Gut microbiota, endotoxemia, inflammation, and oxidative stress in patients with heart failure, left ventricular assist device, and transplant

BACKGROUND

Gut microbial imbalance may contribute to endotoxemia, inflammation, and oxidative stress in heart failure (HF). Changes occurring in the intestinal microbiota and inflammatory/oxidative milieu during HF progression and following left ventricular assist device (LVAD) or heart transplantation (HT) are unknown. We aimed to investigate variation in gut microbiota and circulating biomarkers of endotoxemia, inflammation, and oxidative stress in patients with HF (New York Heart Association, Class I-IV), LVAD, and HT.

METHODS

We enrolled 452 patients. Biomarkers of endotoxemia (lipopolysaccharide and soluble [sCD14]), inflammation (C-reactive protein, interleukin-6, tumor necrosis factor-α, and endothelin-1 adiponectin), and oxidative stress (isoprostane) were measured in 644 blood samples. A total of 304 stool samples were analyzed using 16S rRNA sequencing.

RESULTS

Gut microbial community measures of alpha diversity were progressively lower across worsening HF class and were similarly reduced in patients with LVAD and HT (p < 0.05). Inflammation and oxidative stress were elevated in patients with Class IV HF vs all other groups (all p < 0.05). Lipopolysaccharide was elevated in patients with Class IV HF (vs Class I-III) as well as in patients with LVAD and HT (p < 0.05). sCD14 was elevated in patients with Class IV HF and LVAD (vs Class I-III, p < 0.05) but not in patients with HT.

CONCLUSIONS

Reduced gut microbial diversity and increased endotoxemia, inflammation, and oxidative stress are present in patients with Class IV HF. Inflammation and oxidative stress are lower among patients with LVAD and HT relative to patients with Class IV HF, whereas reduced gut diversity and endotoxemia persist in LVAD and HT.

Michigan Stroke Transitions Trial

BACKGROUND

To test whether access to home-based social worker-led case management (SWCM) program or SWCM program combined with a website providing stroke-related information improves patient-reported outcomes in patients with stroke, relative to usual care.

METHODS AND RESULTS

The MISTT (Michigan Stroke Transitions Trial), an open (unblinded) 3-group parallel-design clinical trial, randomized 265 acute patients with stroke to 3 treatment groups: Usual Care (group-1), SWCM (group-2), and SWCM+MISTT website (group-3). Patients were discharged directly home or returned home within 4 weeks of discharge to a rehabilitation facility. The SWCM program provided in-home and phone-based case management services. The website provided patient-orientated information covering stroke education, prevention, recovery, and community resources. Both interventions were provided for up to 90 days. Outcomes data were collected by telephone at 7 and 90 days. Primary patient-reported outcomes included Patient-Reported Outcomes Measurement Information System Global-10 Quality-of-Life (Physical and Mental Health subscales) and the Patient Activation Measure. Treatment efficacy was determined by comparing the change in mean response (90 days minus 7 days) between the 3 treatment groups using a group-by-time interaction. Subjects were aged 66 years on average, 49% were female, 21% nonwhite, and 86% had ischemic stroke. There were statistically significant changes in Patient-Reported Outcomes Measurement Information System Physical Health ( P=0.003) and Patient Activation Measure ( P=0.042), but not Patient-Reported Outcomes Measurement Information System Mental Health ( P=0.56). The mean change in Patient-Reported Outcomes Measurement Information System Physical Health scores for group-3 (SWCM+MISTT Website) was significantly higher than both group-2 (SWCM; difference, +2.4; 95% CI, 0.46-4.34; P=0.02) and group-1 (usual care; difference, +3.4; 95% CI, 1.41-5.33; P<0.001). The mean change in Patient Activation Measure scores for group-3 was significantly higher than group-2 (+6.7; 95% CI, 1.26-12.08; P=0.02) and marginally higher than group-1 (+5.0; 95% CI, -0.47 to 10.52; P=0.07).

