C-C Motif Chemokine 5 Attenuates Angiotensin II-Dependent Kidney Injury by Limiting Renal Macrophage Infiltration

Inappropriate activation of the renin angiotensin system (RAS) is a key contributor to the pathogenesis of essential hypertension. During RAS activation, infiltration of immune cells into the kidney exacerbates hypertension and renal injury. However, the mechanisms underpinning the accumulation of mononuclear cells in the kidney after RAS stimulation remain unclear. C-C motif chemokine 5 (CCL5) drives recruitment of macrophages and T lymphocytes into injured tissues, and we have found that RAS activation induces CCL5 expression in the kidney during the pathogenesis of hypertension and renal fibrosis. We therefore evaluated the contribution of CCL5 to renal damage and fibrosis in hypertensive and normotensive models of RAS stimulation. Surprisingly, during angiotensin II-induced hypertension, CCL5-deficient (knockout, KO) mice exhibited markedly augmented kidney damage, macrophage infiltration, and expression of proinflammatory macrophage cytokines compared with wild-type controls. When subjected to the normotensive unilateral ureteral obstruction model of endogenous RAS activation, CCL5 KO mice similarly developed more severe renal fibrosis and greater accumulation of macrophages in the kidney, congruent with enhanced renal expression of the macrophage chemokine CCL2. In turn, pharmacologic inhibition of CCL2 abrogated the differences between CCL5 KO and wild-type mice in kidney fibrosis and macrophage infiltration after unilateral ureteral obstruction. These data indicate that CCL5 paradoxically limits macrophage accumulation in the injured kidney during RAS activation by constraining the proinflammatory actions of CCL2.

Experimental inhibition of porcupine-mediated Wnt O-acylation attenuates kidney fibrosis

Activated Wnt signaling is critical in the pathogenesis of renal fibrosis, a final common pathway for most forms of chronic kidney disease. Therapeutic intervention by inhibition of individual Wnts or downstream Wnt/β-catenin signaling has been proposed, but these approaches do not interrupt the functions of all Wnts nor block non-canonical Wnt signaling pathways. Alternatively, an orally bioavailable small molecule, Wnt-C59, blocks the catalytic activity of the Wnt-acyl transferase porcupine, and thereby prevents secretion of all Wnt isoforms. We found that inhibiting porcupine dramatically attenuates kidney fibrosis in the murine unilateral ureteral obstruction model. Wnt-C59 treatment similarly blunts collagen mRNA expression in the obstructed kidney. Consistent with its actions to broadly arrest Wnt signaling, porcupine inhibition reduces expression of Wnt target genes and bolsters nuclear exclusion of β-catenin in the kidney following ureteral obstruction. Importantly, prevention of Wnt secretion by Wnt-C59 blunts expression of inflammatory cytokines in the obstructed kidney that otherwise provoke a positive feedback loop of Wnt expression in collagen-producing fibroblasts and epithelial cells. Thus, therapeutic targeting of porcupine abrogates kidney fibrosis not only by overcoming the redundancy of individual Wnt isoforms but also by preventing upstream cytokine-induced Wnt generation. These findings reveal a novel therapeutic maneuver to protect the kidney from fibrosis by interrupting a pathogenic crosstalk loop between locally generated inflammatory cytokines and the Wnt/β-catenin signaling pathway.

Interleukin-1 Receptor Activation Potentiates Salt Reabsorption in Angiotensin II-Induced Hypertension via the NKCC2 Co-transporter in the Nephron

Hypertension is among the most prevalent and catastrophic chronic diseases worldwide. While the efficacy of renin angiotensin system (RAS) blockade in lowering blood pressure illustrates that the RAS is broadly activated in human hypertension, the frequent failure of RAS inhibition to prevent or reverse hypertensive organ damage highlights the need for novel therapies to combat RAS-dependent hypertension. We previously discovered elevated levels of the macrophage cytokine IL-1 in the kidney in a murine model of RAS-mediated hypertension. Here we report that IL-1 receptor (IL-1R1) deficiency or blockade limits blood pressure elevation in this model by mitigating sodium reabsorption via the NKCC2 co-transporter in the nephron. In this setting, IL-1R1 activation prevents intra-renal myeloid cells from maturing into Ly6C(+)Ly6G(-) macrophages that elaborate nitric oxide, a natriuretic hormone that suppresses NKCC2 activity. By revealing how the innate immune system regulates tubular sodium transport, these experiments should lead to new immunomodulatory anti-hypertensive therapies.

Competing Actions of Type 1 Angiotensin II Receptors Expressed on T Lymphocytes and Kidney Epithelium during Cisplatin-Induced AKI

Inappropriate activation of the renin-angiotensin system (RAS) contributes to many CKDs. However, the role of the RAS in modulating AKI requires elucidation, particularly because stimulating type 1 angiotensin II (AT1) receptors in the kidney or circulating inflammatory cells can have opposing effects on the generation of inflammatory mediators that underpin the pathogenesis of AKI. For example, TNF-α is a fundamental driver of cisplatin nephrotoxicity, and generation of TNF-α is suppressed or enhanced by AT1 receptor signaling in T lymphocytes or the distal nephron, respectively. In this study, cell tracking experiments with CD4-Cre mT/mG reporter mice revealed robust infiltration of T lymphocytes into the kidney after cisplatin injection. Notably, knockout of AT1 receptors on T lymphocytes exacerbated the severity of cisplatin-induced AKI and enhanced the cisplatin-induced increase in TNF-α levels locally within the kidney and in the systemic circulation. In contrast, knockout of AT1 receptors on kidney epithelial cells ameliorated the severity of AKI and suppressed local and systemic TNF-α production induced by cisplatin. Finally, disrupting TNF-α production specifically within the renal tubular epithelium attenuated the AKI and the increase in circulating TNF-α levels induced by cisplatin. These results illustrate discrepant tissue-specific effects of RAS stimulation on cisplatin nephrotoxicity and raise the concern that inflammatory mediators produced by renal parenchymal cells may influence the function of remote organs by altering systemic cytokine levels. Our findings suggest selective inhibition of AT1 receptors within the nephron as a promising intervention for protecting patients from cisplatin-induced nephrotoxicity.

