[Infarction in the per-operative period: check-up, results, treatment, surveillance]

Peroperative infarction (POI) is a frequent and serious event, which is associated with an increase in morbidity and mortality; the risk is aggravated to varying degrees by the techniques of anaesthesia and surgery used. The preoperative evaluation of risk, which combines clinical and paraclinical criteria is described in the algorithm of the new AHA/ACC guidelines. In order to avert these ischemic episodes, beta-blockers must be continued or introduced during vascular surgery. In other types of surgery, they must be considered. It is difficult to diagnose MI in a per-operative context. The electrocardiogram print out and troponin kinetics will identify patients in the postoperative phase that should be oriented towards cardiovascular evaluation and therapy.

[The best of epidemiology and cardiovascular prevention in 2006]

The recent analysis of the French MONICA registries report a reduction in the incidence of fatal MI related to improvement of care whereas the overall incidence of coronary events remain stable, suggesting the need for a better primary prevention. The extensive review of the death certificates and the analysis of the death classification from the same registries indicate an under estimation of MI-related death in the national death registry. It is also confirmed that instead of 50%, approximately 80% of coronary death are explained by the four major risk factors including smoking, hypercholesterolemia, hypertension and diabetes. The international REACH registry has enrolled more than 67 000 individuals including patients with symptomatic atherothrombotic disease and patients with multiple risk factors. The analysis of baseline characteristics and of the one year FU shows a high residual risk and a lack of efficacy of secondary prevention. The existence of a symptomatic disease and the number of symptomatic localization of atherothrombosis are critical factors to predict recurrence of major vascular events Secondary analysis of the INTERHEART study provide the essence of what should any physician know about the relationship between coronary heart disease and smoking, either active or passive. Prevention with respect to this risk factor remains very insufficient. Varenicline, a new nicotinic receptor partial agonist, should help patients involved in smoking cessation program. The established detrimental effects of perioperative smoking represent a unique opportunity to promote smoking cessation in individuals scheduled for surgery. The major cardiovascular impact of second hand smoking has been recently demonstrated by the short-term effects of banning smoking in public places on the incidence of acute coronary events. The SPARCL study has demonstrated the benefit of high dose of atorvastatine to prevent recurrent acute ischemic cerebrovascular event in patients with a prior history of stroke or TIA. In the open ASTEROID study, high doses of rosuvastatine confirm the possibility of reducing the volume of coronary atheroma analyzed by IVUS. The expected benefit of glitazones to reduce the incidence of death, MI and stroke in diabetes patients with a prior history of vascular event has been confirmed in the PROactive study. Pioglitazone provided a clear reduction of recurrent vascular events in diabetes patient with a prior MI at a cost of a significant increase of the risk of heart failure. In the DREAM study, neither ramipril nor rosiglitazone have reduced the incidence of cardiovascular events significantly. The moderate benefit of the fenofibrate to prevent cardiovascular events in the FIELD study, which was carried out in diabetics mostly in primary prevention, needs to be considered after adjustment on statin use in a higher proportion of patients of the placebo group. Postprandial hyperglycaemia, analyzed by the peak of glycaemia after a load in glucose, has been confirmed as a more powerful independent predictive factor of the risk of cardiovascular event than fasting glycaemia. The systematic screening postprandial hyperglycaemia represents an interesting strategy for primary prevention which warrants further investigation. If obesity is a risk factor whose impact on morbi-mortality is well established, a French study shows that body mass index has an unfavourable influence on the cognitive functions in middle-aged men and women.

Glycemia in acute coronary syndromes

Diabetes is an established major factor of poor prognostis after an acute coronary syndrome. Recent studies have addressed the impact of abnormal glucose metabolism at the acute phase in patients without known diabetes. It has been found that abnormal glycemia regulation is more common than normal regulation in patients presenting with acute coronary syndrome, whatever the method used to evaluate blood glucose metabolism. High blood glucose at admission, whether fasting or not, are associated with worse outcome after an acute coronary syndrome, ie. by increased mortality and development of severe heart failure. The prognosistic value of glycemia is valuable for both short and long term outcomes. Admission glycemia measurement allows therapeutic strategies at the acute phase. Fasting glycemia and oral glucose tolerance test performed during the hospital stay discloses valuable diagnostic information and provide useful tools for secondary prevention. Moreover, fasting glycemia is a more powerful predictor for short term outcome after myocardial infarction than admission glycemia. The mechanisms by which hyperglycemia deteriorates the cardiovascular prognosis, in particular for left ventricular dysfunction, are not fully understood. Stress hyperglycemia may be a marker of extensive cardiac damage, reflecting a surge of stress hormones such as catecholamines and cortisol that participate to insulinresistance and affect fatty acid and glucose homeostasis. Recent findings also argue for a direct deleterious effect of hyperglycemia on myocardium.

Synthesis and fungicidal activity of N-2-(3-methoxy-4-propargyloxy)phenethyl amides. Part II: anti-oomycetic mandelamides

Novel types of anti-oomycetic compounds have been designed and prepared. The synthetic approach to these mandelamides is outlined. Biological data demonstrate their high efficacy against important plant diseases such as tomato and potato late blight (Phytophthora infestans De Bary) and grape downy mildew (Plasmopara viticola Berliner & de Toni). Structure-activity relationship studies are discussed. The new development product mandipropamid is presented.

