An Incidental Finding of Coronary-cameral Fistulas in a Critically Ill Patient with a Metastatic Cardiac Tumor

It is extremely rare for a cardiac tumor to present with coronary-cameral fistulas. A 66-year-old Caucasian male presented with worsening dyspnea and subsequently had a cardiac catheterization for an ST-elevation myocardial infarction, revealing no evidence of coronary artery disease but multiple coronary-cameral fistulas. Venoarterial (VA) extracorporeal membrane oxygenation was initiated for a severe cardiogenic shock. Workups including a transesophageal echocardiography and a right heart catheterization led to a diagnosis of metastatic melanoma involving both ventricles of his heart. Angiogenesis is well described in melanomas and our novel case reports the extremely rare association of coronary-cameral fistulas with a metastatic cardiac melanoma. How to cite this article: Thyagarajan B, Bryant C, Khanna AK. An Incidental Finding of Coronary-cameral Fistulas in a Critically Ill Patient with a Metastatic Cardiac Tumor. Indian J Crit Care Med 2021;25(3):340-342.

Associations of changes in fat free mass with risk for type 2 diabetes: Hispanic Community Health Study/Study of Latinos

AIMS

To determine whether loss of muscle mass (approximated using fat free mass [FFM]) is associated with risk for type 2 diabetes mellitus (T2DM) in Hispanic/Latino adults in the United States.

METHODS

Participants were Hispanic/Latino adults (18-74-year-olds) who completed Visit 2 of the Hispanic Community Health Study/Study of Latinos (HCHS/SOL; multi-site, prospective cohort study; 6.1-year follow-up) and did not have T2DM at baseline (n = 6264). At baseline and Visit 2, FFM was measured using bioelectrical impedance analysis and fasting glucose, HbA1c, and fasting insulin were measured by examiners. Diabetes was defined according to American Diabetes Association criteria. Survey-weighted Poisson regression models examined the association of percent change in relative FFM (%ΔFFM) with incident prediabetes and T2DM. Survey-weighted multivariable regression models examined associations of %ΔFFM with changes in glucose and insulin measures.

RESULTS

Relative FFM declined by 2.1% between visits. %ΔFFM was inversely associated with incident prediabetes (p-for-trend = 0.001) and with changes in glucose and insulin measures (p-for-trend <0.0001). Findings were null, except for HOMA-IR, after adjustment for changes in adiposity measures. Associations were generally stronger for individuals with baseline overweight/obesity.

CONCLUSIONS

Reducing loss of FFM during adulthood may reduce prediabetes risk (primarily insulin resistance), particularly among individuals with overweight/obesity.

Sepsis and Septic Shock - Basics of diagnosis, pathophysiology and clinical decision making

Sepsis and septic shock are major causes of mortality among hospitalized patients. The sepsis state is due to dysregulated host response to infection, leading to inflammatory damage to nearly every organ system. Early recognition of sepsis and appropriate treatment with antibiotics, fluids, and vasopressors is essential to reducing organ system injury and mortality. This review summarizes the current understanding of the epidemiology, pathophysiology, diagnosis, and treatment of sepsis and septic shock.

Reversal of warfarin-coagulopathy: How to improve plasma transfusion practice in a community hospital setting?

BACKGROUND

Plasma is often given inappropriately to reverse warfarin-induced coagulopathy, wasting health-care resources and exposing the patients to transfusion-associated risks.

AIMS

The clinical practice at our institution was evaluated in order to reduce the number of unnecessary plasma transfusions.

MATERIALS AND METHODS

Retrospective audit of plasma transfusions was done (July 2014 to June 2015).

DESIGN

To improve the clinical practice, a two-prong strategy was implemented: (1) in-service was given to clinicians on the warfarin-reversal guidelines and (2) for a 30-day period, plasma orders were placed on the approval list of the Transfusion Medicine Service.

RESULTS

Of the 729 units of plasma, 189 (26% of total) were given for the reversal of warfarin-induced coagulopathy. The medical charts of these patients were reviewed: 46 units of plasma (~25%) were given inappropriately (e.g., patients with minimally elevated international normalized ratio, no evidence of bleeding, and no surgery within 24 h). To check the effectiveness of our intervention, two audits of plasma transfusions were done. During the first audit (January 1-February 29, 2016), 24 patients received plasma to reverse warfarin-coagulopathy. Medical chart review revealed that the vast majority of plasma orders (96.66%) followed the guidelines. A second audit was carried out a year later (January 1-March 31, 2017): during this 3-month period, 47 patients were transfused with plasma for warfarin reversal with a 94% adherence to the guidelines.

CONCLUSION

We conclude that plasma transfusion practices may be improved by a combination of education and active enforcement of warfarin reversal guidelines.