Low level detection of Benzene in Food Grade Hexane by Ultraviolet Spectrophotometry

A simple, sensitive, and accurate Ultraviolet Spectrophotometric method has been developed and validated for the determination of Benzene in Food Grade Hexane. Benzene in spectroscopic grade Hexane shows vibrational fine structure having four well resolved peaks. In the wavelength range 240-270nm, peak at 255nm is considered for the method development. Beer's law was obeyed in the concentration range of 0.6-10.0μLL(-1), with correlation coefficient, 0.9999, detection limit 0.2μLL(-1) and quantitation limit 0.6μLL(-1) are established. Percentage recovery studies showed that the method was not affected by the presence of other solvents having the similar boiling range with Hexane. The method was validated by determining its accuracy and precision which proves suitability of the developed method for the routine determination of Benzene in Food Grade Hexane. The proposed method has been applied successfully for the analysis of the Food Grade Hexane.

Tumor necrosis factor-α produced in the kidney contributes to angiotensin II-dependent hypertension

Immune system activation contributes to the pathogenesis of hypertension and the resulting progression of chronic kidney disease. In this regard, we recently identified a role for proinflammatory Th1 T-lymphocyte responses in hypertensive kidney injury. Because Th1 cells generate interferon-γ and tumor necrosis factor-α (TNF-α), we hypothesized that interferon-γ and TNF-α propagate renal damage during hypertension induced by activation of the renin-angiotensin system. Therefore, after confirming that mice genetically deficient of Th1 immunity were protected from kidney glomerular injury despite a preserved hypertensive response, we subjected mice lacking interferon-γ or TNF-α to our model of hypertensive chronic kidney disease. Interferon deficiency had no impact on blood pressure elevation or urinary albumin excretion during chronic angiotensin II infusion. By contrast, TNF-deficient (knockout) mice had blunted hypertensive responses and reduced end-organ damage in our model. As angiotensin II-infused TNF knockout mice had exaggerated endothelial nitric oxide synthase expression in the kidney and enhanced nitric oxide bioavailability, we examined the actions of TNF-α generated from renal parenchymal cells in hypertension by transplanting wild-type or TNF knockout kidneys into wild-type recipients before the induction of hypertension. Transplant recipients lacking TNF solely in the kidney had blunted hypertensive responses to angiotensin II and augmented renal endothelial nitric oxide synthase expression, confirming a role for kidney-derived TNF-α to promote angiotensin II-induced blood pressure elevation by limiting renal nitric oxide generation.

Type 1 angiotensin receptors on macrophages ameliorate IL-1 receptor-mediated kidney fibrosis

In a wide array of kidney diseases, type 1 angiotensin (AT1) receptors are present on the immune cells that infiltrate the renal interstitium. Here, we examined the actions of AT1 receptors on macrophages in progressive renal fibrosis and found that macrophage-specific AT1 receptor deficiency exacerbates kidney fibrosis induced by unilateral ureteral obstruction (UUO). Macrophages isolated from obstructed kidneys of mice lacking AT1 receptors solely on macrophages had heightened expression of proinflammatory M1 cytokines, including IL-1. Evaluation of isolated AT1 receptor-deficient macrophages confirmed the propensity of these cells to produce exaggerated levels of M1 cytokines, which led to more severe renal epithelial cell damage via IL-1 receptor activation in coculture compared with WT macrophages. A murine kidney crosstransplantation concomitant with UUO model revealed that augmentation of renal fibrosis instigated by AT1 receptor-deficient macrophages is mediated by IL-1 receptor stimulation in the kidney. This study indicates that a key role of AT1 receptors on macrophages is to protect the kidney from fibrosis by limiting activation of IL-1 receptors in the kidney.

Abstract 246: Interleukin-1 Potentiates Renal Sodium Retention in Angiotensin Ii-dependent Hypertension by Preventing No-mediated Inhibition of the Na+-k+-2cl- Cotransporter

The current studies define the mechanism through which interleukin-1 receptor (IL-1R) activation exacerbates angiotensin (Ang) II-induced hypertension. We previously reported that IL-1R-deficient (KO) mice had attenuated elevations in blood pressure (BP) vs. wild-types (WT) in our hypertension model of uni-nephrectomy followed by 4 wks of Ang II infusion. As the IL-1 receptor modulates macrophage function, we blindly counted F4/80+ macrophages in KO and WT kidneys after 4 wks of Ang II. Compared to WTs, the KO kidneys contained more macrophages (13.6±1.7 vs. 17.9±0.8 per HPF; p=0.03) and had higher mRNA levels of the macrophage cytokine iNOS (1.0±0.2 vs. 1.7±0.3 au; p<0.05) that drives nitric oxide (NO) generation. As NO regulates renal sodium (Na) handling, we conducted Na balance studies during Ang II infusion. Over days 10-15 of Ang II during which WT and KO BPs separated, the KOs entered negative Na balance while that of the WTs remained positive (-16.8±16.8 vs. 34.8±7.5 μmol/day, p=0.01). Thus, the KOs were protected from Ang II-induced Na retention. To confirm that preserved NO bioavailability in the Ang II-infused KOs led to their lower blood pressures vs. WTs, we blocked NO generation in the groups with L-NAME starting on day 7 of Ang II when the WT and KO BPs were 179±3 vs. 165±6 mm Hg (p<0.01), and by day 14, the BPs had converged (186±5 vs. 185±8; p=NS). Thus, NO depletion abrogated the BP difference between groups. As NO is known to regulate activity of the Na-K-2Cl (NKCC2) cotransporter, we measured NKCC2 activity at day 10 of Ang II by quantitating urine (U) Na/Cr 3 hours after an IP injection of 0.5ml saline with or without furosemide (20mg/kg). Following saline injection alone, the KOs had a higher UNa/Cr than the WTs (237±38 vs. 120±14 mmol/mmol; p=0.01) whereas the UNa/Cr’s converged in response to furosemide (481±103 vs. 453±60; p=NS). By contrast, the UNa/Cr’s did not converge following an IP HCTZ challenge to block NCC channels (not shown). Thus, lower levels of NKCC2 activity in the IL-1R KOs protect them from Ang II-induced sodium retention. In sum, our studies define a novel immune-mediated mechanism of hypertension in which Ang II-induced stimulation of IL-1 signaling promotes renal sodium retention by limiting NO-mediated inhibition of NKCC2 activity.

