Radial Long Sheath Angioplasty for Proximal Severe Flow Limiting Radial Artery Spasm Utilizing the Dotter Technique

BACKGROUND

Although studies continue to demonstrate the advantages of transradial access (TRA) for neurointerventions, radial artery spasm (RAS) remains a frequent cause of TRA failure. Dotter initially described a technique to dilate areas of peripheral vascular stenosis by advancing sequentially larger catheters across the lesion over a wire. We present our institutional experience performing a modified Dotter technique utilizing long radial sheaths to dilate areas of proximal flow limiting RAS.

OBJECTIVE

To review the use of the Dotter technique for alleviating RAS in patients undergoing TRA for neurointerventions.

METHODS

A retrospective review of all patients undergoing TRA for neurointerventions at our institution from 2018-2020 was performed to identify patients with proximal flow limiting RAS. In identified patients, a modified Dotter technique was employed to dilate the stenosis. Demographic and periprocedural data were assessed to identify any adverse outcomes.

RESULTS

Four patients with severe proximal flow limiting RAS were identified. In each case, a hydrophilic long radial sheath and vascular dilator were sequentially advanced through the stenosis. In all cases, repeat angiography demonstrated improvement of the spasm and final radial angiograms demonstrated persistent improvement in caliber and regularity of the vessel. Each procedure was also completed via TRA with no periprocedural complications.

CONCLUSIONS

Our modified Dotter technique is effective in bypassing areas of severe proximal flow limiting RAS thus obviating the need for access site conversion. Additional studies are warranted to understand the implication of the angioplasty-like effects seen within the radial artery following removal of the long radial sheaths.

ISGylation governs the oncogenic function of Ki-Ras in breast cancer

Aberrant expression of the oncogenic Kirsten-Ras (Ki-Ras) and interferon-stimulated gene 15 (ISG15) pathways is common in breast and other cancers. However, whether these dysregulated pathways cooperate to promote malignancy is not known. This study links Ki-Ras and ISG15 in a previously unidentified regulatory loop that may underlie malignant transformation of mammary cells. We show that oncogenic Ki-Ras regulates the expression of the ISG15 pathway (free ISG15 and ISG15 conjugates), and ISG15, in turn, stabilizes Ki-Ras protein by inhibiting its targeted degradation via lysosomes in breast cancer cells. Disruption of this loop by silencing either Ki-Ras or the ISG15 pathway restored the disrupted cellular architecture, a hallmark feature of most cancer cells. We also demonstrate that ISG15 and UbcH8 (ISG15-specific conjugating enzyme) shRNAs reversed Ki-Ras mutation-associated phenotypes of cancer cells, such as increased cell proliferation, colony formation, anchorage-independent growth in soft agar, cell migration, and epithelial-mesenchymal transition. As UbcH8-silenced breast cancer cells are devoid of ISG15 conjugates but have free ISG15, our results using UbcH8-silenced cells suggest that ISG15 conjugates, and not free ISG15, contributes to oncogenic Ki-Ras transformation. We have thus identified the conjugated form of ISG15 as a critical downstream mediator of oncogenic Ki-Ras, providing a potential mechanistic link between ISG15 and Ki-Ras-mediated breast tumorigenesis. Our findings, which show that inhibition of the ISGylation reverses the malignant phenotypes of breast cancer cells expressing oncogenic Ki-Ras, support the development of ISG15 conjugation inhibitors for treating breast and also other cancers expressing oncogenic Ki-Ras.

