Aptamer proteomics for biomarker discovery in heart failure with reduced ejection fraction

Background

Though current heart failure (HF) biomarkers are highly prognostic, systematically characterizing associations between circulating proteins and risk of subsequent events may improve clinical risk prediction and illuminate new biological pathways. Large-scale assays measuring thousands of proteins now enable unbiased proteomic investigation in clinical trials.

Purpose

To identify and replicate serum proteins associated with HF events in patients with chronic HF with reduced ejection fraction (HFrEF), and to develop and validate a proteomic risk score.

Methods

Serum levels of 4076 proteins were measured at baseline in the ATMOSPHERE (n=1261, 487 events over 6 years) and PARADIGM-HF (n=1257, 287 events over 4 years) trials of chronic HFrEF using a modified aptamer-based proteomics assay. Proteins associated with the primary endpoint, HF hospitalization or cardiovascular death, were identified in the ATMOSPHERE discovery cohort (false discovery rate<0.05) by Cox regression adjusted for age, sex, treatment arm, and anticoagulant use, and replicated in PARADIGM-HF (Bonferroni-corrected p<0.05). A proteomic risk score was derived in ATMOSPHERE using Cox LASSO penalized regression and evaluated in PARADIGM-HF compared to the MAGGIC clinical risk score and N-terminal pro-B-type natriuretic peptide (NT-proBNP). For proteins associated with the primary endpoint, pathway analysis was conducted using Ingenuity Pathway analysis and an exploratory two-sample Mendelian randomization was performed using genetic and outcome data from both trials and protein quantitative trait loci from deCODE to infer which identified proteins contribute to HF prognosis.

Results

We identified 377 serum proteins associated with the primary endpoint in ATMOSPHERE and replicated 167 in PARADIGM-HF. Prognostic proteins included known HF biomarkers Growth Differentiation Factor 15, NT-proBNP, and Angiopoietin-2, and also a previously unrecognized HF biomarker: Sushi, Von Willebrand Factor Type A, EGF And Pentraxin Domain Containing 1 (SVEP1) (HR 1.60 [95% CI 1.44–1.79] per standard deviation [SD], p=2x10–17) (Table 1). Proteins related to hepatic fibrosis, granulocyte adhesion, and inhibition of matrix metalloproteinases were over-represented. A 64-protein risk score derived in ATMOSPHERE predicted clinical events in PARADIGM-HF with greater discrimination (c-statistic 0.70) than the MAGGIC clinical score (c-statistic 0.61), NT-proBNP (c-statistic 0.65), or both (c-statistic 0.66) (Figure 1). Genetically predicted levels of NT-proBNP, WISP2, FSTL1, and CTSS were associated with the primary endpoint by Mendelian randomization.

Conclusions

We identify SVEP1, an extracellular matrix protein known to cause inflammation in vascular smooth muscle cells, as a previously unrecognized HF biomarker. A 64-protein score improved risk discrimination compared with NT-proBNP and may assist in identifying high-risk patients for clinical trials or disease management programs.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): The ATMOSPHERE and PARADIGM-HF trials were sponsored by Novartis

Trajectory of pulmonary congestion by lung ultrasound in patients with acute myocardial infarction and association with cardiac structure and function

Background

The PARADISE-MI trial examined the efficacy of sacubitril/valsartan in patients with acute myocardial infarction (AMI) complicated by reduced left ventricular ejection fraction (LVEF), pulmonary congestion or both. Little is known about the trajectory and echocardiographic correlates of pulmonary congestion in this population.

Purpose

We sought to assess the trajectory of pulmonary congestion using lung ultrasound (LUS) and its association with cardiac structure and function in a subset of patients enrolled in PARADISE- MI.

Methods

Participants underwent 8-zone LUS at baseline and 8 months. B-lines were quantified offline, blinded to treatment group, clinical findings, timepoint and outcomes by a core laboratory. Paired t-tests, chi-squared tests, and linear regression analyses were conducted.

Results

Among 152 patients (median age 65 years, 32% women, 35% obese, mean LVEF 41%), any B-lines were detectable in 87%, the median sum of B-lines in 8 zones was 4 [IQR 2–8], and 67% had ≥3 B-lines indicative of congestion. Greater number of B-lines at baseline was associated with larger left atrial (LA) size, higher E/e' and E/A ratios, greater degree of mitral regurgitation, worse right ventricular (RV) systolic function, and higher tricuspid regurgitation velocity (P trend <0.05 for all) (Figure 1). Among 115 patients with 8-month LUS data, there was a significant decline in number of B-lines from baseline (mean ± SD: −1.6±7.3; p=0.018). Adjusted for baseline, B-lines at follow-up were on average 6 (95% CI: 3, 9) higher in a patient who experienced an intercurrent heart failure (HF) event than a non-HF patient (p=0.001). Among 75 patients with ≥3 B-lines at baseline, a decrease in B-lines to <3, indicating decongestion, occurred in 37% and was similar in the sacubitril/valsartan and ramipril groups (36% vs. 39%, p=0.83).

Conclusions

In this post-AMI cohort, sonographic B-lines, indicating pulmonary congestion, were common at baseline and were significantly higher at follow-up in those who developed HF. Worse pulmonary congestion at baseline was associated with prognostically important echocardiographic markers of LV filling pressure, pulmonary pressure, and RV function.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Novartis

Prognostic implications of NYHA class and NT-proBNP levels in mild heart failure: a PARADIGM-HF analysis

Background

Treatment recommendations for heart failure (HF) with reduced ejection fraction are primarily centered on New York Heart Association (NYHA) classification, such that apparently asymptomatic patients might not be eligible for disease-modifying therapies. NYHA classification, however, may be particularly limited to discriminate mild forms of HF.

Purpose

The present study aimed to determine the relationship between NYHA classification and an objective measure of HF severity (N-terminal pro–B-type natriuretic peptide [NT pro-BNP]), and their association with long-term prognosis in the PARADIGM-HF trial.

Methods

We compared PARADIGM-HF patients classified as NYHA class I, II, and III at randomization (NYHA class IV patients or with unavailable NYHA class were excluded [n=73]). We present kernel density estimation (KDE) plots–a non-parametric way to describe the underlying distribution of a variable–to compare NT-proBNP levels across NYHA classes. Logistic regression and the area under the receiver operating characteristic curve (AUC) were used to assess the ability to predict a patient's NYHA class using NT-proBNP levels. Time-to-event data were calculated with Kaplan–Meier estimates and NYHA class were further stratified by median baseline NT-proBNP (< or ≥1600 pg/ml). The primary outcome was cardiovascular death or first HF hospitalization.

