Cerebral cavernoma: an emerging long-term consequence of external beam radiation in childhood

The long-term effects of cranial external beam radiotherapy are emerging as survival rates for cerebral tumours improve. Cerebral cavernoma are a recognized consequence of cranial irradiation. Endocrinologists managing the life-long complications of hypopituitarism associated with irradiation need to be aware and vigilant of the risks of cavernoma formation, in particular in the population with a history of childhood irradiation. We present three cases of young patients who were diagnosed with cerebral cavernoma many years after childhood irradiation treatment and review the current literature on this condition. We discuss implications for endocrine practice as rising numbers of patients survive childhood cancer and irradiation and are now attending adult endocrine services for long-term management of secondary hypopituitarism.

Optimization of the hydroxylamine cleavage of an expressed fusion protein to produce recombinant human insulin-like growth factor (IGF)-I

The application of gene fusion technology for the production of heterologous proteins in Escherichia coli has required the development of specific cleavage methods to separate the coexpressed fusion protein partner from the protein of interest. When hydroxylamine is used to cleave Asn-Gly fusion protein linkages, undesirable chemical modification of asparagine and glutamine amino acids can also occur. In this study, hydroxylamine cleavage conditions were modified to minimize unwanted chemical heterogeneity that occurred during the cleavage of the fusion protein [Met(1)]-pGH(1-11)-Val-Asn-IGF-I (Long-IGF-I). The cleavage reaction was shown to be dependent on the hydroxylamine concentration, temperature, and pH. Optimal cleavage conditions were identified that resulted in very low levels of chemical heterogeneity, but under these mild conditions that cleavage of the labile Asn-Gly bond was reduced. Therefore, the reaction was further modified to improve the yield of IGF-I while minimizing chemical heterogeneity. The yield of unmodified IGF-I was improved from less than 25% to greater than 70%. Analysis of the heterogeneity produced using the modified cleavage technique showed that Asn(26) was converted to a hydroxamate. This variant was characterized in refolding and biological assays where it was equivalent to IGF-I. To further assess the effectiveness of the modified cleavage technique and to evaluate the potential for process scale-up, a gram-scale cleavage reaction of Long-IGF-I was carried out. The process yielded IGF-I with a low level of chemical heterogeneity that was easily removed by ion-exchange chromatography. Moreover, this work shows that the production of unmodified IGFs using hydroxylamine cleavage of fusion proteins is facilitated using the mild cleavage reaction.

PUMA mediates EGFR tyrosine kinase inhibitor-induced apoptosis in head and neck cancer cells

Overexpression of epidermal growth factor receptor (EGFR) is found in over 80% of head and neck squamous cell carcinomas (HNSCC) and associated with poor clinical outcomes. EFGR selective tyrosine kinase inhibitors (TKIs) or antibodies have recently emerged as promising treatments for solid tumors, including HNSCC, though the response rate to these agents is low. p53 upregulated modulator of apoptosis (PUMA), a BH3-only Bcl-2 family protein, is required for apoptosis induced by p53 and various chemotherapeutic agents. In this study, we show that PUMA induction is correlated with EGFR-TKI sensitivity, and is mediated through the p53 family protein p73beta and inhibition of the PI3K/AKT pathway. In some HNSCC cells, the gefitinib-induced degradation of oncogenic Delta Np63 seems to facilitate p73-mediated PUMA transcription. Inhibiting PUMA expression by small hairpin RNA (shRNA) impairs gefitinib-induced apoptosis. Furthermore, PUMA or BH3 mimetics sensitize HNSCC cells to gefitinib-induced apoptosis. Our results suggest that PUMA induction through p73 represents a new mechanism of EGFR inhibitor-induced apoptosis, and provide potential ways for enhancing and predicting the sensitivity to EGFR-targeted therapies in HNSCC.

