The impact of diabetes mellitus on the prognostic value of a normal dobutamine stress echocardiogram in patients with intermediate to high cardiovascular risk

INTRODUCTION

There is currently limited data on the prognostic value of a normal dobutamine stress echocardiogram (DSE) in patients with intermediate to high cardiovascular risk. The impact of diabetes mellitus, recently recognised as a cardiovascular risk-equivalent, has not been previously evaluated. This study aims to determine the prognostic value of a normal DSE in these patients.

METHODS

The study population includes all patients with two cardiovascular risk factors or diabetes mellitus and a normal DSE (baseline and peak stress) with three months follow-up. A total of 122 patients (47 females, 75 males; mean age 59.6 years) were recruited. Impact of diabetes mellitus on subsequent cardiovascular events was determined.

RESULTS

Diabetes mellitus was present in 32.8 percent, hypertension in 72.1 percent, smoking in 27.0 percent, family history of premature coronary artery disease in 15.6 percent, and hypercholesterolemia in 66.4 percent. On follow-up until 6.4 years (mean 4.1 years), there were four myocardial infarctions (0.8 percent per patient/year) and five revascularisation procedures (1.0 percent per patient/year). The majority of adverse events occurred among patients with diabetes mellitus (three out of four myocardial infarctions; four out of five revascularisations). Diabetes mellitus independently predicted subsequent cardiac events on both univariate and multivariate analyses (p value is equal to 0.015 and 0.011, respectively). Presence of diabetes mellitus also conferred a worse outcome on survival analysis (p value is equivalent to 0.0046).

CONCLUSION

The presence of diabetes mellitus adversely affects clinical outcome despite a normal DSE. Patients without diabetes mellitus, but with intermediate to high cardiovascular risk, and a normal DSE have a better medium term outcome.

Hybrid cardiac revascularisation surgery

Currently, 3 methods of myocardial revascularisation are available for the treatment of coronary artery disease: i) coronary artery bypass grafting (CABG); ii) percutaneous transluminal coronary angiography (PTCA), and iii) transmyocardial laser revascularisation (TMR). Until recently, these procedures were performed exclusive to one another. We report 2 cases of minimally invasive direct coronary artery bypass grafting with subsequent PTCA, and 1 case of staged PTCA followed by TMR performed at our institution. We discuss the role of hybrid procedures in the current era of treatment of ischaemic heart disease.

Interleukin-6 in experimental endometriosis

OBJECTIVE

To measure the concentration of interleukin-6 (IL-6) in peripheral serum and conditioned media (CM) of macrophages collected from the peritoneal cavity in rats before and after surgically inducing endometriosis.

DESIGN

Adult female rats (n = 50) underwent autotransplantation of adipose tissue or uterine squares. Peritoneal cavity macrophages were collected at the initial laparotomy. Rats were killed 4 or 8 weeks later, and peripheral serum and peritoneal cavity macrophages were collected. Macrophages were cultured for 48 hours, and the IL-6 concentrations in CM and serum were measured using the B9 hybridoma cell line bioassay.

RESULTS

Serum IL-6 levels were significantly increased at 4 weeks but not at 8 weeks in rats receiving endometrial implants. Interleukin-6 production by macrophages from rats with endometrial implants at 4 or 8 weeks was not significantly different from baseline or from rats receiving adipose tissue implants.

CONCLUSION

The increased serum IL-6 levels at 4 but not 8 weeks after surgical induction of endometriosis suggest that IL-6 may be involved in the initial development of endometriosis in this experimental model.

Severe aortic regurgitation due to Neisseria mucosa endocarditis

A rare occurrence of Neisseria mucosa endocarditis on a native aortic valve not known to be diseased is reported. Despite vigorous antibiotic therapy, severe aortic regurgitation developed necessitating aortic valve replacement. At operation, the right coronary cusp was retracted with two small nodules attached to its edge and the non-coronary cusp was perforated. Neisseria mucosa endocarditis is very rare, and involves abnormal mitral or prosthetic valves predominantly. Infection of a native aortic valve, with no known history of disease, is exceptional.