Role of vaptans in the management of hyponatremia

Hyponatremia, the most commonly encountered electrolyte abnormality, affects as many as 30% of hospitalized patients. It is a powerful predictor of poor outcomes, especially in patients with congestive heart failure or cirrhosis. The failure to excrete electrolyte-free water that results from persistent secretion of antidiuretic hormone despite low serum osmolality usually underlies the development of hyponatremia. Treatment depends on several factors, including the cause, overall volume status of the patient, severity of hyponatremic symptoms, and duration of hyponatremia at presentation. This review focuses on the role of the vasopressin receptor antagonists, or vaptans, in the treatment of hyponatremia. These recently introduced agents have the unique ability to induce an aquaresis, the excretion of electrolyte-free water without accompanying solutes. After a brief historical perspective and discussion of pharmacologic characteristics of vaptans, we review the accumulated experience with vaptans for the treatment of hyponatremia. Vaptans have been shown to increase serum sodium concentrations in patients with euvolemic or hypervolemic hyponatremia in a reproducible manner, but their safe use requires full understanding of their indications and contraindications.

Phytopharmacologic aspects of Canscora decussata Roem and Schult

Nature is an inexhaustible source of secondary metabolites–different types of alkaloids, terpenoids, phenolics, and other classes of organic compounds. In the process of isolation, purification and determination of the structures of lead, with their biological effectiveness, every type of experimental tool and strategy, known too and developed over the years by various practitioners. The present review is an attempt to compile information on various aspects of Canscora decussata, “Shankhpushpi” of Indian traditional system of medicine. The phytoconstituents, such as phenolic compounds, xanthones, and triterpenoids were isolated from different parts of the plant. The plant possesses immunomodulatory, analgesic, anticonvulsant, antitubercular, antiinflammatory, spermicidal, central nervous system–depressive, and cardiostimulant properties. Clinical trials of marketed formulation showed very encouraging results.

Mangifera indica (mango)

Mangifera indica, commonly used herb in ayurvedic medicine. Although review articles on this plant are already published, but this review article is presented to compile all the updated information on its phytochemical and pharmacological activities, which were performed widely by different methods. Studies indicate mango possesses antidiabetic, anti-oxidant, anti-viral, cardiotonic, hypotensive, anti-inflammatory properties. Various effects like antibacterial, anti fungal, anthelmintic, anti parasitic, anti tumor, anti HIV, antibone resorption, antispasmodic, antipyretic, antidiarrhoeal, antiallergic, immunomodulation, hypolipidemic, anti microbial, hepatoprotective, gastroprotective have also been studied. These studies are very encouraging and indicate this herb should be studied more extensively to confirm these results and reveal other potential therapeutic effects. Clinical trials using mango for a variety of conditions should also be conducted.

Abstract 169: Activation of The Interleukin-1 Receptor Contributes to the Pathogenesis of Angiotensin II-dependent Hypertension by Regulating Sodium Excretion

Interleukin 1(IL-1) is an important regulator of inflammation and innate immunity and exerts diverse actions in multiple tissue beds. Previous studies have found increased renal IL-1 production in the setting of angiotensin (Ang) II-induced hypertension. The current study therefore explored whether activation of the IL-1 receptor (IL-1R) contributes to the pathogenesis of Ang II-dependent hypertension. Thus, we chronically infused uni-nephrectomized IL-1R-deficient (IL-1R KO) mice and wild-type (WT) controls (n=9 per group, 129/SvEv strain) with Ang II (1000ng/kg/min) for 4 weeks. At baseline, the mean arterial blood pressure (MAP) was similar in WT and IL-1R KO mice (131±9 vs. 125±6 mm Hg; p=NS). By contrast, after the 1st week of Ang II infusion, IL-1R KO mice had markedly attenuated elevations in BP (169±6 vs.184±3 mm Hg; p<0.05). Consistent with their lower BPs, IL-1R KO mice had smaller heart weight/body weight ratios compared to WTs after Ang II infusion for 14 days (7.4±0.2 vs. 6.7±0.3 mg/g, p=0.058) and 28 days (9.3±0.8 vs. 7.5±0.9 mg/g, p<0.001). Moreover, Ang II-infused IL-1R KOs had nearly 40% less albuminuria than WTs (5.9±0.9 vs. 9.4±1.4 mg/mg Cr; p=0.05). Consistent with reduced renal damage in the Ang II-infused IL-1R KOs, this group had lower renal mRNA expression of the kidney injury marker NGAL than Ang II-infused WTs (0.37±0.06 vs. 1.00±0.19 au; p=0.008) whereas expressions of IL-1α and β were similar in the 2 groups. Levels of urinary sodium excretion were similar in the groups at baseline and during the 1 st week of Ang II when BPs were also similar. However, during the 2 nd week of Ang II when BPs started to diverge between the groups, the IL-1R KOs excreted 23% more sodium than WT controls (416±23 vs. 337±25 μmol/day; p<0.04) while daily food intake was virtually identical in the groups throughout the experiment. As IL-1 has known vascular effects and renal blood flow can impact sodium excretion, we then examined acute pressor responses to Ang II (100ng) after 2 weeks of chronic Ang II infusion. The pressor response was blunted by 25% in IL-1R KOs compared to WT controls (30±2 vs. 41±4 mm Hg, p=0.04). We conclude that activation of the IL-1R potentiates Ang II-dependent hypertension by enhancing vasoconstriction and thereby limiting sodium excretion.

