MDM2 SNP309 promoter polymorphism, an independent prognostic factor in chronic lymphocytic leukemia

BACKGROUND

The single nucleotide polymorphism SNP309 with a change from T to G in the promoter region of the MDM2 gene is shown to increase the MDM2 protein levels and attenuate the p53 levels and associates with disease progression in several tumors.

OBJECTIVE

In this study, the role of the polymorphism was investigated with regard to the clinical outcome in B-cell chronic lymphocytic leukemia (B-CLL).

PATIENTS

A total of 210 patients with B-CLL were followed for up to 19 yr.

RESULTS

The overall survival (OS) of patients with at least one G-allele was significantly shorter when compared with those with two T-alleles (P = 0.024) with a more pronounced difference in patients below the median age. Age at onset of B-CLL was similar irrespective of MDM2 status. The presence of a G-allele in combination with TP53 mutations or unmutated IgVH gene status resulted in an additive risk of death.

CONCLUSION

In this report, with a high proportion of B-CLL patients with an advanced Binet stage and with an unmutated IgVH gene, MDM2 SNP309 was found to be independently associated with OS. The survival difference was more pronounced in younger patients.

Long-term survival according to ventilation mode in acute respiratory failure secondary to chronic obstructive pulmonary disease: a multicenter, inception cohort study

PURPOSE

The aim of the study was to investigate 5-year survival stratified by mechanical ventilation modality in chronic obstructive pulmonary disease (COPD) patients treated in the ICU.

MATERIALS AND METHODS

Prospective, observational study of COPD patients with acute respiratory failure admitted to 9 multidisciplinary ICUs in Sweden. Characteristics on admission, including illness severity scores and the first blood gas, and survival were analyzed stratified by ventilation modality (noninvasive [NIV] vs invasive mechanical ventilation).

RESULTS

Ninety-three patients, mean age of 70.6 (SD, 9.6) years, were included. Sixteen patients were intubated immediately, whereas 77 were started on NIV. Patients who were started on NIV had a lower median body mass index (BMI) (21.9 vs 27.0; P < .01) and were younger compared to those who were intubated immediately (median age, 70 vs 74.5 years; P < .05). There were no differences in the initial blood gas results between the groups. Long-term survival was greater in patients with NIV (P < .05, log rank). The effect of NIV on survival remained after including age, Acute Physiology and Chronic Health Evaluation II score, and BMI in a multivariate Cox regression model (NIV hazard ratio, 0.44; 95% confidence interval, 0.21-0.92). Fifteen patients with failed NIV were intubated and mechanically ventilated. Long-term survival in patients with failed NIV was not significantly different from patients who were intubated immediately.

CONCLUSION

The short-term survival benefit of NIV previously found in randomized controlled trials still applies after 5 years of observation.

Association between admission supine systolic blood pressure and 1-year mortality in patients admitted to the intensive care unit for acute chest pain

CONTEXT

High resting blood pressure (BP) is among the best studied and established risk factors for cardiovascular disease. However, little is known about the relationship between BP under acute stress, such as in acute chest pain, and subsequent mortality.

OBJECTIVE

To study long-term mortality related to supine BP in patients admitted to the medical intensive care unit (ICU) for acute chest pain.

DESIGN, SETTING, AND PARTICIPANTS

Data from the RIKS-HIA (Registry of Information and Knowledge About Swedish Heart Intensive Care Admissions) was used to analyze the mortality in relation to supine admission systolic BP in 119,151 participants who were treated at the ICU for the symptom of chest pain from 1997 through 2007. Results from this prospective cohort study were presented according to systolic BP quartiles: Q1, less than 128 mm Hg; Q2, from 128 to 144 mm Hg; Q3, from 145 to 162 mm Hg; and Q4, at or above 163 mm Hg.

MAIN OUTCOME MEASURE

Total mortality.

