band with negligible deep level emission, indicating the high optical property of our ZnO nanowall samples.

Luminescence tuning of amorphous Si quantum dots prepared by plasma-enhanced chemical vapor deposition

Amorphous Si (a-Si) quantum dots (QDs) embedded in a silicon nitride film were prepared by a plasma-enhanced chemical vapor deposition (PECVD) technique using gaseous mixtures of silane, hydrogen and nitrogen. We observed that the Si QDs had an amorphous structure from the Raman spectroscopy measurement. The Fourier transform infrared (FTIR) spectra showed that the relative transmittance of the SiH bands decreased, but that of the NH bands increased, with increasing nitrogen flow rate. During the deposition of SiNx, the number of dangling bonds of silicon acting as nucleation sites increased. As the hydrogen flow rate increased the growth rate decreased, due to the reduction in the hydrogen partial pressure. The hydrogen and nitrogen gas flow rates were found to be important parameters for determining the size of the a-Si QDs. In addition, we observed that the PL peak shifted toward a higher energy with increasing hydrogen and nitrogen gas flow rates, which was attributed to the increase in the quantum confinement effect in the a-Si QDs.

Monoclonal antibody recognizing N-terminal epitope of hepatitis C virus nonstructural 5B inhibits viral RNA replication

The nonstructural 5B (NS5B) protein of hepatitis C virus (HCV) is an RNA-dependent RNA polymerase (RdRp) with a key role in HCV replication. To characterize the functional roles of NS5B in HCV replication, we produced a panel of 10 monoclonal antibodies (mAbs) directed against NS5B protein from mice immunized with functionally active RdRp. The epitopes of eight mAbs are localized in the middle region (amino acid 240-263) of NS5B protein. On the other hand, the epitopes of two mAbs are mapped to amino acids 67-88 at the N-terminus of NS5B protein. To examine the effects of mAbs on HCV-RNA replication, we performed in vitro RdRp assay using either the 3'-untranslated region (UTR) or the full-length of HCV-RNA as a template in the presence of each mAb. mAbs specific for the middle region of NS5B had no effect on RdRp activity. Surprisingly, mAb recognizing the N-terminal region of NS5B inhibited RdRp activity in a dose-dependent manner. We have confirmed the same result using the other subclass of mAb, whose epitope is also localized to the same N-terminal region of NS5B. These data show that NS5B contains a B-cell epitope located between amino acid residues 67 and 88. Binding of this epitope with an antibody interferes with the enzymatic function of NS5B.

CD4+CD25+ regulatory T cells in transplantation: progress, challenges and prospects

The involvement of CD4(+)CD25(+) regulatory T cells (Treg) in general immune homeostasis and protection from autoimmune syndromes is now well established. Similarly, there has been increasing evidence for Treg involvement in allograft rejection and current immunotherapies. However, despite significant advances in understanding the development, function, and therapeutic efficacy of Treg in certain well-defined rodent models, the relevance of Treg to clinical transplantation remains unclear. In this review, we summarize our current understanding of the role of Treg in immunity and organ transplantation in experimental and clinical settings. In addition, we review advances in using Treg as a form of immune therapy. The goal is to highlight the complexities and opportunities in the field and to provide evidence to support the use of antigen-specific Tregs in the context of transplantation to facilitate a robust and selective state of immune tolerance.

Experience with steroid-free maintenance immunosuppression in simultaneous pancreas-kidney transplantation

INTRODUCTION

Steroid avoidance is possible in simultaneous pancreas-kidney transplantation with the use of newer immunosuppressive agents and induction therapy. We undertook a retrospective consecutive case review of patients treated at a university tertiary referral center.

METHODS

Medical records of 44 consecutive patients receiving a pancreas-kidney transplant from November 2000 to September 2002 were reviewed. The immunosuppression protocol used in this series of patients consisted of thymoglobulin induction, combined with mycophenolate mofetil, tacrolimus, and sirolimus for maintenance immunosuppression. Steroids were used only while thymoglobulin was given and were typically discontinued by postoperative week 1. Main outcome measures included graft and patient survival rates, rejection rates of the kidney or pancreas, infection rates, and surgical complication rates.