MON-618 National In-Hospital Trends in Acquired Hypothyroidism

Background - Factors contributing to acquired hypothyroidism have increased in the United States during recent years. Known factors include advanced age, thyroidectomy, anti-thyroid and thyroid-affecting medications, susceptibility to autoimmune thyroiditis, iodine intake, radioactive ablation, and external beam neck irradiation. However, it is not understood how this increase in contributing factors impacts inpatient trends related to acquired hypothyroidism. Research aim - The objective of this epidemiological study is to describe the national inpatient trends in acquired hypothyroidism including prevalence, in-hospital mortality, length of stay (LOS), and healthcare expenditure. Methods - The National Inpatient Sample database was used to identify individuals 18 years or older, hospitalized between January 2000 and December 2014, with ICD 9 Code 244 acquired hypothyroidism as the principal discharge diagnosis. Longitudinal differences related to acquired hypothyroidism in the total number of hospital discharges, mean LOS, in-hospital mortality percentage, and inflation-adjusted cost were assessed. Linear regression analysis was used to assess the relationship between these variables and time. Relationships with a p-value of less than or equal to 0.05 were deemed significant. Analyses were performed using SAS® Software (version 9.4; Cary, NC). Results - During the 15-year period, the total number of discharges with the principal diagnosis of acquired hypothyroidism increased by 95 cases/year (p<0.0001), and the mean charges per acquired hypothyroidism hospitalization increased by $1218/year (p<0.0001). Conversely, the mean LOS per hospitalization decreased by 0.06 days/year (p= 0.0423) and the mean age of hospitalization decreased by 0.32 years/year (p<0.0001). Acquired hypothyroidism-related in-hospital mortality rate did not change over time (p=0.2048). Discussion - This is the first study to describe the trends in acquired hypothyroidism in the United States over a 15-year period utilizing the largest publicly available inpatient database. The considerable rise in the incidence of acquired hypothyroidism along with a significant growth in associated health care costs in this condition may be attributable to the rise in risk factors for acquired hypothyroidism and the general rise in health care cost, respectively. Hospitalization LOS has decreased possibly indicating better utilization of outpatient follow up for these patients. While the decrease in mean age may be secondary to a younger population exposed to more risk factors. In-hospital mortality in patients with acquired hypothyroidism did not change, which should be further evaluated in future studies focusing on better outcomes and treatment strategies.

A Diagnostic Conundrum of Distributive Shock: Autoimmune Polyglandular Syndrome Type II

Autoimmune polyglandular syndrome (AIPS) is a heterogeneous condition characterized by the loss of immune tolerance and resultant dysfunction of multiple endocrine organs. Although this condition is insidious in nature, it frequently presents initially as adrenal insufficiency (AI). For patients in shock, physicians routinely assess for infections, volume depletion as well as cardiogenic and iatrogenic causes of shock. However, the case described in this report emphasizes the need for high suspicion of AI syndrome when the etiology of shock remains unclear after primary assessment. A subsequent evaluation for autoimmune etiology, especially in young adults in appropriate clinical setting, may also be warranted.

Association between cytomegalovirus seropositivity and Type 2 diabetes is explained by age and other demographic characteristics: the National Health and Nutrition Examination Survey

AIMS

To assess the association between cytomegalovirus and Type 2 diabetes among 6664 participants from the National Health and Nutrition Examination Survey.

METHODS

We used existing data from adults aged 20-49 years who participated in the National Health and Nutrition Examination Survey from 1999 to 2004. Cytomegalovirus status was determined using cytomegalovirus-specific immunoglobulin G antibodies. Prevalent Type 2 diabetes was assessed through self-report or a plasma fasting glucose of ≥7 mmol/l. Logistic regression models were used to evaluate the association between Type 2 diabetes and cytomegalovirus seropositivity after adjustment for age, gender, race/ethnicity, smoking status, education, BMI and physical activity.

RESULTS

In a univariate model, the crude odds of Type 2 diabetes were 47% higher in those who were cytomegalovirus-seropositive vs cytomegalovirus-seronegative. The association was attenuated and no longer significant after adjustment for age and other covariates: the odds ratio for diabetes was 1.09 (95% CI 0.71 to 1.66) for cytomegalovirus-seropositive vs -seronegative individuals.

CONCLUSIONS

Our study suggests that the association between cytomegalovirus and Type 2 diabetes is explained by age and other risk factors for diabetes.

A Single-Center Retrospective Study of Acute Kidney Injury Incidence in Patients With Advanced Malignancies Treated With Antimitochondrial Targeted Drug

Introduction

Mitochondrial dysfunction plays an important role in the pathophysiology of kidney disease. Inhibitors of mitochondrial metabolism are being developed for the treatment of solid organ and hematologic malignancies. We describe the incidence and clinical features of acute kidney injury (AKI) in patients treated with the antimitochondrial drug CPI-613.

Methods

We identified 33 patients with relapsed or refractory malignancy, previously enrolled in 3 open-label phase II studies, who received single-agent CPI-613 chemotherapy. AKI was defined by the Kidney Disease Improving Global Outcomes serum creatinine criteria. Participants were followed for a median (25th–75th percentile) of 120.0 (74.0–301.0) days. Risk factors for AKI were assessed by proportional hazards regression using univariate and multivariate analyses.