Modulation of alpha-catenin Tyr phosphorylation by SHP2 positively effects cell transformation induced by the constitutively active FGFR3

The Src homology 2 phosphotyrosyl phosphatase (SHP2) is a nonreceptor-type phosphatase that acts as a positive transducer of receptor Tyr kinase (RTK) signaling, particularly the Ras-REK and PI3K-Akt pathways. Recently, we have demonstrated that SHP2 is required for cell transformation induced by the constitutively active fibroblast growth factor receptor 3 (K/E-FR3) (Oncogene, 22, 6909-6918). In that study, we had detected a phosphotyrosyl protein of approximately 100 KDa (p100) in cells expressing dominant-negative SHP2 (R/E-SHP2), but its identity and relevance in SHP2-meditaed transformation was not known. Here, we report the identification of p100 as alpha-catenin, a vinculin-related protein involved in adherens junction-mediated intercellular adhesion. We show that alpha-catenin becomes Tyr phosphorylated in intercellular adhesion-dependent manner and this event is counteracted by SHP2. Substrate trapping in intact cells and immunocomplex phosphatse assays confirmed that alpha-catenin is in deed an SHP2 substrate. Tyr phosphorylation of alpha-catenin enhances its translocation to the plasma membrane and its interaction with beta-catenin, leading to enhanced actin polymerization and stabilization of adherens junction-mediated intercellular adhesion, a phenomenon commensurate with loss of the transformation phenotype. Site-directed mutagenesis studies also suggested that Tyr phosphorylation of alpha-catenin enhances its inhibitory role on cell transformation. Based on our previous work and the current report, we demonstrate that mediation of cell transformation by SHP2 is a complex process that involves modulation of the Ras-ERK and PI3K-Akt signaling pathways, intercellular adhesion, focal adhesion and actin cytoskeletal reorganization. To our knowledge, this is the first report showing regulation of alpha-catenin function by Tyr phosphorylation and its inhibitory effect on cell transformation.

The tmRDB and SRPDB resources

Maintained at the University of Texas Health Science Center at Tyler, Texas, the tmRNA database (tmRDB) is accessible at the URL http://psyche.uthct.edu/dbs/tmRDB/tmRDB.html with mirror sites located at Auburn University, Auburn, Alabama (http://www.ag.auburn.edu/mirror/tmRDB/) and the Royal Veterinary and Agricultural University, Denmark (http://tmrdb.kvl.dk/). The signal recognition particle database (SRPDB) at http://psyche.uthct.edu/dbs/SRPDB/SRPDB.html is mirrored at http://srpdb.kvl.dk/ and the University of Goteborg (http://bio.lundberg.gu.se/dbs/SRPDB/SRPDB.html). The databases assist in investigations of the tmRNP (a ribonucleoprotein complex which liberates stalled bacterial ribosomes) and the SRP (a particle which recognizes signal sequences and directs secretory proteins to cell membranes). The curated tmRNA and SRP RNA alignments consider base pairs supported by comparative sequence analysis. Also shown are alignments of the tmRNA-associated proteins SmpB, ribosomal protein S1, alanyl-tRNA synthetase and Elongation Factor Tu, as well as the SRP proteins SRP9, SRP14, SRP19, SRP21, SRP54 (Ffh), SRP68, SRP72, cpSRP43, Flhf, SRP receptor (alpha) and SRP receptor (beta). All alignments can be easily examined using a new exploratory browser. The databases provide links to high-resolution structures and serve as depositories for structures obtained by molecular modeling.

Comparative 3-D modeling of tmRNA

BACKGROUND

Trans-translation releases stalled ribosomes from truncated mRNAs and tags defective proteins for proteolytic degradation using transfer-messenger RNA (tmRNA). This small stable RNA represents a hybrid of tRNA- and mRNA-like domains connected by a variable number of pseudoknots. Comparative sequence analysis of tmRNAs found in bacteria, plastids, and mitochondria provides considerable insights into their secondary structures. Progress toward understanding the molecular mechanism of template switching, which constitutes an essential step in trans-translation, is hampered by our limited knowledge about the three-dimensional folding of tmRNA.

