How effective is endovascular intracranial revascularization in stroke prevention? Results from Borgess Medical Center Intracranial Revascularization Registry

BACKGROUND AND PURPOSE

The WASID study established the risk of subsequent ischemic stroke at 1 year in subjects with symptomatic intracranial atherosclerotic stenosis (70%-99%) at 18%. The efficacy of different methods of endovascular revascularization in stroke prevention still has not been established. We compared the stroke rate in our registry at 1 year following intervention with the WASID results to identify which method, if any, provides the most benefit in stroke prevention. This result from the BMC-IRR follows a previously published article comparing stent placement and angioplasty outcomes.

MATERIALS AND METHODS

We maintained a nonrandomized single-center single-operator registry of consecutive symptomatic patients who underwent endovascular intracranial revascularization. Data were collected prospectively and retrospectively and analyzed retrospectively. Patients were treated with angioplasty, BMS, or self-expanding WS. To make our data comparable with that in the WASID study, we selected patients with a single lesion of 50%-99% stenosis undergoing a single intervention. Data was collected on patients until symptom recurrence, repeat intervention, or 1 year postintervention, whichever occurred first.

RESULTS

We found that 115 patients fit the inclusion criteria, with 38 angioplasty, 28 BMS, and 49 WS cases. For patients with 70%-99% stenosis, the overall probability of stroke at 1 year postintervention was 19.3%. The overall stroke probability per device, independent of clinical presentation, was 12.5% for angioplasty, 20.2% for BMS, and 24.1% for WS.

CONCLUSIONS

Compared with the WASID data, angioplasty appears to have a lower stroke rate after 1 year than medical therapy alone. However, neither stent-placement arm compared favorably with the WASID results.

Lobar torsion after video-assisted thoracoscopic lobectomy: 2 case reports

Lung torsion is a rare but potentially lethal complication after pulmonary resection. We report two cases of right middle lobar torsion after video-assisted thoracoscopic (VATS) right upper lobectomy in our unit. The two cases were diagnosed definitely 7 and 14 days after VATS surgery by computed tomography (CT) scan and bronchoscopy, respectively. Rethoracotomy and right middle lobectomy were performed in both patients. VATS lobectomy contributes to the development of lobar torsion so this complication should be considered. Carefully checking anatomical structures before thoracotomic closure and correctly suturing the middle lobe to the consecutive lobe are effective ways to prevent this complication.

The feasibility of light microscopic measurements of intercellular spaces in squamous epithelium in the lower-esophagus of GERD patients

The study aims to determine whether light microscopy can be used to accurately measure the diameters of intercellular spaces between squamous epithelial cells in the lower esophagus, and whether changes in this outcome measure can be used as a diagnostic marker for gastroesophageal reflux disease (GERD). The study has two parts. Part 1 involves 42 asymptomatic controls and 119 patients with typical symptoms of GERD, including 58 with erosive esophagitis (EE), and 61 patients with nonerosive gastroesophageal reflux disease (NERD). All biopsies were taken from the lower esophagus. All samples were observed using an immersion objective, after which diameters were measured by computer-assisted morphometry. Part 2 involves 61 individuals who were randomly selected from part 1, including 19 controls, 13 with NERD and 29 with EE. Diameter measurements using both light microscopy and transmission electron microscopy (TEM) were performed for samples of 61 individuals. Samples from a total of 61 individuals (31 male, 30 female, mean age 44.3 ± 16.0 years) were observed using both light microscopy and TEM. Both methods showed significant differences between control and disease groups; the outcomes from the two methods had a certain correlation (r = 0.605, P = 0.000). Morphometric analysis of all 161 individuals (83 males, 78 females, mean age 41.4 ± 15.7) showed mean diameters from light microscopy to be 0.58 ± 0.16 µm for controls, 1.07 ± 0.30 µm for NERD, and 1.29 ± 0.20 µm for EE; differences between control and disease groups were significant (P<0.05). The optimal cut-off value from receiver operator characteristic analysis was 0.85 µm. Diagnoses were validated using the combination of symptoms of GERD, endoscopy, and 24 h ambulatory pH monitoring as the gold standard. At the optimal cutoff, sensitivity was 93.3% and specificity was 100%. The diameters of the intercellular spaces in squamous epithelium of lower esophagus from controls and in patients with GERD can be quantitatively measured using light microscopy. Dilated diameters can serve as a sensitive, specific, and objective indicator for diagnosis of GERD.

