Predictors of oxidative stress in heart failure patients with Cheyne-Stokes respiration

PURPOSE

Cheyne-Stokes respiration during sleep is associated with increased mortality in heart failure. The magnitude of oxidative stress is a marker of disease severity and a valuable predictor of mortality in heart failure. Increased oxidative stress associated with periodic breathing during Cheyne-Stokes respiration may mediate increased mortality in these patients. We hypothesized that the presence of Cheyne-Stokes respiration is associated with oxidative stress by increasing the formation of reactive oxygen species in patients with heart failure.

METHODS AND RESULTS

Twenty-three patients with heart failure [left ventricular ejection fraction 30.2 ± 9% (mean ± standard deviation)] and 11 healthy controls underwent nocturnal polysomnography. Subjects with obstructive sleep apnea were excluded. The majority (88%) of patients with heart failure had Cheyne-Stokes respiration during sleep. The intensity of oxidative stress in neutrophils was greater in patients with heart failure (4,218 ± 1,706 mean fluorescence intensity/cell vs. 1,003 ± 348 for controls, p < 0.001) and correlated with the duration of Cheyne-Stokes respiration. Oxidative stress was negatively correlated with SaO(2) nadir during sleep (r = -0.43, p = 0.039). The duration of Cheyne-Stokes respiration predicted severity of oxidative stress in patients with heart failure (beta = 483 mean fluorescence intensity/cell, p < 0.02).

CONCLUSIONS

Levels of oxidative stress are increased in patients with heart failure and Cheyne-Stokes respiration during sleep compared with healthy controls. The duration of Cheyne-Stokes respiration predicts the magnitude of oxidative stress in heart failure. Increased oxidative stress may mediate increased mortality associated with Cheyne-Stokes respiration in patients with heart failure.

Short-term health-related quality of life and symptom control with docetaxel, cisplatin, 5-fluorouracil and cisplatin (TPF), 5-fluorouracil (PF) for induction in unresectable locoregionally advanced head and neck cancer patients (EORTC 24971/TAX 323)

Background:

The EORTC 24971/TAX 323, a phase III study of 358 patients with unresectable locoregionally advanced squamous cell carcinoma of the head and neck, showed an improved progression-free and overall survival (OS) with less toxicity when docetaxel (T) was added to cisplatin and 5-fluorouracil (PF) for induction and given before radiotherapy (RT). The impact of the addition of docetaxel on patients’ health-related quality of life (HRQOL) and symptoms was investigated.

Methods:

HRQOL was assessed at baseline, at end of cycle 2, and 4, 6, and 9 months after completion of RT using the European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire C30 (QLQ-C30) and the EORTC QLQ Head and Neck Cancer-Specific Module (EORTC QLQ-H&N35). The primary HRQOL scale was global HRQOL per protocol.

Results:

Compliance to HRQOL assessments was 97% at baseline, but dropped to 54% by 6 months. Data were analysed up to 6 months. There was a trend towards improved global HRQOL during the treatment period. At 6 months after the end of RT, global HRQOL was higher in the TPF arm than in the PF arm, but the low compliance does not allow to draw definitive conclusions. Swallowing and coughing problems decreased more in the TPF arm than in the PF arm at the end of cycle 2, but to a limited extent.

Conclusion:

Induction chemotherapy with TPF before RT not only improves survival and reduces toxicity compared with PF but also seems to improve global HRQOL in a more sustainable manner.

Sleep disordered breathing and arrhythmia burden in pacemaker recipients

BACKGROUND

Sleep disordered breathing (SDB), a common condition among patients with permanent pacemaker (PM), is associated with greater incidence of cardiac arrhythmias. Scarce availability of sleep laboratories and the high costs of nocturnal-attended polysomnography limit the routine screening of patients with PM for SDB. We investigated whether a novel PM that utilizes variations in transthoracic impedance to record the fluctuations in breathing pattern and minute ventilation could be used to screen patients for SDB.

METHODS

Twenty patients who underwent dual-chamber PM implantation were studied. The Talent 3 DR PM (SORIN Group Italy S.r.l., Milan, Italy) calculates apnea-hypopnea index (AHI) by computing minute ventilation signal derived from transthoracic impedance measurements. Within a month after PM implantation, an in-home respiratory monitoring was performed to evaluate the accuracy of PM-derived AHI. Patients were followed for mean ± standard deviation, 487 ± 166 days. The PM was checked at each follow-up visit to retrieve the information about recurrent arrhythmias.

RESULTS

Eleven patients were diagnosed with SDB by an in-home respiratory monitoring. An AHI derived from an in-home respiratory monitoring was similar to pacemaker-derived AHI (27 ± 14 vs 16 ± 13 events/hour, P = 0.15). The cumulative incidence of cardiac arrhythmias, including atrial fibrillation, extrasystolic beats, sustained and nonsustained ventricular tachycardia, and supraventricular tachycardia was similar in patients with and without SDB.