RESULTS

To facilitate experimental testing of the molecular intricacies of trans-translation, which often require appropriately modified tmRNA derivatives, we developed a procedure for building three-dimensional models of tmRNA. Using comparative sequence analysis, phylogenetically-supported 2-D structures were obtained to serve as input for the program ERNA-3D. Motifs containing loops and turns were extracted from the known structures of other RNAs and used to improve the tmRNA models. Biologically feasible 3-D models for the entire tmRNA molecule could be obtained. The models were characterized by a functionally significant close proximity between the tRNA-like domain and the resume codon. Potential conformational changes which might lead to a more open structure of tmRNA upon binding to the ribosome are discussed. The method, described in detail for the tmRNAs of Escherichia coli, Bacillus anthracis, and Caulobacter crescentus, is applicable to every tmRNA.

CONCLUSION

Improved molecular models of biological significance were obtained. These models will guide in the design of experiments and provide a better understanding of trans-translation. The comparative procedure described here for tmRNA is easily adopted for the modeling the members of other RNA families.

tmRDB (tmRNA database)

Maintained at the University of Texas Health Science Center at Tyler, Texas, the tmRNA database (tmRDB) is accessible at the URL http://psyche.uthct.edu/dbs/tmRDB/tmRDB.html with mirror sites located at Auburn University, Auburn, Alabama (http://www.ag.auburn.edu/mirror/tmRDB/) and the Bioinformatics Research Center, Aarhus, Denmark (http://www.bioinf.au.dk/tmRDB/). The tmRDB collects and distributes information relevant to the study of tmRNA. In trans-translation, this molecule combines properties of tRNA and mRNA and binds several proteins to form the tmRNP. Related RNPs are likely to be functional in all bacteria. In this release of tmRDB, 186 new entries from 10 bacterial groups for a total of 274 tmRNA sequences have been added. Lists of the tmRNAs and the corresponding tmRNA-encoded tag-peptides are presented in alphabetical and phylogenetic order. The tmRNA sequences are aligned manually, assisted by computational tools, to determine base pairs supported by comparative sequence analysis. The tmRNA alignment, available in a variety of formats, provides the basis for the secondary and tertiary structure of each tmRNA molecule. Three-dimensional models of the tmRNAs and their associated proteins in PDB format give evidence for the recent progress that has been made in the understanding of tmRNP structure and function.

Difficult cases in heart failure: familial dilated cardiomyopathy

While originally thought to be uncommon, familial dilated cardiomyopathy may occur quite often. Aside from symptoms of heart failure, these forms of dilated cardiomyopathy may be associated with arrhythmias and sudden death. The case detailed describes such a patient and emphasizes the importance of a careful family history. Also discussed is the importance of screening of first- and second-degree relatives of these patients. (c)2001 by CHF, Inc.

Current use of endovascular grafts for the treatment of abdominal aortic aneurysms

The development of endovascular techniques for the treatment of abdominal aortic aneurysms has significantly reduced the major morbidity associated with standard surgical repair. The indications for use of endovascular grafts and the limitations of their use have not been fully defined. The effectiveness of the numerous commercially fabricated devices is currently being evaluated. This article describes the general principles of use for endovascular devices and details the features and results for the devices in current use.

Expression and immunogenicity of hemagglutinin A from Porphyromonas gingivalis in an avirulent Salmonella enterica serovar typhimurium vaccine strain

Porphyromonas gingivalis is a major etiologic agent of periodontitis, a chronic inflammatory disease that ultimately results in the loss of the supporting tissues of the teeth. Previous work has demonstrated the usefulness of avirulent Salmonella enterica serovar Typhimurium strains as antigen delivery systems for protective antigens of pathogens that colonize or cross mucosal surfaces. In this study, we constructed and characterized a recombinant S. enterica serovar Typhimurium avirulent vaccine strain which expresses hemagglutinin A and carries no antibiotic resistance markers. HagA, a major virulence-associated surface protein, is a potentially useful immunogen that contains an antigenic epitope which, in humans, elicits an immune response that is protective against subsequent colonization by P. gingivalis. The hagA gene, including its promoter, was cloned into a balanced-lethal Salmonella vector and transferred to the vaccine strain. Heterologous expression of HagA was demonstrated in both Escherichia coli JM109 and S. enterica serovar Typhimurium vaccine strain chi4072. The HagA epitope was present in its native configuration as determined by immunochemistry and immunoelectron microscopy. Purified recombinant HagA was recognized by sera from mice immunized with the S. enterica serovar Typhimurium vaccine strain. The HagA-specific antigen of the vaccine was also found to be recognized by serum from a periodontal patient. This vaccine strain, which expresses the functional hemagglutinin protein, induces a humoral immune response against HagA and may be useful for developing a protective vaccine against periodontal diseases associated with P. gingivalis.