RESULTS

Mean (SD) follow-up time was 2.47 (1.5) years (range, 1-10 years). One-year mortality rate by Cox proportional hazard model (adjusted for age, sex, smoking, diastolic BP, use of antihypertensive medication at admission and discharge, and use of lipid-lowering and antiplatelet medication at discharge) showed that participants in Q4 had the best prognosis (hazard ratio [HR], 0.76; 95% confidence interval [CI], 0.72-0.80, Q4 compared with Q2; corresponding risks for Q1 were HR, 1.46; 95% CI, 1.39-1.52, and for Q3, HR, 0.83; 95% CI, 0.79-0.87). Patients in Q4 had a 21.7% lower absolute risk compared with Q2, patients in Q3 had a 15.2% lower risk than in Q2, and patients in Q1 had a 40.3% higher risk for mortality than in Q2. The worse prognosis in Q2 compared with Q4 was independent of body mass index and previous diagnoses and similar when analysis was restricted to patients with a final diagnosis of angina or myocardial infarction (HR, 0.75; 95% CI, 0.71-0.80, Q4 compared with Q2).

CONCLUSION

Among patients admitted to the ICU for chest pain, there is an inverse association between admission supine systolic BP and 1-year mortality rate.

To continue or discontinue aspirin in the perioperative period: a randomized, controlled clinical trial

BACKGROUND

Major adverse cardiac events (MACEs) are a common cause of death after non-cardiac surgery. Despite evidence for the benefit of aspirin for secondary prevention, it is often discontinued in the perioperative period due to the risk of bleeding.

METHODS

We conducted a randomized, double-blind, placebo-controlled trial in order to compare the effect of low-dose aspirin with that of placebo on myocardial damage, cardiovascular, and bleeding complications in high-risk patients undergoing non-cardiac surgery. Aspirin (75 mg) or placebo was given 7 days before surgery and continued until the third postoperative day. Patients were followed up for 30 days after surgery.

RESULTS

A total of 220 patients were enrolled, 109 patients received aspirin and 111 received placebo. Four patients (3.7%) in the aspirin group and 10 patients (9.0%) in the placebo group had elevated troponin T levels in the postoperative period (P=0.10). Twelve patients (5.4%) had an MACE during the first 30 postoperative days. Two of these patients (1.8%) were in the aspirin group and 10 patients (9.0%) were in the placebo group (P=0.02). Treatment with aspirin resulted in a 7.2% absolute risk reduction [95% confidence interval (CI), 1.3-13%] for postoperative MACE. The relative risk reduction was 80% (95% CI, 9.2-95%). Numbers needed to treat were 14 (95% CI, 7.6-78). No significant differences in bleeding complications were seen between the two groups.

CONCLUSIONS

In high-risk patients undergoing non-cardiac surgery, perioperative aspirin reduced the risk of MACE without increasing bleeding complications. However, the study was not powered to evaluate bleeding complications.

Visual grading regression: analysing data from visual grading experiments with regression models

For visual grading experiments, which are an easy and increasingly popular way of studying image quality, hitherto used data analysis methods are often inadequate. Visual grading analysis makes assumptions that are not statistically appropriate for ordinal data, and visual grading characteristic curves are difficult to apply in more complex experimental designs. The approach proposed in this paper, visual grading regression (VGR), consists of an established statistical technique, ordinal logistic regression, applied to data from single-image and image-pair experiments with visual grading scores selected on an ordinal scale. The approach is applicable for situations in which, for example, the effects of the choice of imaging equipment and post-processing method are to be studied simultaneously, while controlling for potentially confounding variables such as patient and observer identity. The analysis can be performed with standard statistical software packages using straightforward coding of the data. We conclude that the proposed statistical technique is useful in a wide range of visual grading studies.

Ventromedial prefrontal neurokinin 1 receptor availability is reduced in chronic pain

Neurokinin 1 (NK1) receptors are involved in pain and anxiety behaviors in animals, but little is known about central alterations in this receptor system in human pain. With positron emission tomography, using a [11]-Carbon labeled NK1 receptor antagonist, we demonstrate attenuated NK1 receptor availability in frontal, insular and cingulate cortex, as well as the hippocampus, amygdala and the periaqueductal gray area in patients with chronic pain. The reduced availability was most pronounced in the ventromedial prefrontal cortex (vmPFC), where attenuations correlated to measures of fear and avoidance of movement. Further, vmPFC NK1 levels also displayed opposing influences in patients as compared to controls on regional cerebral blood flow in the anterior cingulate. We conclude that the central NK1 receptor system is altered in human chronic pain. The results suggest that NK1 receptors in the vmPFC modulate motor inhibition, and contribute to fear and avoidance of movement.