Results

8326 patients were included in this analysis (median age, 64 years; women, 22%; and median left ventricular ejection fraction, 30%). Of 389 patients classified as NYHA class I at randomization, 228 (59%) changed functional class during the first year after randomization. For log-transformed NT-proBNP, KDE overlapped substantially across NYHA classes (Figure 1A). NT-proBNP levels were a poor predictor of NYHA classification: for NYHA class I vs. II, AUC (95% confidence interval [CI]) was 0.51 (0.48–0.54); for NHYA I vs. III, 0.57 (0.54–0.60); and for NYHA II vs. III, 0.56 (0.54–0.57). NYHA class III patients displayed a distinctively higher rate of cardiovascular deaths or first HF hospitalizations (Figure 1B). NYHA class I and II patients revealed lower event rates that were not significantly different (NYHA II vs. I, HR 1.24 [0.97–1.58]). Stratification by NT-proBNP levels identified subgroups with distinctive risk, such that NYHA I patients with high NT-proBNP levels (n=175) had a higher event rate than patients with low NT-proBNP with any NYHA class (Figure 1C).

Conclusion

NYHA class I and II patients overlapped substantially in objective HF measures and long-term prognosis. NYHA classification remains a powerful predictor of cardiovascular events but might be limited to differentiate mild forms of HF, as apparently asymptomatic patients based on physician-defined functional class might become symptomatic within a year and conceal subjects at substantial risk for adverse outcomes.

Funding Acknowledgement

Type of funding sources: None.

Global differences in heart failure with preserved ejection fraction: the paragon-hf trial

Background

Heart failure with preserved ejection fraction (HFpEF) is a global public health problem with important regional differences. We investigated these differences in the PARAGON-HF trial, the largest, most inclusive global HFpEF trial.

Methods

We studied differences in clinical characteristics, outcomes and regional treatment effects of Sacubitril/Valsartan in 4796 patients with HFpEF from the PARAGON-HF trial, grouped according to geographic region.

Results

Regional differences in patient characteristics and comorbidities were observed (Figure 1): patients from Western Europe were oldest (75±7 years) with the highest prevalence of atrial fibrillation (36%); Central/Eastern European patients were youngest (71±8 years) with the highest prevalence of coronary artery disease (CAD, 49%); North American patients had the highest prevalence of obesity (64%) with metabolic syndrome; Latin American patients were youngest and had a high prevalence of obesity (53%); Asia-Pacific patients had a high prevalence of diabetes (44%) despite low prevalence of obesity (26%). Rates of the primary composite endpoint of total hospitalizations for HF and death from cardiovascular causes was lowest in patients from Central Europe (9 per 100 patient years) and highest in patients from North America (28 per 100 patient years), which was primarily driven by a greater number of total hospitalizations for HF and independent of confounders. In the total population, sacubitril–valsartan did not result in a significantly lower rate of total hospitalizations for heart failure and death from cardiovascular causes with no significant heterogeneity in treatment response to sacubitril-valsartan across regions.

Conclusion

This first report on regional differences in the largest prospective global trial in HFpEF suggests substantial regional heterogeneity with respect to phenotype, outcomes and quality of life.

Figure 1

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Study funded by Novartis

Effect of sacubitril/valsartan on cognitive function in patients with HFpEF: a prespecified analysis of PARAGON-HF

Background

A theoretical concern has been raised about detrimental effects of sacubitril/valsartan (sac/val) on cognitive function as neprilysin is one of many pathways involved in clearance of amyloid beta peptides from brain tissue.

Purpose

To examine effect of sac/val, compared with valsartan, on cognitive function in patients with heart failure (HF) and preserved ejection fraction (HFpEF).

Methods

In the PARAGON-HF trial, cognitive function was tested in a subgroup of patients at baseline and follow-up, using Mini-Mental State Examination [MMSE] having a maximum score of 30 (higher scores reflect better cognitive function). Change in MMSE score from baseline to 96 wks was a prespecified exploratory endpoint. Other post hoc analyses included “cognitive decline” (fall in MMSE ≥3 pts) and assessment of cognition-related adverse events (AEs).

Results

Among 2895 patients (60% of total) in PARAGON-HF with baseline MMSE measurement, mean (SD) score was 27.4 (3.0) in patients receiving sac/val (1453) and 27.4 (2.9) in patients receiving valsartan (1442). There was no difference between sac/val and valsartan in MMSE score change from baseline to wk 96: sac/val −0.02 (SE 0.07) and valsartan 0.00 (0.07); between-treatment difference −0.02 (95% CI: −0.22 to 0.18); p-value = 0.83. Cognitive decline at 96 weeks occurred in 115 of 1071 evaluable patients (10.7%) in sac/val group and 121 of 1053 patients (11.5%) in valsartan group; risk ratio 0.97 (0.75–1.26), p-value = 0.82. Cognition-related AEs were more frequent, than in PARADIGM-HF (likely as patients in PARAGON-HF were older) but, as in PARADIGM-HF, did not differ between sac/val and comparator treatment (Table).

Conclusions

Cognitive change, measured by MMSE, did not differ between treatment with sac/val & valsartan in patients with HFpEF.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): PARAGON-HF study was funded by Novartis Pharma.

Serum uric acid, influence of sacubitril/valsartan, and cardiovascular outcomes in heart failure with preserved ejection fraction: PARAGON-HF

Background

Serum uric acid (SUA) is a biomarker of several pathobiologies relevant to the pathogenesis of heart failure with preserved ejection fraction (HFpEF), though by itself may also worsen outcomes. In HF with reduced EF, SUA is independently associated with adverse outcomes and sacubitril/valsartan reduces SUA compared to enalapril. These effects in HFpEF have not been delineated.

Purpose

To determine the prognostic value of SUA, relationship of change in SUA to quality of life and outcomes, and influence of sacubitril/valsartan on SUA in HFpEF.