Results

Participants had baseline mean (SD) age of 63.8 (11.6) years and serum creatinine 0.9 (0.3) mg/dl. AKI developed in 9 (27%) patients; chart review failed to identify a potential cause of AKI other than CPI-613 administration in 5 (15%) patients, of whom 1 had AKI stage 1, 1 had AKI stage 2, and 3 experienced AKI stage 3. Time from initiation of CPI-613 treatment to AKI was 51.0 (16.0–58.0) days. Age, per 5-year increase, was associated with higher risk of AKI (adjusted hazard ratio 2.01, 95% confidence interval 1.06–3.79, P = 0.03). Follow-up serum creatinine was available in 4 participants 174.8 (139.6) days after the episode of AKI; 3 patients had complete recovery in kidney function and 1 had partial recovery.

Conclusion

AKI is a possible complication during treatment with mitochondria-targeted chemotherapy.

Endocarditis in left ventricular assist device

Heart failure is one of the leading causes of death in developed nations. End stage heart failure often requires cardiac transplantation for survival. The left ventricular assist device (LVAD) has been one of the biggest evolvements in heart failure management often serving as bridge to transplant or destination therapy in advanced heart failure. Like any other medical device, LVAD is associated with complications with infections being reported in many patients. Endocarditis developing secondary to the placement of LVAD is not a frequent, serious and difficult to treat condition with high morbidity and mortality. Currently, there are few retrospective studies and case reports reporting the same. In our review, we found the most common cause of endocarditis in LVAD was due to bacteria. Both bacterial and fungal endocarditis were associated with high morbidity and mortality. In this review we will be discussing the risk factors, organisms involved, diagnostic tests, management strategies, complications, and outcomes in patients who developed endocarditis secondary to LVAD placement.

Extracardiac manifestations of atrial myxomas

Primary cardiac tumors are extremely rare and constitute only about 5% of all cardiac tumors. Cardiac myxomas are noncancerous primary tumors of the heart and constitute about of 50% of all primary heart tumors. Left-sided atrial myxomas are more common than right-sided atrial myxomas. Atrial myxomas can lead to a triad of complications. The most common symptoms are associated with obstruction due to the size and location of the tumor. The next most common symptoms are associated with pulmonary and systemic embolization. Patients may also present with constitutional symptoms. Diagnosis is made via means of transesophageal echocardiography and magnetic resonance imaging. Early diagnosis and surgical resection remain the treatment of choice to prevent complications. Patients usually have a good prognosis after resection.

Richter's transformation presenting as splenic rupture after 6 years of complete remission of chronic lymphocytic leukaemia

Richter's transformation is a rare clinical condition occurring in about 5-10% of patients with chronic lymphocytic leukaemia (CLL). Patients usually present with lymphadenopathy, hepatosplenomegaly and elevated serum lactate dehydrogenase levels. These patients have a very poor prognosis with a median survival of about 10 months. We present a patient, with a history of CLL in complete remission, who presented with splenic rupture requiring splenectomy. She was eventually diagnosed with diffuse large B-cell lymphoma with Richter's transformation.

Abstract 37: Measure of Appropriateness in the Placement of Intravenacaval Filters Among Guidelines From Major Medical Societies

Objective: With healthcare focusing towards quality based healthcare it has created significant interest among physicians in measuring and defining appropriateness in the treatment of medical conditions. We compared the indications for which the Intravenacaval (IVC) filter was placed in our hospital with the current guidelines by three of the major medical societies the American Heart Association (AHA), American College of Chest Physicians (ACCP) and Society for Interventional Radiology (SIR) to compare the measure of appropriateness in the placement of IVC filters among the guidelines

Methods: We conducted a retrospective review of all charts with the ICD 9 code for placement of IVC filter from January, 2010 to January, 2015. Each patient chart was reviewed for patient demographics, complications and indications which were compared with the guidelines as defined by AHA, ACCP and SIR

Results: During the 5 years, 592 patients underwent the procedure which included 233 men and 359 women who had a mean age of 67.2 +/- 17.4. 75.8% filters were inserted by vascular surgery and 24.2% filters were inserted by interventional radiology. 1.8% of the patients had some form of complication either during insertion or retrieval. On comparing the indications, we found that 35.5%(AHA), 30.9%(ACCP), 35.5%(SIR) were appropriate. While 4.4%(AHA), 4.4%(ACCP), 47.4%(SIR) were relatively appropriate and 60.1%(AHA), 64.7%(ACCP), 17.1%(SIR) were not appropriate. Commonly used indications not defined clearly included prophylaxis for bariatric surgery (14.4%) and high risk for fall (11%). Statistical analysis with the Chi-square test showed there was no statistical difference between AHA and ACCP (p =0.243), while statistical difference was present between AHA and SIR (p <0.001) and ACCP and SIR (p < 0.001)

Conclusion: This study demonstrates that there are significant differences between the guidelines from major medical societies for the placement of IVC filter which leads to compelling discrepancies amongst physicians in their decision for the placement of IVC filters

Utility of a real-time appropriate use criteria decision support application for percutaneous coronary interventions in non-acute coronary syndrome

OBJECTIVES

The aim of this study was to test the feasibility and value of a real-time online appropriate use criteria (AUC) application for percutaneous coronary intervention (PCI) in patients without acute coronary syndrome.