Porphyromonas gingivalis virulence factors and invasion of cells of the cardiovascular system

Our laboratory is interested in the genes and gene products involved in the interactions between Porphyromonas gingivalis (Pg) and the host. These interactions may occur in either the periodontal tissues or other non-oral host tissues such as those of the cardiovascular system. We have previously reported the cloning of several genes encoding hemagglutinins, surface proteins that interact with the host tissues, and are investigating their roles in the disease process. Primary among these is HagA, a very large protein with multiple functional groups that have significant sequence homology to protease genes of this species. Preliminary evidence indicates that an avirulent Salmonella typhimurium strain containing hagA is virulent in mice. These data indicate that HagA may be a key virulence factor of Pg. Additionally, we are investigating the invasion of primary human coronary artery endothelial cells (HCAEC) by Pg because of the recent epidemiological studies indicating a correlation between periodontal disease (PD) and coronary heart disease (CHD). We found that some, but not all, strains of Pg are able to invade these cells. Scanning electron microsopy of the infected HCAEC demonstrated that the invading organisms initially attached to the host cell surface as aggregates and by a "pedestal"-like structure. By transmission electronmicroscopy it could be seen that internalized bacteria were present within multimembranous compartments localized with rough endoplasmic reticulum. In addition, invasion of the HCAEC by Pg resulted in an increase in the degradation of long-lived cellular proteins. These data indicate that Pg are present within autophagosomes and may use components of the autophagic pathway as a means to survive intracellularly. However, Pg presence within autophagosomes in KB cells could not be observed or detected. It is therefore likely that Pg uses different invasive mechanisms for different host cells. This and the role of HagA in invasion is currently being investigated further.

Comparison of treatment plans for lower extremity arterial occlusive disease made with electrocardiography-triggered two-dimensional time-of-flight magnetic resonance angiography and digital subtraction angiography

BACKGROUND

The purpose of the study was to determine whether preoperative treatment plans for patients with lower extremity ischemia can be made with electrocardiography (EKG)-triggered two-dimensional (2D) time-of-flight (TOF) magnetic resonance angiography (MRA) as accurately as digital subtraction angiography (DSA).

METHODS

Forty patients were prospectively evaluated with the combination of EKG-triggered 2D TOF MRA, DSA, and pulse volume recordings. Blinded reviewers graded arterial segments for disease severity. Accuracy of separate MRA- and DSA-based treatment plans was compared with the procedures performed based on all available information.

RESULTS

There was an 86% exact match between MRA- and DSA-based plans (92% MRA and 94% DSA accuracy). The MRA-based plan accurately predicted 90% of suprainguinal and 95% of infrainguinal procedures, whereas the DSA-based plan accurately predicted 100% of suprainguinal and 85% of infrainguinal procedures. Two-year primary patency was 83% for all procedures. Radiologists' review of disease severity resulted in a mean exact correlation between studies of 81% (kappa = 0.64). The agreement between radiologists interpreting the MRA was 84% (kappa = 0.7) compared with 82% (kappa = 0.66) for the DSA.

CONCLUSIONS

MRA- and DSA-based preoperative management plans were of comparable efficacy. Significant interobserver variability was seen with the interpretations of both preoperative studies. EKG-triggered 2D TOF MRA can be used to plan arterial reconstructions; however, all patients require arterial pressure measurements prior to suprainguinal repair and confirmatory intraoperative angiography during infrainguinal revascularization.