Sorption behavior of a synthetic antioxidant, polycyclic musk, and an organophosphate insecticide in wastewater sludge

Emerging contaminants (ECs) are chemicals that are currently unregulated due to limited understanding of health effects and limited data regarding occurrence. Wastewater treatment plants (WWTP) receive many ECs as components of influent waste and the removal of organic contaminants, such as ECs, occurs primarily by sorption to sludge. Therefore, it is important to develop measures of sorption behavior by ECs to sludge. This study evaluates sorption of three ECs: 3-tert-butyl-4-hydroxyanisole (BHA) a synthetic antioxidant, 1,3,4,6,7,8-hexahydro-4,6,6,7,8,8-hexamethyl-cyclopenta(g)-2-benzopyrane (HHCB) a polycyclic musk, and chlorpyrifos a organophosphate insecticide. Twenty-four hour laboratory-scale sorption experiments were conducted for each compound individually and then in combination, which allowed the quantification of sorption onto wastewater sludge and the affects of multiple compounds. ECs in both the liquid and solid phases were analyzed using a gas chromatograph with flame ionization detector (GC/FID). Isotherms of individual sorption behavior followed a linear trend (R2 > 0.9) for individual ECs, while K(d) averaged 2,689 L kg(-1), 27,786 L kg(-1) and 31,402 L kg(-1) for BHA, chlorpyrifos and HHCB, respectively. Sorption behavior for BHA was linear during combined studies with K(d) of 1,766 L kg(-1) or a decrease of 34%, while HHCB and chlorpyrifos followed non-linear isotherm models. Synergistic effects were observed with spike concentrations > or =25 mg L(-1) for HHCB and > or =20 mg L(-1) for chlorpyrifos. K(d) values ranged from 16,984-6,000,000 L kg(-1) for HHCB and 19,536-3,000,000 L kg(-1) for chlorpyrifos. These distribution coefficients differed substantially from previously published values, mainly because few studies used sludge as the sorption media. Results suggest that HHCB and chlorpyrifos may be contained in the sludge unlike BHA, which is more available in the aqueous phase. Future investigations should evaluate WWTP processes for degrading ECs to harmless products and releases of ECs from sludge.

Genetic association analyses of non-synonymous single nucleotide polymorphisms in diabetic nephropathy

AIMS/HYPOTHESIS

Diabetic nephropathy, characterised by persistent proteinuria, hypertension and progressive kidney failure, affects a subset of susceptible individuals with diabetes. It is also a leading cause of end-stage renal disease (ESRD). Non-synonymous (ns) single nucleotide polymorphisms (SNPs) have been reported to contribute to genetic susceptibility in both monogenic disorders and common complex diseases. The objective of this study was to investigate whether nsSNPs are involved in susceptibility to diabetic nephropathy using a case-control design.

METHODS

White type 1 diabetic patients with (cases) and without (controls) nephropathy from eight centres in the UK and Ireland were genotyped for a selected subset of nsSNPs using Illumina's GoldenGate BeadArray assay. A chi (2) test for trend, stratified by centre, was used to assess differences in genotype distribution between cases and controls. Genomic control was used to adjust for possible inflation of test statistics, and the False Discovery Rate method was used to account for multiple testing.

RESULTS

We assessed 1,111 nsSNPs for association with diabetic nephropathy in 1,711 individuals with type 1 diabetes (894 cases, 817 controls). A number of SNPs demonstrated a significant difference in genotype distribution between groups before but not after correction for multiple testing. Furthermore, neither subgroup analysis (diabetic nephropathy with ESRD or diabetic nephropathy without ESRD) nor stratification by duration of diabetes revealed any significant differences between groups.

CONCLUSIONS/INTERPRETATION

The nsSNPs investigated in this study do not appear to contribute significantly to the development of diabetic nephropathy in patients with type 1 diabetes.

Long-Term Retrievability of IVC Filters: Should We Abandon Permanent Devices?