[Preventing the cardiotoxic effects of anthracyclins. From basic concepts to clinical data]

The chronic cardiotoxicity of the cytotoxic agents such as anthracyclines is one of the main factors, which limits their prolonged use. Clinically, this cardiotoxicity results in a cardiomyopathy with irreversible congestive heart failure, with high mortality. The molecular mechanisms, which could explain this cardiac toxicity, are complex but it seems distinct from the anticancer mechanism. Several hypotheses were advanced but it appears that the induction of an oxidative stress within myocardial tissue constitutes the common denominator. The prevention of this cardiotoxicity lies on:--a rigorous cardiac monitoring--the use of anthracyclines analogues with lower cardiotoxicity,--modifications of the protocols of administration. The myocardial protection, with cardioprotective agents targeting oxidative stress during chemotherapy would be of great interest for an optimal use of the anthracyclines.

Crystal structures of the methylene chloride disolvates of tetrakis(3,5- dimethoxyphenyl)porphyrin and its isotypic copper(II) and nickel(II) complexes, C52H46N4O8 · 2CH2Cl2, Cu(C52H44N4O8) · 2CH2Cl2, Ni(C52H44N4O8) · 2CH2Cl2

C54H50Cl4N4O8, triclinic, P1̅ (no. 2), a = 11.295(1) Å, b = 11.255(1) Å, c = 11.797(1) Å, α = 108.904(2)°, β = 101.091(2)°, γ = 110.992(2)°, V = 1241.4 Å3, Z = 1, Rgt(F) = 0.056, wRref(F2) = 0.135, T = 100 K.

C54H48Cl4CuN4O8, triclinic, P1̅ (no. 2), a = 11.2204(5) Å, b = 11.3499(6) Å, c = 11.7610(6) Å, α = 109.187(1)°, β = 100.830(1)°, γ = 110.681(1)°, V = 1242.7 Å3, Z = 1, Rgt(F) = 0.033, wRref(F2) = 0.092, T = 100 K.

C54H48Cl4N4NiO8, triclinic, P1̅ (no. 2), a = 11.196(1) Å, b = 11.329(1) Å, c = 11.785(1) Å, α = 109.486(2)°, β = 101.230(2)°, γ = 110.607(2)°, V = 1233.8 Å3, Z = 1, Rgt(F) = 0.040, wRref(F2) = 0.110, T = 100 K.

Hospital care of patients with ST-elevation myocardial infarction in four different European regions. Data from four regional myocardial infarction registries in Berlin, Dijon, Florence, and Tartu

National surveys as well as European comparative studies suggest that differences in treatment of patients with ST-elevation myocardial infarction (STEMI) exist. The extent to which these variations influence the outcome of hospital care delivered to STE-MI patients in everyday routine is mostly unknown. In this study data representative of hospital care received by STEMI patients in four European regions (Berlin, Dijon, Florence and Tartu) were compared. The four registries are population based. The percentage of women and the mean age of the patients differed among the registries. Risk factors such as hypertension and hypercholesterolaemia also differed among the different regions, whereas a history of diabetes mellitus was similar among the registries. The percentage of patients receiving reperfusion therapy ranged from 47 to 81%. An appreciable difference also resulted after breaking down reperfusion therapy into thrombolysis and primary percutaneous coronary intervention (PCI). Hospital mortality as an outcome measure was very similar among the regions. After adjustment for age, the comparative magnitude of hospital mortality proportion was also very similar among three registries. Only the patients from Florence demonstrated a comparatively lower death rate, with a ratio of 0.81. In summary, there are important differences among baseline characteristics and hospital care of STE-Ml patients in the four study regions. Nevertheless, it was interesting to ascertain that the outcome measured in hospital mortality was very similar among the four registries compared.

[The best of epidemiology and cardiovascular prevention in 2005]

It is difficult to summarize in a few pages the wealth of information appeared during the year 2005 in the field of epidemiology and cardiovascular prevention. The general epidemiological data on the evolutionary tendencies of coronary mortality and morbidity make it possible to underline the effectiveness of the control of the great risk factors within the framework of the primary prevention. Although lipids and diabetes have still this year held the front of the scene through many trials, this analysis is also focused on smoking, subject more and more tackled in the cardiologic journals, and to which a larger attention should be paid in our daily practice. The Paris Prospective Study I brought new data concerning the early identification of the subjects at risk of sudden death, starting from the analysis of the evolution of heart rate profile during and after exercise. Is the concept of metabolic syndrome a phenomenon of mode or does it constitute in itself an autonomous prognostic factor beyond the risk related to the plurality of the factors which define it? The cardiologist will have to be interested more and more in the living conditions of his patients and in particular with the environmental factors such as the air pollution, who seems to have a considerable impact on the incidence of the acute coronary events. Lastly, the ADMA (asymmetric dimethylarginine), seems a possible new marker of cardiovascular risk, but its real prognostic interest remains to be defined.

Impact of chronic oral anticoagulation on management and outcomes of patients with acute myocardial infarction: data from the RICO survey

OBJECTIVE

To determine the prevalence of chronic oral anticoagulant drug treatment (COA) among patients with acute myocardial infarction (AMI) and its impact on management and outcome.

METHODS

All patients with ST segment elevation AMI on the RICO (a French regional survey for AMI) database were included in this analysis. COA was defined as continuous use >or= 48 hours before AMI.