Myocardial infarction in patients aged 40 years and below: an angiographic review

Over a period of 27 months, 32 patients aged 40 and below were admitted for acute myocardial infarction. Twenty-nine had coronary angiography with a mean of 15.7 +/- 10.0 days following infarction. Fourteen patients had single vessel, 10 multi-vessel and 5 had only minor coronary disease. Disease in the left anterior descending (LAD) artery was more common than in the circumflex or right coronary artery (RCA), but myocardial infarction occurred with near equal frequency in both the LAD and RCA territories. Only 2 infarct-related vessels were collateralized. Spontaneous coronary dissection was detected in 2 patients. The left ventricular function was significantly impaired in about half of the patients.

Hybrid structural modeling of alloantibody binding to human leukocyte antigen with rapid and reproducible cross-linking mass spectrometry

Alloantibody recognition of donor human leukocyte antigen (HLA) is associated with poor clinical transplantation outcomes. However, the molecular and structural basis for the alloantibody-HLA interaction is not well understood. Here, we used a hybrid structural modeling approach on a previously studied alloantibody-HLA interacting pair with inputs from ab initio, in silico, and in vitro data. Highly reproducible cross-linking mass spectrometry data were obtained with both discovery- and targeted mass spectrometry-based approaches approaches. The cross-link information was then used together with predicted antibody Fv structure, predicted antibody paratope, and in silico-predicted interacting surface to model the antibody-HLA interaction. This hybrid structural modeling approach closely recapitulates the key interacting residues from a previously solved crystal structure of an alloantibody-HLA-A∗11:01 pair. These results suggest that a predictive-based hybrid structural modeling approach supplemented with cross-linking mass spectrometry data can provide functionally relevant structural models to understand the structural basis of antibody-HLA mismatch in transplantation.

A case of unusual electrocardiographic presentation of right ventricular myocardial infarction

This is a case of an unusual electrocardiographic manifestation of a patient with right ventricular (RV) myocardial infarction occurring in association with left ventricular inferoposterior myocardial infarction. There was massive ST-segment elevation in the precordial leads resembling that of an anterior myocardial infarct in addition to the ST-segment elevation seen normally in right ventricular leads. Two-dimensional echocardiography confirmed right ventricular hypokinesia and coronary angiography revealed single-vessel coronary artery disease involving the right coronary artery. It served to remind us that the presence of diffuse and massive ST-segment elevation in the precordial leads in a patient with inferior myocardial infarction may indicate simultaneous RV infarction and warrants further confirmatory tests.

S1.3d The human pathobiont Malassezia furfur secreted protease MfSAP1 regulates cell dispersal and exacerbates skin inflammation

S1.3 Malassezia: genetics, genomics, and biology, September 21, 2022, 11:00 AM - 12:30 PM

 

Objectives

Malassezia forms the dominant eukaryotic microbial community on the human skin. The Malassezia genus possesses a repertoire of secretory hydrolytic enzymes involved in protein and lipid metabolism which alter the external cutaneous environment. The exact role of most Malassezia secreted enzymes, including those in interaction with the epithelial surface, is not well characterized.

Methods and Results

In this study, we compared the expression level of secreted proteases, lipases, phospholipases, and sphingomyelinases of M. globosa in healthy subjects and seborrheic dermatitis or atopic dermatitis patients. We observed upregulated gene expression of the previously characterized secretory aspartyl protease MgSAP1 in both the lesional and non-lesional skin sites of affected compared to healthy subjects. To explore the functional roles of MgSAP1 in skin disease, we generated a knockout mutant of the homologous protease MfSAP1 in the genetically tractable M. furfur. We observed the loss of MfSAP1 resulted in dramatic changes in the cell adhesion and dispersal in both culture and a human 3D reconstituted epidermis model. In a murine model of Malassezia colonization, we further demonstrated MfSAP1 contributes to inflammation as observed by reduced edema and myeloid pustule formation with the knockout mutant versus wildtype.

Conclusion

Taken together, we show that this dominant secretory M. aspartyl protease has an important role in enabling a planktonic cellular state that can potentially aid in colonization and additionally as a virulence factor in barrier-compromised skin, further highlighting the importance of considering the contextual relevance when evaluating the functions of secreted microbial enzymes.