A novel role for type 1 angiotensin receptors on T lymphocytes to limit target organ damage in hypertension

RATIONALE

Human clinical trials using type 1 angiotensin (AT(1)) receptor antagonists indicate that angiotensin II is a critical mediator of cardiovascular and renal disease. However, recent studies have suggested that individual tissue pools of AT(1) receptors may have divergent effects on target organ damage in hypertension.

OBJECTIVE

We examined the role of AT(1) receptors on T lymphocytes in the pathogenesis of hypertension and its complications.

METHODS AND RESULTS

Deficiency of AT(1) receptors on T cells potentiated kidney injury during hypertension with exaggerated renal expression of chemokines and enhanced accumulation of T cells in the kidney. Kidneys and purified CD4(+) T cells from "T cell knockout" mice lacking AT(1) receptors on T lymphocytes had augmented expression of Th1-associated cytokines including interferon-γ and tumor necrosis factor-α. Within T lymphocytes, the transcription factors T-bet and GATA-3 promote differentiation toward the Th1 and Th2 lineages, respectively, and AT(1) receptor-deficient CD4(+) T cells had enhanced T-bet/GATA-3 expression ratios favoring induction of the Th1 response. Inversely, mice that were unable to mount a Th1 response due to T-bet deficiency were protected from kidney injury in our hypertension model.

CONCLUSIONS

The current studies identify an unexpected role for AT(1) receptors on T lymphocytes to protect the kidney in the setting of hypertension by favorably modulating CD4(+) T helper cell differentiation.

Simultaneous estimation of andrographolide and wedelolactone in herbal formulations

Andrographolide and wedelolactone are active components of Andrographis paniculata and Eclipta alba, respectively. The extracts of these plants are used in many traditional hepatoprotective formulations. An attempt has been made to develop an accurate, precise and specific HPTLC method to quantify simultaneously both these chemical markers of diversified chemical structures in different dosage forms like tablet and syrup. Precoated silica 60F(254) plates with toluene:acetone:formic acid (9:6:1) as mobile phase and detection wavelength of 254 nm were used. The method was validated in terms of linearity, accuracy, precision and specificity. The calibration curve was found to be linear between 200 to 400 ng/spot for andrographolide and 100 to 200 ng/spot for wedelolactone. The limit of detection and the limit of quantification for andrographolide were 26.16 and 79.28 ng/spot, respectively and for wedelolactone 5.06 and 15.32 ng/spot, respectively.

Liver x receptor: a novel therapeutic target

The liver X receptors α and β are orphan nuclear receptors that are key regulators in maintaining cholesterol homeostasis. Originally they were found to play an important role in reverse cholesterol transport, a pathway for the removal of excess cellular cholesterol. However several groups have now shown that the liver X receptors also functions in lipid and carbohydrate metabolism, cellular differentiation, apoptosis and many immune responses. Tissue distribution of the two paralogues differs with liver X receptor β ubiquitously expressed, while liver X receptor α is confined to the liver, kidney, intestine, spleen, adipose tissue, macrophages and skeletal muscle. The endogenous ligands for the liver X receptors are certain oxidized derivatives of cholesterol, the oxysterols. Upon activation by oxysterols, the receptors form obligate heterodimers with retinoid X receptors α, β and γ; and become competent to activate the transcription of target genes.

Cleidocranial dysplasia: a report of two cases

Cleidocranial dysplasia (CCD) is an autosomal dominant disorder that presents with skeletal dysplasia. It commonly presents with significant dental problems such as retention of multiple deciduous teeth, impaction or delay in eruption of permanent teeth, and often with the presence of supernumerary teeth. We report two cases showing clinical and radiographic features of CCD.

Hypoglycemic activity of C-glycosyl flavonoid from Enicostemma hyssopifolium

CONTEXT

Enicostemma hyssopifolium Verdoon (Gentianaceae) has been documented for various therapeutic effects in traditional systems of medicine; the hypoglycemic and hypolipidemic activities are also well reported.

OBJECTIVE

Bioactivity guided fractionation of methanol extract of E. hyssopifolium to test the hypothesis that E. hyssopifolium and its constituents influence cells and systemic glucose homeostasis.

MATERIALS AND METHODS

Derived fraction and isolated compounds were studied for (1) aldose reductase (AR) inhibition, (2) α-glucosidase inhibition, (3) effect on gluconeogenesis in rat hepatoma, (4) cytoprotection against streptozotocin (STZ)-induced toxicity on RINm5F cells, (5) normalization of glycemic control in acute hyperglycemic rat model, and (6) insulin-releasing effect both in vitro and in vivo.

RESULTS

The results indicated that E. hyssopifolium can modify the glucose homeostasis at the cellular level. Two bioactive constituents were identified. Swertisin was found to inhibit AR (IC(50) 1.23 μg/mL) and α-glucosidase (IC(50) 1.89 μg/mL). It also possessed a significant cytoprotective action of RINm5F cell line against toxicant STZ. Swertiamarin was found to have hepatic gluconeogenesis inhibiting and insulin-releasing effect on rat hepatoma and RINm5F cells, respectively. The results of the in vivo study showed that swertiamarin, unlike the in vitro effect, produced no significant raise of insulin secretion. Swertisin normalized the serum glucose 60 min after high dose of glucose (2 g/kg, i.p.) in rats.

DISCUSSION AND CONCLUSION

These findings demonstrate that the fraction derived from the aerial part of E. hyssopifolium achieve normoglycemic status in hyperglycemic conditions via various mechanisms. The constituents swertiamarin and swertisin are responsible for bioactivity.