RESULTS

Among the 2112 patients with ST elevation myocardial infarction (STEMI), 93 (4%) patients were receiving COA. These patients were older and more likely to have a history of hypertension, diabetes and prior myocardial infarction than patients without COA. In addition, fewer patients who received COA underwent reperfusion therapy or received an antiplatelet agent (aspirin/thienopyridines). Moreover, patients receiving COA experienced a higher incidence of in-hospital major adverse events (death, recurrent myocardial infarction or major bleeding, p = 0.005). Multivariate analysis showed that only ejection fraction, current smoking and multiple vessel disease, but not COA, were independent predictive factors for major adverse events. In contrast, COA was an independent predictive factor for heart failure when adjusted for age, diabetes, creatinine clearance, reperfusion, heparin and glycoprotein IIb/IIIa inhibitors (odds ratio 2.06, CI 95% 1.23 to 3.43, p = 0.005).

CONCLUSION

In this population based registry, patients with STEMI with prior use of COA constituted a fairly large group (4%) with an overall higher baseline risk profile than that of patients without COA. Fewer in the COA group received reperfusion therapy or aggressive antithrombotic treatment and they experienced more adverse in-hospital outcomes. Thus, further studies are warranted to develop specific management strategies for this high risk group.

Major impact of admission glycaemia on 30 day and one year mortality in non-diabetic patients admitted for myocardial infarction: results from the nationwide French USIC 2000 study

OBJECTIVE

To analyse the short and long term prognostic significance of admission glycaemia in a large registry of non-diabetic patients with acute myocardial infarction.

METHODS

Assessment of short and long term prognostic significance of admission blood glucose in a consecutive population of 1604 non-diabetic patients admitted to intensive care units in France in November 2000 for a recent (<or= 48 hours) myocardial infarction.

RESULTS

In-hospital mortality, compared with that of patients with admission glycaemia below the median value of 6.88 mmol/l (3.7%), rose gradually with each of the three upper sextiles of glycaemia: 6.5%, 12.5% and 15.2%. Conversely, one year survival decreased from 92.5% to 88%, 83% and 75% (p < 0.001). Admission glycaemia remained an independent predictor of in-hospital and one year mortality after multivariate analyses accounting for potential confounders. Increased admission glycaemia also was a predictor of poor outcome in all clinical subsets studied: patients without heart failure on admission, younger and older patients, patients with or without reperfusion therapy, and patients with or without ST segment elevation.

CONCLUSION

In non-diabetic patients, raised admission blood glucose is a strong and independent predictor of both in-hospital and long term mortality.

[Role of visual analysis of first-pass contrast-enhanced MRI in reperfused myocardial infarction]

The aim of this work is to evaluate the relationship between improvement of regional myocardial function and visual analysis of contrast-enhanced (CE) MRI in patients after acute myocardial infarction. MRI was performed on 19 patients 1 and 11 weeks after a reperfused acute myocardial infarction. Perfusion data (first-pass images [FPI] and delayed CE images) were acquired after an intravenous bolus of gadolinium-DTPA and visually analyzed using a 17 segment model. Each segment was then classified in 3 groups, according to the presence or absence of FPI and CE patterns at baseline study: group 0: normal-appearing segments; group 1: segments with delayed hyper-enhancement but no early hypo-enhancement; group 2: segments with early hypoenhancement. Relative Wall thickening (RWT) was analyzed in each segment and its improvement evaluated in each group. Between first MRI and follow-up study, a significant improvement of RWT occurred in group 1 (mean +/- SD) [from 43.43 +/- 26.59% to 76.71 +/- 47.38%; p = 0.001] but not in group 2 (from 32.73 +/- 25.58% to 39.57 +/- 30.57%; p = NS). In group 0, RWT despite normal value at baseline study exhibited a significant improvement at follow-up (from 65.23 +/- 46.52% to 79.73 +/- 48.46%; p = 0.0015). In conclusion, the combined analysis of early and delayed perfusion abnormalities in MRI in the week following myocardial infarction can predict myocardial viability and allows in the future an evaluation of the efficacy of perfusion therapy.

[Risk stratification in pre-hospital management of myocardial infarction with ST elevation: value of a risk score profile]

The aims of this study were to evaluate new tools of risk stratification in an unselected population of myocardial infarction (MI), usable in a pre-hospital situation, and to compare the risk profile of these patients with those of other clinical trials or myocardial infarction registries. The risk scores of death at 30 days (TIMI score and TIMI risk index) based on data available in the context of coronary emergencies, were applied to the population base of the MI observatory of myocardial infarction in the Côte d'Or (RICO). The risk profile was expressed by the smoothed graph of frequency distribution of each score. The TIMI score applied to the RICO population had a high discriminating power (c = 0.80) for mortality whereas TIMI risk index was less powerful (c = 0.57). The risk profile of the RICO population was comparable to that of InTIME II, ASSENT 2 and the NRMI with reperfusion registry. The NRMI without reperfusion and the MAGIC studies had different profiles characterised by a shift in the graph towards high risk patients. The authors conclude that risk stratification scores, like the TIMI score, are valuable tools for early triage in the management of MI patients. The risk profiles allow comparative analysis of risk levels of populations notably with respect to other registries and also with respect to randomised clinical trials.