ReoPro Observational Registry (RAPOR): insights from the multicentre use of abciximab in Asia

INTRODUCTION

The pattern of use of abciximab in real-life clinical patients undergoing percutaneous coronary intervention (PCI) in 11 high-volume centres in Singapore, Malaysia, Thailand, Philippines, India, Pakistan and Korea was prospectively examined.

METHODS

These centres enrolled 224 consecutive patients over eight months to receive abciximab during PCI for the study. The cohort consisted of 82.1 percent males, with mean age of 55 (+/- 11) years and mean weight of 67 (+/- 17) kg.

RESULTS

The use of abciximab during PCI ranged between 6.2 percent and 21.6 percent. The indications for the use of abciximab were: acute coronary syndromes (34.3 percent), complex coronary lesions (17.9 percent) and multivessel PCI (17.7 percent). Based on a risk scoring system devised for this registry, majority (60.0 percent) of the patients was considered high risk when abciximab was used. Among the patients enrolled, 36.6 percent received abciximab as a "bail-out". The overall in-hospital ischaemic event rates were low at 4.0 percent. The complication rates included major bleeding 0.7 percent, thrombocytopenia 2.7 percent and need for blood transfusion 2.8 percent. There was a trend towards a higher incidence of in-hospital non-Q myocardial infarction in the "bail-out" group (2.1 percent versus 7.3 percent, p-value equals 0.07).

CONCLUSION

Abxicimab was uncommonly used among patients (9.4 percent) undergoing PCI in this Asian region, with the operators reserving it mainly for high-risk patients.

Human VEGF165-myoblasts produce concomitant angiogenesis/myogenesis in the regenerative heart

Bioengineering the regenerative heart may provide a novel treatment for heart failure. On May 14, 2002, a 55-year-old man suffering from ischemic myocardial infarction received 25 injections carrying 465 million cGMP-produced pure myoblasts into his myocardium after coronary artery bypass grafting. As on August 28, 2002, his EKG was normal and showed no arrhythmia. His ejection fraction increased by 13%. He no longer experienced shortness of breath and angina as he did before the treatment. Three myogenesis mechanisms were elucidated with 17 human/porcine xenografts using cyclosporine as immunosuppressant. Some myoblasts developed to become cardiomyocytes. Others transferred their nuclei into host cardiomyocytes through natural cell fusion. As yet others formed skeletal myofibers with satellite cells. De novo production of contractile filaments augmented the heart contractility. Human myoblasts transduced with VEGF165 gene produced six times more capillaries in porcine myocardium than in placebo. Xenograft rejection was not observed for up to 20 weeks despite cyclosporine discontinuation at 6 weeks. Pros and cons of autografts vs. allografts are compared to guide future development of heart cell therapy.

CAMK2D serves as a molecular scaffold for RNF8-MAD2 complex to induce mitotic checkpoint in glioma

MAD2 is a spindle assembly checkpoint protein that participates in the formation of mitotic checkpoint complex, which blocks mitotic progression. RNF8, an established DNA damage response protein, has been implicated in mitotic checkpoint regulation but its exact role remains poorly understood. Here, RNF8 proximity proteomics uncovered a role of RNF8-MAD2 in generating the mitotic checkpoint signal. Specifically, RNF8 competes with a small pool of p31comet for binding to the closed conformer of MAD2 via its RING domain, while CAMK2D serves as a molecular scaffold to concentrate the RNF8-MAD2 complex via transient/weak interactions between its p-Thr287 and RNF8's FHA domain. Accordingly, RNF8 overexpression impairs glioma stem cell (GSC) mitotic progression in a FHA- and RING-dependent manner. Importantly, low RNF8 expression correlates with inferior glioma outcome and RNF8 overexpression impedes GSC tumorigenicity. Last, we identify PLK1 inhibitor that mimics RNF8 overexpression using a chemical biology approach, and demonstrate a PLK1/HSP90 inhibitor combination that synergistically reduces GSC proliferation and stemness. Thus, our study has unveiled a previously unrecognized CAMK2D-RNF8-MAD2 complex in regulating mitotic checkpoint with relevance to gliomas, which is therapeutically targetable.