Methods

We analyzed 4,795 participants from the Prospective Comparison of ARNI with ARB Global Outcomes in HF with Preserved Ejection Fraction (PARAGON-HF) trial. We related baseline hyperuricemia to the primary outcome (CV death and total HF hospitalization), its components, myocardial infarction or stroke, and a renal composite outcome. At the 4-month visit, the relationship between SUA change and Kansas City Cardiomyopathy Questionnaire overall summary score (KCCQ-OSS) and several biomarkers including N-terminal pro-B-type natriuretic peptide (NT-proBNP) were also assessed. We simultaneously adjusted for baseline and time-updated SUA to determine whether lowering SUA was associated with clinical benefit.

Results

Average age was 73±8 years and 52% were women. After multivariable adjustment, hyperuricemia was associated with increased risk for most outcomes (primary outcome HR 1.61, 95% CI 1.37, 1.90, Fig 1A). The treatment effect of sacubitril/valsartan for the primary outcome was not modified by baseline SUA (interaction p=0.11). Sacubitril/valsartan reduced SUA −0.38 mg/dL (95% CI: −0.45, −0.31) compared with valsartan (Fig 1B), with greater effect in those with baseline hyperuricemia (−0.50 mg/dL) (interaction p=0.013). Change in SUA was independently and inversely associated with change in KCCQ-OSS (p=0.019) and eGFR (p<0.001), but not NT-proBNP (p=0.52). Time-updated SUA was a stronger predictor of adverse outcomes over baseline SUA.

Conclusions

SUA independently predicts adverse outcomes in HFpEF. Sacubitril/valsartan significantly reduces SUA compared to valsartan, an effect that was stronger in those with higher baseline SUA, and reducing SUA was associated with improved outcomes.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Novartis

A randomized, double-blind, placebo-controlled trial of tegaserod in female patients suffering from irritable bowel syndrome with constipation

BACKGROUND

Irritable bowel syndrome is a common functional gastrointestinal disorder which affects up to 20% of the population, with a predominance in females.

AIM

To evaluate the efficacy and safety of tegaserod in female patients with irritable bowel syndrome characterized by symptoms of abdominal pain/discomfort and constipation.

METHODS

In a randomized, double-blind, multicentre study, 1519 women received either tegaserod, 6 mg b.d. (n = 767), or placebo (n = 752) for 12 weeks, preceded by a 4-week baseline period without treatment and followed by a 4-week open withdrawal period. The primary efficacy evaluation was the patient's symptomatic response as measured by the Subject's Global Assessment of Relief. Other efficacy variables included abdominal pain/discomfort, bowel habits and bloating.

RESULTS

Tegaserod produced significant (P < 0.05) improvements in the Subject's Global Assessment of Relief and other efficacy variables. These improvements were seen within the first week, and were maintained throughout the treatment period. After withdrawal of treatment, the symptoms rapidly returned. Overall, tegaserod was well tolerated. Diarrhoea was the most frequent adverse event; however, this led to discontinuation in only 1.6% of tegaserod-treated patients.

CONCLUSIONS

Tegaserod, 6 mg b.d., produced rapid and sustained improvement of symptoms in female irritable bowel syndrome patients and was well tolerated.

Transdermal fentanyl for chronic pain in AIDS: a pilot study

This prospective, open-label, before-after trial was designed to compare the efficacy of oral opioids with that of transdermal fentanyl in severe AIDS-related chronic pain, as well as assess barriers, patient satisfaction, and side effects. Thirty-five sequentially selected male and female outpatients with AIDS who were at least 18 years old were enrolled. All had chronic pain requiring continuous treatment with > or = 45 mg/day oral morphine or an equivalent. Eighteen of the patients had a history of chemical dependency. Baseline data were collected while patients received their previously prescribed opioid; assessments were made again after a stable transdermal fentanyl dose (25--300 microg/h) had been maintained for 15 days. Patients completed the International Association for the Study of Pain Classification of Chronic Pain Syndromes questionnaire, the Brief Pain Inventory, and a Satisfaction With Pain Medication questionnaire for assessing pain intensity, relief, and interference with normal functioning. With transdermal fentanyl, pain severity scores decreased significantly, mean pain relief scores increased, and daily functioning measures improved significantly. Most adverse events were mild and unrelated to fentanyl use. Transdermal fentanyl was effective for chronic pain in both chemically dependent and non-chemically dependent patients with AIDS.

An alternative algorithm for dosing transdermal fentanyl for cancer-related pain

Many cancer patients are undermedicated and inappropriately managed for pain, leading to a diminished quality of life. Patients with moderate to severe pain often require opioid analgesics. Recently published guidelines emphasize individualization of opioid treatment to provide the drug and route of administration that meet the needs of the particular patient. Intolerable side effects, ineffective pain relief, or a change in the patient's clinical status can dictate the need for a new pain management regimen. Physicians must be able to readily quantify relative analgesic potency when converting from one opioid to another or from one route of administration to another. Transdermal fentanyl (Duragesic) is an opioid agonist that has been shown to be safe and effective for the treatment of cancer pain. However, clinicians should realize that the manufacturer's recommendations for equianalgesic dosing of transdermal fentanyl may result in initial doses that are too low in some patients, and in a titration period that is too long. Under these circumstances, the patient is likely to experience unrelieved pain. An alternative dosing algorithm that considers both a review of the literature and our combined clinical experience with transdermal fentanyl should help clinicians individualize the treatment of pain.

Embolization of neurosurgical lesions involving the ophthalmic artery

OBJECTIVE

A number of anteriorly located cranial base and extracranial lesions receive their vascular supply wholly or in part from the ophthalmic artery, and embolization of the ophthalmic artery can be helpful in the management of these lesions, either as the primary treatment or as an adjunct to surgery. We present situations in which the embolization of lesions involving the ophthalmic artery was performed to effect a partial or total cure of the lesion.

METHODS

Twelve patients underwent a total of 15 embolization attempts on lesions involving the ophthalmic artery. Four patients had arteriovenous malformations of the orbit, four had dural arteriovenous fistulae, two had orbital meningiomas, one had a planum sphenoidale meningioma, and one had a juvenile nasal angiofibroma. In each case, a Tracker No. 18 microcatheter (Target Therapeutics, Inc., Fremont, CA) was navigated into the ophthalmic artery using a steerable guidewire and digital road mapping. Embolic agents included polyvinyl alcohol particles ranging from 350 to 1500 microm in diameter, 2-mm platinum microcoils, and n-butyl-cyanoacrylate. In 12 of 15 cases, lidocaine and amytal provocation tests were conducted before any attempt at embolization to assess the role of the ophthalmic artery in vision.