Data-Dependent Electron Capture Dissociation FT−ICR Mass Spectrometry for Proteomic Analyses

Electron capture dissociation (ECD) offers many benefits for the analysis of peptides and proteins, and consequently shows great potential for the field of proteomics. Recent developments have reduced the time scale required for ECD to milliseconds resulting in the technique's compatibility with on-line separation techniques, e.g., HPLC. Here, we demonstrate incorporation of ECD into a high-throughput data-dependent LC-MS/MS approach for the analysis of proteomic samples. The approach is applied to analysis of the protein Fc-ROR2 isolated from chondrocytes and is the first example of LC-ECD-MS/MS of such a sample. Protein sequence coverage was 29%. Within that coverage, fifteen peptides were isolated and subjected to ECD. In most cases, the sequence tag generated by ECD was over 70% (in terms of the number of peptide backbone cleavages). The ECD data were searched against the nonredundant human NCBI database using the SEQUEST algorithm. Protein ROR2 was assigned, as was IgG (Fc domain). The results demonstrate the suitability of ECD as an integral technique in high-throughput proteomic strategies.

[Stratification scores for risk in the context of acute coronary syndromes]

The patients presenting acute coronary syndrome with or without ST segment elevation form a heterogeneous population and thus the short and long-term risk of death or recurrent ischemic events can vary considerably. During ACS without ST elevation (unstable angina and non-ST elevation MI), the evaluation of risk is an essential step in the management of such patients, because it determines ulterior strategy. This evaluation is simple and reliable, and is principally based on three scores: the TIMI, the GRACE Score or the PURSUIT. Thanks to this stratification, high and medium-risk patients are able to benefit from early invasive management (stents and anti-GPIIb/IIIa) as recent studies have clearly shown. Even if immediate management of patients with non-ST elevation ACS does not take account of risk stratification, using such information in the medium and long-term does help determine the prognosis. Finally, the risk profile score, whatever the score used is today an essential tool, which helps qualify and especially compare patients included in international clinical studies.

[Atrial fibrillation during myocardial infarction with and without ST segment elevation]

INTRODUCTION

The occurrence of atrial fibrillation (AF) in the acute phase of myocardial infarction with ST segment elevation is common and responsible for an excess hospital mortality. The aim of this work was to define the incidence, predictive factors, and the prognostic impact of AF during MI with and without raised ST segment in the RICO study.

PATIENTS AND METHODS

Between January 2001 and July 2003, 1701 patients were included in this study: 130 (7.6%) had AF in the first 24 hours of management (AF+ group); 1571 (92.4%) remained in sinus rhythm (AF- group).

RESULTS

Among the 1701 patients included in this study, 1197 (70.4%) had MI with raised ST and 504 (29.6%) had MI without raised ST. The incidence of AF was identical whatever the type of MI (7.6% with raised ST versus 7.7% without, p=0.334). The presence of Killip class >2 on admission and chronic obstructive pulmonary disease were independent predictive factors for the occurrence of AF (OR=3.84, p=0.007, and OR=2.47, p=0.014 respectively). The presence of AF was significantly associated with the occurrence of ventricular arrhythmia and/or cardiovascular mortality during admission in the non-selected MI population whatever the type of MI (raised ST ; AF+; 34% and AF-; 18%, p<0.01 versus without raised ST; AF+; 36% and AF-; 16%, p = 0.01).

CONCLUSION

This study provides evidence that the incidence of AF during the first 24 hours of MI, as well as its poor prognosis, are identical whether or not there is ST segment elevation.

Reducing tobacco addiction through tobacco product regulation

Tobacco product regulation has the potential to help reduce tobacco attributable disease by reducing the toxicity of these products and by reducing the prevalence of tobacco use and addiction.

[Predictive value of glycemia in acute coronary syndromes]

Intravenous insulin therapy is used in diabetic patients at the acute phase of coronary syndrome (ACS). However, hyperglycemia in diabetic patients is a powerful predictive factor for patient outcome as it is associated with a doubling of in-hospital mortality and poor long-term prognosis. Recent studies involving non-diabetic patients show that even mild hyperglycemia in the setting of ACS is also a predictive factor of in-hospital mortality. Moreover, the new entity called impaired fasting glucose (IFG) (6.1 to 7 mmol/L) is not only an independent factor of mortality for coronary patients, but very recently has also been associated with a doubling of the risk of in-hospital mortality in the setting of ACS. Admission as well as follow-up glycaemia are fundamental parameters in ACS on the one hand for their prognostic value, and on the other end as a diagnostic tool in determining the presence of diabetes or IFG.

Experimental assessment of new stent technologies: validation of a comparative paired rabbit iliac artery study model

Preventing coronary in-stent restenosis is a major challenge for physicians and industry. To assess new stent technologies, a comparative paired iliac artery model in rabbits is proposed. One tubular stent was implanted in each external iliac artery in 12 rabbits (i.e., 24 stents). An artery overdilatation level of 20% was strictly observed. Restenosis was examined at 30 days by angiography, intravascular ultrasound (IVUS) examination, and histomorphometry. On quantitative angiography, the mean loss of angiographic diameter was 9.8 +/- 4.4% in the right as compared to 9.3 +/- 55% in the left artery (p = 0.75). On IVUS, the volume of intrastent neointimal proliferation was 26.6 +/- 4.9 mm(3) in the right and 25.8 +/- 3.5 mm(3) in the left artery (p = 0.58). In histomorphometry, the neointimal proliferation area was 0.78 +/- 17 mm(2) in the right and 0.76 +/- 0.17 mm(2) in the left artery (p = 0.87). Intrastent neointimal proliferation was comparable between the left and right arteries of all rabbits. The model has three main advantages: (1) arterial dilatation and thus arterial wall aggression are controlled, (2) pairing makes each animal its own control subject, and (3) the statistical power for comparative testing is maximized. The model enables the effect of a new drug-delivery device to be assessed.