Multiple sclerosis care: an integrated disease-management model

A disease-management model must be integrated, comprehensive, individual patient focused and outcome driven. In addition to high quality care, the successful model must reduce variations in care and costs. MS specialists need to be intimately involved in the long-term care of MS patients, while not neglecting primary care issues. A nurse care manager is the "glue" between the managed care company, health care providers and the patient/family. Disease management focuses on education and prevention, and can be cost effective as well as patient specific. To implement a successful program, managed care companies and health care providers must work together.

A randomized trial of intravenous heparin in conjunction with anistreplase (anisoylated plasminogen streptokinase activator complex) in acute myocardial infarction: the Duke University Clinical Cardiology Study (DUCCS) 1

OBJECTIVES

We designed a randomized trial to evaluate the effects of heparin administration in conjunction with anistreplase (anisoylated plasminogen streptokinase activator complex [APSAC]) on arterial patency and clinical end points.

BACKGROUND

The role of conjunctive intravenous heparin therapy with APSAC has not been tested despite the recommendations that intravenous heparin should be used.

METHODS

Four hours after APSAC administration, 250 patients with acute myocardial infarction were randomly assigned to receive 325 mg of either aspirin alone or aspirin and a continuous infusion of heparin (15 IU/kg body weight per h). Clinical ischemic events and bleeding complications were monitored. On hospital day 5, coronary arteriography and left ventriculography were performed.

RESULTS

The primary end point of the trial (the combined outcome of death, reinfarction, recurrent ischemia and occlusion of the infarct-related artery) occurred in 42% of the heparin-treated group versus 43% of the group treated without heparin (p = 0.94). A patent infarct-related artery was present in 80% of the patients treated with heparin and in 73% of those treated without heparin (p = 0.26). Left ventricular function, as measured by ejection fraction, was well preserved in both groups (52% vs. 50.5%, respectively, p = 0.29). The overall bleeding rate was higher in patients with (32%) than without (17.2%) heparin (p = 0.006).

CONCLUSIONS

Weight-adjusted intravenous heparin therapy after APSAC in acute myocardial infarction does not reduce the combined incidence of death, reinfarction, recurrent ischemia and occlusion of the infarct-related artery. Furthermore, withholding intravenous heparin therapy is associated with a 46% reduction in bleeding complications. Our findings do not support the addition of intravenous heparin after APSAC therapy, as currently recommended, and suggest that a strategy of withholding heparin is simpler and safer and does not place the patient at increased risk for ischemic complications after myocardial infarction.

Health care costs of veterans with multiple sclerosis: implications for the rehabilitation of MS. VA Multiple Sclerosis Rehabilitation Study Group

We retrospectively determined health care costs among veterans with multiple sclerosis (MS) and correlated the costs with neurologic dysfunction. Total health care costs for the 165 patients averaged $35,000/year. VA benefits and homecare together accounted for 85% of the total costs. Total health care costs correlated with two measures of neurologic dysfunction, the Expanded Disability Status Scale (EDSS) (r = 0.61, p < 0.001) and the Incapacity Status Scale (ISS) (r = 0.64, p < 0.001). The costs of VA benefits, homecare, and hospitalizations also correlated with the EDSS, ISS, and other measures of neurologic dysfunction whereas the cost of outpatient clinic visits did not. In a period of three years, there were 40 hospitalizations, at a total cost of $412,800, that were potentially preventable with appropriate outpatient management. Improving selfcare and avoiding preventable hospitalizations might lower the considerable health care costs of MS.