Thromboembolic disease produces a considerable disease burden, with death from pulmonary embolism in the UK alone estimated at 30,000-40,000 per year. Whilst it is unproven whether filters actually improve longevity, the morbidity and mortality associated with thromboembolic disease in the presence of contraindications to anticoagulation is high. Thus complications associated with filter insertion, and whilst they remain in situ, must be balanced against the alternatives. Permanent filters remain in situ for the remainder of the patient's life and any complications from the filters are of significant concern. Filters that are not permanent are therefore attractive in these circumstances. Retrievable filters, to avoid or decrease long-term filter complications, appear to be a significant advance in the prevention of pulmonary embolism. In this review, we discuss the safety and effectiveness of both permanent and retrievable filters as well as the retrievability of retrievable inferior vena cava (IVC) filters, to explore whether the use of permanent IVC filters can be abandoned in favor of retrievable filters. Currently four types of retrievable filters are available: the Recovery filter (Bard Peripheral Vascular, Tempe, AZ, USA), the Günther Tulip filter (Cook, Bloomington, IN, USA), the OptEase Filter (Cordis, Roden, The Netherlands), and the ALN filter (ALN Implants Chirurgicaux, Ghisonaccia, France). Efficacy and safety data for retrievable filters are as yet based on small series, with a total number of fewer than 1,000 insertions, and follow-up is mostly short term. Current long-term data are poor and insufficient to warrant the long-term implantation of these devices into humans. The case of fractured wire from a Recovery filter that migrated to the heart causing pericardial tamponade requiring open heart surgery is a reminder that any new endovascular device remaining in situ in the long term may produce unexpected problems. We should also bear in mind that the data on permanent filters are much more robust, with reports on over 9,500 cases with follow-up of up to 8 years. The original implantation time of 10-14 days has been extended to more than 100 days as the mean implantation time with some of the filter types. Follow-up (preferably prospective) is necessary for all retrievable filters, whether or not they are retrieved. Until these data become available we should restrict ourselves to the present indications of permanent and retrievable filters. If long-term follow-up data on larger numbers of cases confirm the initial data that retrievable filters are as safe and effective as permanent filters, the use of the retrievable filters is likely to expand.

Hic-5 promotes endothelial cell migration to lysophosphatidic acid

Endothelial cell migration is critical for proper blood vessel development. Signals from growth factors and matrix proteins are integrated through focal adhesion proteins to alter cell migration. Hydrogen peroxide-inducible clone 5 (Hic-5), a paxillin family member, is enriched in the focal adhesions in bovine pulmonary artery endothelial (BPAE) cells, which migrate to lysophosphatidic acid (LPA) on denatured collagen. In this study, we investigate the role of Hic-5 in LPA-stimulated endothelial cell migration. LPA recruits Hic-5 to the focal adhesions and to the pseudopodia in BPAE cells plated on collagen, suggesting that recruitment of Hic-5 to focal adhesions is associated with endothelial cell migration. Knockdown of endogenous Hic-5 significantly decreases migration toward LPA, confirming involvement of Hic-5 in migration. To address the role of Hic-5 in endothelial cell migration, we exogenously expressed wild-type (WT) Hic-5 and green fluorescent protein Hic-5 C369A/C372A (LIM3 mutant) constructs in BPAE cells. WT Hic-5 expression increases chemotaxis of BPAE cells to LPA, whereas migration toward LPA of the green fluorescent protein Hic-5 C369A/C372A-expressing cells is similar to that shown in vector control cells. Additionally, ERK phosphorylation is enhanced in the presence of LPA in WT Hic-5 cells. A pharmacological inhibitor of MEK activity inhibits LPA-stimulated WT Hic-5 cell migration and ERK phosphorylation, suggesting Hic-5 enhances migration via MEK activation of ERK. Together, these studies indicate that Hic-5, a focal adhesion protein in endothelial cells, is recruited to the pseudopodia in the presence of LPA and enhances migration.

Risk factors for sporadic Shiga toxin-producing Escherichia coli O157 infections in FoodNet sites, 1999-2000

To monitor risk factors for illness, we conducted a case-control study of sporadic Shiga toxin-producing Escherichia coli O157 (STEC O157) infections in 1999-2000. Laboratory-confirmed cases of STEC O157 infection were identified through active laboratory surveillance in all or part of seven states. Patients and age-matched controls were interviewed by telephone using a standard questionnaire. Information was collected on demographics, clinical illness, and exposures to food, water, and animals in the 7 days before the patient's illness onset. During the 12-month study, 283 patients and 534 controls were enrolled. STEC O157 infection was associated with eating pink hamburgers, drinking untreated surface water, and contact with cattle. Eating produce was inversely associated with infection. Direct or indirect contact with cattle waste continues to be a leading identified source of sporadic STEC O157 infections.

Resistance to HIV infection

The biological correlates of an effective immune response that could contain or prevent HIV infection remain elusive despite substantial scientific accomplishments in understanding the interactions among the virus, the individual and the community. The observation that some individuals appear to possess resistance to HIV infection or its consequences has generated a host of epidemiologic investigations to identify biological or behavioral characteristics of these individuals. These data might hold the keys to developing appropriate strategies for mimicking the effective responses of those who appear immune. In this paper we review genetic mechanisms including the role of chemokines and their receptors, cytokines, host genetic immune response to HIV infection, local immune response correlating with behavioral variables, co-infection and immune based mechanisms that have been elucidated so far. We offer suggestions for how to use these observations as platforms for future research to further understand natural resistance to HIV infection through cohort studies, population genotype sampling, mathematical modeling of virus-host interactions and behavioral analyses.