Production and Properties of Nanoelectrospray Emitters Used in Fourier Transform Ion Cyclotron Resonance Mass Spectrometry: Implications for Determination of Association Constants for Noncovalent Complexes

Electrospray ionization (ESI) is extensively used in the analysis of biological compounds; yet some fundamental properties of this technique are not completely understood. It is widely recognized that care should be exercised when noncovalent complexes are being studied by ESI, since weak noncovalent binding can be broken or formed during the desolvation process. In the present work, spectra from the noncovalent complex, vancomycin/diacetyl-L-lysyl-D-alanyl-D-alanine, obtained from ESI and from nanoelectrospray ionization (nanoESI), have been compared. The results indicated that the milder desolvation conditions arising as a result of the smaller sizes of droplets produced in the nanoESI source attenuated effects upon weak bonds in the desolvation process. The association constant values calculated from the relative peak intensities suggest that, when using ESI, the analyzed noncovalent complex dissociated in the condensed phase during the spraying process. The influences of experimental parameters such as tip diameter and coating for nanoESI needles were investigated. Principal component analysis, a multivariate analysis method, was applied to achieve a better evaluation of the spectra obtained using different needle diameters and coatings for the analysis of the noncovalent complex vancomycin/diacetyl-L-lysyl-D-alanyl-D-alanine. It was found that 2-microm tip diameter resulted in more reproducible spectra than the larger tip diameters tested (6-20 microm).

Crystal structure of 5,10,15,20-tetrakis(5′-methylthien-2′-yl)porphyrin, C40H30N4S4

C40H30N4S4, triclinic, P1̅ (no. 2), a = 6.5126(7) Å, b = 10.499(1) Å, c = 12.635(1) Å, α = 87.818(2)°, β = 79.141(2)°, γ = 86.737(2)°, V = 846.7 Å3, Z = 1, Rgt(F) = 0.057, wRref(F2) = 0.150, T = 100 K.

N-Terminal Pro-Brain Natriuretic Peptide Levels in Patients with Non-ST-Elevation Myocardial Infarction

METHODS AND RESULTS

101 patients hospitalized for acute non-ST-elevation myocardial infarction (NSTEMI) were included in the study. Median N-terminal fragment of the brain natriuretic peptide (BNP) prohormone (Nt-proBNP) plasma level was 136 (40-335) pmol/l. Patients with increasing levels of troponin I [from low (0.1-10 ng/ml), intermediate (10-40 ng/ml) to high (> or =40 ng/ml) levels] had significantly increased levels of Nt-proBNP (p < 0.05). High-risk patients classified by a high PURSUIT score (i.e. supramedian) had significantly increased Nt-proBNP levels compared to patients with low scores (p < 0.001). Moreover, patients with in-hospital events (death, recurrent MI or clinical heart failure: 27%) had significantly increased median levels of Nt-proBNP compared to event-free patients (184 vs. 105 pmol/l, p = 0.02).

CONCLUSION

Our data in an unselected population of NSTEMI patients indicate that high levels of circulating Nt-proBNP levels are associated with an increased risk of early cardiovascular events.

[Non-revascularisation of acute coronary syndrome with ST elevation]

National therapeutic strategies in acute coronary syndromes (ACS) required revaluation, especially with regards to reperfusion. RICO is an observatory of ACS in the Côte d'Or district. Between January 1st 2001 and April 31st 2003, the cases of 706 patients with ACS and persistent ST elevation or appearances of left bundle branch block eligible for revascularisation (admitted < 12 hours after onset of symptoms and no contra-indications to thrombolysis), were reviewed. The number of revascularised patients was 488 (69%) and 218 (31%) were not revascularised. Thrombolysis was the most commonly used method of revascularisation (66%) in this district: 34% underwent primary angioplasty. Multivariate analysis showed only three independent predictive factors of non-reperfusion during the acute phase. They were: age (> or = 75 years) (p < 0.001), left bundle branch block (p = 0.002) and hospital admission > or = 6 hours after onset of symptoms (p < 0.001). These results confirm the utility of developing networks to improve the efficacy of management and reduce the delay before hospital admission. They also identify specific population groups, the elderly for example, who require specific therapeutic strategies for coronary revascularisation in ACS.

Intramural neovascularization and haemorrhages are major long-term effects of intravascular gamma-radiation after stenting

Structural changes that might influence the structural integrity of the vessel in response to intravascular brachytherapy (IVB) and stenting were examined, focus being on the importance of neovascularization in rabbit stented arteries. Stents were implanted in the infrarenal aortas of rabbits, immediately followed by gamma IVB or a sham radiation procedure, and the arteries harvested at 6 months. Labelling for von Willebrand factor showed an increase in adventitial and medial neovascularization in irradiated versus control arteries group (5.04+/-0.89 versus 1.51+/-0.23 mm(-2), respectively; p=0.004). Moreover, intramedial haemorrhages (free hemosiderin deposition) and inflammation (macrophages) were only observed in irradiated arteries. No significant change in expression of matrix metalloproteinase 1, 2 or 3 was observed between the irradiated and control group while collagen content decreased in the irradiated versus the control group (10.05%+/-1.48% versus 31.92%+/-3.12%, respectively; p<0.001). The study supports the hypothesis that IVB associated with stenting induces late deleterious effects on the medial layer, characterized by formation of intramural neovessels, haemorrhages and a decrease in collagen content.

