Bleeding complications in patients undergoing percutaneous coronary intervention in coronary artery bypass grafts: the impact of clinical presentation, access site and selection bias

Background

Percutaneous coronary intervention (PCI) in patients with prior coronary artery bypass graft (CABG) surgery is commonly done via the femoral approach. Relatively few cases are done via the radial approach.

Purpose

To assess bleeding complications in patients with either radial/brachial or femoral access when undergoing graft PCI, saphenous vein graft or internal mammary artery (IMA) graft.

Method

Data was collected for quality control on all patients that underwent PCI between 2010 and 2018 at 6 tertiary care hospitals in our system. Outcomes were classified and reported in accordance with the Bleeding Academic Research Consortium (BARC) criteria. BARC Type 4 (CABG-related) and BARC Type 5 (fatal) bleeds were excluded. Major bleeding was defined as BARC Type ≥3. Major adverse cardiac and cerebrovascular events (MACCE) was the combined endpoint of hospital death; post procedural myocardial infarction; cerebrovascular events (ischemic and hemorrhagic) and major bleeding complications. Due to the high intraclass correlation of procedures within patients, only the first procedure within the study period was selected from each patient for analysis. The two-sample t-test, Wilcoxon rank sum test, chi-square or Fisher's exact test were used as appropriate.

Results

A total of 1153 of 1196 patients who underwent graft intervention had BARC outcome data. Of these only 81 (7%) was via radial/brachial access. Baseline clinical characteristics are shown in the Table. A higher percentage of BARC ≥3 patients presented with NSTEMI/STEMI or had IMA graft intervention. Access site was not associated with bleeding complications. However, MACCE, post procedural heart failure (HF) and post procedural myocardial infarction (MI) rates were higher in patients who had femoral access (Figure).

Conclusions

In a large contemporary dataset of post CABG patients undergoing graft interventions: 1) the majority of patients (93%) underwent graft PCI via femoral access; 2) clinical presentation and acuity was associated with more severe bleeding complications; 3) access site did not seem to be associated with bleeding complications (possible selection bias); and 4) there was a trend towards higher MACCE rates in patients who had a femoral access. Additional analysis will be done to further investigate our findings.

Funding Acknowledgement

Type of funding sources: None.

Bleeding in patients undergoing percutaneous coronary intervention: factors associated with procedural outcomes and major bleeding complications

Background

Bleeding complications are infrequent in patients undergoing percutaneous coronary interventions (PCI), however they are associated with a poor outcome and increased mortality and morbidity rates.

Purpose

To assess bleeding complications in patients undergoing PCI adjusting for other factors such as estimated glomerular filtration rate (eGFR), sex, left ventricular ejection fraction (EF), ST-segment elevation myocardial infarction (STEMI), intra-aortic balloon pump (IABP) and/or Impella, age, and prior coronary artery bypass graft (CABG).

Methods

Data was collected for quality control on all patients that underwent PCI between 2010 and 2018 at 6 tertiary care hospitals in our system. Outcomes were classified and reported in accordance with the Bleeding Academic Research Consortium (BARC) criteria. BARC Type 4 (CABG-related) and BARC Type 5 (fatal) bleeds were excluded. Major bleeding was defined as BARC Type ≥3. Major adverse cardiac and cerebrovascular events (MACCE) was the combined endpoint of hospital death; post procedural myocardial infarction; cerebrovascular events (ischemic and hemorrhagic) and major bleeding complications. Due to the clustering of patients within hospitals, hierarchical generalized linear mixed models were used. Due to the high intraclass correlation of procedures within patients, only the first procedure within the study period was selected from each patient for analysis.

Results

A total of 25,647 patients underwent PCI during the time period. Baseline and procedural characteristics are shown in the Table. Patients with major bleeding (BARC ≥3) differed significantly from patients with BARC <3 bleeding complications. By multivariate analysis, age (OR: 1.15, CI: 1.1–1.2), femoral site (OR: 1.5, CI: 1.2–1.8), CKD (OR: 1.7, CI: 1.4–2.0), STEMI (OR: 3.3, CI: 2.8–4.0), prior cardiogenic shock (OR: 5.8, CI: 4.1–8.3), and use of IABP/Impella (OR: 5.5, CI: 4.4–6.9) were associated withBARC ≥3 (Figure).

Conclusion

In large contemporary dataset of patients undergoing PCI: 1) patients with BARC ≥3 bleeding complications were significantly different from those having BARC<3 bleeding complications; 2) femoral access, chronic kidney disease, STEMI on presentation and the use of mechanical circulatory devices were associated with major bleeding complications; and 3) male patients had significantly lower odds of major bleeding complications.