Neuroticism-related personality traits are related to symptom severity in patients with premenstrual dysphoric disorder and to the serotonin transporter gene-linked polymorphism 5-HTTPLPR

Neuroticism has been linked to a functional polymorphism in the serotonin transporter gene (5-HTTLPR), with short-allele carriers being overrepresented among high-scorers on neuroticism. Studies evaluating neuroticism-related personality traits in relation to the 5-HTTLPR polymorphism among patients with premenstrual dysphoric disorder (PMDD) and are lacking. The primary aim of this study was to evaluate the relationship between PMDD and neuroticism-related personality traits, and secondly, to relate the personality trait scores of PMDD patients to experienced symptom severity and to the 5-HTTLPR short allele. Thirty PMDD patients and 55 asymptomatic healthy controls were included in the study. The Swedish Universities Scale of Personality was used to evaluate personality traits. Genotype analyses were available in 27 PMDD patients and 18 healthy controls. Women with PMDD displayed higher levels of neuroticism-related personality traits (psychic trait anxiety, somatic trait anxiety, embitterment, stress susceptibility and mistrust) than healthy controls, and these effects were most prominent in women with more severe luteal phase symptoms. Furthermore, PMDD patients with at least one copy of the short allele of the 5-HTTLPR polymorphism scored higher on psychic trait anxiety and lack of assertiveness than PMDD patients who were homozygous for the long allele. PMDD patients who suffer from more severe luteal phase symptoms also display increased scores of neuroticism-related personality traits in comparison with healthy controls. Within the group of PMDD patients, differences in certain personality trait scores are associated with the short allele of the 5-HTTLPR polymorphism.

Predictors of cardiac events in high-risk patients undergoing emergency surgery

BACKGROUND

The aim of this study was to determine the incidence of myocardial damage and left ventricular myocardial dysfunction and their influence on outcome in high-risk patients undergoing non-elective surgery.

METHODS

In this prospective observational study, 211 patients with American Society of Anesthesiologists classification III or IV undergoing emergent or urgent surgery were included. Troponin I (TnI) was measured pre-operatively, 12 and 48 h post-operatively. Pre-operative N-terminal fragment of B-type natriuretic peptide (NT-proBNP), as a marker for left ventricular systolic dysfunction, was analyzed. The diagnostic thresholds were set to TnI >0.06 microg/l and NT-proBNP >1800 pg/ml, respectively. Post-operative major adverse cardiac events (MACE), 30-day and 3-months mortality were recorded.

RESULTS

Elevated TnI levels were detected in 33% of the patients post-operatively. A TnI elevation increased the risk of MACE (35% vs. 3% in patients with normal TnI levels, P<0.001) and 30-day mortality (23% vs. 7%, P=0.003). Increased concentrations of NT-proBNP were seen in 59% of the patients. Elevated NT-proBNP was an independent predictor of myocardial damage post-operatively, odds ratio, 6.2 [95% confidence interval (CI) 2.1-18.0] and resulted in an increased risk of MACE (21% vs. 2.5% in patients with NT-proBNP < or = 1800 pg/ml, P<0.001).

CONCLUSION

Myocardial damage is common in a high-risk population undergoing unscheduled surgery. These results suggest a close correlation between myocardial damage in the post-operative period and increased concentration of NT-proBNP before surgery. The combinations of TnI and NT-proBNP are reliable markers for monitoring patients at risk in the peri-operative period as well as useful tools in our risk assessment pre-operatively in emergency surgery.

Disentangling the web of fear: amygdala reactivity and functional connectivity in spider and snake phobia