The impact of chromatography and mass spectrometry on the analysis of protein phosphorylation sites

Protein phosphorylation analysis is an enormous challenge. This review summarises the currently used techniques, which are based on radiolabelling and mass spectrometry as well as electrophoretic and chromatographic separation. Many methods exist, but there is still no single procedure applicable to all phosphoproteins. MS is able to deliver information about the location of phosphorylation sites, but phosphospecific properties with respect to ionisation present obstacles. Therefore, multidimensional approaches involving several analytical methods are often necessary to conquer phosphorylation site identification.

[Is there an increased risk for cardiovascular disease in HIV-infected patients on antiretroviral therapy?]

There is a growing concern about an increased risk for cardiovascular disease in HIV infected patients receiving antiretroviral therapy (ART). This risk could be related to metabolic abnormalities associated with long-term use of antiretroviral drugs. In fact, well recognized cardiovascular risk factors such as hypertension, dyslipidaemia, diabetes mellitus and central fat deposition are increasingly seen in HIV patients on ART. These factors can also be associated with non reversible risk factors, such as male sex, age greater than 40 years and family history of premature coronary artery disease. In addition, cigarette smoking and sedentary lifestyle may predispose these patients to significant cardiovascular disease. A direct atherogenic effect of HIV infection itself or antiretroviral drugs is unlikely. Epidemiological studies have suggested an increased risk for coronary artery disease in HIV infected persons; nevertheless, only long term follow-up could confirm this statement. Despite these uncertainties, it seems reasonable to identify and manage cardiovascular risk factors in HIV infected patients.

Mutations of the beta myosin heavy chain gene in hypertrophic cardiomyopathy: critical functional sites determine prognosis

OBJECTIVES

To assess patients with different types of mutations of the beta myosin heavy chain (beta MHC) gene causing hypertrophic cardiomyopathy (HCM) and to determine the prognosis of patients according to the affected functional domain of beta MHC.

DESIGN AND SETTING

Cohort study of subjects referred to an HCM clinic at an academic hospital.

PATIENTS

70 probands from the HCM clinic were screened for mutations of the beta MHC gene and 148 family members of the genotype positive probands were further assessed. The control group for the genetic studies consisted of 106 healthy subjects.

MAIN OUTCOME MEASURES

Direct DNA sequencing was used to screen 70 probands for mutations of the beta MHC gene. Family members underwent genotypic and detailed clinical, ECG, and echocardiographic assessments. The survival of genotype positive subjects was evaluated according to the type of functional domain affected by the missense mutation and according to phenotypic characteristics.

RESULTS

A mutation of the beta MHC gene was detected in 15 of 70 probands (21%). Of 148 family members studied in these 15 families, 74 were identified with a beta MHC defect. Eleven mutations were detected, including four novel mutations: Ala196Thr, Pro211Leu, Val404Leu, and Arg870Cys. Median survival was 66 years (95% confidence interval (CI) 64 to 77 years) in all affected subjects. There was a significant difference in survival between subjects according to the affected functional domain (p = 0.02). Significant independent predictors of decreased survival were the non-conservative (that is, associated with a change in the amino acid charge) missense mutations that affected the actin binding site (hazard ratio 4.4, 95% CI 1.6 to 11.8; p = 0.003) and those that affected the rod portion of beta MHC (hazard ratio 4.8, 95% CI 1.2 to 19.4; p = 0.03). No phenotypic characteristics were associated with decreased survival or cardiovascular morbidity.

CONCLUSIONS

The type of beta MHC functional domain affected by the missense mutation is predictive of overall prognosis in HCM.

[Application of risk stratification scores in acute myocardial infarction. Results of RICO (observation of infarction in the Ivory Coast)]

Several risk stratification scores for myocardial infarction have been developed in recent years, based on clinical trials. The object of this study was to assess the application of these scores in an unselected population of myocardial in farction in a French department. One thousand and fifty-four patients with acute myocardial infarction were included in the RICO observatory in the Côte d'Or. Those with ST elevation (SST), N = 746, had 30 day-mortality rates which increased with the TIMI and GUSTO scores (khi2 tendency, p < 0.001). There was a good discriminatory power of both these scores (correlations of 0.71 and 0.69 respectively). Similarly, logistic regression analysis showed a significant relationship between TIMI and GUSTO scores and 30 day mortality (p < 0.001). No correlation was observed between mortality and increased TIMI score in cases of infarction without ST elevation, N = 308, p = 0.344. Moreover, this score had a low discriminatory value in the study population with a correlation of 0.54. On the other hand, regression analysis showed a strong predictive value of the PURSUIT score in infarction without ST elevation for mortality. In addition, there was a correlation between death and the value of this score (p < 0.05). This score also showed a good discriminatory power with a correlation of 0.71. This study shows that, in an unselected population, risk stratification scores may be used as a routine in myocardial infarction, especially in cases with ST elevation.

[Factor V Leiden and myocardial infarction: a case, review of the literature with a meta-analysis]

Mutation in blood coagulation factor V Leiden is the most frequently genetic polymorphism implied in venous thrombosis. A 57 year old man was hospitalised for acute myocardial infarction (MI). An emergency coronary angiography was performed, and no significant stenosis was observed. The haematologic check-up showed an heterozygous Leiden mutation of factor V. We report all publications about the relation between factor V Leiden and coronary thrombosis, and we performed a meta-analysis. We analysed the relation in general population and in subgroups, such as, younger and older, and patient with or without coronary stenosis. In global population, the meta-analysis did not found significant association between Factor V Leiden and myocardial infarction (OR = 1.25; IC = 0.97-1.58). In contrast, in patients less than < 55 years old after MI, Factor V Leiden prevalence was significantly higher than in control group (OR = 1.48; IC = 1.05-2.08). In addition, after MI without significant coronary stenosis Factor V Leiden prevalence was significantly higher than in normal patients (OR = 2.84; IC = 1.46-5.51). After MI, in patients without significant coronary stenosis, Factor V Leiden prevalence was significantly higher than in patients with significant coronary stenosis (OR = 3.26; IC = 1.67-6.36). Our study suggests that Factor V Leiden could be search after MI in young subjects and/or without significant stenosis.