Use of reporter transposons for tagging and detection of Mycobacterium sp. strain 1B in PAH-contaminated soil

An environmental Mycobacterium able to degrade phenanthrene, pyrene and fluoranthene was transformed with an IS1096-based transposon marker system. Electroporation and subsequent delivery of the transposon enabled formation of constitutive lacZ transformants, with similar growth rates on pyrene and R2A media to the parental strain. A semi-selective medium was developed to recover and detect colonies of the transformed strain after inoculation into polycyclic aromatic hydrocarbon-contaminated soil. Microcosm experiments involving inoculation of the tagged Mycobacterium strain into a historically PAH-contaminated soil indicated survival when an appropriate carbon source was available. The results reported show that transposon systems developed for clinical mycobacterial isolates are also applicable for use in environmental isolates. The results also show that inoculated Mycobacterium strains could survive for at least 100 days at 10(6)-10(7) cfu g-1 in the PAH-contaminated soil tested here.

Cost-effectiveness of endovascular abdominal aortic aneurysm repair

Background

The rapid introduction of endovascular abdominal aortic aneurysm repair (EVAR) has considerable implications for the management of abdominal aortic aneurysm (AAA). This study was undertaken to determine an optimal strategy for the use of EVAR based on the best currently available evidence.

Methods

Economic modelling and probabilistic sensitivity analysis considered reference cases representing a fit 70-year-old with a 5·5-cm diameter AAA (RC1) and an 80-year-old with a 6·5-cm AAA unfit for open surgery (RC2). Results were assessed as incremental cost-effectiveness ratio (ICER) compared with open repair (RC1) or conservative management (RC2).

Results

In RC1 EVAR produced a gain of 0·10 quality-adjusted life years (QALYs) for an estimated cost of £11 449, giving an ICER of £110 000 per QALY. EVAR consistently had an ICER above £30 000 per QALY over a range of sensitivity analyses and alternative scenarios. In RC2 EVAR produced an estimated benefit of 1·64 QALYs for an incremental cost of £14 077 giving an incremental cost per QALY of £8579.

Conclusion

It is unlikely that EVAR for fit patients suitable for open repair is within the commonly accepted range of cost-effectiveness for a new technology. For those unfit for conventional open repair it is likely to be a cost-effective alternative to non-operative management. Sensitivity analysis suggests that research efforts should concentrate on determining accurate rates for late complications and reintervention, particularly in patients with high operative risks.

Results from the Prospective Registry of Endovascular Treatment of Abdominal Aortic Aneurysms (RETA): Mid Term Results to Five Years

OBJECTIVES

To assess the mid-term outcomes up to 5 years following endovascular repair of abdominal aortic aneurysms (EVAR), following its initial introduction into practice in the UK.

DESIGN

A prospective voluntary Registry of Endovascular Treatment of Aneurysms (RETA) collected demographic and risk factor data, short term (30 day) outcomes and follow up outcomes up to 5 years from the 41 centres that initially undertook EVAR in the UK.

RESULTS

Short term outcomes (30 days): 90.4% of aneurysms were successfully excluded, 6.1% had persistent endoleaks and 5.8% of patients had died. Follow up was obtained from 30 days up to 5 years (mean 3.1 years). Returns rates for requested follow up data were 87% at 1 year and 77, 65, 52 and 51% at 2, 3, 4 and 5 years, respectively. Ninety percent of deaths at follow up were unrelated to the stent-graft or aneurysm. Persistent proximal type I endoleak was associated with significant mortality both from attempted open repair or from rupture if untreated. Other endoleaks were more benign. Complications related to the aneurysm or device occurred at an average rate of 15% per annum. The most common complications were secondary endoleaks or graft migration. Endovascular treatment was preferred if treatment was necessary for graft complications. The cumulative freedom from secondary procedure (Kaplan-Meier) were 87, 77, 70, 65 and 62% at 1, 2, 3, 4 and 5 years of follow up, respectively.

CONCLUSIONS

Registry data provides useful information to guide the design of more formal trials. Collecting follow up from voluntarily submitted data is difficult. The registry data remains well ahead of the trial data, but indicate that long term follow up is required in these trials, because of the high rate of complications seen at follow up.