Funding Acknowledgement

Type of funding sources: None.

The ASOS Surgical Risk Calculator: development and validation of a tool for identifying African surgical patients at risk of severe postoperative complications

BACKGROUND

The African Surgical Outcomes Study (ASOS) showed that surgical patients in Africa have a mortality twice the global average. Existing risk assessment tools are not valid for use in this population because the pattern of risk for poor outcomes differs from high-income countries. The objective of this study was to derive and validate a simple, preoperative risk stratification tool to identify African surgical patients at risk for in-hospital postoperative mortality and severe complications.

METHODS

ASOS was a 7-day prospective cohort study of adult patients undergoing surgery in Africa. The ASOS Surgical Risk Calculator was constructed with a multivariable logistic regression model for the outcome of in-hospital mortality and severe postoperative complications. The following preoperative risk factors were entered into the model; age, sex, smoking status, ASA physical status, preoperative chronic comorbid conditions, indication for surgery, urgency, severity, and type of surgery.

RESULTS

The model was derived from 8799 patients from 168 African hospitals. The composite outcome of severe postoperative complications and death occurred in 423/8799 (4.8%) patients. The ASOS Surgical Risk Calculator includes the following risk factors: age, ASA physical status, indication for surgery, urgency, severity, and type of surgery. The model showed good discrimination with an area under the receiver operating characteristic curve of 0.805 and good calibration with c-statistic corrected for optimism of 0.784.

CONCLUSIONS

This simple preoperative risk calculator could be used to identify high-risk surgical patients in African hospitals and facilitate increased postoperative surveillance.

CLINICAL TRIAL REGISTRATION

NCT03044899.

Is malnutrition a risk factor of stroke?

Obesity is an established risk factor of stroke. Malnutrition in post-stroke period is common and can influence outcome. But malnutrition, though predicted, has not yet been established as a risk factor of stroke. This descriptive study was carried out in the Department of Neurology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka and Department of Neurology, Dhaka Medical College (DMC), from January 2009 to December 2010 to explore whether malnutrition is an independent risk factor of stroke. Nutritional status of 100 stroke patients and 100 healthy controls were assessed in this study. Anthropometric measurements including Body Mass Index (BMI), Triceps skin fold (TSF), Mid-arm circumference (MAC) and Arm-muscle circumference (AMC) were measured within 7 days of stroke. Haemoglobin and haematocrit percentage, serum iron and serum albumin were measured at the same time. No significant difference was observed regarding TSF thickness, MAC, AMC, mean Hb and mean albumin level between the stroke patients and the control group, although iron level was significantly lower in stroke group. Multiple logistic regressions analysis showed that increase in age, smoking and decreased serum iron level has a positive association with stroke. Malnutrition is, according to this study, not a significant risk factor of stroke and triceps skin fold (TSF) thickness, mid-arm circumference (MAC), arm-muscle circumference (AMC), hemoglobin and serum albumin are not appropriate predictor of stroke.

Inhibition of prostate specific antigen expression by genistein in prostate cancer cells

Recent studies have provided convincing evidence for the role of soy-isoflavones, particularly genistein, in the inhibition of prostate cancer cell growth. Prostate specific antigen (PSA) is a biological marker used to detect and monitor the treatment of prostate cancer patients. Previous studies have documented that isoflavones can inhibit the secretion of PSA in the androgen-dependent prostate cancer cell line, LNCaP, however, the effects of genistein on androgen-independent PSA expression has not been explored. In this study, we have utilized a prostate cancer cell line, VeCaP, which expresses PSA in an androgen-independent manner, to determine the effects of genistein on cell proliferation and PSA expression. Here we show that genistein inhibits cell growth similarly in both the LNCaP and VeCaP cell lines, but has differential effects on PSA expression. We demonstrate using concentrations of genistein that have been detected in the serum of humans consuming a soy-rich diet, that genistein decreases PSA mRNA, protein expression and secretion. Conversely, only high concentrations of genistein inhibited PSA expression in VeCaP cells. Additionally, we have demonstrated that genistein inhibits cell proliferation independent of PSA signaling pathways, providing further evidence to support the role of genistein as a chemopreventive/therapeutic agent for prostate cancer irrespective of androgen responsiveness.