Aqueous Extract of Ficus bengalensis Linn. Bark for Inflammatory Bowel Disease

The present study was designed to evaluate the effects of aqueous extract of Ficus bengalensis Linn. bark (AEFB) on inflammatory bowel disease (IBD). Effects of AEFB were studied on 2, 4, 6-trinitrobenzenesulfonic acid (TNBS, 0.25 ml 120 mg/ml in 50% ethanol intrarectally, on first day only)-induced IBD in rats. Effects of co-administration of prednisolone (2 mg/kg) and AEFB (250, 500 mg/kg) for 21 days were also evaluated. Various physical parameters including body weight, food, and water intake measured on 1st and 21st days. At end of the experiment, various histopathological indexes are assessed. The colon homogenate malondialdehyde (MDA), myeloperoxidase (MPO), superoxide dismutase (SOD), and nitric oxide (NO) levels and % mast cell protection in mesentery were also measured. In our study, we found that AEFB has a significant protective effect in the inflammatory bowel disease as compared to prednisolone in rats.

Do media players cause interference with pacemakers?

BACKGROUND

Electrical devices generate electromagnetic fields that may interfere with pacemakers. Media players cause telemetry interference with pacemakers, but it is not known whether they cause direct interference with pacemakers. The purpose of this study was to examine the interaction between pacemakers and 3 different media players.

METHODS

In this prospective, randomized study, 54 patients with dual chamber pacemakers who were in sinus rhythm underwent baseline observation, followed by observation under telemetry communication. These patients were then randomly evaluated with 3 media players (iPod 3G, iPod Photo, and iPod Touch Apple, Cupertino, CA) with and without telemetry communication for 1 minute each. Patients were monitored for pacemaker malfunction using a single-channel ECG during exposure to media players. The pacemaker was interrogated after each exposure and an interrogation report was printed for evaluation. Pacemaker interference was categorized as type I, II, or III. Types I and II interference described telemetry interference and type III interference was defined as any direct interference with pacemaker function or programmed parameters.

RESULTS

A total of 54 patients (29 men and 25 women; mean age 77.2 +/- 9.3 y) were evaluated. In total, of the 162 tests (for telemetry interference) 36.4% were positive (Type I and II). Type III interference was also evaluated in 162 tests and none showed any evidence of direct interference.

CONCLUSION

Media players cause telemetry interference with pacemakers, but they do not directly interfere with pacemaker function.

High defibrillation threshold: the science, signs and solutions

Defibrillation threshold (DFT) testing has traditionally been an integral part of implantable cardioverter defibrillator (ICD) implantation. With the increasing number of patients receiving ICDs, physicians are encountering high DFT more often than before. Tackling the problem of high DFT, warrants an in-depth understanding of the science of defibrillation including the key electrophysiological concepts and the underlying molecular mechanisms. Numerous factors have been implicated in the causation of high DFT. Due consideration to the past medical history, pharmacotherapy, laboratory data and cardiac imaging, help in assessing the pre-procedural risk for occurrence of high DFT. Drugs, procedural changes, type and location of ICD lead system are some of the key players in predicting DFT during implantation. In the event of encountering an unacceptably high DFT, we recommend to follow a step-wise algorithm. Ruling out procedural complications like pneumothorax and tamponade is imperative before embarking on a search for potentially reversible clinical or metabolic derangements. Finally, if these attempts fail, the electrophysiologist must choose from a wide range of options for device adjustment and system modification. Although this review article is meant to be a treatise on the science, signs and solutions for high DFT, it is bound by limitations of space and scope of the article.

Relation of porphyria to atrial fibrillation

Porphyrias are a group of inherited disorders affecting enzymes in the heme biosynthesis pathway, leading to overproduction and/or accumulation of porphyrin or its precursors. Porphyrias have been associated with autonomic dysfunction, which in turn can develop atrial fibrillation (AF). The purpose of this study was to characterize the prevalence of AF and atrial flutter (AFl) in patients with porphyrias. A single-center retrospective cohort study was designed using data from chart reviews of patients who were admitted to the hospital from January 2000 to June 2008. Fifty-six distinct cases were found with a discharge diagnosis of porphyria including all its subtypes. From the same database, age- and gender-matched controls were identified using computer-generated random numbers. We selected 1 age- and gender-matched control for each case. Electrocardiograms and echocardiograms were reviewed by 2 independent reviewers. Only patients with available 12-lead electrocardiograms that showed AF/AFl were labeled with that diagnosis. All patients with a diagnosis of porphyria were included in the study irrespective of their age. Seven of 56 patients with porphyria met inclusion criteria, yielding a prevalence of AF/AFl of 12.5%. This association was significant (p = 0.028, relative risk 7.45, 95% confidence interval 1.01 to 66.14) compared with the age- and gender-matched control group (2%). In conclusion, our observations suggest that porphyria may be significantly associated with AF/AFl.

Predictors of hemodynamic compromise with propofol during defibrillator implantation: a single center experience

BACKGROUND

Intra-operative hypotension has been reported in cardiac resynchronization therapy defibrillator (CRT-D) clinical trials but this phenomenon is not well characterized. The purpose of this study was to understand the frequency and determinants of intra-operative hypotension in patients undergoing defibrillator implantations.

METHODS

We retrospectively reviewed clinical data of all CRT-D implantations over a 21-month period. We compared a randomly selected contemporaneous group undergoing implantable cardiac defibrillator (ICD) implantations as a reference group. Procedure protocol involved intra-arterial blood pressure monitoring throughout the case. Lidocaine (1%) was routinely used along with propofol for sedation in all patients. Procedure time was defined as the time from initial administration of lidocaine for arterial line access, to completion of defibrillator pocket closure. Cumulative dose of propofol was calculated in each patient. Hypotension was defined as a fall in the systolic blood pressure of >or=30% from baseline or a systolic blood pressure of <or=80 mm Hg for >3 min. CRT-D and ICD patients were divided into hypotensive and non-hypotensive subsets.