Ultrasound for central venous cannulation: economic evaluation of cost-effectiveness

We compared the economics of using two-dimensional ultrasound locating devices and more traditional landmark methods for central venous cannulation in the National Health Service (NHS). The evaluation consisted of a systematic review of randomised controlled trials and an economic evaluation using decision analytic cost-effectiveness modelling. Incremental costs per complication avoided associated with landmark and ultrasound central venous cannulation were modelled for patients scheduled for central venous cannulation. The marginal economic cost of using ultrasound for central venous cannulation was less than 10 pounds sterling per procedure, assuming that a machine is used for 15 procedures each week. The base case scenario implied that 2000 pounds sterling worth of resource savings result for every 1000 procedures undertaken and 90 avoided complications. Sensitivity analysis indicated that the results of modelling appear robust to the central assumptions used. Ultrasound guidance used in central venous cannulation procedures saves NHS resources even with conservative modelling assumptions.

Physiological characterization of Mycobacterium sp. strain 1B isolated from a bacterial culture able to degrade high-molecular-weight polycyclic aromatic hydrocarbons

AIM

The aim of this study was to further characterize a bacterial culture (VUN 10,010) capable of benzo[a]pyrene cometabolism.

METHODS AND RESULTS

The bacterial culture, previously characterized as a pure culture of Stenotrophomonas maltophilia (VUN 10,010), was found to also contain another bacterial species (Mycobacterium sp. strain 1B), capable of degrading a similar range of PAH substrates. Analysis of its 16S rRNA gene sequence and growth characteristics revealed the strain to be a fast-growing Mycobacterium sp., closely related to other previously isolated PAH and xenobiotic-degrading mycobacterial strains. Comparison of the PAH-degrading characteristics of Mycobacterium sp. strain 1B with those of S. maltophilia indicated some similarities (ability to degrade phenanthrene and pyrene), but some differences were also noted (S. maltophilia able to degrade fluorene, but not fluoranthene, whereas Mycobacterium sp. strain 1B can degrade fluoranthene, but not fluorene). Unlike the S. maltophilia culture, there was no evidence of benzo[a]pyrene degradation by Mycobacterium sp. strain 1B, even in the presence of other PAHs (ie pyrene) as co-metabolic substrates. Growth of Mycobacterium sp. strain 1B on other organic carbon sources was also limited compared with the S. maltophilia culture.

CONCLUSIONS

This study isolated a Mycobacterium strain from a bacterial culture capable of benzo[a]pyrene cometabolism. The Mycobacterium strain displays different PAH-degrading characteristics to those described previously for the PAH-degrading bacterial culture. It is unclear what role the two bacterial strains play in benzo[a]pyrene cometabolism, as the Mycobacterium strain does not appear to have endogenous benzo[a]pyrene degrading ability.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study describes the isolation and characterization of a novel PAH-degrading Mycobacterium strain from a PAH-degrading culture. Further studies utilizing this strain alone, and in combination with other members of the consortium, will provide insight into the diverse roles different bacteria may play in PAH degradation in mixed cultures and in the environment.

Gene expression in Escherichia coli biofilms

DNA microarrays were used to study the gene expression profile of Escherichia coli JM109 and K12 biofilms. Both glass wool in shake flasks and mild steel 1010 plates in continuous reactors were used to create the biofilms. For the biofilms grown on glass wool, 22 genes were induced significantly (p< or =0.05) compared to suspension cells, including several genes for the stress response ( hslS, hslT, hha, and soxS), type I fimbriae ( fimG), metabolism ( metK), and 11 genes of unknown function ( ybaJ, ychM, yefM, ygfA, b1060, b1112, b2377, b3022, b1373, b1601, and b0836). The DNA microarray results were corroborated with RNA dot blotting. For the biofilm grown on mild steel plates, the DNA microarray data showed that, at a specific growth rate of 0.05/h, the mature biofilm after 5 days in the continuous reactors did not exhibit differential gene expression compared to suspension cells although genes were induced at 0.03/h. The present study suggests that biofilm gene expression is strongly associated with environmental conditions and that stress genes are involved in E. coli JM109 biofilm formation.