The objective was to study effects of fear on brain activity, functional connectivity and brain-behavior relationships during symptom provocation in subjects with specific phobia. Positron emission tomography (PET) and (15)O water was used to measure regional cerebral blood flow (rCBF) in 16 women phobic of either snakes or spiders but not both. Subjects watched pictures of snakes and spiders serving either as phobic or fear-relevant, but non-phobic, control stimuli depending on phobia type. Presentation of phobic as compared with non-phobic cues was associated with increased activation of the right amygdala and cerebellum as well as the left visual cortex and circumscribed frontal areas. Activity decreased in the prefrontal, orbitofrontal and ventromedial cortices as well as in the primary somatosensory cortex and auditory cortices. Furthermore, amygdala activation correlated positively with the subjective experience of distress. Connectivity analyses of activity in the phobic state revealed increased functional couplings between voxels in the right amygdala and the periamygdaloid area, fusiform gyrus and motor cortex. During non-phobic stimulation, prefrontal activity correlated negatively with amygdala rCBF, suggesting a phobia-related functional decoupling. These results suggest that visually elicited phobic reactions activate object recognition areas and deactivate prefrontal areas involved in cognitive control over emotion-triggering areas like the amygdala, resulting in motor readiness to support fight or flight.

Arterial blood pressure and general sympathetic activation in essential hypertension during stimulation

We asked whether exaggerated blood pressure (BP) reactivity in patients with essential hypertension (HT) is a sign of specific activation of the cardiovascular system or of generalized sympathetic activation. Fourteen patients with essential hypertension and 14 matched normotensive (NT) controls were subjected to tasks involving attentional demands, mental arithmetic, a cold pressor test and isometric muscular contraction. Systolic and diastolic BPs, skin and muscle blood flows, heart rate, skin conductance level and fluctuations during each task were recorded. Urine samples for determination of epinephrine and norepinephrine excretion were collected after task completion. All tasks caused BP increases in both groups. HT showed greater absolute and percentage BP reactivity than NT during isometric muscle contraction. Variables for which reactivity differences were observed were poorly correlated across tasks both in HT and NT, whereas resting values prior to each task were highly correlated in both groups. Skin conductance activity, epinephrine and norepinephrine excretion rates being examples of non-cardiovascular sympathetic nervous system (SNS) indicators did not separate HT from NT. Thus, the exaggerated pressor response in HT is not accompanied by signs of generalized SNS activation.

Arterial blood pressure and electrodermal activity in hypertensive and normotensive subjects during inner- and outer-directed attention

Arterial blood pressure (BP), skin conductance level (SCL) and spontaneous fluctuations in skin conductance (SFs) were monitored in 14 subjects with essential hypertension (HT), and 14 matched normotensive (NT) controls during a letter identification task (L) and mental arithmetic (MA). During both tasks, the groups displayed different response patterns such that SFs and BP tended to be negatively correlated in the HT group but were positively correlated in the NT group. No correlation between BT and SCL was obtained in any group during either task. SFs and SCL were positively correlated in the NT group during both tasks whereas no correlation was found in the HT group. The results are consistent with the hypothesis that an increased BP is associated with the rejection of the environment.

Muscle fibre composition in relation to blood pressure response to isometric exercise in normotensive and hypertensive subjects

A positive relationship was demonstrated between the blood pressure and the fibre composition of the vastus muscle at rest in 17 hypertensive and 17 age- and sex-matched normotensive subjects. The hypertensive group had a higher proportion of fast twitch (FT) fibres (p less than 0.1). The circulatory response was measured during isometric exercise (IE) and cold pressor test (CPT). During IE the blood pressure increase was positively related to the percentage of FT fibres. No such relationship was demonstrated during CPT. It was thus found, particularly in hypertensive subjects, that an individual's muscle fibre profile is of importance for the blood pressure response during IE.

Genotype over-diagnosis in amygdala responsiveness: affective processing in social anxiety disorder

BACKGROUND

Although the amygdala is thought to be a crucial brain region for negative affect, neuroimaging studies do not always show enhanced amygdala response to aversive stimuli in patients with anxiety disorders. Serotonin (5-HT)-related genotypes may contribute to interindividual variability in amygdala responsiveness. The short (s) allele of the 5-HT transporter linked polymorphic region (5-HTTLPR) and the T variant of the G-703T polymorphism in the tryptophan hydroxylase-2 (TPH2) gene have previously been associated with amygdala hyperresponsivity to negative faces in healthy controls. We investigated the influence of these polymorphisms on amygdala responsiveness to angry faces in patients with social anxiety disorder (SAD) compared with healthy controls.

METHODS

We used positron emission tomography with oxygen 15-labelled water to assess regional cerebral blood flow in 34 patients with SAD and 18 controls who viewed photographs of angry and neutral faces presented in counterbalanced order. We genotyped all participants with respect to the 5-HTTLPR and TPH2 polymorphisms.