RESULTS

The incidence of hypotension in the CRT-D group (N = 100) was 56%, as compared to 40% in the ICD group (N = 97). The mean duration of procedure in the CRT-D group was 114 +/- 95 min in the hypotensive subset versus 69 +/- 31.9 min in the non-hypotensive subset (p = 0.0015). The mean NYHA class in the hypotensive subset of the CRT-D group was 2.85 +/- 1.2 vs 2.2 +/- 1.5 in the non-hypotensive subset (p = 0.0179). Cumulative dose of propofol in the hypotensive subset of the CRT-D group was 386 +/- 22 mg, while that in the non hypotensive subset was 238.3 +/- 17 mg (p < 0.0001). Creatinine clearance in the hypotensive subset of the CRT-D group was 63.8 +/- 12.8 ml/min, while that in the non-hypotensive subset was 78.7 +/- 23.5 ml/min (p = 0.003). Patients in the CRT-D group who developed hypotension had a lower left ventricular ejection fraction of 21.1 +/- 10.2% versus 29 +/- 14.8% in the non-hypotensive subset (p = 0.0035).

CONCLUSIONS

Hypotension is a common occurrence during defibrillator implantation under conscious sedation. Risk factors for significant hypotension include: higher NYHA class, lower left ventricular ejection fraction, lower creatinine clearance, higher doses of propofol and longer procedure times.

A media player causes clinically significant telemetry interference with implantable loop recorders

BACKGROUND

The implantable loop recorder is a useful diagnostic tool for intermittent cardiovascular symptoms because it can automatically record arrhythmias as well as a patient-triggered ECG. Media players have been shown to cause telemetry interference with pacemakers. Telemetry interference may be important in patients with implantable loop recorders because capturing a patient-triggered ECG requires a telemetry link between a hand-held activator and the implanted device. The purpose of this study was to determine if a media player causes interference with implantable loop recorders.

METHODS

Fourteen patients with implantable loop recorders underwent evaluation for interference with a 15 GB third generation iPod (Apple, Inc.) media player. All patients had the Reveal Plus (Medtronic, Inc.) implantable loop recorder. We tested for telemetry interference on the programmer by first establishing a telemetry link with the loop recorder and then, the media player was placed next to it, first turned off and then, on. We evaluated for telemetry interference between the activator and the implanted device by placing the activator over the device (normal use) and the media player next to it, first turned off and then, on. We made 5 attempts to capture a patient-triggered ECG by depressing the activator switch 5 times while the media player was off or on.

RESULTS

Telemetry interference on the programmer screen, consisting of either high frequency spikes or blanking of the ECG channel was seen in all patients. Telemetry interference with the activator resulted in failure to capture an event in 7 patients. In one of these patients, a green indicator light on the activator suggested that a patient-triggered event was captured, but loop recorder interrogation did not show a captured event. In the remaining 7 patients, an event was captured and appropriately recognized by the device at least 1 out of 5 times.

CONCLUSION

A media player playing in close proximity to an implanted loop recorder may interfere with capture of a patient-triggered event. Patients should be advised to keep media players away from their implanted loop recorder.

Guillain-Barré Syndrome with asystole requiring permanent pacemaker: a case report

Introduction

Guillain-Barré syndrome is an acute demyelinating disorder of the peripheral nervous system that results from an aberrant immune response directed at peripheral nerves. Autonomic abnormalities in Guillain-Barré syndrome are usually transient and reversible. We present a case of Guillain-Barré syndrome requiring a permanent pacemaker in view of persistent symptomatic bradyarrhythmia.

Case Presentation

An 18-year-old Caucasian female presented with bilateral lower limb paraesthesias followed by bilateral progressive leg weakness and difficulty in walking. She reported an episode of an upper respiratory tract infection 3 weeks prior to the onset of her neurological symptoms. Diagnosis of Guillain-Barré syndrome was considered and a lumbar puncture was performed. Cerebrospinal fluid revealed albuminocytologic dissociation (increased protein but normal white blood cell count) suggestive of Guillain-Barré syndrome and hence an intravenous immunoglobulin G infusion was started. Within 48 hours, she progressed to complete flaccid quadriparesis with involvement of respiratory muscles requiring mechanical ventilatory support. Whist in the intensive care unit, she developed multiple episodes of bradycardia and asystole requiring a temporary pacemaker. In view of the persistent requirement for the temporary pacemaker for more than 5 days, she received a permanent pacemaker. She returned for follow-up three months after discharge with an intermittent need for ventricular pacing.

Conclusion

Guillain-Barré syndrome can result in permanent damage to the cardiac conduction system. Patients with multiple episodes of bradycardia and asystole in the setting of Guillain-Barré syndrome should be evaluated and considered as potential candidates for permanent pacemaker implantation.

Reel syndrome-not a twiddler variant

We report three cases of an unusual form of "reel syndrome" characterized by isolated, reeling dislodgement of a single lead in patients with dual-chamber or biventricular devices. One of these patients presented with worsening heart failure due to loss of left ventricular pacing and the others were detected incidentally during scheduled device checks. We suspect that a ratchet mechanism was probably responsible for this and that this type of dislodgement is not a twiddler variant. We propose a simple solution for prevention.

Electromagnetic interference with pacemakers caused by portable media players

BACKGROUND

Electromagnetic fields generated by electrical devices may cause interference with permanent pacemakers. Media players are becoming a common mode of portable entertainment. The most common media players used worldwide are iPods. These devices are often carried in a shirt chest pocket, which may place the devices close to an implanted pacemaker.

OBJECTIVE

The purpose of this study was to determine if iPods cause interference with pacemakers.