RESULTS

All 44 patients received a kidney-pancreas transplant with systemic venous anastomosis and enteric drainage of the pancreas. Patient kidney, and pancreas survival rates were 95.6%, 93.2%, and 88.7%, respectively. Biopsy-proven pancreas rejection rates at 1 and 6 months posttransplant were 2.3% and 2.3%. Kidney rejection rates at 1 and 6 months were 2.3% and 4.6%. Reasons for patient loss included one death from sepsis and one cardiovascular death. Reasons for kidney loss besides death included a thrombotic microangiopathy. Reasons for pancreas loss included three thromboses, one mild rejection/infection, and one duodenal segment leak with infection. All patients who have been free of rejection have been off steroids for the duration of follow-up.

CONCLUSIONS

Newer immunosuppression protocols without maintenance steroids are possible with minimal rejection in the first 3 months and equivalent patient and graft survival rates compared with earlier protocols utilizing steroids. The potential beneficial long-term impact of steroid avoidance will require further study.

Polyomavirus-Associated nephropathy in simultaneous Kidney-Pancreas transplant recipients: a Single-Center experience

BACKGROUND

With the introduction of more potent immunosuppressive agents, rejection rates have decreased markedly in simultaneous pancreas-kidney transplant (SPK) recipients. However, with more intense immunosuppression, opportunistic infections such as polyoma virus have been more frequent. The purpose of this article is to outline the clinical course of SPK patients who developed documented polyoma infection in the transplanted kidney.

METHODS

A retrospective review of 146 consecutive SPK recipients from 1996 to 2002 was performed. Induction and maintenance immunosuppression, surgical complications, rejection episodes, and opportunistic infections were reviewed. Patients who developed biopsy-proven polyoma virus infection in the renal allograft were identified.

RESULTS

Nine patients (6%) were identified who developed polyoma. All had received induction therapy with either OKT3 (5 mg/d for 10.5 days) or thymoglobulin (5.7 mg/kg). Patients without polyoma had received similar induction. Maintenance immunosuppression included Prograf/MMF in six patients, CsA/MMF in two, and CsA/azathioprine in one. Time to diagnosis was an average of 359.3 days (range 136 to 836) after transplantation. Two patients had undergone treatment for kidney rejection prior to the diagnosis of polyoma. Immunosuppression was decreased in all patients when polyoma was identified, and more recently Cidofovir has been administered. Despite these interventions, five of the nine lost kidney function (creatinine > 5.0 or resumption of dialysis). However, none of the nine developed pancreatic abnormalities as demonstrated by normal blood glucose and amylase and no requirement for exogenous insulin. Two patients underwent LRRT more than 1 year after polyoma diagnosis; both have normal kidney function (Cr < 1.5 mg/dL) at 4 years of follow-up. Polyoma virus was the leading cause of renal loss in this cohort of patients.

CONCLUSIONS

Polyoma is a serious concern for SPK transplant recipients. The pancreas, however, is spared from clinical evidence of infection, and no rejection was noted when immunosuppression was decreased. These graft losses appear to be a penalty of more potent immunosuppression, and a better treatment strategy is needed to prevent renal graft loss when polyoma is diagnosed. Retransplantation can be considered based on our limited experience.

Laparoscopic live donor nephrectomy at the University of California San Francisco

Laparoscopic donor nephrectomy is quickly becoming the preferred technique for kidney retrieval, since it removes many of the disincentives of kidney donation. Our experience at UCSF has confirmed that the procedure is safe, with excellent donor recovery. The transplanted kidney appears to function as well as any kidney retrieved using an open technique, at least in the short-term. Development of a successful laparoscopic donor program is best done initially with a team approach, utilizing the skills of an advanced laparoscopic surgeon, and with careful patient selection. With time, the technique can be done well by properly trained transplant surgeons with basic laparoscopic skills, with or without a hand-assist technique. As experience grows, this procedure can be applied to virtually every potential donor, and hopefully will improve live kidney donation rates.

Expression of thrombospondin-1 inversely correlated with tumor vascularity and hematogenous metastasis in colon cancer

Solid tumors require neovascularization for growth and metastasis. Angiogenesis depends on the local balance between various molecules that induce and inhibit neovascularization. Thrombospondin-1 (TSP-1) is thought to be an antiangiogenic factor. In this study, we examined the correlation between expression of TSP-1 and tumor vascularity, and determined its prognostic significance in colon cancer. Microvessel density, determined by immunostaining for factor VIII-related antigen, was significantly higher in tumors that were TSP-1-negative. TSP-1 expression was inversely correlated with prognosis. Patients with TSP-1-negative tumors had a significantly worse prognosis than did those with TSP-1-positive tumors. Frequency of hepatic recurrence was significantly higher in patients with tumors that were TSP-1-negative. In conclusion, TSP-1 is an important negative-regulator of tumor angiogenesis, and TSP-1 may be useful for predicting recurrence in patients with colon cancer.