RESULTS

Patients with SAD and controls had increased left amygdala activation in response to angry compared with neutral faces. Genotype but not diagnosis explained a significant portion of the variance in amygdala responsiveness, the response being more pronounced in carriers of s and/or T alleles.

LIMITATIONS

Our analyses were limited owing to the small sample and the fact that we were unable to match participants on genotype before enrollment. In addition, other imaging techniques not used in our study may have revealed additional effects of emotional stimuli.

CONCLUSION

Amygdala responsiveness to angry faces was more strongly related to serotonergic polymorphisms than to diagnosis of SAD. Emotion activation studies comparing amygdala excitability in patient and control groups could benefit from taking variation in 5-HT-related genes into account.

Imaging the placebo response: a neurofunctional review

An emerging literature has started to document the neuronal changes associated with the placebo phenomenon. This has altered placebo from being considered a nuisance factor in clinical research to a target of scientific investigation per se. This paper reviews the neuroimaging literature on the placebo effect, and illustrates how imaging tools can improve current understanding of brain mechanisms underlying the placebo response. Imaging studies provide evidence of specific, predictable and replicable patterns of neural changes associated with placebo administration. In general, placebo responses seem mediated by "top-down" processes dependent on frontal cortical areas that generate and maintain cognitive expectancies. Dopaminergic reward pathways may underlie these expectancies. Placebo-induced clinical benefits also involve disorder-specific neuronal responses, yielding neurofunctional or neurochemical alterations similar to those produced by pharmacological treatments.

The genetic covariation between fear conditioning and self-report fears

BACKGROUND

Fear conditioning is a traditional model for the acquisition of phobias, whereas behavioral therapies use processes underlying extinction to treat phobic and other anxiety disorders. Furthermore, fear conditioning has been proposed as an endophenotype for genetic studies of anxiety disorders. Although prior studies have demonstrated that fear conditioning and self-report fears are heritable, no studies have determined whether they share a common genetic basis.

METHODS

We obtained fear conditioning data from 173 twin pairs from the Swedish Twin Registry who also provided self-report ratings of 16 common fears. With multivariate structural equation modeling, we analyzed factor-derived scores for the subjective fear ratings together with the electrophysiologic skin conductance responses during habituation, acquisition, and extinction to determine the extent of their genetic covariation.

RESULTS

Phenotypic correlations between experimental and self-report fear measures were modest and, counter-intuitively, negative (i.e., subjects who reported themselves as more fearful had smaller electrophysiologic responses). Best-fit models estimated a significant (negative) genetic correlation between them, although genetic factors underlying fear conditioning accounted for only 9% of individual differences in self-report fears.

CONCLUSIONS

Experimentally derived fear conditioning measures share only a small portion of the genetic factors underlying individual differences in subjective fears, cautioning against relying too heavily on the former as an endophenotype for genetic studies of phobic disorders.

Spectrophotometric analysis of melanocytic naevi during pregnancy

Malignant melanoma is the most common cancer during pregnancy, but it is unknown whether melanocytic naevi in general are activated. A total of 381 melanocytic naevi in 34 Caucasian primigravidae were examined using spectrophotometric intracutaneous analysis (SIAscopy) technology in early pregnancy and prior to delivery. The Siagraphs of each naevus were then compared in order to evaluate changes over time. A total of 163 melanocytic naevi in 21 nulliparous women served as an additional control group. At the first visit none of the Siagraphs examined for the case or control groups aroused suspicion of dysplastic naevus or melanoma and no significant structural changes were noted during the observation period. However, 2.1% of the melanocytic naevi in the pregnant group increased and 1.3% decreased in size. Corresponding figures in the non-pregnant group were 1.8% and 0%, respectively. Only one naevus in a pregnant woman increased slightly in epidermal pigmentation, and a decrease in pigmentation was noted in 3.7% of the melanocytic naevi in the cases and 1.8% in the controls. None of the differences within or between the groups was statistically significant. We conclude that pregnancy does not influence the appearance of pigmented naevi. A changing naevus during pregnancy should be examined carefully and considered for excision and histopathology.