RESULTS

Embolization was successfully performed in the 14 situations in which it was attempted. Positive results of two lidocaine/amytal tests were noted. In one case, embolization was not attempted. In the other case, a larger caliber embolic agent (2-mm platinum coils) was used. A single transient decrease in visual acuity lasting 4 days was the only embolization-related complication.

CONCLUSION

Proper case selection, judicious use of embolic agents, and use of provocative testing can result in safe embolization of lesions supplied by the ophthalmic artery.

Pain management guidelines: implications for managed care--a roundtable discussion

One of the most important concerns of patients with cancer, particularly those with metastatic disease, is "Will I be in constant pain?" This is a similar concern voiced by patients with late-stage human immunodeficiency virus infection. The management of chronic pain has enormous implications on a patient's ability to function and on his or her quality of life. In June 1996, Medical Interface convened a panel of experts in Chicago to discuss pain management therapies, guidelines, and how these issues will affect, and be affected by, the managed care environment.

Pain management for the AIDS patient

The relief of pain in persons with HIV disease, while similar to other patient populations such as cancer patients, has some unique aspects. Pain must be a focus, and a priority, of care in persons with HIV disease along with treatment of the underlying HIV infection and the complications of immune compromise. Pain in patients with AIDS is very prevalent and often undertreated. Pain contributes to psychological and functional morbidity in AIDS. At the present time, the guidelines developed for treatment of cancer pain are used in patients with HIV disease, with the recognition that neuropathic pain should be treated differently from nociceptive pain. A multidisciplinary approach to pain management is optimal; however, consultations with pain specialists are adequate for management of pain in most patients, including those with HIV disease. Approaches to management of pain in patients with HIV disease are: Localize and characterize pain Work up possible etiologies Rule out infections and malignancies Be aware of multiple etiologies Explore the psychological/emotional contribution to pain Perform a thorough history and physical examination including medication history, history of substance use/abuse, and neurological and psychological assessments Treat the medical and psychological causes of pain Use appropriate pain medications in adequate doses Consult specialists in pain management, when necessary.

Aggressive angiomyxoma: a clinicopathologic study of 29 female patients

BACKGROUND

Aggressive angiomyxoma is an uncommon mesenchymal tumor that preferentially involves the pelvic and perineal regions of females. Since its initial description in 1983, approximately 65 cases have been reported in the English literature.

METHODS

The clinical and pathologic features of 29 cases of aggressive angiomyxoma were evaluated in a review of archival material from the Armed Forces Institute of Pathology (1960-1992). Histochemical stains for mucosubstances and immunohistochemistry (avidin-biotin complex method) were utilized to characterize the neoplasms further.

RESULTS

All patients were females, between 16 and 70 years (median; 34 years). The soft tissues of the pelvis, perineum, vulva, buttock, retroperitoneum, and inguinal regions were involved. The majority of the tumors were > or = 10 centimeters in greatest dimension. Follow-up ranging from 8 to 198 months (mean, 93 months; median, 95 months) was available for 22 patients. Eight patients developed recurrent tumor, from 10 months to 7 years after the initial resection. No patient developed metastases and there were no tumor related deaths. Histologically, the neoplasms were sparsely to moderately cellular and predominantly composed of bland, relatively nondescript. stellate and spindled cells embedded in a loosely collagenized matrix with scattered vessels of varied caliber. A few cases contained some tumor cells with more abundant eosinophilic cytoplasm that raised the possibility of focal smooth muscle differentiation. The tumor matrix was no more than weakly reactive for mucosubstances; thus, while glycosaminoglycans are present to a limited extent, edema fluid appears to be a major component of the noncollagenous stroma. The neoplastic cells were at least focally immunoreactive for desmin (22/22), smooth muscle actin (19/20), muscle specific actin (16/19), vimentin (17/17), CD34/QBEND-10 (8/16), and estrogen (13/14) and progesterone (9/10) receptor. All of the examined tumors were negative for S100 protein (20/20). Ki67 (MIB1) immunoreactivity was present in <1% of the tumor nuclei in all 16 cases tested.

CONCLUSIONS

Aggressive angiomyxoma is a distinctive, locally aggressive, mesenchymal tumor that appears to be relatively site specific and has a peak incidence in females in the fourth decade of life. There is a strong propensity for local recurrence but metastatic disease has not been reported. Since the first evidence of recurrence may be many years after the initial resection, long term follow-up is required. The neoplastic cells of aggressive angiomyxoma exhibit fibroblastic and myofibroblastic features and appear to be hormonally influenced. The possibility that the progenitor cell has a capacity for smooth muscle differentiation is raised.

Atypical apocrine adenosis of the breast: a clinicopathologic study of 37 patients with 8.7-year follow-up

BACKGROUND

Apocrine metaplasia is occasionally superimposed on sclerosing adenosis (apocrine adenosis) in breast biopsies, and cytologic atypia is sometimes present (atypical apocrine adenosis). The long term risk of patients developing breast carcinoma subsequent to the diagnosis of this lesion is unknown.

METHODS

Atypical apocrine adenosis was defined as apocrine adenosis with enlarged nucleoli and a greater than threefold variation in nuclear area. Lesions with recognizable cytoarchitectural patterns of intraductal carcinoma were excluded. Surveillance, Epidemiology and End Results (SEER) data were used as the reference population for calculations of relative risk.

RESULTS

Thirty-seven women with atypical apocrine adenosis had a mean follow-up of 8.7 years. Four patients developed invasive ductal carcinoma of the breast (3 ipsilateral, 1 contralateral) after a mean of 5.6 years. The relative risk of developing carcinoma was 5.5 (95% confidence interval [CI], 1.9-16). All patients who developed carcinoma were older than age 60 at the time of breast biopsy showing atypical apocrine adenosis, and carcinoma developed at a mean age of 70 years. In the older than 60 years age group (11 patients), the relative risk of developing carcinoma was 14 (95% CI, 4.1-48).