BACKGROUND

High rates of non-appropriate elective PCI in the National Cardiovascular Data Registry (NCDR) CathPCI Registry have created interest in integrating decision support tools into routine clinical care to improve the frequency of appropriate PCIs.

METHODS

Patients undergoing diagnostic coronary angiography and subsequent PCI for non-ACS indications at a single center were scored using a real-time AUC application pre-procedure. Blinded angiographic review was performed subsequently for each case. Rates of appropriate, inappropriate, uncertain and not rated PCIs were tabulated according to specific clinical scenarios using information available both before and after the angiographic audit.

RESULTS

Of 308 PCIs in 272 patients, 196 (63.6%) were deemed appropriate, 79 (25.6%) uncertain, and two (0.6%) inappropriate; 31 (10.1%) scenarios could not be rated. With angiographic audit, inappropriate PCIs increased to 9.7%. There was a significant improvement in the rate of appropriate PCI using the real-time AUC application compared with retrospective data collection for NCDR reporting (64% vs. 53%, P = 0.01).

CONCLUSIONS

Use of a real-time AUC application together with angiographic audit may improve the accuracy of reporting PCI appropriateness. © 2015 Wiley Periodicals, Inc.

Atrial Fibrillation Due to Over The Counter Stimulant Drugs in A Young Adult

The usage of over the counter stimulant drugs and energy drinks is increasing on a day to day basis for various purposes including work, sports and leisure among individuals in all age groups. Multiple formulations are available in the market including pills, liquid capsules and drinks in various flavours. Many of them contain excessively high doses of caffeine along with a variety of stimulant compounds that have multiple effects in different parts of the human body. The consumption of such high amounts of caffeine itself has shown to have caused cardiac arrhythmias in healthy individuals and when it is mixed with a number of stimulant compounds can be associated with a number of adverse effects in the human body. However, the awareness of such life threatening complications associated with these energy drinks does not exist among people who consume it on a day to day basis. We report a case of 25-year-old Caucasian male with no significant past medical history for cardiac diseases, no risk factors for atrial fibrillation, non smoker, occasional alcohol drinker who presents with new onset atrial fibrillation with rapid ventricular response due to the consumption of over the counter stimulant energy capsule which had high doses of caffeine.

Atrial Fibrillation Due to Over The Counter Stimulant Drugs in A Young Adult

The usage of over the counter stimulant drugs and energy drinks is increasing on a day to day basis for various purposes including work, sports and leisure among individuals in all age groups. Multiple formulations are available in the market including pills, liquid capsules and drinks in various flavours. Many of them contain excessively high doses of caffeine along with a variety of stimulant compounds that have multiple effects in different parts of the human body. The consumption of such high amounts of caffeine itself has shown to have caused cardiac arrhythmias in healthy individuals and when it is mixed with a number of stimulant compounds can be associated with a number of adverse effects in the human body. However, the awareness of such life threatening complications associated with these energy drinks does not exist among people who consume it on a day to day basis. We report a case of 25-year-old Caucasian male with no significant past medical history for cardiac diseases, no risk factors for atrial fibrillation, non smoker, occasional alcohol drinker who presents with new onset atrial fibrillation with rapid ventricular response due to the consumption of over the counter stimulant energy capsule which had high doses of caffeine.

Adhesion molecules, endothelin-1 and lung function in seven population-based cohorts

CONTEXT

Endothelial function is abnormal in chronic obstructive pulmonary disease (COPD); whether endothelial dysfunction causes COPD is unknown.

OBJECTIVE

Test associations of endothelial biomarkers with FEV1 using instrumental variables.

METHODS

Among 26 907 participants with spirometry, ICAM-1, P-selectin, E-selectin and endothelin-1 were measured in subsets.

RESULTS

ICAM-1 and P-selectin were inversely associated with FEV1 among European-Americans (-29 mL and -34 mL per standard deviation of log-transformed biomarker, p < 0.001), as was endothelin-1 among African-Americans (-22 mL, p = 0.008). Genetically-estimated ICAM-1 and P-selectin were not significantly associated with FEV1. The instrumental variable for endothelin-1 was non-informative.

CONCLUSION

Although ICAM-1, P-selectin and endothelin-1 were inversely associated with FEV1, associations for ICAM-1 and P-selectin do not appear causal.