CONCLUSION

SDB is highly prevalent in patients with permanent pacemaker. Screening for SDB with Talent 3 DR PM may facilitate diagnosis and treatment of SDB.

Vascular inflammation in obesity and sleep apnea

BACKGROUND

Unrecognized obstructive sleep apnea (OSA) is highly prevalent in obesity. Both obesity and OSA are associated with vascular endothelial inflammation and increased risk for cardiovascular diseases. We investigated directly whether the endothelial alterations that are attributed commonly to obesity are in fact related to OSA.

METHODS AND RESULTS

Seventy-one subjects with a body mass index ranging from normal to obese underwent attended polysomnography. To assess vascular inflammation and oxidative stress directly, we quantified the expression of nuclear factor-kappaB and nitrotyrosine by immunofluorescence in freshly harvested venous endothelial cells. To evaluate basal endothelial nitric oxide (NO) production and activity, we quantified the expression of endothelial NO synthase (eNOS) and phosphorylated eNOS. Vascular reactivity was measured by brachial artery flow-mediated dilation. Expression of eNOS and phosphorylated eNOS and flow-mediated dilation were significantly lower, whereas expression of nitrotyrosine was significantly greater in OSA patients (n=38) than in OSA-free subjects (n=33) regardless of central adiposity. Expression of nuclear factor-kappaB was greater in obese OSA patients than in obese OSA-free subjects (P=0.004). Protein expression and flow-mediated dilation were not significantly affected by increasing body mass index or central obesity in OSA patients and in OSA-free subjects. After 4 weeks of continuous positive airway pressure therapy, flow-mediated dilation and expression of eNOS and phosphorylated eNOS significantly increased whereas expression of nitrotyrosine and nuclear factor-kappaB significantly decreased in OSA patients who adhered to continuous positive airway pressure >/=4 hours daily.

CONCLUSIONS

Untreated OSA rather than obesity is a major determinant of vascular endothelial dysfunction, inflammation, and elevated oxidative stress in obese patients.

Do we know how many cancer patients have a family history of cancer?

PURPOSE

It has been estimated that approximately 5-10% of the general population have a family history that is indicative of hereditary cancer, predominately breast and colorectal. However, it is not precisely known how many patients have positive family history of cancer. The purpose of this study was to determine how many cancer patients have positive family history of cancer.

METHODS

Patients were interviewed during the first visit to Daily Chemotherapy Hospital (DCH) of the Institute for Oncology and Radiology of Serbia, Belgrade. Data about patient cancer type and cancer types among family members were recorded in the hospital chart and analyzed.

RESULTS

During an 8-month period, 677 newly diagnosed cancer patients with 9 cancer types were referred to DCH for chemotherapy. Positive family history (at least one first degree relative) for any cancer type was recorded in 163 (24.1%) patients and in 47 (6.9%) patients for the same cancer type. The highest percentage of the positive family history for the same type of cancer showed patients with breast cancer (9.9%), followed by colorectal (7.2%) and brain tumors (6.25%).

CONCLUSION

The overall incidence of positive family cancer history was 31.0% and was higher than expected. Cancer can be more disturbing for persons who already had experience with this disease in a close family member. Those patients need special attention with more intensive and carefully preplanned psychological support.

Comparison between Steroid Receptors and Her2 Status in Primary Breast Carcinoma and Completely Resected Breast Carcinoma Metastases from Different Visceral Organ Sites