CONCLUSIONS

Atypical apocrine adenosis confers an increased risk of developing breast carcinoma in women older than age 60, and the risk in younger women is probably low. Some cases of atypical apocrine adenosis may represent in situ apocrine carcinomas that are difficult to diagnose because of the absence of the usual architectural features of intraductal carcinoma.

Primary diffuse large B-cell lymphoma of the breast. A clinicopathologic study of 31 cases

Primary non-Hodgkin's lymphoma of the breast is a rare neoplasm for which survival data vary among the reported studies. Thirty-one cases of diffuse large B-cell lymphoma of the breast, which had been seen in consultation from 1973 to 1985 at our institution, were reviewed. This represents the largest number of lymphomas of this histologic subtype reported to date in the English literature. Histologic examination and immunophenotypic analysis were performed and the results were correlated with clinicopathologic data. The patient population consisted of 29 females and 2 males with a mean patient age of 58.2 years. At the time of diagnosis, 26 patients had unilateral involvement (16 left, 10 right), and 5 had bilateral disease. Mean tumor size was 3.8 cm. Histologically, all cases showed a diffuse large B-cell lymphoma as classified by the Revised European-American Classification of Lymphoid Neoplasms (R.E.A.L Classification). Immunophenotypic studies on paraffin sections confirmed a B-cell lineage in every case. The majority of patients received chemotherapy and/or radiation therapy. The median survival was 36 months, confirming that this neoplasm has a poor prognosis.

Adenosarcoma of the uterine cervix: a clinicopathological study of 12 cases

The clinical and pathologic features of 12 cervical adenosarcomas from the files of the Armed Forces Institute of Pathology are described. The patients ranged in age from 13 to 67 years (mean 37). The majority (58%) presented with abnormal bleeding. All tumors were located in the cervix and consisted of soft, tan, polypoid or papillary masses ranging in size from 1.5 to 4.5 cm. Microscopically, they showed a biphasic pattern with mesenchymal and epithelial components. There was a characteristic stromal condensation below the epithelial surface and around glandular structures. The cytologic atypia of stromal cells was 1+ in three, 2+ in five, and 3+ in four. The mitotic activity ranged from four to 28 (mean 7.0) mitotic figures per 10 high-power fields. One neoplasm contained cartilage and one striated muscle. Myometrial invasion was present in three. Treatment consisted of hysterectomy in nine patients and excisional biopsy in three. Two patients received radiotherapy; one before surgery and the other after hysterectomy. Two were treated with chemotherapy. Follow-up ranged from 9 months to 18.8 years. Nine patients were alive and well with no evidence of recurrent tumor at postoperative intervals of 0.8-18.8 years. One patient died 1 year after diagnosis with intraabdominal metastasis. One developed a recurrent tumor. This study demonstrates a favorable prognosis for patients with cervical adenosarcoma. Similar to patients with uterine adenosarcoma, prognosis is mostly affected by the presence of deep myometrial invasion.

The effects of nonsteroidal anti-inflammatory drugs on blood pressures of patients with hypertension controlled by verapamil

BACKGROUND

Nonsteroidal anti-inflammatory drugs may attenuate the antihypertensive effects of diuretics, beta-blockers, angiotensin-converting enzyme inhibitors, central alpha-agonists, and other vasodilators. Their effects on the antihypertensive efficacy of calcium channel blockers are inadequately studied in small numbers of patients but appear to be minimal.

METHODS

A three-phase, randomized, double-blind, placebo-controlled multicenter study included 162 patients aged 18 to 75 years with essential hypertension. After diastolic blood pressure was controlled to 90 mm Hg or less with once-daily verapamil hydrochloride, patients received ibuprofen, naproxen, or placebo matching capsules for 3 weeks, and blood pressure, heart rate, weight, and adverse effects were evaluated. A general linear model with 95% confidence intervals was used to compare each nonsteroidal anti-inflammatory drug treatment group with the placebo group.

RESULTS

No significant differences in sitting, standing, or supine blood pressure were noted with naproxen or ibuprofen compared with placebo. The percentages of patients in each treatment group with increases of 10 mm Hg or more in either systolic or diastolic blood pressure were similar. Statistically significant increases in weight were seen with both nonsteroidal anti-inflammatory drug therapies. Changes in pulse rate were not significant. The incidence of adverse effects was similar across all three treatment groups.

CONCLUSIONS

The addition of naproxen or ibuprofen to the treatment of hypertensive patients in whom blood pressure is controlled by once-daily verapamil does not cause an increase in blood pressure. Verapamil may therefore offer considerable advantages in maintaining control of blood pressure in patients who regularly receive nonsteroidal anti-inflammatory drug therapy.

A pilot, open-labelled, phase II study using oral ribavirin in the treatment of patients with chronic active hepatitis B

BACKGROUND

Ribavirin is a synthetic purine nucleoside with demonstrated antiviral activity against several DNA and RNA viruses.

OBJECTIVES

An open-labelled pilot study to evaluate the safety and effect of ribavirin in the treatment of patients with chronic active hepatitis B (CAH-B).

STUDY DESIGN

24 CAH-B patients were treated with oral ribavirin 1200 mg daily in 3 divided doses for 4 weeks. Biochemical and virological parameters were monitored at regular interval during and after treatment.

RESULTS

The serum hepatitis B e antigen (HBeAg) and HBV DNA measured by dot-blot hybridization were positive in all patients before treatment. At the end of 4 weeks of therapy, the HBV DNA levels decreased in 15 (63%) patients and became undetectable in 1 (4%) of these individuals. The mean HBV DNA decreased from 288+/-78 pg/ml at baseline to 219+/-79 pg/ml at the end of the 4 weeks of treatment (p = 0.046). Eight weeks after cessation of treatment, HBV DNA was undetectable in 10 (42%) patients, and the mean HBV DNA was 46+/-23 pg/ml (p < 0.01 when compared to mean baseline value). Seven (29%) patients seroconverted from HBeAg positive to anti-HBe positive but no patients lost hepatitis B surface antigen (HBsAg) during the 8 weeks of follow-up. At the end of 4 weeks of ribavirin treatment, serum levels of alanine aminotransferase (ALT) decreased in all but 1 patient; only 1 patient normalized serum ALT at this time. The mean serum ALT decreased significantly from 416+/-72 IU/l at baseline to 179+/-35 IU/l at the end of 4 weeks of treatment (p = 0.001). Eight weeks after cessation of therapy, the mean serum ALT value was 151+/-32 IU/l (p < 0.001 when compared to mean baseline value) and 5 (21%) patients normalized serum ALT at this time. During ribavirin treatment, the main side effect was a decrease in the hemoglobin level which returned to the pretreatment level in each instance within 2 months after discontinuance of therapy.