Analysis methods to improve the diagnostic power of treadmill exercise stress testing in patients with suspected angina pectoris

To assess the ability of 3 established analysis methods in exercise stress electrocardiography to non-invasively detect the presence of coronary artery disease (CAD), 67 consecutive patients who had typical angina, positive exercise stress electrocardiography (ST segment depression > or = 1 mm) and coronary arteriography were studied. Thirty-three patients had significant CAD, and 34 had normal coronary arteriograms. The results showed that the Treadmill Score Method, utilising both ST and non-ST segment variables, had the highest accuracy in predicting disease. The predictive power of all 3 methods was lower in females.

Right and left bundle branch block in acute inferior myocardial infarction

An 88-year-old man presented with acute Q wave inferior, posterior and right ventricular myocardial infarction which was associated with intermittent complete right and left bundle branch block.

A case of broken heart from blunt trauma

A young man with blunt chest trauma presented acutely in shock as a result of cardiac rupture causing acute bloody tamponade. We discuss the clinical presentation, the importance of rapid and accurate diagnosis and management of such cases.

Fatal pulmonary haemorrhage with the combined use of abciximab and fibrinolytic agent

The increased bleeding risk associated with the use of abciximab has been well reported. The risk appears to be amplified when abciximab is administered concurrently with a fibrinolytic agent. We report and review the literature on the occurrence of a case of fatal pulmonary haemorrhage, a rare bleeding complication, in a patient who received both these drugs.

Liver Disease Among Patients with Psoriasis: The Malaysian Psoriasis Registry

BACKGROUND

Therapeutic options for psoriasis may be limited for patients with concomitant liver disease.

OBJECTIVE

We aim to report the frequency of liver disease among psoriasis patients, describe the clinical features, treatment modalities and quality of life.

METHODS

This was a multi-center cross-sectional study of psoriasis patients notified to the Malaysian Psoriasis Registry (MPR) from January 2007 to December 2018.

RESULTS

Of 21,735 psoriasis patients, 174 (0.8%) had liver disease. The three most common liver diseases were viral hepatitis (62.1%), fatty liver (14.4%) and liver cirrhosis (10.9%). The male-to-female ratio was 3.8:1. Mean age of onset of psoriasis was higher in those with liver disease compared to those without (37.25 ± 13.47 years vs 33.26 ± 16.96 years, p < 0.001). Psoriasis patients with liver disease had a higher rate of dyslipidemia (27.5%vs16.4%, p < 0.001), hypertension (33.9%vs23.7%, p = 0.002), diabetes mellitus (22.4%vs15.9%, p = 0.021) and HIV infection (5.3%vs0.4%, p < 0.001) compared to those without liver disease.They were also more likely to have severe disease (BSA > 10% and/or DLQI > 10) (59.3%vs49.9%, p = 0.027), psoriatic arthropathy (21.1%vs13.0%, p = 0.002), and nail involvement (78.2%vs56.1%, p < 0.001) compared to those without liver disease. The use of phototherapy (8.4%vs2.6%, p < 0.001), acitretin (7.3%vs2.8%, p < 0.001) and cyclosporin (3.0%vs0.7%, p < 0.001) were significantly higher in the group with liver disease. The mean Dermatology Life Quality Index were similar in both groups (9.69 ± 7.20vs9.62 ± 6.75, p = 0.88).

CONCLUSIONS

The frequency of psoriasis patients with liver disease in MPR was 0.8%. Psoriasis patients with liver disease were more likely to be male, had a higher rate of co-morbidities, severe disease, nail and joint involvement than those without liver disease.