Regulatory strategies to reduce tobacco addiction in youth

Preventing tobacco addiction and achieving cessation in established users are the cornerstones of efforts to reduce tobacco use and disease. It has been increasingly recognised that reducing tobacco toxin exposure has theoretical potential to reduce disease in continuing tobacco users. This has been controversial because such approaches also carry the potential to undermine prevention and cessation. As complicated as harm reduction issues are for adults, they are still more complicated for youth. Harm reduction is not a singular approach, but rather a concept that encompasses an extremely diverse array of potential approaches. These carry equally diverse potential risks and benefits. The regulatory framework (for example, whether or not the Food and Drug Administration regulates the approach) is also predicted to be a major factor in determining the consequences of harm reduction approaches. This paper examines the various issues and potential approaches concerning the application of harm reduction to youth. We conclude that although some carry great risk, others may actually support broader tobacco control efforts to prevent tobacco use and foster cessation in youth and adults.

A rapid nonradioactive peptide phosphorylation assay

Radioactive assays are commonly employed to monitor protein or peptide phosphorylation. They not only have all the disadvantages related to radioactivity, but also require large amounts of sample. An alternative is the use of mass spectrometric peptide mapping with sensitivities in the fmole range. We demonstrate here that desalting is a requirement for reproducible results, and we optimized the method for very hydrophilic peptide substrates. The method is very efficient with respect to time and effort.

Sodium dodecyl sulfate versus acid-labile surfactant gel electrophoresis: comparative proteomic studies on rat retina and mouse brain

A long-chain derivative of 1,3-dioxolane sodium propyloxy sulfate, with similar denaturing and electrophoretic properties as SDS, and facilitated protein identification following polyacrylamide gel electrophoresis (PAGE) for Coomassie-stained protein bands, has been tested. Comparative acid-labile surfactant/sodium dodecyl sulfate two-dimensional (ALS/SDS 2-D)-PAGE experiments of lower abundant proteins from the proteomes of regenerating rat retina and mouse brain show that peptide recovery for mass spectrometry (MS) mapping is significantly enhanced using ALS leading to more successful database searches. ALS may influence some procedures in proteomic analysis such as the determination of protein content and methods need to be adjusted to that effect. The promising results of the use of ALS in bioanalytics call for detailed physicochemical investigations of surfactant properties.

[Magnetic resonance imaging early after acute myocardial infarction. A visual analysis of myocardial perfusion based on a 17 segment model]

Magnetic resonance imaging allows an accurate calculation of the left ventricular ejection fraction and left ventricular volumes. Additionally, it makes possible to assess myocardial perfusion after gadolinium chelate injection. Late after the injection, the presence of a myocardial hyper-enhancement can be visualized. The present study has used the 17 segment standardized nomenclature for tomographic imaging of the heart as recommended for all cardiac imaging modalities. Sixty nine patients were studied after a revascularised myocardial infarction. All patients had Timi grade 3 flow in the infarct-related artery after therapy. Regional and global function was studied using cine MR short axis slices. The gadolinium chelate first pass was scored using a 5 level scale reflecting the transmural extent of the segmental myocardial enhancement. The delayed enhancement due to gadolinium accumulation in the myocardium 10 min post injection was scored in the same manner. Left ventricular ejection fraction was 51 +/- 13%. Segmental thickening parameters (systolic thickness, absolute thickening and relative thickening) appeared statistically related to the hypoperfusion and delayed enhancement scores. Absolute myocardial thickening varied from 4.8 +/- 2.7 mm in the myocardial segments free of any delayed enhancement to 2.4 +/- 2.1 mm in segments presenting with a transmural extent of the delayed hyper-enhancement. Scores obtained after gadolinium injection were also well correlated with the global left ventricular function (r = 0.65, p < 0.01 for late enhancement). Magnetic resonance imaging of the heart allows a precise characterisation of revascularised myocardium which makes this technique very attractive for evaluating the treatments designed to improve myocardial microperfusion.

Use of an acid-labile surfactant as an SDS substitute for gel electrophoresis and proteomic analysis

Modern protein identification and analysis relies largely on proteolytic in-gel digestion of proteins separated during polyacrylamide gel electrophoresis (PAGE) followed by mass spectrometric (MS) measurement of the extracted peptides. Sodium dodecyl sulfate (SDS) is routinely used in nonnative PAGE. However, SDS can interfere with MS. We report the use of an acid-labile surfactant (ALS-I) in place of SDS. ALSI is a long chain derivative of 1,3-dioxolane sodium propyloxy sulfate and has similar denaturing and electrophoretic properties as SDS, but it decomposes at low pH and enhances MS detection of proteins.