CONCLUSIONS

An intervention that combined SWCM with access to online stroke-related information produced greater gains in patient-reported physical health and activation compared with usual care or case management alone. There was no intervention effect on mental health.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov . Unique identifier: NCT02653170.

Abstract 119: Final Patient-Level Results From the Michigan Stroke Transitions Trial (MISTT): A Randomized Clinical Trial to Improve Stroke Transitions

Background: Navigating the transition after returning home following a stroke can be associated with substantial psychosocial and health-related challenges. The Michigan Stroke Transitions Trial (MISTT) tested the efficacy of a social work case management (SWCM) program and access to an online information and support resource (MISTT Website) to improve outcomes in acute stroke patients who returned home.

Methods: MISTT was a randomized, pragmatic, open, 3-group parallel designed trial conducted in 3 Michigan hospitals. Eligible subjects were acute stroke patients who returned home either directly or within 4 weeks of being discharged to a rehab facility. A total of 265 patients were randomized to one of 3 groups: 1) usual care, 2) SWCM program only, or 3) SWCM plus MISTT Website access. Interventions concluded after 90-days. Primary outcomes including Quality-of-Life (PROMIS Global-10 physical- and mental-health subscales) and the Patient Activation Measure (PAM) were collected by telephone at 7- and 90-days. The change in outcomes (90-day minus 7-day) between the three treatment groups was assessed using a differences-in-differences (D-in-D) analysis.

Results: The mean age of the 265 randomized subjects was 66 years, 49% were female, 21% non-white, 14% had hemorrhagic stroke, 56% were discharged to a rehab facility. Following the intervention there were statistically significant treatment group differences in PROMIS physical-health (p=0.003) and PAM (p=0.042), but not PROMIS mental-health (p=0.56). Mean change in physical-health scores for group-3 (SWCM+Website) was significantly higher than both group-1 (Usual Care) (difference= 3.4; 95%CI=1.41, 5.33; p<0.001) and group-2 (SWCM) (difference= 2.4; 95%CI=0.46, 4.34; p=0.02). The mean change in PAM scores for group-3 was significantly higher than group-2 (6.7; 95%CI=1.26, 12.08; p=0.02) and marginally higher than group-1 (5.0; 95%CI=-0.47, 10.52; p=0.07).

Conclusion: An intervention that combined social worker-led case management with access to online stroke-related information produced greater gains in patient-reported physical health and activation compared to usual care or case management alone. [ClinicalTrials.gov: NCT02653170].

Prognostic implications of serial outpatient blood pressure measurements in patients with an axial continuous-flow left ventricular assist device

BACKGROUND

Elevated blood pressure (BP) has been linked to adverse events during left ventricular assist device support. In this study we investigated the association between outpatient BP and stroke or suspected pump thrombosis among HeartMate II (HMII) recipients.

METHODS

We retrospectively studied 220 HMII patients. Serial outpatient BP measurements were averaged. Patients were categorized by: (1) mean arterial pressure (MAP), high (>90 mm Hg) vs intermediate (80 mm Hg ≤ MAP ≤ 90 mm Hg) vs low (<80 mm Hg); (2) systolic BP (SBP), high (≥101 mm Hg, median) vs low; and (3) pulse pressure (PP), high (≥22 mm Hg, median) vs low. To assess visit-to-visit BP variability, patients were divided in quartiles of standard deviation of MAP and SBP. The primary end-point was the composite of stroke or suspected pump thrombosis.

RESULTS

The risk for the primary end-point was increased in the high MAP group (adjusted hazard ratio [HR] 2.75, 95% confidence interval [CI] 1.49 to 5.05, vs intermediate MAP; and 6.73, 1.9 to 23.9, vs low MAP). MAP had higher predictive value for the primary end-point compared with SBP (p = 0.05). Patients with high SBP had a higher rate of stroke (HR 2.8, 95% CI 1.09 to 7.17, vs low SBP). The combination of high SBP and low PP was associated with the highest risk for stroke. The lowest quartile of visit-to-visit MAP variability was associated with the highest risk for the primary end-point.