Oral Contraceptive, Menopausal Hormone Therapy Use and Risk of non-Hodgkin Lymphoma in the California Teachers Study

Objective: To evaluate whether use of oral contraceptives (OCs) or menopausal hormonal therapy (MHT) is associated with B-cell non-Hodgkin lymphoma (NHL).

Methods: Within the prospective California Teachers Study cohort, women under age 85 with no history of hematopoietic cancer were followed from 1995 through 2007 for diagnosis of B-cell NHL. Overall, 547 women of 116,779 women eligible for analysis of OC use and 402 of 54,758 postmenopausal women eligible for analysis of MHT use developed B-cell NHL. Relative risks (RR) and 95% confidence intervals (CI) were estimated by fitting multivariable Cox proportional hazards models.

Results: Women who used OCs had marginally lower risk of B-cell NHL than women who had never used OCs (RR = 0.86, 95% CI = 0.69-1.06). The reduced risk was most pronounced among women who started OCs before age 25, but did not decrease with increasing duration. No association with MHT was observed when MHT ever users were compared to the never users (RR = 1.05, 95% CI = 0.83-1.33); this result was consistent across formulations of MHT [unopposed estrogen therapy (ET), combined estrogen and progestin therapy (EPT)]. Among women who had never used MHT, women with a bilateral oophorectomy had three times greater risk than those with natural menopause (RR = 3.15, 95% CI = 1.62-6.13), whereas there was no association with bilateral oophorectomy among women who had used MHT. In stratified analyses according to hysterectomy and oophrectomy status, ET and EPT did not affect risk for women with natural menopause or those with hysterectomy who had at least part of an ovary remaining. Among women who had a bilateral oophorectomy, ET reduced risk of NHL (RR = 0.41, 95% CI = 0.21-0.82).

Conclusion: These data suggest that ET use decreases the risk of B-cell NHL among women with both ovaries removed, but not among women retaining at least part of an ovary. In other subgroups MHT does not influence risk. Additional study of associations of MHT and OCs with B-cell NHL are warranted.

Passive smoking and risk of oesophageal and gastric adenocarcinomas

Few studies have examined the association between passive smoking and the risk of oesophageal and gastric adenocarcinomas. In a population-based case-control study with 2474 participants in Los Angeles County, there was no evidence that passive smoking had any appreciable effect on oesophageal or gastric adenocarcinomas.

Identification of potential protein regulators bound to the tissue-specific positive and negative cis-acting elements of a green tissue-specific promoter in rice

Although some tissue-specific cis-acting elements have been identified, the molecular mechanisms of tissue-specific gene expression remain elusive. Here, we report the identification by a yeast one-hybrid screen of five proteins, Os10g31330/glycine-rich, Os01g10400/metallothionein-like, Os05g51180/nucleic acid-binding, Os05g37930/unknown and Os01g01689/phosphatidylinositol kinase that bound to either the positive or negative tissue-specific cis elements of a rice promoter from the green tissue-specific D54O gene. These proteins are localised in the nucleus and the genes encoding them are differentially expressed in different tissues, further suggesting their putative roles in regulating gene expression. These results suggest that the green tissue-specific expression of the D54O gene may be regulated by the interaction of multiple proteins with cis elements in the promoter region.

The development and genetic diversity of H5N1 influenza virus in China, 1996-2006

Since it was first detected in 1996, the Goose/Guangdong/1/1996 (Gs/GD) H5N1 influenza virus and its reassortants have spread to over 60 countries, with over 20 distinct genetic reassortants previously recognized. However, systematic analysis of their interrelationship and the development of genetic diversity have not been explored. As each of those reassortants was first detected in China, here 318 full-length H5N1 virus genomes isolated from 1996 to 2006 in this region were phylogenetically analyzed. Our findings revealed two major group reassortment events in 2001 and 2002 that were responsible for the generation of the majority of the 44 distinct Gs/GD genotypes identified, excepting those 1997 variants. Genotype replacement and emergence occurred continually, with 34 transient genotypes detected while only 10 variants were persistent. Two major replacements of predominant genotypes were also observed: genotype B replaced by Z in 2002 and then genotype Z replaced by the now predominant genotype V in 2005.