CONCLUSIONS

Results of this pilot study indicated that oral ribavirin was well tolerated in CAH-B patients and resulted in lowering of serum ALT and HBV DNA values. A randomized controlled trial is needed to fully evaluate the beneficial effects of ribavirin in CAH-B patients.

Additive effects of verapamil and enalapril in the treatment of mild to moderate hypertension

A factorial design was applied in this multicenter, double-blind, placebo-controlled trial of the calcium-channel blocker verapamil and the ACE inhibitor enalapril to assess the hypotensive effects of the combination compared with monotherapy, to evaluate safety, and to determine the effects on quality of life (QOL) of both drugs, alone and in combination. The study consisted of a 3 x 2 factorial design wherein 186 men and women with a sitting diastolic blood pressure (BP) of between 95 mm Hg and 114 mm Hg, after a 4-week placebo washout, were randomized to one of six treatment groups for 4 weeks of active treatment. Monotherapy with both 240 mg verapamil and 10 mg enalapril reduced systolic and diastolic BP to a similar extent and significantly more than placebo. The 240 mg verapamil + 10 mg enalapril combination was additive for both systolic and diastolic blood pressure; 120 mg verapamil + 10 mg enalapril was additive for systolic BP only. The total number of adverse events reported was similar for all six treatment groups. QOL scores were unchanged from baseline and not different between treatment groups. The combination of 240 mg verapamil and 10 mg enalapril was significantly more effective at reducing BP than either drug alone; this additivity of effect was not linked to a higher rate of adverse experiences or to a deterioration in QOL. Thus, combination therapy at lower doses may offer an alternative treatment option to higher dose monotherapy.

Management of postherpetic neuralgia

Postherpetic neuralgia is a perplexing disorder in which pain develops as a result of herpes zoster. It is a common cause of neuropathic pain and may render its effects especially on the elderly and immunocompromised. Once established, postherpetic neuralgia is resistant to most treatment modalities and can lead to much despair. Many therapeutic approaches have been attempted through the years, most with varying results. This review describes clinical manifestations including allodynia, hyperaesthesia and anaesthesia. It also reviews pharmacologic and non-pharmacologic treatment modalities including a review of anaesthetic nerve blocks, neurostimulation, acupuncture and surgical techniques.

Correlation of serum HCV RNA and alanine aminotransferase levels in chronic hepatitis C patients during treatment with ribavirin

To evaluate the effect of ribavirin on serum hepatitis C virus (HCV) RNA and alanine aminotransferase (ALT) levels, 22 patients with chronic HCV infection were treated with oral ribavirin 1200 mg daily in three divided doses for 4 weeks. At the end of 4 weeks treatment, the serum ALT decreased in all but one patient and became normal in three individuals. The mean pretreatment serum ALT was reduced significantly from 193 +/- 45 i.u./L to 95 +/- 16 i.u./L after 4 weeks therapy (P = 0.009). However, 8 weeks after cessation of treatment, the serum ALT rose to a mean value of 154 +/- 21 i.u./L. The mean pretreatment serum HCV RNA was not significantly decreased at the end of 4 weeks treatment (7.0 x 10(5) vs. 4.1 x 10(5) copies/mL, P > 0.05). However, serum HCV RNA levels were decreased in 12 and increased in 10 patients at the end of 4 weeks therapy. Eight weeks after cessation of therapy, the serum HCV RNA of 22 patients rose to a mean value of 4.9 +/- 10(5) copies/mL. Six patients who continued to have elevated serum ALT and positive HCV RNA after the initial 4 weeks treatment received oral ribavirin at the same dosage for an additional 24 weeks. The serum ALT again decreased in all six patients during therapy, but rose to pretreatment values by 8 weeks after cessation of the treatment. In addition, no significant changes were noted in the mean serum HCV RNA levels during and after 24 weeks of ribavirin therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Intraductal (intracystic) papillary carcinoma of the breast and its variants: a clinicopathological study of 77 cases

The clinical and pathological features of 77 cases of intraductal (intracystic) papillary carcinoma (IPC) of the breast are reported. It should be recognized as an intraductal carcinoma variant and distinguished from invasive papillary carcinoma. Intraductal papillary carcinoma remains a difficult diagnosis as there are four different epithelial growth patterns any of which may predominate. Low grade nuclear features occur in one third of cases, a so-called "stratified spindled cell" epithelial proliferation with bland morphology occurs in one quarter of cases, and a dimorphic population of malignant cells, which may in part be confused with myoepithelial cells, occurs in one quarter of cases. The 77 cases studied were from the 10-year interval 1970 to 1979. The effect on prognosis of cytoarchitectural features, duct wall and stromal invasion, and associated intraductal carcinoma were evaluated. The contribution of immunohistochemistry to the diagnosis using antibodies to smooth muscle actin, S-100 protein, and CAM 5.2 was examined. The 10-year survival rate was 100%, and the 10-year disease-free survival rate was 91%. Mastectomy had been performed in 72% of patients. Three of the patients developed metastases; two were alive with tumor and one died of other causes. Six patients had local recurrence in the chest wall; one was alive without disease, two were alive with tumor, and three died of other causes. An associated intraductal carcinoma of usual nonnecrotic or comedo type was present in 40% of all cases. When IPC recurred or metastasized, it did so as invasive papillary carcinoma in six of seven cases. Stromal invasion was found in 13 patients. Local recurrence developed in two of these. Invasion was not seen in any of the three patients who developed metastases. However, this may be a function of sampling as there was an average of 5.2 tumor sections per case. Patients with low grade tumors had no recurrence or metastasis, and in the absence of invasion may be treated by local excision. Patients with higher grade tumors have an increased risk of recurrence and metastasis.

Pain in hospitalized patients with AIDS: analgesic and psychotropic medications

OBJECTIVE

We undertook this study to evaluate the use of analgesic and psychotropic medication in acquired immunodeficiency syndrome (AIDS) patients with pain and to determine whether our previous findings of a high prevalence of pain in patients with AIDS who were hospitalized could be replicated. Additional factors related to pain were evaluated, such as death during hospital stay, i.v. drug abuse, and length of hospital stay.