Myelin basic protein and proteolipid protein reactivity of brain- and cerebrospinal fluid-derived T cell clones in multiple sclerosis and postinfectious encephalomyelitis

T cells were directly cloned from autopsied MS brain plaque tissue and reactivity was measured with the major encephalitogenic neuroantigens, myelin basic protein (MBP), and proteolipid protein (PLP). Control clones were simultaneously derived from the blood. The proportion of T4+ and T8+ T cell clones from the brain tissue differed from that of peripheral blood T cell clones derived at the same time, suggesting that the clones were not derived from the peripheral blood. None of 57 brain-derived T cell clones proliferated to either MBP or PLP, although they responded well to PHA and IL 2. An additional 235 clones derived from the cerebrospinal fluid and 126 clones from the peripheral blood of other subjects with multiple sclerosis also did not proliferate to MBP or PLP. In contrast, five of nine T4+ clones from the CSF of a subject with postinfectious encephalomyelitis exhibited low but clear reactivity to human MBP, supporting the possible role of MBP as the target antigen in this disease. These studies, the first to clone T cells directly from MS plaque tissue, suggest that the lack of consistent T cell reactivity to MBP or PLP in the peripheral blood of MS patients does not appear to be secondary to the sequestration of a large number of these cells in the brain.

Myelin basic protein and proteolipid protein reactivity of brain- and cerebrospinal fluid-derived T cell clones in multiple sclerosis and postinfectious encephalomyelitis

T cells were directly cloned from autopsied MS brain plaque tissue and reactivity was measured with the major encephalitogenic neuroantigens, myelin basic protein (MBP), and proteolipid protein (PLP). Control clones were simultaneously derived from the blood. The proportion of T4+ and T8+ T cell clones from the brain tissue differed from that of peripheral blood T cell clones derived at the same time, suggesting that the clones were not derived from the peripheral blood. None of 57 brain-derived T cell clones proliferated to either MBP or PLP, although they responded well to PHA and IL 2. An additional 235 clones derived from the cerebrospinal fluid and 126 clones from the peripheral blood of other subjects with multiple sclerosis also did not proliferate to MBP or PLP. In contrast, five of nine T4+ clones from the CSF of a subject with postinfectious encephalomyelitis exhibited low but clear reactivity to human MBP, supporting the possible role of MBP as the target antigen in this disease. These studies, the first to clone T cells directly from MS plaque tissue, suggest that the lack of consistent T cell reactivity to MBP or PLP in the peripheral blood of MS patients does not appear to be secondary to the sequestration of a large number of these cells in the brain.

Breathing pattern during and after exercise of different intensities

We recently observed rapid shallow breathing during recovery from maximal exercise in some normal subjects. We wondered whether this phenomenon is randomly related to level of exercise or is limited to recovery from very high levels of exercise. We monitored ventilation, tidal volume, and respiratory frequency in seven normal subjects during and after exercise. Each subject exercised on several occasions on separate days. At least two of the tests were maximal (i.e., subject terminated). In the other tests exercise was terminated by the experimenter at different fractions of the highest level attained by the subject. There was no systematic difference between breathing pattern during exercise and recovery in tests where final O2 consumption (VO2) was 45-92% of the subjects' highest VO2. By contrast 13 of 19 studies in which final VO2 was 92-100% of highest VO2 were followed by relative rapid shallow breathing. We conclude that rapid shallow breathing during recovery from exercise is a phenomenon that is limited to very high exercise levels. On consideration of the various mechanisms that may be entertained to explain this phenomenon, we believe that development of pulmonary congestion-interstitial edema at very high levels of exercise is the most consistent with our findings.

Prognostic implications of ventricular arrhythmias during 24 hour ambulatory monitoring in patients undergoing cardiac catheterization for coronary artery disease

The prognostic importance of ventricular arrhythmias detected during 24 hour ambulatory monitoring was evaluated in 395 patients with and 260 patients without significant coronary artery disease. Ventricular arrhythmias were found to be strongly related to abnormal left ventricular function. A modification of the Lown grading system (ventricular arrhythmia score) was the most useful scheme for classifying ventricular arrhythmias according to prognostic importance. When only noninvasive characteristics were considered, the score contributed independent prognostic information, and the complexity of ventricular arrhythmias as measured by this score was inversely related to survival. However, when invasive measurements were included, the ventricular arrhythmia score did not contribute independent prognostic information. Furthermore, ejection fraction was more useful than the ventricular arrhythmia score in identifying patients at high risk of sudden death.