Point mutations in the pfcrt and pfmdr-1 genes of Plasmodium falciparum and clinical response to chloroquine, among malaria patients from Nigeria

Chloroquine (CQ) resistance in Plasmodium falciparum has been associated with specific point mutations in the pfcrt and pfmdr-1 genes. In the present study, 30 children aged 1-12 years, who were all suffering from acute, uncomplicated, P. falciparum malaria in Ibadan, Nigeria, were evaluated to assess the association between these mutations and clinical outcome following treatment with CQ. The parasites, in blood samples collected pre-treatment and, in those who failed treatment, on the day symptoms re-occurred post-treatment, were genotyped using the polymorphic MSP1, MSP2 and GLURP loci and PCR-RFLP. The results showed that, pre-treatment, all 30 patients had polyclonal infections, the mean numbers of P. falciparum clones detected per infection being 2.6 with MSP1, 4.2 with MSP2 and 2.8 with GLURP. The T76 allele of pfcrt and the Y86 allele of pfmdr-1 were found in 53% and 40%, respectively, of the pre-treatment samples from the 15 patients who failed CQ treatment, but the Y1246 mutation in pfmdr-1 was never detected. Although the parasites from the two patients with high-grade (RIII) resistance to CQ had both of these point mutations, the presence of the T76 allele of pfcrt or the Y86 allele of pfmdr-1 (considered individually) could not be used to predict treatment outcome. However, a high frequency of clonal multiplicity may confound attempts to associate the point mutations in pfcrt or pfmdr-1 with clinical response to CQ. It remains unclear whether the present results represent the characteristics of the predominant parasite populations in the study area. Further studies are needed before the strength of the association between the point mutations identified as markers of drug resistance and clinical outcome can be accurately evaluated, in this and other regions of intense transmission.

Prevalence of Plasmodium falciparum pfcrt polymorphisms and in vitro chloroquine sensitivity in Senegal

Mutations in pfcrt K76T are associated with chloroquine resistance in Plasmodium falciparum. Previous studies of K76T mutations in Senegal reported the association of T76 with in vitro-resistant isolates, but this mutation was also prevalent in chloroquine-sensitive isolates. This suggests involvement of additional genetic loci in modulating chloroquine resistance. Additional pfcrt polymorphisms at codons A220S, Q271E, N326S and R371I have been found in chloroquine-resistant isolates. We wanted to test if sequential acquisition of mutations at these codons leads to in vitro chloroquine resistance. Stepwise accumulation of mutations was not detected, rather there was almost complete linkage between the pfcrt K76T mutation and polymorphisms in these codons. Therefore these additional polymorphisms do not enhance the correlation between pfcrt T76 and chloroquine resistance in Senegal. These data suggest that in vitro chloroquine resistance requires the genetic background of the pfcrt K76T mutation and additional mutations in genetic loci outside the pfcrt gene.

P38 mitogen-activated protein kinase mediates hexosamine-induced TGFbeta1 mRNA expression in human mesangial cells

AIMS/HYPOTHESIS

The hexosamine pathway has been implicated in the induction of TGFbeta1 expression and in the pathophysiology of diabetic glomerulopathy. Glucose-induced TGFbeta1 expression is mediated by p38 mitogen-activated-protein-kinase (p38-MAPK) and this kinase is activated in the diabetic glomeruli. We examined whether the p38-MAPK is implicated in hexosamine-induced TGFbeta1 mRNA expression in human mesangial cells. GFAT overexpression induced an increase in p38-MAPK activation after 6 and 12 h incubation in normal glucose, and this was prevented by the GFAT inhibitor azaserine. Furthermore, high glucose enhanced p38-MAPK activation in GFAT tranfected cells ( p</=0.04). P38-MAPK inhibition using SB202190 (1 micro mol/l) reduced hexosamine-induced TGFbeta1 expression in normal and high glucose. The activation of the p38-MAPK was dependent on protein kinase-C.

METHODS

The products of the hexosamine biosynthetic pathway were increased by the addition of glucosamine or by the overexpression of the rate-limiting enzyme of the hexosamine pathway, glutamine: fructose-6-phosphate amidotransferase (GFAT).

RESULTS

Glucosamine addition resulted in cell death. UDP-N-Acetylglucosamine, one of the major hexosamine end-products, was increased in normal (7 mmol/l) and high (25 mmol/l) glucose conditions in GFAT-transfected cells compared to control transfected cells by twofold and 1.7-fold respectively ( p</=0.04) and this was accompanied by a 1.6- and 2.3-fold increase ( p</=0.02) in TGFbeta1 mRNA expression. Addition of the GFAT inhibitor azaserine (10 micro mol/l) prevented the induction of TGFbeta1 in GFAT transfected cells.