Induction of apoptosis and inhibition of c-erbB-2 in breast cancer cells by flavopiridol

Flavopiridol is a flavone that inhibits several cyclin-dependent kinases and exhibits potent growth-inhibitory activity against a number of human tumor cell lines, both in vitro and when grown as xenografts in mice. It is presently being investigated as a novel antineoplastic agent in the primary screen conducted by the Developmental Therapeutics Program, National Cancer Institute. Because breast cancer is the most common cancer and second leading cause of cancer-related deaths in women in the United States, we investigated whether flavopiridol could be an effective agent against a series of isogenic breast- cancer cell lines having different levels of erbB-2 expression and differential invasion and metastatic characteristics. Flavopiridol was found to inhibit the growth of MDA-MB-435 (parental) and 435.eB (stable transfectants) cells that were established by transfecting c-erbB-2 cDNA into MDA-MB-435. Induction of apoptosis was also observed in these cell lines when treated with flavopiridol, as measured by DNA laddering, PARP, and CPP32 cleavages. We also found modest up-regulation of Bax and down-regulation of Bcl-2, but there was a significant down-regulation of c-erbB-2 in flavopiridol-treated cells. Gelatin zymography showed that flavopiridol inhibits the secretion of matrix metalloproteinase (MMP; MMPs 2 and 9) in the breast cancer cells and that the inhibition of c-erbB-2 and MMPs may be responsible for the inhibition of cell invasion observed in flavopiridol-treated cells. Collectively, these molecular effects of flavopiridol, however, were found to be independent of c-erbB-2 overexpression, suggesting that flavopiridol may be effective in all breast cancer. From these results, we conclude that flavopiridol inhibits the growth of MDA-MB-435 breast cancer cells, induces apoptosis, regulates the expression of genes, and inhibits invasion and, thus, may inhibit metastasis of breast cancer cells. These findings suggest that flavopiridol may be an effective chemotherapeutic or preventive agent against breast cancer.

No evidence of germline mutation or somatic deletion of the MEN1 gene in a case of familial multiple endocrine neoplasia type 1 (MEN1)

The MEN1 gene has recently been cloned as the gene responsible for multiple endocrine neoplasia type 1 (MEN1) and its germline mutations have been identified in a number of familial MEN1 patients. However, mutation-negative cases have also been reported in some MEN1 families. We report here a Japanese MEN1 family, including a proband with no evidence of MEN1 gene mutation. The proband (51 y.o., female) had three major MEN1 lesions, including primary hyperparathyroidism (HP), prolactinoma, and pancreatic tumor. Her father and brother had HP, and her daughter had both HP and prolactinoma. When we analyzed the proband for a germline mutation of the MEN1 gene, the direct sequencing analysis showed no mutation in the coding region, on the promoter, 5' and 3' untranslated regions of the MEN1 gene. We next examined the loss of heterozygosity (LOH) in the proband's parathyroid tumors using two benign polymorphisms (C2249G in intron 1 and 2248del3 in exon 10) in the MEN1 gene to detect LOH. LOH was not found in any of the four separate regions of the tumor tissues.

Induction of apoptosis and inhibition of c-erbB-2 in MDA-MB-435 cells by genistein

Breast cancer is the most common cancer and second leading cause of cancer related deaths in women in the United States. Genistein is a protein tyrosine kinase inhibitor and prominent isoflavonoid in soy products and has been proposed as the agent responsible for lowering the rate of breast cancer in Asian women. We have previously shown that genistein inhibits the growth of MDA-MB-231 breast cancer cells, regulates the expression of apoptosis-related genes, and induces apoptosis through a p53-independent pathway. In this study, we investigated these effects of genistein in the breast cancer cell line MDA-MB-435 and 435.eB cells that were established by transfecting c-erbB-2 cDNA into MDA-MB-435. We also investigated the effect of genistein on matrix metalloproteinase (MMP) secretion previously shown to be effected by erbB-2 transfection. Genistein was found to inhibit MDA-MB-435 and 435.eB cell growth. Induction of apoptosis was also observed in these cell lines when treated with genistein, as measured by DNA laddering, poly(ADP-ribose) polymerase (PARP) cleavage, and flow cytometric analysis. We also found an up-regulation of Bax and p21WAF1 expression and down-regulation of Bcl-2 and c-erbB-2 in genistein-treated cells. Gelatin zymography showed that genistein inhibits the secretion of MMP in the breast cancer cells. From these results, we conclude that genistein inhibits the growth of MDA-MB-435 breast cancer cells, induces apoptosis, regulates the expression of genes, and may inhibit invasion and metastasis of breast cancer cells. These findings suggest that genistein may be a potentially effective chemopreventive or therapeutic agent against breast cancer.