DESIGN

One hundred thirty-nine medical charts randomly selected from 1 year of hospital admissions of patients with AIDS were reviewed in a systematic manner for pain, prescription of analgesic and psychotropic medication, patient demographics, and disease characteristics.

RESULTS

Sixty-one percent of the charts reviewed had at least one note of nonprocedural pain. Sixty-eight percent of pain patients were prescribed a nonnarcotic (most commonly acetaminophen), and 44% a narcotic. Sixty-two percent of pain patients were prescribed a psychotropic medication. Patients with pain were significantly more likely to receive an analgesic as well as psychotropic medication, particularly a sedative-hypnotic, than patients without pain. Having pain was not significantly related to other factors such as i.v. drug abuse except for length of hospital stay. Most of the previous study findings were replicated with the notable exception of the rate of prescription of psychotropics as well as acetaminophen, which increased substantially in this study.

CONCLUSIONS

Although pain is a prevalent problem in hospitalized AIDS patients, narcotics as well as antidepressants appear to be underutilized. It is suggested that medical education regarding pain management in AIDS patients is an important first step in a more aggressive approach.

Epithelioid stromal cells in lymphocytic mastitis--a source of confusion with invasive carcinoma

Fourteen examples of lymphocytic mastitis (LM) with epithelioid stromal cells characterized by formation of a palpable, hard breast mass composed of a predominantly lobulocentric lymphocytic infiltrate, stromal fibrosis, and an unusual stromal infiltrate of epithelioid cells are presented. The epithelioid cells were so prominent and abundant that the possibility of an infiltrating carcinoma was raised in three cases, and a fourth case was misinterpreted as a granular cell tumor. Interestingly, eight of the 12 women and the only male patient had long standing, insulin dependent diabetes mellitus (IDDM), whereas two had IDDM and hypothyroidism, one had hypothyroidism alone, and one had systemic lupus erythematosus. Contrary to the conclusions in a recent report, our findings indicate that these mammary changes are not exclusive to patients with IDDM, and may also occur in nondiabetic patients particularly those with autoimmune disorders. The morphologic features of the epithelioid stromal cells which have been mistaken for infiltrating carcinoma are emphasized; immunohistochemical and ultrastructural findings favoring their myofibroblastic nature are presented.

A new method for reduction of hip dislocations

Traumatic hip dislocations and dislocation of total hip arthroplasties are common injuries. Closed reduction of either a dislocated hip or a total hip arthroplasty can be a demanding procedure and may necessitate open reduction if unsuccessful or lead to further complications. These include fracture or neurovascular injury to the patient, as well as injury to the surgeon when reducing the hip. This article describes a technique that reliably reduces dislocations while minimizing complications.

Electrical properties of axons within probst bundles of acallosal mice and callosi that have reformed upon glial-coated polymer implants

Lesioning of the developing cerebral midline and corpus callosum of mice results in the formation of bilateral masses of axons known as Probst's longitudinal bundles. These ectopic axons were examined using an in vitro brain slice technique, and they were found to be functional and to have electrical properties that were similar to those of the unlesioned corpus callosum at a comparable age. When a nitrocellulose bridge is properly oriented at the site of the callosal lesion in neonates, the implant will support the migration of glia which, in turn, promote the redirection of callosal axons across the midline. These axons were also analyzed by in vitro brain slice techniques, and they were found to be functional and to have electrical properties that were similar to the unlesioned corpus callosum with respect to conduction velocity and chronaxie but dissimilar with respect to charge threshold and rheobase current.

Sphenopalatine ganglion block: clinical use in the pain management clinic

Clinical experience with the sphenopalatine ganglion (SPG) block combined with a review of prior studies led to conducting a retrospective evaluation of four patients with chronic pain treated with the SPG block. The review of case reports suggests the usefulness of SPG blocks in the pain management clinic.

Reflex sympathetic dystrophy and posttraumatic stress disorder. Multidisciplinary evaluation and treatment

Reflex sympathetic dystrophy (RSD) may co-occur with posttraumatic stress disorder (PTSD). A case study is reported of a challenging adolescent patient who presented to a chronic pain service with RSD and PTSD. A multidisciplinary approach utilizing nerve-block therapy with adjunctive pharmacologic treatment, physical rehabilitation, and behavioral/cognitive psychological therapy was employed to produce a significant reduction in pain as well as a more physically and psychologically functional adolescent. The diagnosis and treatment of each disease is essential for the successful resolution of symptoms.

Granulomatous angiopanniculitis of the breast

The clinical and pathologic features of six examples of nonnecrotizing granulomatous angiopanniculitis (GAP) of the breast are reported. The patients presented with a solitary ill-defined breast mass causing clinical suspicion of carcinoma. Histopathologically, all lesions consisted of multiple nonnecrotic, noncaseous granulomas with a giant cell component predominantly involving the subcutaneous adipose tissue, extending into the underlying mammary tissue without affecting lobules or ducts. A nonleukocytoclastic lymphocytic angiitis involved small vessels and capillaries. None of the patients had a history of an autoimmune disorder or had previous diagnoses of erythema nodosum or multiforme, leukocytoclastic or nonleukocytoclastic vasculitis, or Weber-Christian disease. Treatment was limited to biopsy in all six patients. Studies for infectious agents on specimens were negative. Five of the six patients developed one or more recurrences in the breast or elsewhere on the body. Four patients experienced spontaneous regression of their recurrent lesions. GAP appears to be a self-limited disorder of uncertain etiology which involves the breast and other sites. It may represent a variant of Weber-Christian disease, as the two diseases share similar clinical and histologic features. GAP must be distinguished from causes of granulomatous inflammation of the breast for which specific medical therapy is available.