Association between genetic variants in adhesion molecules and outcomes after hematopoietic cell transplants

Allogeneic hematopoietic cell transplant (HCT) is associated with a high morbidity and mortality. Adhesion molecules play an important role in endothelial activation and initiation of inflammatory response. We hypothesized that single nucleotide polymorphisms (SNPs) in the endothelial molecules may contribute to heterogeneity in HCT outcomes. We evaluated the association of 4 SNPs in ICAM1 (rs5498), PECAM1 (rs668 and rs1131012) and SELL (rs2229569) genes with acute and chronic graft-versus-host disease (GvHD) and those experiencing transplant-related mortality (TRM) within 1 year among 425 allogeneic HCT recipient-donor pairs. Using a Fine and Gray proportional hazards model to evaluate the association between genetic variants and clinical outcomes, after adjustment for recipient age, race, diagnosis, disease status, gender mismatch, cytomegalovirus serostatus, gender, donor type, conditioning regimen and year of transplant, only rs5498 in the ICAM1 gene among both recipients and donors was associated with a decreased risk of TRM (P ≤ 0.02). None of the SNPs were associated with acute or chronic GvHD risk. These findings suggest that genetic variants in the vascular adhesion molecules may be used to identify patients at high risk for TRM.

Lean mass predicts asthma better than fat mass among females

The obesity phenotype associated with asthma is not known. Our objective was to define the relative contribution of various distributions of fat and lean mass to asthma prevalence. Data were obtained from 2,525 participants (including 1,422 females) who underwent dual-energy X-ray absorptiometry (DEXA) at the year 20 examination in the Coronary Artery Risk Development in Young Adults (CARDIA) cohort. Total, truncal, arm and leg distributions of fat and lean mass were adjusted to the person's height. Self-reported asthma was the outcome. Asthma among females was associated with greater total fat mass, arm fat mass, total lean mass, truncal lean mass and arm lean mass. Among males, none of these mass measures were significantly associated with asthma. Among females, the association with asthma was stronger for total lean mass than for total fat mass. Further, among various regional distributions of lean and fat mass in females, truncal lean mass was the strongest predictor. Total lean mass is more strongly associated with asthma than total fat mass among females. These findings are contrary to the popular perception that excess physiological fat drives the obesity-asthma association. Rather, we hypothesise that ectopic fat within the "lean" tissues drives this association among females.

Mechanisms of potentiation of Angiotensin II-induced contractile response of isolated rat aorta by hydrogen peroxide and tert-butyryl hydroperoxide

Objective:

To study the mechanism involved in hydrogen peroxide (H₂O₂) or tert-butyl hydroperoxide (t-BHP)-induced potentiation of the Ang II-mediated contraction of isolated rat thoracic aorta.

Materials and Methods:

Thoracic aorta was isolated from the Sprauge dawley rats (300–320 gm), cut spirally and response to Ang II (5 × 10⁻⁸M) was taken in the absence and presence of H₂O₂ (10⁻⁶M) and t-BHP (10⁻⁵M). To explore the probable mechanism of H₂O₂ and t-BHP-induced potentiation of Ang II-mediated contractile response, different blockers such as losartan (AT₁ receptor blocker; 1 μM), catalase (H₂O₂ scavenger; 500 U/ml), lercanidipine (L-type calcium channel blocker; 1 μM), geinistein (tyrosine kinase inhibitor; 100 μM), and indomethacin (cyclo-oxygenase inhibitor; 10 μM) were used.

Results:

In spiral preparation of rat thoracic aorta, H₂O₂ (10⁻⁶M) and t-BHP (10⁻⁵M) did not produce the contraction as such. However, when they are added simultaneously with Ang II (5 × 10⁻⁸ M), they potentiated the contractile response of the Ang II. Catalase (500 U/ml) partially antagonized the Ang-II-induced contraction, as well as antagonized the potentiation induced by H₂O₂. Losartan (1 μM) and lercanidipine (1 μM) antagonized the Ang II-induced contractile response without affecting H₂O₂ (10⁻⁶M)-mediated potentiation. Geinistein (100 μM) antagonized H₂O₂ (10⁻⁶M)-mediated potentiation, but it slightly decreased the Ang II response. Losartan (1 μM) and lercanidipine (1 μM) and Geinistein (100 μM) antagonized the Ang II-induced contractile response but not t-BHP-mediated potentiation. Indomethacin antagonized t-BHP-mediated potentiation without affecting much of Ang II response.

Conclusion:

From the above-mentioned results, we can reasonably conclude that H₂O₂ and t-BHP potentiated the contraction induced by the Ang II. H₂O₂-induced potentiation of Ang II response may be mediated through tyrosine kinase activation and t-BHP through the activation of cyclo-oxygenase enzyme.

New approaches for genotyping paraffin wax embedded breast tissue from patients with cancer: the Iowa women's health study

BACKGROUND

The use of paraffin wax embedded tissue samples as a source of DNA for genotype analysis has been limited because of difficulties in DNA extraction and single nucleotide polymorphism (SNP) analysis.

AIMS

To test the feasibility of applying the combination of a commonly used DNA isolation procedure, PureGene, and a high throughput SNP analysis method, the polymerase chain reaction (PCR)-INVADER assay, to genotype several types of paraffin wax embedded breast tissues.

METHODS

Twenty formalin fixed, paraffin wax blocks were obtained from five participants in the Iowa women's health study. Each participant provided several types of tissue including normal lymph node, normal nipple/areola tissue, inflammatory/fibrotic breast tissue, or normal breast tissue, and tumour tissue.