A combination analysis of p53 and p21 in gastric carcinoma as a strong indicator for prognosis

We studied p53 and p21 expression simultaneously in gastric carcinoma tissues to investigate the clinical significance of p53-p21 pathway in this disease. One hundred sixty-four primary gastric carcinoma specimens were immunohistochemically stained for p53 and p21 protein, and clinicopathological features of the cases were examined. P53 was stained negatively, while p21 was stained positively in each normal stomach epithelium. P53, and p21 positive staining was observed in 82 (50%) and 61 (37.2%) tumors, respectively. Unexpectingly, no correlation was found between p53 and p21 staining status. Tumors demonstrating preserved p53-p21 pathway [p53(-)/p21(+)], observed in 20.1% of the tumors, displayed less aggressive characteristics, and no recurrent disease after curative resection. While tumors demonstrating disrupted p53-p21 pathway [p53(+)/p21(-)], observed in 32.9% of the tumors, displayed significantly more aggressive characteristics, poorer survival and higher recurrence rate than the tumors demonstrating other staining patterns. P53-p21 pathway was widely altered in gastric carcinomas. The combined evaluation of p53 and p21 expression in gastric carcinoma tissues is suggested to have clinical importance by indicating not only the malignant potential of each tumor, but also the prognosis of this disease.

Posttraumatic concerns: a patient-centered approach to outcome assessment after traumatic physical injury

BACKGROUND

Approximately 2.5 million Americans are admitted to the hospital after traumatic physical injury each year. Few investigations have elicited patients' perspectives regarding posttraumatic outcomes.

OBJECTIVE

To identify and categorize physically injured trauma survivors' posttraumatic concerns.

RESEARCH DESIGN

Prospective longitudinal investigation; trauma survivors were interviewed during the post-injury hospitalization and again 1, 4, and 12 months after the trauma.

SUBJECTS

Ninety-seven, randomly selected, English speaking, hospitalized survivors of motor vehicle-crashes or assaults.

MEASURES

At the end of each interview patients were asked, "Of all the things that have happened to you since you were injured, what concerns you the most?" Using an iterative process and working by consensus, investigators categorized patient concerns in content domains. Concern domains were then compared with established measures of posttraumatic stress disorder (PTSD) symptoms and limitations in physical functioning.

RESULTS

Seven categories of posttraumatic concerns were identified. During the course of the year, 73% of patients expressed physical health concerns, 58% psychological concerns, 53% work and finance concerns, 40% social concerns, 10% legal concerns, 10% medical concerns, and 20% uncodable concerns. Rater agreement on concern categorization was substantial (kappa = 0.72). The mean number of concerns expressed per patient gradually decreased over time (1 month mean = 1.51; 12 month mean = 1.26) and resembled the trajectories of PTSD symptoms and functional limitations.

CONCLUSIONS

The concerns of physically injured trauma survivors are readily elicited and followed up during the course of the year after injury. Open-ended inquiry regarding posttraumatic concerns may complement standardized outcome assessments by identifying and contextualizing the outcomes of greatest importance to patients.

Effects of left atrial compliance on left atrial pressure in pure mitral stenosis

In mitral stenosis (MS), left atrial (LA) pressure is commonly elevated because of increased LA afterload. There is a wide spectrum of LA pressure in patients with MS, however, despite a similar mitral valve orifice area. LA compliance is an important determinant of both cardiovascular performance and pathological physiology. Few data are available, however, regarding the effects of LA compliance on LA pressure. We hypothesized that LA pressure may be higher in patients with decreased LA compliance. We analyzed the right heart and transseptal catheterization data in 47 patients (41 female, mean age 40 +/- 10 years) with pure MS and sinus rhythm. The magnitude of LA a and v waves was measured from transseptal catheterization. Fick's method was used to determine cardiac output. LA compliance was calculated by dividing the systolic rise in LA pressure (DeltaP(LA) = P(LA(v)) - P(LA(x))) into the stroke volume. LA size, mitral valve area (MVA), mean diastolic pressure gradient (MG), left ventricular (LV) end-diastolic and end-systolic dimensions were obtained by using two-dimensional and Doppler echocardiography. Multiple regression analysis was performed to identify independent factors determining LA pressure. The mean MVA was 0.95 +/- 0.22 cm(2). MG and LA dimension were 11.2 +/- 5.2 mm Hg and 50.6 +/- 5.2 mm, respectively. The mean LA pressure and cardiac output obtained by cardiac catheterization were 23.4 +/- 8.4 mm Hg and 4.3 +/- 1.5 L/min, respectively. The calculated LA compliance was 4.9 +/- 2.8 cm(3)/mm Hg. Univariate analysis showed that factors associated with increased LA pressure were smaller MVA (r = -0.33, P < 0.05), higher MG (r = 0.69, P < 0.01) and lower LA compliance (r = -0.55, P < 0.01); among them, MG (beta coefficient 0.59, SE 0.19, P < 0.01) and LA compliance (beta coefficient -0.26, standard error 0.34, P < 0.05) were the strongest predictors of LA pressure. In conclusion, LA compliance, along with MG that reflects the severity of MS, is an important contributing factor determining LA pressure in patients with pure MS and sinus rhythm.