p53-independent apoptosis induced by genistein in lung cancer cells

Lung cancer is the leading cause of cancer-related deaths in the world, with increasing incidence in many developed countries. Epidemiological data suggest that consumption of soy products may be associated with a decreased risk of cancer. Despite the association of nutrition and cancer, the molecular mechanisms by which the active metabolite in the soy diet, genistein, exerts its biological response have not been studied. We previously showed that genistein can inhibit the growth of H460 non-small-cell lung cancer (NSCLC) cells in vitro. To explore the molecular mechanisms by which genistein inhibits the growth of NSCLC cells, we investigated cell growth inhibition, modulation in gene expression, and induction of apoptosis by genistein in H460 cells, which harbor wild-type p53, and H322 cells, which possess mutated p53. Genistein was found to inhibit H460 and H322 cell growth in a dose-dependent manner. Staining with 4,6-diamidino-2-phenylindole, poly(ADP-ribose) polymerase cleavage, and flow cytometric apoptosis analysis were used to investigate apoptotic cell death, and the results show that 30 microM genistein causes cell death via a typical apoptotic pathway. Western blot analysis demonstrated upregulations of p21WAF1 and Bax by genistein in wild-type and mutant p53 cell lines. Furthermore, cells treated with genistein showed an increased expression of endogenous wild-type p53, while the level of the mutant p53 protein remained unchanged. From these results, we conclude that genistein induces apoptosis in NSCLC cells through a p53-independent pathway and, thus, may act as an anticancer agent.

Induction of apoptosis in breast cancer cells MDA-MB-231 by genistein

Breast cancer is the most common cancer among American women, whereas Asian women, who consume a traditional diet high in soy products, have a relatively low incidence. Genistein is a prominent isoflavonoid in soy products and has been proposed as the agent responsible for lowering the rate of breast cancer in Asian women. We investigated the effects of genistein on cell growth and apoptosis-related gene expression in breast cancer cells MDA-MB-231. We found up-regulation of Bax and p21WAF1 expressions and down-regulation of Bcl-2 and p53 expression in genistein-treated cells. Furthermore, DNA ladder formation, CPP32 activation, and PARP cleavage were observed after treatment with genistein, indicating apoptotic cell deaths. Flow cytometry with 7-amino actinomycin D staining showed that the number of apoptotic cells increased with longer treatment of genistein. From these results, we conclude that genistein inhibits the growth of MDA-MB-231 breast cancer cells, regulates the expression of apoptosis-related genes, and induces apoptosis through a p53-independent pathway. The up-regulation of Bax and p21WAF1 may be the molecular mechanisms by which genistein induces apoptosis, however, further definitive studies are needed. These results suggest that genistein may be a potentially effective chemopreventive or therapeutic agent against breast cancer.

Genistein-induced upregulation of p21WAF1, downregulation of cyclin B, and induction of apoptosis in prostate cancer cells

Increased soy consumption in Asian diets, resulting in increased serum isoflavone levels, has been associated with a decreased risk for prostate adenocarcinoma (PCa). The isoflavone genistein is believed to be the anticancer agent found in soy, and significant levels of genistein have been detected in human prostatic fluid, implicating the role of genistein in PCa prevention. Recent studies have demonstrated genistein's ability to inhibit cell growth and induce apoptosis in several cell lines; however, the molecular mechanisms of genistein's effect are not known. We have evaluated the mechanism by which genistein may inhibit PCa cell growth. Here we report that genistein inhibits PCa cell growth in culture in a dose-dependent manner, which is accompanied by a G2/M cell cycle arrest. Cell growth inhibition was observed with concomitant downregulation of cyclin B, upregulation of the p21WAF1 growth-inhibitory protein, and induction of apoptosis. Collectively, these results provide experimental evidence for a novel effect of genistein on cell cycle gene regulation, resulting in the inhibition of cell growth and ultimate demise of tumor cells.

Structural alteration of p53 protein correlated to survival in patients with pancreatic adenocarcinoma

Mutations in the p53 tumor-suppressor gene represent the most common form of genetic alterations found in diverse types of human cancer. The majority of the mutations occur in the core domain, which contains the sequence-specific DNA-binding site. They may result in loss of DNA binding and disability of transcriptional activation of genes involved in cell-cycle regulation. Analysis of the protein-structure model of these mutations can provide clues to the function of specific regions of p53 and to the clinical significance of p53 mutation. We examined 68 cases of pancreatic adenocarcinoma for p53 mutation and mutant protein-structure model by polymerase chain reaction-single-strand conformational polymorphism (PCR-SSCP), PCR-DNA sequencing, and computer-generated protein modeling. Twenty (29.41%) of 68 cases showed p53 mutation. Statistical analysis showed there was no significant difference in survival between p53 mutation and wild-type p53 (median survival, 12 vs. 13 months; p = 0.2034). Among p53 mutations, nine mutations were located at or near the DNA-binding site, and the protein structures of the DNA-binding site were changed. Patients in this group had a shorter median survival compared with those with mutation far from the DNA-binding site (median survival, 5 vs. 15 months; p = 0.0435). We conclude that detecting and modeling the p53 gene mutation may be used as a tool in predicting the clinical course of patients diagnosed with pancreatic adenocarcinoma.