RESULTS

Good quality DNA (260/280 ratio >1.6) was obtained from all tissues. Normal lymph nodes yielded the largest amount of DNA (97.1 mug). DNA obtained from the samples was tested for a germline C1183T polymorphism in the MnSOD gene by three methods-PCR-RFLP (restriction fragment length polymorphism), INVADER assay, and PCR-INVADER assay. Of the 20 samples, PCR-RFLP genotyped 16, the PCR-INVADER assay 18, and the INVADER assay two. This methodology was then used to analyse five additional genotypes and confirmed the general applicability of the method.

CONCLUSIONS

This study demonstrated the feasibility of (1) using several paraffin wax embedded breast tissues as a source of DNA for germline genetic analysis, with lymph nodes providing the highest yield, and (2) using the combination of a common extraction method with a high throughput SNP analysis method, the PCR-INVADER assay.

Expression of Trp3 determines sensitivity of capacitative Ca2+ entry to nitric oxide and mitochondrial Ca2+ handling: evidence for a role of Trp3 as a subunit of capacitative Ca2+ entry channels

The role of Trp3 in cellular regulation of Ca(2+) entry by NO was studied in human embryonic kidney (HEK) 293 cells. In vector-transfected HEK293 cells (controls), thapsigargin (TG)-induced (capacitative Ca(2+) entry (CCE)-mediated) intracellular Ca(2+) signals and Mn(2+) entry were markedly suppressed by the NO donor 2-(N,N-diethylamino)diazenolate-2-oxide sodium salt (3 microm) or by authentic NO (100 microm). In cells overexpressing Trp3 (T3-9), TG-induced intracellular Ca(2+) signals exhibited an amplitude similar to that of controls but lacked sensitivity to inhibition by NO. Consistently, NO inhibited TG-induced Mn(2+) entry in controls but not in T3-9 cells. Moreover, CCE-mediated Mn(2+) entry into T3-9 cells exhibited a striking sensitivity to inhibition by extracellular Ca(2+), which was not detectable in controls. Suppression of mitochondrial Ca(2+) handling with the uncouplers carbonyl cyanide m-chlorophenyl hydrazone (300 nm) or antimycin A(1) (-AA(1)) mimicked the inhibitory effect of NO on CCE in controls but barely affected CCE in T3-9 cells. T3-9 cells exhibited enhanced carbachol-stimulated Ca(2+) entry and clearly detectable cation currents through Trp3 cation channels. NO as well as carbonyl cyanide m-chlorophenyl hydrazone slightly promoted carbachol-induced Ca(2+) entry into T3-9 cells. Simultaneous measurement of cytoplasmic Ca(2+) and membrane currents revealed that Trp3 cation currents are inhibited during Ca(2+) entry-induced elevation of cytoplasmic Ca(2+), and that this negative feedback regulation is blunted by NO. Our results demonstrate that overexpression of Trp3 generates phospholipase C-regulated cation channels, which exhibit regulatory properties different from those of endogenous CCE channels. Moreover, we show for the first time that Trp3 expression determines biophysical properties as well as regulation of CCE channels by NO and mitochondrial Ca(2+) handling. Thus, we propose Trp3 as a subunit of CCE channels.

Directed evolution of a recombinase for improved genomic integration at a native human sequence

We previously established that a unidirectional site-specific recombinase, the phage phiC31 integrase, can mediate integration into mammalian chromosomes. The enzyme directs integration of plasmids bearing the phage attB recognition site into pseudo attP sites, a set of native sequences related to the phage attP recognition site. Here we use two cycles of DNA shuffling and screening in Escherichia coli to obtain evolved integrases that possess significant improvements in integration frequency and sequence specificity at a pseudo attP sequence located on human chromosome 8, when measured in the native genomic environment of living human cells. Such integrases represent custom integration tools that will be useful for modifying the genomes of higher eukaryotic cells.

Site-specific genomic integration in mammalian cells mediated by phage phiC31 integrase

We previously established that the phage phiC31 integrase, a site-specific recombinase, mediates efficient integration in the human cell environment at attB and attP phage attachment sites on extrachromosomal vectors. We show here that phage attP sites inserted at various locations in human and mouse chromosomes serve as efficient targets for precise site-specific integration. Moreover, we characterize native "pseudo" attP sites in the human and mouse genomes that also mediate efficient integrase-mediated integration. These sites have partial sequence identity to attP. Such sites form naturally occurring targets for integration. This phage integrase-mediated reaction represents an effective site-specific integration system for higher cells and may be of value in gene therapy and other chromosome engineering strategies.