METHOD

In this prospective, single-blinded study, 100 patients who had cardiac pacemakers were tested with four types of iPods to assess for interference. Patients were monitored by a single-channel ECG monitor as well as the respective pacemaker programmer via the telemetry wand. iPods were tested by placing them 2 inches anterior to the pacemaker and wand for up to 10 seconds. To simulate actual use, standard-issue headphones were plugged into the iPods. To maintain consistency, the volume was turned up maximally, and the equalizer was turned off. A subset of 25 patients underwent testing on 2 separate days to assess for reproducibility of interference. Pacemaker interference was categorized as type I or type II telemetry interference. Type I interference was associated with atrial and/or ventricular high rates on rate histograms. Type II interference did not affect pacemaker rate counters. Electromagnetic emissions from the four iPods also were evaluated in a Faraday cage to determine the mechanism of the observed interference.

RESULTS

One hundred patients (63 men and 37 women; mean age 77.1 +/- 7.6 years) with 11 single-chamber pacemakers and 89 dual-chamber pacemakers underwent 800 tests. The incidence of any type of interference was 51% of patients and 20% of tests. Type I interference was seen in 19% of patients and type II in 32% of patients. Reproducibility testing confirmed that interference occurred regardless of pacing configuration (unipolar or bipolar), pacing mode (AAI, VVI, or DDD), and from one day to the next. Electromagnetic emissions testing from the iPods demonstrated maximum emissions in the pacemaker carrier frequency range when the iPod was turned "on" with the headphones attached.

CONCLUSION

iPods placed within 2 inches of implanted pacemakers monitored via the telemetry wand can cause interference with pacemakers.

Dynamics of tissue ubiquitin pools and ubiquitin-proteasome pathway component activities during the systemic response to traumatic shock

Based on the biological significance of the ubiquitin-proteasome pathway (UPP) and its potential role during sepsis, burns and ischemia-reperfusion injury, we hypothesized that the systemic response to traumatic shock (TS) is accompanied by tissue-specific UPP alterations. Therefore, we studied tissue ubiquitin pools, chymotryptic- and tryptic-like proteasome peptidase activities and ubiquitin-protein ligation (UbPL) rates in skeletal muscle, heart, lung, liver, spleen and kidney using a clinically relevant porcine model (bilateral femur fracture/hemorrhage followed by fluid resuscitation). TS induced a systemic reduction of tissue-specific high molecular mass ubiquitin-protein conjugates (>50 kDa). Free ubiquitin was unaffected. The dynamic organ patterns of ubiquitin pools paralleled the typical physiological response to TS and resuscitation. Reduction of ubiquitin-protein conjugates was most pronounced in heart and lung (p<0.05 vs. control) and accompanied by significant increases in proteasome peptidase and UbPL activities in these organs. Unlike all other tissues, spleen proteasome peptidase and UbPL activities were significantly reduced 10 h after TS. These findings support the concept that the UPP could play an important role in regulation of cell functions during the early whole-body response to TS. The UPP might be a therapeutic target to improve the metabolic care after TS, particularly in the heart, lung, and spleen.

Distribution and interrelationship of ubiquitin proteasome pathway component activities and ubiquitin pools in various porcine tissues

The ubiquitin-proteasome pathway fulfills major biological functions, but its physiologic tissue distribution and the interrelationship between pathway component activities and ubiquitin pools are unknown. Therefore, we analyzed free and conjugated ubiquitin, ubiquitin-protein ligation rates (UbPL) and chymotryptic- and tryptic-like proteasome peptidase activities in porcine skeletal muscle, heart, lung, liver, spleen and kidney (n=5 each). There were considerable differences between tissues (p<0.05 for all parameters). Lung and spleen showed high levels of free and conjugated ubiquitin and high UbPL. Proteasome activities were highest in kidney and heart. There were linear relationships between tryptic-like and chymotryptic-like proteasome peptidase activities (r(2) = 0.624, p<0.001) and between free and conjugated ubiquitin tissue levels (r(2) = 0.623, p<0.001). Tissue levels of free and conjugated ubiquitin correlated linear with UbPL (p<0.005), but they were not correlated with proteasome peptidase activities. The results suggest that tissue ubiquitin pools are tightly regulated and indicate a constant proportion of conjugated ubiquitin. They further support the hypothesis that ubiquitin-protein ligase systems, and probably deubiquitylating enzymes, are key regulators of ubiquitin homeostasis. The detected differences are suggestive of tissue-specific roles of ubiquitin-proteasome pathway components. Besides the known importance of the ubiquitin proteasome pathway in heart, kidney and the immune system, the results suggest the lung as another organ in which ubiquitin proteasome pathway components may also significantly contribute to disease processes.

Regulation of the ubiquitin proteasome system in mechanically injured human skeletal muscle

Metabolic consequences of direct muscle trauma are insufficiently defined. Their effects on the ubiquitin-proteasome pathway (UPP) of protein degradation in human skeletal muscles are as yet unknown. Thus, we investigated whether the UPP is involved in the metabolic response evoked in directly traumatized human skeletal muscles. Biopsies were obtained from contused muscles after fractures and from normal muscles during elective implant removal (control). As estimated by western blot analyses, concentrations of free ubiquitin and ubiquitin protein conjugates were similar in extracts from injured and uninjured muscles. Ubiquitin protein ligation rates were reduced after injury (1.5+/-0.2 vs. 1.0+/-0.15 fkat/microg; p=0.04). Chymotryptic-, tryptic- and caspase-like proteasome peptidase activities (total activity minus activity in the presence of proteasome inhibitors) increased significantly after trauma (p=0.04 - 0.001). Significant increases in total chymotryptic- and caspase-like activities were attributable to proteasome activation. Our results extend the possible role of the UPP in muscle wasting to direct muscle trauma. They further suggest that the effects of direct mechanical trauma are not limited to the proteasome and imply that ubiquitin protein ligase systems are also involved. Based on the potential role of the UPP in systemic diseases, it might also be a therapeutic target to influence muscle loss in critically ill blunt trauma patients, in which large proportions of muscle are exposed to direct trauma.