The prevalence and management of pain in patients with AIDS: a review of 134 cases

In light of the lack of any prior systematic evaluations of the prevalence and types of pain syndromes and treatments found in patients with AIDS, a chart review study was undertaken to evaluate this issue. Fifty-two of 96 charts reviewed (54%) had at least one note on nonprocedural pain or analgesic prescription. Although chest pain was the most prevalent pain location (22%), presumably because of the high incidence of Pneumocystis carinii pneumonia, other possible AIDS-related entities, such as peripheral neuropathy and thrombophlebitis, were also found. No specific AIDS syndromes could be identified that were related to a higher incidence of pain. Nearly one-third of patients with pain received codeine (31%), others received acetaminophen (27%), and 17% of patients received acetaminophen and oxycodone HCl. Specific pain management interventions must be evaluated and applied to control the nontrivial occurrence of pain in patients who have AIDS symptoms that may be overlooked by the physician given the overwhelming disease process.

Cat-scratch disease masquerading as a solitary tumor of the breast

Cat-scratch disease in breast lymph node tissue may present as a mass lesion and require clinical investigation to rule out malignancy. Four cases involving prepectoral lymph nodes have been diagnosed at the Armed Forces Institute of Pathology, Washington, DC. Mammographic findings of a smooth-edged soft-tissue density without spiculation or calcification may suggest the diagnosis. Warthin-Starry silver impregnation of tissue sections is the preferred method of diagnosis, and should be added to the diagnostic workup of granulomatous lesions of the breast.

Increase in natural killer activity in cyclosporine-treated renal allograft recipients during rejection

Natural killer (NK) activity was assessed in a prospective fashion in 15 renal transplant recipients receiving single HLA-haplotype matched allografts and maintained on cyclosporine (CYA) immunosuppression. There was marked variability in NK activity pretransplantation in this population; however, a strong correlation (r = 0.92, p less than 0.01) was found between determinations in an individual patient upon repeated testing. No significant depression of NK activity occurred within the first 12 weeks following transplantation. Whole blood CYA levels did not correlate with NK activity. Although NK activity prior to transplantation did not predict clinical outcome of the allograft, a marked rise in NK activity was observed in patients undergoing rejection compared with those not rejecting (p less than 0.01). A large increment in activity was seen in eight of 11 rejection episodes; a similar increase was rarely seen in the absence of rejection. These results indicate that NK activity is stimulated during allograft rejection in CYA treated renal transplant recipients. It remains to be determined whether this rise in NK function represents a manifestation of alloreactivity accompanying the rejection process or whether NK cells directly contribute to allograft destruction.

Ductal metaplasia of human exocrine pancreas and its association with carcinoma

Monoclonal antibodies to cell surface markers of human exocrine pancreas were used to establish the cytotypic expression of cells forming "tubular complexes" in pancreases from six adults without carcinoma and in the nontumorous pancreatic parenchyma of 16 pancreases with carcinoma. These cells manifested duct cell determinants. In general, the presence of cells with duct cell surface markers within the acini corresponded to the normal distribution of centroacinar cells in the 30 control human pancreases (from cadaveric donors); however, foci of abnormal acini were seen in these pancreases independent of or intermingled with the "tubular complexes." The acini in these abnormal areas were formed by a core of cells and cell processes that expressed duct cell determinants. They were partially surrounded by acinar cells and showed slight or no lumenal dilation. While the causative agent(s), the cell(s) of origin, and the regression and/or progression of these lesions are yet to be determined, the replacement of acini by the spectrum of lesions composed of cells with duct cell surface marker is suggested to constitute ductal metaplasia.

Canine left ventricular function during experimental pancreatitis

Left ventricular contractility following induction of experimental pancreatitis (EP) was studied. Contractility was evaluated by analyzing the left ventricular end systolic pressure-diameter relationship (sigma ES). Sigma ES is independent of large changes in preload, afterload, and heart rate, but sensitive to changes in ventricular contractility. Following injection of 100,000 IU trypsin in 4% taurocholate into the pancreas to induce EP, seven of eight dogs survived 5 hr. These dogs exhibited an initial significant reduction in mean arterial pressure (MABP) which stabilized at 90% of control at 3-5 hr post-EP. Cardiac output (CO) dropped slowly after EP induction (from 3.08 +/- 0.43 to 2.22 +/- 0.22 liters/min) associated with no significant change in peripheral resistance. Stroke work and stroke volume were markedly depressed reflecting the changes in MABP and CO. No consistent changes in +dP/dt or -dP/dt were observed. The ratio of endo/epicardial blood flow was unchanged as was blood Ca2+ levels throughout the experiment. Ventricular contractility as reflected by sigma ES tended to improve (from 49.7 to 69.6 mm Hg/mm at 4 hr following EP). Therefore, it was concluded that these animals exhibited no loss of ventricular contractility during EP.

Intracranial metastases in prostate cancer

In a clinicopathologic review of 126 autopsied cases with prostate cancer, 14 demonstrated intracranial metastases. Only two of nine symptomatic patients were evaluated for suspected central nervous system metastases prior to death, and five asymptomatic patients were incidentally found to have metastases at autopsy. Intracranial metastases in prostate cancer occur in the setting of widespread disease, and tissue pathology may reveal moderately to poorly differentiated tumor (11 of 14 cases).

Renal failure secondary to angiomyolipoma. Case of Forme-Fruste tuberous sclerosis

A fifty-four-year-old woman without the clinical features of tuberous sclerosis underwent nephrectomy at age thirty-three years for angiomyolipoma, and twenty-one years later severe renal failure developed. At necropsy the remaining kidney had extensive angiomyolipomatous involvement; not until the brain was examined was the diagnosis of tuberous sclerosis made. To date, this would appear to be the third case without clinical tuberous sclerosis in which renal involvement was the sole clinical expression of tuberous sclerosis, and the seventh reported instance of renal failure due to renal angiomyolipomatous hamartomatous transformation.

Naked megakaryocyte nuclei: a clue to malignancy

Bone marrow smears from 63 patients with various malignancies and a series of 51 controls were examined for the presence and percentage of naked megakaryocyte nuclei (NMN). Patients with malignancy had more than 15% NMN, which, when compared with the incidence in controls, was statistically significant. The etiology of this artifact is unknown. It is a clue to the presence of malignancy, and might be useful in following treated cases of malignancy for evidence of relapse. NMN should not be confused with metastatic malignant cells.

Postoperative ventilatory failure in an obese, myopathic woman with periodic somnolence: A case report

An obese woman with periodic sommolence developed postoperative ventilatory problems following an uncomplicated cholecystectomy. A severe myopathic process involving the respiratory muscles was found at necropsy. A brother, who died a week later, had myotonic dystrophy.