A phage integrase directs efficient site-specific integration in human cells

The integrase from the Streptomyces phage phiC31 carries out efficient recombination between the attP site in the phage genome and the attB site in the host bacterial chromosome. In this paper, we show that the enzyme also functions in human cells. A plasmid assay system was constructed that measured intramolecular integration of attP into attB. This assay was used to demonstrate that in the presence of the phiC31 integrase, precise unidirectional integration occurs with an efficiency of 100% in Escherichia coli and >50% in human cells. This assay system was also used to define the minimal sizes of attB and attP at 34 bp and 39 bp, respectively. Furthermore, precise and efficient intermolecular integration of an incoming plasmid bearing attP into an established Epstein-Barr virus plasmid bearing attB was documented in human cells. This work is a demonstration of efficient, site-specific, unidirectional integration in mammalian cells. These observations form the basis for site-specific integration strategies potentially useful in a broad range of genetic engineering applications.

Mammalian genomes contain active recombinase recognition sites

Recombinases derived from microorganisms mediate efficient site-specific recombination. For example, the Cre recombinase from bacteriophage P1 efficiently carries out recombination at its loxP target sites. While this enzyme can function in mammalian cells, the 34bp loxP site is expected to be absent from mammalian genomes. We have discovered that sequences from the human and mouse genomes surprisingly divergent from loxP can support Cre-mediated recombination at up to 100% of the efficiency of the native loxP site in bacterial assays. Transient assays in human cells demonstrate that such pseudo-lox sites also support Cre-mediated integration and excision in the human cell environment. Pseudo sites for Cre and other recombinases may be useful for site-specific insertion of exogenous genes into mammalian genomes during gene therapy and other genetic engineering processes.

Epstein-Barr virus plasmid model system for analyzing recombination in human cells

Homologous recombination stimulated by a double-strand break at a desired target site offers a method to achieve site-specific integration useful for gene therapy and other genetic engineering. To test parameters needed for this strategy, we developed an Epstein-Barr virus shuttle vector model system as a genetic tool. This extrachromosomal plasmid assay system has several advantages over a chromosomal assay. The system detects all classes of recombination events without selection and allows rapid analysis of the frequency and nature of recombination events. We found that a double-strand break at the target site stimulated a large increase in recombination frequency. The resulting recombinants included one-sided insertion events, as well as two-sided or gene conversion events. A circular donor substrate was more effective in recombination than linearized donor DNA.

Nucleolin promotes homologous DNA pairing in vitro

We purified to near homogeneity a previously identified 100 kDa mammalian homologous DNA pairing protein. The purified 100 kDa protein also catalyzed high levels of cell-free homologous DNA recombination activity. This ATP-dependent activity was capable of forming conservative recombinant products between two circular, double-stranded DNA molecules. We were unable to detect any DNA polymerase, DNA ligase, or 5' or 3' exonuclease activity associated with this purified material. The purified 100 kDa protein bound silver nitrate as well as a monoclonal antibody specific for nucleolin. A recombinant protein comprised of the Escherichia coli maltos-ebinding protein fused to the carboxyl-terminal two-thirds of human nucleolin possessed homologous DNA pairing activity. These data indicate that the 100 kDa homologous DNA pairing protein is nucleolin. The observation that nucleolin can carry out homologous DNA strand pairing in vitro raises the prospect that it may function similarly in vivo.

Reduced Ca2+ uptake by mitochondria in pyruvate dehydrogenase-deficient human diploid fibroblasts

Physiological and pathological Ca2+ loads are thought to be taken up by mitochondria via a process dependent on aerobic metabolism. We sought to determine whether human diploid fibroblasts from a patient with an inherited defect in pyruvate dehydrogenase (PDH) exhibit a decreased ability to sequester cytosolic Ca2+ into mitochondria. Mobilization of Ca2+ stores with bradykinin (BK) increased the cytosolic Ca2+ concentration ([Ca2+]c) to comparable levels in control and PDH-deficient fibroblasts. In normal fibroblasts transfected with plasmid DNA encoding mitochondrion-targeted apoaequorin, BK elicited an increase in Ca2(+)-dependent aequorin luminescence corresponding to an increase in the mitochondrial Ca2+ concentration ([Ca2+]mt) of 2.0 +/- 0.2 microM. The mitochondrial uncoupling agent carbonyl cyanide p-(trifluoromethoxy)phenylhydrazone blocked the BK-induced [Ca2+]mt increase, although it did not affect the [Ca2+]c transient. Basal [Ca2+]c and [Ca2+]mt in control and PDH-deficient cells were similar. However, confocal imaging of the potential-sensitive dye JC-1 indicated that the percentage of highly polarized mitochondria was reduced from 30 +/- 1% in normal cells to 19 +/- 2% in the PDH-deficient fibroblasts. BK-elicited [Ca2+]mt transients in PDH-deficient cells were reduced to 4% of control, indicating that PDH-deficient mitochondria have a decreased ability to take up cytosolic Ca2+. Thus cells with compromised aerobic metabolism have a reduced capacity to sequester Ca2+.