CONCLUSION/INTERPRETATION

Overexpression of GFAT increases hexosamine accumulation which mediates TGFbeta1 expression via a protein kinase-C and p38-MAPK dependent mechanism. Increased glucose concentrations magnify these effects.

Registry of endovascular treatment of abdominal aortic aneurysms (RETA): the fate of patients with primary endoleaks

Background

The aim was to present the follow-up data of patients with a primary endoleak identified in the periprocedural period to establish the consequences of these endoleaks.

Methods

There were 123 primary endoleaks in the 1000 operations logged in the Registry of Endovascular Treatment of Abdominal Aortic Aneurysms (RETA) database, visualized either immediately after the procedure or at 30-day computed tomography. The sites of these were: collateral, 42 (34 per cent); proximal anastomotic (PA), 41 (33 per cent); distal anastomotic (DA), 19 (15 per cent); midgraft, 12 (10 per cent); occluder, three (2 per cent); and site not stated in six (5 per cent). The fate of these endoleaks was examined from available follow-up data.

Results

Nine patients (22 per cent) with PA endoleaks died from rupture (n = 3) or following surgery for the endoleak (n = 6). Eleven patients had persistent primary PA endoleak with or without treatment; three of these patients had rupture. Others were treated successfully with surgery, proximal cuffs or angioplasty of the proximal anastomosis. Twenty-two collateral endoleaks (52 per cent) resolved spontaneously at 30 days. There were no ruptures at follow-up. Seven of the 19 DA endoleaks resolved spontaneously by 30 days and four had further endovascular treatment before discharge. Of the eight persistent endoleaks, three resolved spontaneously and three had endovascular treatment. There were no ruptures at follow-up. Two of the three occluder endoleaks resolved spontaneously; the other patient died suddenly from an unknown cause. Nine of the 12 midgraft endoleaks resolved by 30 days, and one had resolved spontaneously at 1 year; again there were no ruptures in this group.

Conclusion

The presence of a PA endoleak justifies an aggressive approach to treatment because of their association with aneurysm rupture. However, open surgical treatments carry a significant mortality rate. Other endoleaks follow a more benign course, and many will resolve spontaneously.

RETA: update on the short-term (30 day) and long-term (1 and 2 years) results of endovascular repair of abdominal aortic aneurysms

Background

The updated results from the Registry of Endovascular Treatment of Aneurysms (RETA) for short- and long term outcomes from 3 years of data collection are presented.

Methods

Some 611 patients were submitted to RETA from January 1996 to December 1999 from 31 centres. In the same period 1-year follow-up was received for 299 of the 340 cases requested (88 per cent return rate) and 2-year follow-up for 88 of the 155 cases requested (57 per cent return rate).

Results

At 30 days 90 per cent of abdominal aortic aneurysms (AAA) were excluded. The rate of conversion to open repair was 5 per cent. Complications occurred in 25 per cent of patients. The overall 30-day mortality rate was 7 per cent with significantly more deaths in the aortouni-iliac and crossover groups (12 versus 4 per cent; adjusted odds ratio (OR) 2·6 (95 per cent confidence interval (c.i.) 1·2–5·9); P = 0·018), in unfit patients (18 versus 4 per cent; adjusted OR 4·3 (95 per cent c.i. 2·0–9·5); P &lt; 0·001) and in patients with larger aneurysms (10 versus 2 per cent; adjusted OR 4·4 (95 per cent c.i. 1·4–13); P = 0·009). At 1 year the mortality rate was 11 per cent, with four deaths (1 per cent) due to ruptured AAA. New complications were reported in 53 patients (20 per cent) with 31 (12 per cent) related to the device or AAA. In the second year of follow-up the mortality rate was 11 per cent with one death (1 per cent) due to ruptured AAA. New complications in the second year after device placement were reported in 24 per cent of patients, with 16 (20 per cent) related to the device or AAA. The cumulative endoleak-free survival for all patients was 57 per cent at 2 years.

Conclusion

The 30-day mortality rate for endovascular repair was comparable to reported results for conventional surgery, particularly in fit patients. There was a relatively high complication rate at follow-up, with ruptures reported. Most complications had endovascular treatment.