Identification of the progenitors of Indonesian and Vietnamese avian influenza A (H5N1) viruses from southern China

The transmission of highly pathogenic avian influenza H5N1 virus to Southeast Asian countries triggered the first major outbreak and transmission wave in late 2003, accelerating the pandemic threat to the world. Due to the lack of influenza surveillance prior to these outbreaks, the genetic diversity and the transmission pathways of H5N1 viruses from this period remain undefined. To determine the possible source of the wave 1 H5N1 viruses, we recently conducted further sequencing and analysis of samples collected in live-poultry markets from Guangdong, Hunan, and Yunnan in southern China from 2001 to 2004. Phylogenetic analysis of the hemagglutinin and neuraminidase genes of 73 H5N1 isolates from this period revealed a greater genetic diversity in southern China than previously reported. Moreover, results show that eight viruses isolated from Yunnan in 2002 and 2003 were most closely related to the clade 1 virus sublineage from Vietnam, Thailand, and Malaysia, while two viruses from Hunan in 2002 and 2003 were most closely related to viruses from Indonesia (clade 2.1). Further phylogenetic analyses of the six internal genes showed that all 10 of those viruses maintained similar phylogenetic relationships as the surface genes. The 10 progenitor viruses were genotype Z and shared high similarity (>/=99%) with their corresponding descendant viruses in most gene segments. These results suggest a direct transmission link for H5N1 viruses between Yunnan and Vietnam and also between Hunan and Indonesia during 2002 and 2003. Poultry trade may be responsible for virus introduction to Vietnam, while the transmission route from Hunan to Indonesia remains unclear.

Callus distraction for the treatment of acquired radial club-hand deformity after osteomyelitis

We report our experience of the use of callus distraction with a monolateral fixator for the treatment of acquired radial club-hand deformity after osteomyelitis. Between 1994 and 2004, 13 patients with a mean age of eight years (4 to 15) were treated by callus distraction with a monolateral fixator after a preliminary period of at least four weeks in a corrective short-arm cast. All patients achieved bony union and were satisfied with the functional and cosmetic outcome. There were no major complications, but three patients required cancellous bone grafting at the docking site for delayed union. Local treatment and oral antibiotics were required for pin-site infection in six patients. There were no deep infection or recurrence of osteomyelitis.

Cerebral White Matter Lesions and Cognitive Function in a Non-demented Chinese Veteran Cohort

This study examined the association between cerebral white matter lesions (WMLs) and cognitive function in a male, non-demented Chinese veteran cohort. A total of 662 participants underwent CT scan and cognitive function assessments; 51 were excluded from the analysis because they exhibited non-lacunar infarcts or suspected dementia. Subjects were allocated to one of four groups according to WML status and between-group comparisons were made for seven cognitive function tests. Logistic regression was used to assess odds ratios for impaired performance associated with WML status. In all cognitive tests, subjects with severe WMLs differed significantly from those without WMLs or with mild WMLs, and in three tests subjects with severe WMLs differed significantly from those with moderate WMLs. For each cognitive test severe WMLs were strongly associated with increased risk of impaired performance. Severe WMLs were associated with greater diminished cognitive function and there may be a WML threshold after which, in elderly Chinese subjects, an impact on cognitive function occurs.

The protein kinases ERK1/2 and their roles in pancreatic beta cells

Extracellular signal-regulated protein kinases 1 and 2 (ERK1/2) activities are modulated in a manner that reflects the secretory demand on beta cells to integrate long- and short-term nutrient sensing information. Our studies have focused on the mechanisms of ERK1/2 activation in beta cells and on the actions of ERK1/2 that regulate beta cell function. Insulin and growth factors regulate ERK1/2 in beta cells in a largely calcium-independent manner. Nutrients and anticipatory hormones, in contrast, activate ERK1/2 in a calcium-dependent manner in these cells. We are exploring the key intermediates in these distinct activation pathways and find that calcineurin is essential for the nutrient pathway but is not essential for the growth factor pathway. Using reporter assays, heterologous reconstitution, electrophoretic mobility shift assays, Northern analysis, Q-PCR and chromatin immunoprecipitation, we have examined several genes that are regulated by ERK1/2, primarily the insulin gene and the apoptotic factor C/EBP-homologous protein (CHOP)-10 (GADD153/DDIT-3), a bZIP protein. ERK1/2-sensitive transcriptional regulators common to these two genes are C/EBP-beta and MafA. The insulin promoter is both positively and negatively regulated by glucose and other nutrients. Exposure to glucose for minutes to hours causes an increase in the rate of insulin gene transcription. In contrast, exposure to elevated glucose for 48 h or more results in inhibition of the insulin gene promoter. Both of these processes depend on ERK1/2 activity. Expression of CHOP is induced by stresses including nutrient deprivation and endoplasmic reticulum stress. CHOP gene expression, especially that regulated by nutrients, is also ERK1/2-dependent in beta cells, These studies support the hypothesis that the genes regulated by ERK1/2 and the mechanisms employed are key to maintaining normal beta cell function.