Exercise stress testing for detection of silent myocardial ischemia in human immunodeficiency virus-infected patients receiving antiretroviral therapy

The prevalence of silent myocardial ischemia (SMI) and the factors associated with SMI were evaluated in patients infected with human immunodeficiency virus (HIV) who had been receiving highly active antiretroviral therapy (HAART) for > or =12 months and did not have known coronary artery disease or cardiac symptoms. Patients prospectively underwent exercise stress testing. The prevalence of SMI was 11% (11 of 99 patients). Patients who had SMI were significantly older than were patients who did not (mean+/-SD, 51+/-8 years vs. 42+/-9 years; P=0.001) and were more likely to have trunk obesity (54% of patients vs. 17%; P=.004). A significant correlation was found between a positive exercise test result and obesity (correlation,.006), waist-to-hip ratio (.007), and glucose and cholesterol levels (.04; P=.03). In multivariate analysis, age, central fat accumulation, and cholesterol level were independent variables associated with the detection of SMI. Exercise testing might be recommended for patients with HIV who have central fat accumulation and hypercholesterolemia.

[Beneficial effects of direct call to Emergency Medical Services on time delays and management of patients with acute myocardial infarction. The RICO (obseRvatoire des Infarctus de Côte-d'Or) data]

The influence of direct calls to specialized Emergency Medical Services in case of suspected myocardial infarction has not been extensively studied. The RICO registry is an exhaustive registry implemented in all six institutions participating in primary care of patients with acute myocardial infarction in one French administrative department (Côte-d'Or). From January 2001 to October 2001, 322 patients were admitted for acute myocardial infarction, among whom only 57 (18%) had directly called emergency medical services after the onset of symptoms. The baseline characteristics of patients who had directly called the emergency services were not different from those of the patients who had not. However, the time from symptom onset to first medical intervention (48 versus 105 minutes, p = 0.02) and from first medical intervention to hospital admission (60 versus 103 minutes, p = 0.02) were markedly shorter in patients who had directly called the emergency medical services. This resulted in a significant increase in the use of reperfusion therapy (70% versus 38%, p = 0.003), including a higher proportion of primary angioplasty (33% versus 20%, p = 0.04). This study documents the beneficial effect of a direct call to the Emergency Medical Services by the patients themselves. Too few patients, however use this opportunity and actions should be taken for informing the lay public of the benefits of this medical service.

Hyperprolactinemia in asymptomatic patients is related to high molecular weight posttranslational variants or glycosylated forms

Circulating human Prolactin (PRL) exists in different variants related to posttranslational modifications, dimerization or association with other serum proteins. Compared to monomeric prolactin these variants usually have little or no biologic activity and include BigBig (BB PRL), Big (B PRL), and Glycosylated forms (G PRL). The aim of the present study was to assess levels of BB PRL, B PRL, little PRL (L PRL) and G PRL in hyperprolactinemic patients with no menstrual alterations or galactorrhea. L PRL, B PRL, and BB PRL were identified by gel filtration chromatography on Sephadex G-100; G PRL and NG PRL were identified by chromatography on Concanavalin A Sepharose. PRL was measured by IRMA DPC. Eleven women, aged 22-50 yrs, were studied for: breast dysplasia (1), controlled hypothyroidism (3), dysmenorrhea (3), microadenoma follow-up (2), and gynecological control (2). Pituitary MRI was normal in all but one patient, who had a microadenoma discovered by Magnetic Resonance Imaging. Six patients had normal L PRL levels, and their hyper PRL was due to excess BPRL or BB PRL. Five patients had increased L PRL levels, but excess G PRL. Patients harboring molecular PRL variants do not present the symptoms typical of the hyperprolactinemic syndrome. Furthermore in patients with clinically controlled prolactinomas the presence of PRL variants should be ruled out to avoid an unnecessary increase of dopamine agonist dosage.

Use of nonspecific cleavage products for protein sequence analysis as shown on calcyclin isolated from human granulocytes

In this paper, analysis strategies developed for a sequencing problem concerning the identification of an S100 protein isolated from human granulocytes are discussed. The analysis of a trypsinized lyophilized sample suggested the presence of a number of peptides which are non-tryptic in origin. During purification of proteins from cell lysates nonspecific cleavage can be observed which may reflect biological processes and can become an unavoidable analytical problem. Current mass spectrometric software is evaluated for the analysis of nonspecific digests in this context. Matrix-assisted laser desorption ionization mass spectrometry (MALDI-MS), high-performance liquid chromatography (HPLC)-MS/MS, and selected ion monitoring (SIM)-MS/MS have been used for peptide analysis and in addition HPLC-MS was carried out for protein analysis leading to the detection of an N-terminal modification of the protein. The success of the study is mainly due to the careful investigation of nonspecific cleavage products. Data obtained from the routine mass spectrometric analysis of an in-gel-digest allowed the identification of this protein as S100 calcium-binding protein A6-calcyclin whose expression in granulocytes has not been described so far.

Validation and quality assurance of planar chromatographic procedures in pharmaceutical analysis

Within the process of the International Conference on Harmonization (ICH), 2 guidelines were released containing a standardized terminology, a verified model of requirements for the validation of analytical procedures, and some guidance in the practical aspects of conducting validation studies in pharmaceutical analysis. For planar chromatographic procedures, which may be used at different levels either in qualitative identity testing, assays, semiquantitative limit tests, or quantitative determination of impurities, this paper tries to transfer these formal requirements into practical approaches for validation. Basic acceptance criteria for evaluation of validation experiments based on practical experience are proposed. In addition, selected parameters for robustness testing of given procedures and quality assurance of quantitative planar chromatographic testing by control charts is described.