Determination and use of a transition state for the enzyme estrone sulfatase (ES) from a proposed reaction mechanism

Using the postulated mechanism for the enzyme estrone sulfatase (ES), we have determined a possible transition state for the reaction catalysed by ES as a representation of the active site. Using the derived structure, we have undertaken the molecular modelling of several steroidal and non-steroidal inhibitors in an attempt to rationalise the inhibitory activity of a number of potent inhibitors.

Conditioned blood reperfusion during angioplasty (CoBRA) treatment of acute myocardial infarction

Acute myocardial infarct (MI) results in ischemia distal to lesions which puts heart muscle at risk for reperfusion injury (RI). Neutrophils, platelets and complement are putative mediators of RI. Recent advances in filtration technology provide integrated neutrophil and platelet removal together with complement-attenuating properties in a single blood-conditioning device. The present study characterizes the properties of a blood-conditioning filter and describes its clinical effect when used in conjunction with active hemoperfusion for acute MI. The filter reduces leukocytes by 99.9998 +/- 0.0002% (p<0.0001) and platelets by 99.9934 +/- 0.0069% (p<0.0001). Human plasma, derived from heparinized blood that was 'conditioned' by filtration, was studied using the Langendorff isolated rabbit heart preparation. The deposition of membrane attack complex and the resultant functional myocardial impairments [reflected in hemodynamic and biochemical measurements, including developed pressure, coronary blood flow, lymph-derived myocardial creatine kinase (CK)] are significantly attenuated by blood conditioning. Integration of the blood-conditioning filter into an active hemoperfusion system during primary percutaneous transluminal coronary angioplasty (PTCA) for acute MI (n=8) did not delay the procedure or cause any complications. Reperfusion of occluded coronary arteries with 300 cm3 of conditioned blood led to significant improvement in echocardiographic global wall motion scores (in standard deviations) following treatment (-1.64 +/- 0.18 to -1.45 +/- 0.15, p=0.02). Initial reperfusion of totally occluded coronary arteries with conditioned blood leads to acutely improved ventricular function. Collectively, these data provide a strong indication for continued investigation of conditioned blood reperfusion in angioplasty following acute MI for the long-term effect upon recovery of salvagable myocardium.

Macrophage lipoprotein lipase promotes foam cell formation and atherosclerosis in low density lipoprotein receptor-deficient mice

The role of macrophage lipoprotein lipase (LPL) expression in atherosclerotic lesion formation was examined in low density lipoprotein receptor (LDLR(-/-)) mice using dietary conditions designed to induce either fatty streak lesions or complex atherosclerotic lesions. First, LDLR(-/-) mice chimeric for macrophage LPL expression were created by transplantation of lethally irradiated female LDLR(-/-) mice with LPL(-/-) (n = 12) or LPL(+/+) (n = 14) fetal liver cells as a source of hematopoietic cells. To induce fatty streak lesions, these mice were fed a Western diet for 8 weeks, resulting in severe hypercholesterolemia. There were no differences in plasma post-heparin LPL activity, serum lipid levels, or lipoprotein distribution between these two groups. The mean lesion area in the proximal aorta in LPL(-/-) --> LDLR(-/-) mice was significantly reduced by 33% compared with LPL(+/+) --> LDLR(-/-) mice, and a similar reduction (38%) in lesion area was found by en face analysis of the aortae. To induce complex atherosclerotic lesions, female LDLR(-/-) mice were lethally irradiated, transplanted with LPL(-/-) (n = 14), LPL(+/-) (n = 13), or LPL(+/+) (n = 14) fetal liver cells, and fed the Western diet for 19 weeks. Serum cholesterol and triglyceride levels did not differ between the three groups. After 19 weeks of diet, the lesions in the proximal aorta were complex with relatively few macrophages expressing LPL protein and mRNA in LPL(+/+) --> LDLR(-/-) mice. Analysis of cross-sections of the proximal aorta demonstrated no differences in the extent of lesion area between the groups, whereas en face analysis of the aortae revealed a dose-dependent effect of macrophage LPL on mean aortic lesion area in LPL(-/-) --> LDLR(-/-), LPL(-/+) --> LDLR(-/-), and LPL(+/+) --> LDLR(-/-) mice (1.8 +/- 0. 2%, 3.5 +/- 0.5% and 5.9 +/- 0.8%, respectively). Taken together, these data indicate that macrophage LPL expression in the artery wall promotes atherogenesis during foam cell lesion formation, but this impact may be limited to macrophage-rich lesions.

Human cytomegalovirus UL37 immediate-early regulatory proteins traffic through the secretory apparatus and to mitochondria

The human cytomegalovirus (HCMV) UL36-38 immediate-early (IE) locus encodes the UL37 exon 1 (pUL37x1) and UL37 (gpUL37) regulatory proteins, which have anti-apoptotic activities. pUL37x1 shares its entire sequence, including a hydrophobic leader and an acidic domain, with the exception of one residue, with the amino terminus of gpUL37. gpUL37 has, in addition, unique N-linked glycosylation, transmembrane and cytosolic domains. A rabbit polyvalent antiserum was generated against residues 27-40 in the shared amino-terminal domain and a mouse polyvalent antiserum was generated against the full-length protein to study trafficking of individual UL37 proteins in human cells that transiently expressed gpUL37 or pUL37x1. Co-localization studies by confocal laser scanning microscopy detected trafficking of gpUL37 and pUL37x1 from the endoplasmic reticulum to the Golgi apparatus in permissive U373 cells and in human diploid fibroblasts (HFF). Trafficking of gpUL37 to the cellular plasma membrane was detected in unfixed HFF cells. FLAG-tagged gpUL37 trafficked similarly through the secretory apparatus to the plasma membrane. By using confocal microscopy and immunoblotting of fractionated cells, gpUL37 and pUL37x1 were found to co-localize with mitochondria in human cells. This unconventional dual trafficking pattern through the secretory apparatus and to mitochondria is novel for herpesvirus IE regulatory proteins.