Elevated homologous recombination activity in fanconi anemia fibroblasts

It is widely believed that Fanconi anemia cells possess a reduced ability to repair inter-strand DNA cross-links. While the mechanism through which inter-strand DNA cross-links are removed from mammalian chromosomes is unknown, these lesions are repaired via homologous recombination in lower eukaryotes and bacteria. Based on the hypothesis that a similar mechanism of DNA repair functions in mammalian somatic cells, we measured homologous recombination activity in diploid fibroblasts from healthy donors, and Fanconi anemia patients. Somewhat surprisingly, homologous recombination levels in nuclear protein extracts prepared from Fanconi anemia cells were nearly 100-fold higher than in extracts prepared from control cells. We observed a similar increase in the activity of a 100-kDa homologous DNA pairing protein in extracts from Fanconi anemia cells. Transfection studies confirmed that plasmid homologous recombination levels in intact Fanconi anemia cells were substantially elevated, compared with control cells. These results suggest that inappropriately elevated levels of homologous recombination activity may contribute to the genomic instability and cancer predisposition that characterize Fanconi anemia.

Mammalian mitochondria possess homologous DNA recombination activity

Mitochondrial protein extracts from normal and immortalized mammalian somatic cells catalyze homologous recombination of plasmid DNA substrates. Mitochondrial homologous recombination activity required exogenous adenosine triphosphate, although substantial activity remained when non-hydrolyzable analogs were used instead. There was no requirement for added nucleoside triphosphates, and the reaction was not inhibited by dideoxyadenosine triphosphate or aphidicolin. The majority of recombinant plasmid molecules result from a conservative process, indicating that nuclease-mediated strand-annealing is not responsible for the mitochondrial homologous recombination activity. Affinity-purified anti-recA antibodies inhibited the reaction, suggesting that activity is dependent on a mammalian mitochondrial homolog of the bacterial strand-transferase protein. The presence of homologous recombination activity within mammalian mitochondrial extracts suggests that this process is involved in mitochondrial DNA repair.

Characterization of homologous DNA recombination activity in normal and immortal mammalian cells

Homologous DNA recombination levels were measured in normal and spontaneously immortalized murine and human fibroblasts, and in a number of primate and murine established fibroblast cell lines. Immortal cell lines and tumor-derived clones homologously recombined extrachromosomal plasmid substrates at frequencies approximately 100-fold higher than did normal cells. To further explore the mechanism responsible for this phenotype, homologous recombination frequency was measured using nuclear extracts derived from normal and immortalized murine and human fibroblasts. Extracts prepared from immortal cells catalyzed high levels of homologous recombination, whereas very little recombination activity was detected in extracts prepared from normal fibroblasts. Similarly, only extracts derived from immortal cells contained strand-transferase activity as measured by the recently described pairing-on-membrane assay. Mixing experiments indicated that a recombination enhancing factor or factors present in immortal cells, rather than a recombination inhibitor in normal cells, was responsible for the enhanced homologous recombination activity observed using extracts derived from the former.

Elevated levels of recombinational DNA repair in human somatic cells expressing the Saccharomyces cerevisiae RAD52 gene

The Saccharomyces cerevisiae RAD52 gene was introduced into the human fibrosarcoma-derived cell line HT1080. Transfected cell lines that expressed the yeast transgene catalyzed inter-plasmid homologous DNA recombination at frequencies approx. 12-fold higher than did control cells. Additional experiments revealed that yeast RAD52 gene expression increased the level of resistance to the DNA damaging agents diepoxybutane, and methyl methanesulfonate, but did not alter sensitivity to ultraviolet radiation. These results indicate that the S. cerevisiae Rad52 protein can function in a human somatic cell background and provide support for the idea that a homologous recombination-based DNA repair process functions in mammalian somatic cells.

Elevated levels of homologous DNA recombination activity in the regenerating rat liver

We have characterized homologous DNA recombination activity in nuclear protein extracts prepared from quiescent and regenerating rat livers. Activity measured in regenerating liver extracts was elevated approximately 35-fold above control, and its appearance closely mirrored the first wave of DNA synthesis, peaking 24 hours after a regenerative stimulus, and returning fairly rapidly to basal levels. We also identified a strand-transferase protein of approximately 100 kDa whose presence in these extracts correlates with homologous recombination activity. Recent evidence suggests that mammalian somatic cells possess a recombinational DNA repair mechanism analogous to that described in the yeast Saccharomyces cerevisiae. Our results indicate that this recombinational repair process may be regulated in vivo by, or play a role in, progression through the cell division cycle.

The effect of target site transcription on gene targeting in human cells in vitro

We evaluate the effect of target site transcription on gene targeting in cultured human fibrosarcoma cells. A number of cell lines that harbored a plasmid recombination substrate within their chromosomal DNA were created. Gene targeting frequency was then measured at these different loci in the presence and absence of an agent that stimulated target site transcription. We observed that gene targeting was significantly enhanced by RNA transcription. The magnitude of transcription-stimulated gene targeting varied from 3-fold to > 20-fold. No increase in gene targeting was observed, however, when transcription proceeded away from, rather than through, the recombination site. Transcription-stimulated gene targeting was also observed when single-stranded plasmid vectors complementary to either the coding or template strand were used as recombination substrates. Our results indicate that gene targeting, like other forms of DNA recombination, can be stimulated by target site transcription. The implications of our observations on current models of transcription-stimulated recombination are discussed.