Assessment of elastic properties of the descending thoracic aorta by transesophageal echocardiography with acoustic quantification in patients with a stroke

Previous studies have described the use of transesophageal echocardiography (TEE) with acoustic quantification (AQ) in assessing aortic elastic properties. We hypothesized that patients with a prior history of stroke (ST) may have a higher risk of atherosclerotic change in great vessels compared to nonstroke subjects (NST) and thus have decreased elastic properties. We assessed the elastic properties of the descending thoracic aorta (DTA) by TEE in ST patients and compared them with data in NST patients. Subjects included 31 with ST without any evidence of emboli originating from the heart (age 51 +/- 10 years, M:F = 20:11) and 25 age-matched NST (M:F = 8:17). Patients with significant valvular heart disease including aortic and mitral regurgitation, left ventricular dysfunction (ejection fraction < 55%), and congenital heart disease were excluded. Compliance (C), distensibility (D), and stiffness index (SI) were measured using AQ and M-mode measurement at a level of the left atrium. We scored atherosclerotic risk factors (ARF) such as a history of diabetes, hypertension, smoking, hypercholesterolemia, and the presence of atheroma of DTA. There was no evidence of atheroma of DTA in NST. There were no significant differences in heart rate and systolic and diastolic blood pressure between ST and NST patients. Fractional area change (FAC) of DTA was significantly lower in ST than in NST patients (3.2 +/- 1.6 vs 5.4 +/- 2.5%, P = 0.000). ST patients had significantly lower C (1.2 +/- 0.4 vs 1.5 +/- 0.7 x 10(-3) cm2 mmHg(-1), P = 0.039), lower D (0.8 +/- 0.3 vs 1.5 +/- 0.8 x 10(-3) mmHg(-1), P = 0.000), and higher SI (10.3 +/- 8.8 vs 5.3 +/- 2.9, P = 0.006) than NST patients. ST patients without atheroma of DTA (n = 21) also had significantly lower C (1.1 +/- 0.4 vs 1.5 +/- 0.7 x 10(-3) cm2 mmHg(-1), P = 0.038) and lower D (3.5 +/- 1.4 vs 4.8 +/- 2.4 x 10(-3) mmHg(-1), P = 0.021) than NST patients. There was a significant positive correlation between SI and the score of ARF (r = 0.51, P = 0.000). The regional elastic properties of DTA measured by TEE with AQ and M-mode method were abnormal in ST. Therefore, TEE with AQ technique may have a possible clinical application for the detection of early atherosclerotic changes such as alteration of elastic properties in morphological normal DTA.

Expression of osteopontin in calcified coronary atherosclerotic plaques

Advanced atherosclerosis is often associated with dystrophic calcification and remodeling of extracellular matrix of vascular wall. Recently many studies have documented a general relationship between calcification and severity of coronary disease, and discussed the feasibility of electron beam computed tomography for detecting and quantifying the coronary artery calcification in the patients. The present study investigated the expression and the localization of osteopontin, one of noncollagenous bone matrix protein, within the calcified coronary arteries. Autopsy-derived coronary artery specimens were scanned and reconstructed to visualize the pattern of coronary calcification using a novel microscopic computed tomography technique. The localization of the osteopontin were evaluated by immunohistochemial stain with LF7. The present study showed that the pattern of coronary calcification is variable and the expression of osteopontin is localized mainly to calcified lesion. The smooth muscle cells in addition to macrophage expressed osteopontin protein in human coronary atherosclerotic plaques. Soluble osteopontin released near to the sites of vascular calcification may represent an adaptive mechanism aimed at regulating the process of vascular calcification.