Induction of apoptosis in breast cancer cells by TPA

Bcl-2, Bax and p53 gene products have been linked to programmed cell death pathways. p21WAF1 has been shown to mediate p53-induced cell cycle arrest and to inhibit cyclin-dependent kinase activity. We have analysed the expression of these genes and apoptosis induced by 12-O-tetradecanoyl-phorbol-13-acetate (TPA) in several human breast cancer cell line. We found up-regulation of p21WAF1 and Bax expressions, however, the expressions of p53 and Bcl-2 genes remained unchanged in TPA-treated cells. Furthermore, DNA ladder formation and PARP cleavage were observed after treatment for 24 h, indicating apoptotic cell death. Flow cytometry with 7-amino actinomycin D staining showed that the number of apoptotic cells increased with longer treatment of TPA. From these results, we conclude that TPA is not only a tumor promoter, but also induces apoptosis in breast cancer cells. TPA-induced apoptosis appears to be mediated through a p53-independent pathway, and the up-regulation of p21WAF1 and Bax may be the molecular mechanisms by which TPA induces apoptosis.

Genistein-induced G2-M arrest, p21WAF1 upregulation, and apoptosis in a non-small-cell lung cancer cell line

Lung cancer is the leading cause of cancer-related death in the world, with increasing incidence in many developed countries. Epidemiological data suggest that consumption of soy products (the isoflavone genistein) may be associated with a decreased risk of breast and prostate cancer; however, such studies are not available for lung cancer. We investigated cell growth inhibition, modulation in gene expression, and induction of apoptosis by genistein in H460 non-small lung cancer cells. Genistein inhibited H460 cell growth in a dose-dependent manner. Flow-cytometric analysis showed that 30 microM genistein arrested cell cycle progression at the G2-M phase. 4,6-Diamidino-2-phenylindole staining, flow-cytometric analysis, and DNA laddering were used to investigate apoptotic cell death, and the results show that 30 microM genistein can cause typical DNA laddering, a hallmark for apoptosis. In addition, flow cytometry and 4,6-diamidino-2-phenylindole staining showed induction of apoptosis by genistein. Our investigation also demonstrated the modulation of p21WAF1 by Western blot analysis of cell lysates obtained from cultured cells treated with 30 and 50 microM genistein for 24, 48, and 72 hours. Simultaneously, immunocytochemical staining was conducted for the expression of p21WAF1 protein. Our results showed that genistein can upregulate p21WAF1 expression in genistein-treated cells. From these results, we conclude that genistein may act as an anticancer agent, and further studies may prove its efficacy in non-small lung cancer cells. Thus the biological effects of genistein may, indeed, be due to the modulation of cell growth, cell death, and cell cycle regulatory molecules.

Molecular analysis of the p53 gene in pancreatic adenocarcinoma

Mutations in the p53 tumor suppressor gene are the most common genetic alterations found in human cancer. Most mutations are accompanied by stabilization of the protein, which renders the mutations detectable through immunohistochemical techniques. The immunoreactivity of p53, however, might not correlate with the result of p53 DNA sequencing. In order to explain the discrepancy, we studied the p53 expressions, mutations, and changes of the three-dimensional protein structure of mutant p53 in a series of 61 pancreatic adenocarcinoma specimens using immunohistochemistry, polymerase chain reaction-single strand conformation polymorphism (PCR-SSCP), DNA sequencing, and computerized protein modeling. PCR-SSCP followed by DNA sequencing of the p53 gene showed mutations in 31.2% (19 of 61) of the pancreatic adenocarcinomas. Eight of 19 cases showed p53 immunopositivity. These mutations were located on the surface of the three-dimensional structure or formed unfolded proteins, which were easily recognized by the antibody. Among other mutations in which p53 was immunonegative, five cases with deletions and insertion caused frameshift and formation of severely truncated p53 protein structures unreactive with the antibody used. In three cases with point mutations, the mutant amino acids were located in the core of the tightly packed beta sandwich inaccessible to the antibody. Three silent mutations were immunonegative, corresponding with the absence of amino acid changes. These results strongly suggest that the analysis of a computer-generated p53 three-dimensional model based on DNA sequencing data can assist in evaluating the significance of p53 immunostaining and mutations for clinical applications.