Background: Metastases biopsy are seldom performed in metastatic breast carcinoma (MBC) and hormonal, and anti-Her2 therapy are given upon biological markers of the primary breast cancer (PBC).However, there are reports about discrepancies in biological markers between PBC and MBC that could significantly influence treatment outcome.Aim: The aim of this paper is to compare steroid receptors and Her2 status of the PBC and of resected metastases (MBC) Patients and methods: Pathology reports were analyzed for all patients who underwent resection of PBC and resection of liver, brain or lung metastases. Rationale for this patients selection is the assumption that BC, as a heterogeneous malignancy might have differently expressed biological markers in different parts of metastases and therefore, biopsy only might not be completely informative about biological marker status of MBC. Results: 36 pts were identified: 27 with liver metastasis resection; 8 with brain metastasis resection; and 1 patient with lung metastasis resection. Median age was 51,5 years (31-73) Median DFI was 36 months (0-144) ER/PGR status of PBC was known for 32/36 pts and for 30/36 pts in metastasis (MBC). HER2 status of PBC was known for 30/36 pts and for 29/36 in MBC. To facilitate results interpretation, steroid receptor status is divided in 2 groups upon indication for hormonal treatment: A. hormone dependent, (one or both receptors score ≥ 4): B. hormone independent, (both receptors ≤ score 3). Her2 status is also divided in 2 groups upon indication for trastuzumab as: C. Her2 negative if IHC Her 2 was 0+,1+, or 2 + D. Her2 positive, if IHC was 3+ or CISH +; E. Triple negative if both steroid receptors were score 0 and Her2 0+ Results are presented at table 1.ResultsInitial biological markers status in PBCNo of pts (%)Changed biological markers status in MBC (%)CommentA. ER or PGR ≥ 421 (65,6%)12 (57%)12/21 (57%) hormone dependent PBC become hormone independent in MBCB.ER and PGR ≤ 311 (34,3%)1 (9 %)1/11 (9%) hormone independent PBC become hormone dependent in MBCC. Her2 0+,1+,2+24 (80%)0 (0%)0/24 (0%) Her2 0+,1+,2+ PBC has changed status to Her2 3+ in MBCD.Her2 3+6 (20%)1 (16,6%)1/6 (16,6%) Her2 3+ PBC has changed status in Her2 1+ in MBCE.Triple negative3 (10%)0 (0%)0/3 (0%) triple negative PBC has changed status in MBC     Conclusion: Biological markers, that are considered as poor prognostic factors are more stable characteristics of BC hence they tends to change in MBC in much lesser degree than biological markers that are considered as good prognostic factors. Although obtained in selected subgroup of BC patients who developed resectable BC metastases, these results could be implemented in every day clinical practice, hence triple negative, steroid receptor negative and Her2 positive PBC almost always retains these characteristics in MBC.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4048.

Sleep-disordered breathing in acute decompensated heart failure

Sleep-disordered breathing (SDB), including obstructive sleep apnea (OSA) and central sleep apnea (CSA), is highly prevalent and frequently unrecognized in patients with chronic heart failure (HF). Untreated SDB may worsen acute decompensation of HF and delay recovery by increasing vascular inflammation and oxidative stress, impeding control of the blood pressure, and promoting arrhythmias. Untreated OSA doubles the risk for developing HF, and patients with HF who develop OSA are thought to have a worse prognosis than patients with HF alone. Similar to the findings in the general population, treatment of OSA appears to reduce cardiovascular morbidity and mortality in HF. The presence of CSA is associated with increased mortality in HF patients. Efficacious suppression of central sleep apnea with continuous positive airway pressure therapy may reduce mortality in HF.

Endothelial repair capacity and apoptosis are inversely related in obstructive sleep apnea

Purpose:

To investigate the impact of obstructive sleep apnea (OSA) on endothelial repair capacity and apoptosis in the absence of potentially confounding factors including obesity.

Patients and methods:

Sixteen patients with a body mass index <30 and newly diagnosed OSA and 16 controls were studied. Circulating levels of endothelial progenitor cells, a marker of endothelial repair capacity, and endothelial microparticles, a marker of endothelial apoptosis, were quantified before and after four-week therapy with continuous positive airway pressure (CPAP). Endothelial cell apoptotic rate was also quantified in freshly harvested venous endothelial cells. Vascular reactivity was measured by flow-mediated dilation.

Results:

Before treatment, endothelial microparticle levels were greater and endothelial progenitor cell levels were lower in patients with OSA than in controls (P < 0.001 for both). Levels of endothelial microparticles and progenitors cells were inversely related (r = −0.67, P < 0.001). Endothelial progenitor cell levels increased after effective treatment (P = 0.036).

Conclusions:

In the absence of any co-morbid conditions including obesity, OSA alone impairs endothelial repair capacity and promotes endothelial apoptosis. These early endothelial alterations may underlie accelerated atherosclerosis and increased cardiovascular risk in OSA.

Expression of HER2/neu, estrogen and progesterone receptors, CA 125 and CA19-9 on cancer cell membrane in patients with serous and mucinous carcinoma of the ovary

PURPOSE

To examine the expression of the membrane markers of estrogen (ER) and progesterone receptors (PR), CA-125, CA 19-9 and HER2/neu in ovarian cancer tissues.

METHODS

Fifty-four samples of ovarian cancer tissues originating from 55 patients were examined by immunohistochemistry. Forty-three had serous papillary ovarian cancer, 9 of which were grade I, 12 grade II and 2 grade III. Twelve patients had a classic mucinous ovarian cancer, 5 of which were grade I, 4 grade II and 0 grade III.

RESULTS

Out of 43 patients with serous ovarian cancer, 7 expressed both steroid receptors, 22 had only one (10 ER and 12 PR), while 14 were negative. Only 2/12 patients with classic mucinous ovarian cancer expressed of both receptors. CA-125 was expressed in 37/43 patients with serous ovarian cancer and in 4/12 patients with classic mucinous ovarian cancer. CA 19-9 was expressed in 3/43 patients with serous ovarian cancer, and coexpressed with CA-125 in 2/3 patients. In patients with classic mucinous ovarian cancer, 4/12 had expression of CA 19-9 without coexpression with CA-125. HER2/neu positivity (3+) was proven in only one case with classic mucinous ovarian cancer, and any other expression (1+) in 7 additional patients (1 mucinous and 6 serous ovarian cancers).