Effects of some non-steroidal anti-inflammatory drugs (NSAIDS) on steroidogenesis in rat and porcine testis

Using the rapid gas chromatographic steroid profiling technique, a number of metabolites of pregnenolone have been separated and quantified after incubation of this steroid with adult rat and neonatal porcine testicular homogenates. It was shown that the 5-ene-3 beta-hydroxy- and the 4-en-3-oxosteroid pathways for androgen biosynthesis were operating in both species, although the former pathway appeared to be more important in porcine testis. This tissue was characterised by the formation of several odorous, and pheromonal, 16-androstenes, which were quantitatively more important than the androgens. Three non-steroidal anti-inflammatory drugs (NSAIDS) caused dose-related inhibition of androgen and 16-androstene biosynthesis when co-incubated with pregnenolone. The order of potency was flurbiprofen > indomethacin > > > aspirin. The possibility that the NSAIDS may interfere with cytochrome P-450 is discussed, since several steroid-transforming enzymes, known to be dependent on this cytochrome for their activity, were markedly inhibited.

Review of patients with infective endocarditis of native valves over a five-year period

The clinical characteristics, echocardiographic features, bacteriologic data, morbidity and mortality of patients who were admitted to our hospital with infective endocarditis of their native valves over a five-year period were reviewed. There were 32 patients with a mean age of 38.2 +/- 16.2 years (range: 17 to 71 years) in our study population; 24 patients had underlying valvular abnormalities, six patients had congenital heart disease and two patients had no structural cardiac abnormality. Echocardiography was performed for all patients. Vegetations were absent in three (9.4%) patients, single in 19 (59.4%) patients and multiple in ten (31.3%) patients. Of the 24 (75%) patients who had left-sided endocarditis, mitral valve disease was the commonest valvular abnormality (16 patients). Ventricular septal defect was the commonest underlying abnormality in patients with right-sided endocarditis. Blood cultures were positive in 26 (81.3%) patients; the commonest organism was streptococcal (16 or 50% patients). Complications were present in 13 (40.6%) patients, of which eight patients had evidence of embolism, four patients had cardiac failure and one patient had a paravalvular abscess. Four (12.5%) patients died, two as a result of refractory heart failure and two as a consequence of septic embolism. Advances in medicine have resulted in a better outcome for patients with infective endocarditis, however, it remains an important disease with significant morbidity and mortality.

Clinical predictors of a positive troponin T test in patients presenting with probable acute coronary syndromes

Acute coronary syndrome (ACS) patients with positive troponin T (TnT) test are at higher risk for death and myocardial reinfarction. They would significantly benefit from early aggressive pharmacologic and invasive therapy. However, TnT test is not widely available. This retrospective study of 173 patients with ACS showed: that prolonged or repetitive episodes of angina at rest in the previous 24 hours (p = 0.01) and evidence of myocardial ischaemia on ECG (p < 0.001) were associated with positive TnT tests (> or = 0.1 ng/mL). The two variables in combination showed 100% positive predictive value, facilitating early identification and streamlining of therapy.

Occlusion of TCR binding to HLA-A*11:01 by a non-pathogenic human alloantibody

Over the last decades, organ transplantation has made rapid progress as a curative therapy for organ failure. However, the adaptive immune system-alloreactive T cells and antibodies targeting human leukocyte antigens (HLA)-is the leading cause of graft rejection. The presence of anti-donor HLA antibodies is considered a risk factor that disqualifies a particular donor-recipient pair. However, alloantibodies are found in some long-term graft survivors, suggesting a protective blocking function of some alloantibodies. Therefore, whether alloantibodies can have a positive as well as a negative effect in transplantation remains unclear. Here, HLA-A*11:01-specific monoclonal antibodies were generated from a human non-immune antibody library, and the effect of these antibodies was investigated on activation of A*11:01- specific T cells. We identified an A*11:01-specific monoclonal antibody with the capacity to block TCR recognition, TCR recruitment to the immune synapse, and T cell activation. The antibody reduced translocation of the transcription factor NFAT1 and phosphorylation of the MAP kinase ERK, which are both required for T cell effector function and TCR signal transduction. Cross-linking mass spectrometry was used to identify the epitope, demonstrating that this alloantibody can inhibit TCR from binding to the HLA molecule. These findings indicate that some HLA-specific alloantibodies can reduce T cell responses to the allograft. This has significant implications for interpretation of the existence of donor-specific antibodies, since some of them can protect the graft. Moreover, such antibodies may have therapeutic potential as specific treatments targeting mismatched donor HLA molecules.