CONCLUSION

Positive HER2/neu expression in the cells of ovarian cancer is very rare and HER2/neu overexpression is even rarer. Expression of ER and PR does not depend on tumor grade and/or at least not in grade I and II. Positive CA 19-9 expression may be present not only in cases of classic mucinous ovarian cancer but also in typical serous ovarian cancer. However, in the classic mucinous ovarian cancer, CA-125 may be expressed, though in relatively low percentage.

Chronic obstructive pulmonary disease in the elderly: an update on pharmacological management

The prevalence of chronic obstructive pulmonary disease (COPD) continues to rise in association with an aging Western society. While barriers to receiving optimal healthcare exist for aging patients, pharmacotherapy of COPD in the elderly is important because the treatment benefits in this group are comparable to those seen in the younger COPD population. The frequent presence of co-morbidities and reduced clearance capacity make selection of pharmacotherapy in elderly patients with stable COPD challenging. The adverse effects of standard therapy for COPD may also be more pronounced in elderly patients. A careful risk-versus-benefit assessment should always be carried out when prescribing long-term inhaled bronchodilator and corticosteroid therapy to an elderly COPD patient, and when prescribing beta(2)-adrenoceptor agonists and methylxanthines, in particular, to those with cardiovascular co-morbidities. The present review focuses on the special considerations regarding initiation and maintenance of pharmacotherapy in elderly patients with stable COPD.

Circulating KL-6, a biomarker of lung injury, in obstructive sleep apnoea

In obstructive sleep apnoea (OSA), oxidative stress contributes to endothelial dysfunction in the peripheral circulation. In the lung, oxidative stress can lead to alveolar injury. The present authors hypothesised that patients with OSA would have biomarker evidence of increased alveolar wall permeability. Sleep characteristics, brachial artery flow-mediated dilation and plasma KL-6 levels were observed in 11 otherwise healthy patients with OSA and 10 controls. Median (interquartile range) plasma KL-6 levels were higher in patients with OSA compared with controls: 317 (232-506) U.mL(-1) versus 226 (179-257) U.mL(-1), respectively. Higher plasma KL-6 levels were associated with greater time spent asleep with an oxyhaemoglobin saturation <90%, lower nadir saturation, more frequent desaturation of >4% during sleep and lower brachial artery flow-mediated dilation. Adjustment for nadir saturation or flow-mediated dilation attenuated the association between plasma KL-6 levels and OSA. Circulating KL-6 levels are elevated in some patients with obstructive sleep apnoea, possibly reflecting increased alveolar wall permeability.

Investigation of constitutive and cytokine-induced expression of pSTAT 1, 3, and 5 in PBL of breast cancer patients

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Background: Although cytokines mediate their effects by latent transcription factors, STATs, their dysregulation has not been much investigated in peripheral blood lymphocytes (PBL) of breast cancer patients. As alterations in the JAK-STAT pathway contribute to immunosuppression in cancer patients in this study, aside from baseline-level, we investigated the level and cytokine-mediated activation of STAT1, 3, and 5 in healthy controls and breast cancer patients. Methods: PBL (5x106/ml) of breast cancer patients in all four clinical stages, as well as healthy controls, were treated in vitro with culture medium (CM) alone, IFNα (250 IU/ml CM) and IL-2 (500 IU/ml) for 24h at 37°C. Induction of phosphorylated STAT proteins was assessed in cellular lysates by Western blotting using monoclonal anti-STAT1, 3, and 5 antibodies. Treated PBL were also analyzed for IFNγ using an intracellular flow cytometry assay. Results: Our results indicate that untreated PBL of breast cancer patients, compared to healthy controls, express a significantly lower baseline level of pSTAT1, 3, and 5. The induction of pSTAT1 expression by IFNα, similar to the induction of pSTAT3 and pSTAT5 by IL-2, is significant for healthy controls and breast cancer patients, although the effect in patients is significantly below that for healthy controls. Moreover, the induction of pSTAT5 by IL-2 is of a higher magnitude than pSTAT3. PBL of breast cancer patients, compared to healthy controls, have a lower level of IFNγ. The production of IFNγ in PBL is enhanced by IFNα, as well as IL-2, although in breast cancer patients to a much lower level than in healthy controls. Conclusions: These results provide evidence that evaluation of STAT expression in PBL of breast cancer patients could be of diagnostic and therapeutic significance for cytokine-based therapy.

No significant financial relationships to disclose.