CONCLUSIONS

Elevated outpatient BP is associated with increased risk for stroke or suspected pump thrombosis in HMII recipients. Reduced PP and low visit-to-visit BP variability may confer additional risk.

SIRT1 gene polymorphisms associated with decreased risk of atherosclerotic coronary artery disease

Coronary artery disease (CAD) exhibits the rules of the multifactorial hereditary. Notwithstanding, the role of genetic factors in the prevalence of CAD is estimated very high. SIRT1 plays an athero-protective role and alterations in its expression have some important consequence in the metabolism, cholesterol, and fat deposition. The aim of our study was to investigate the association between rs4746720, rs12413112, and rs1467568 polymorphisms in the SIRT1 gene and CAD in the high-risk cases. In the present retrospective case-control study, 150 healthy individuals and 150 cases diagnosed with atherosclerotic lesions were investigated. ARMS PCR was used to determine the genotypes of rs4746720 polymorphism, while tetra primer-ARMS PCR was used for genotyping of rs12413112 and rs1467568 polymorphisms. Considering rs12413112 polymorphism, the frequency of the AG heterozygote genotype was significantly lower in cases than controls (P < 0.001). Furthermore, the frequency of the A-positive (AA+AG vs. GG) genotype was significantly different between groups (P < 0.001). The frequency of the variant A allele was 0.36% in cases and 0.46% in controls (P = 0.01). Except for a borderline protective effect in the present of rs1467568AG genotype, the allele and genotype distributions of both rs1467568 and rs4746720 polymorphisms did not differ between two groups. The haplotype constructed from rs1467568A, rs12413112A, and rs4746720T alleles showed a significant protective effect on the risk of CAD (OR: 0.53; 95%CI: 0.35-0.78; P = 0.001). In conclusion, the SIRT1 gene may contribute to the pathogenesis of CAD, while further investigations were suggested to confirm our results.

Soap-film flow induced by electric fields in asymmetric frames

Net fluid flow of soap films induced by (ac or dc) electric fields in asymmetric frames is presented. Previous experiments of controllable soap film flow required the simultaneous use of an electrical current passing through the film and an external electric field or the use of nonuniform ac electric fields. Here a single voltage difference generates both the electrical current going through the film and the electric field that actuates on the charge induced on the film. The film is set into global motion due to the broken symmetry that appears by the use of asymmetric frames. If symmetric frames are used, the film flow is not steady but time dependent and irregular. Finally, we study numerically these film flows by employing the model of charge induction in ohmic liquids.

Investigation of uranium (VI) adsorption by polypyrrole

The purpose of this study was to investigate the adsorption of uranium (VI) ions on the polypyrrole adsorbent. Polypyrrole was synthesized by a chemical method using polyethylene glycol, sodium dodecylbenzenesulfonate, and cetyltrimethylammonium bromide as the surfactant and iron (III) chloride as an oxidant in the aqueous solution. The effect of various surfactants on the synthesized polymers and their performance as the uranium adsorbent were investigated. Adsorbent properties were characterized by scanning electron microscopy (SEM) and Fourier transform infrared spectroscopy (FTIR) techniques. The effect of different parameters such as pH, contact time, initial metal ion concentrations, adsorbent dose, and the temperature was investigated in the batch system for uranium adsorption process. It has been illustrated that the adsorption equilibrium time is 7min. The results showed that the Freundlich model had the best agreement and the maximum adsorption capacity of polypyrrole for uranium (VI) was determined 87.72mg/g from Langmuir isotherm. In addition, the mentioned adsorption process was fast and the kinetic data were fitted to the Pseudo first and second order models. The adsorption kinetic data followed the pseudo-second-order kinetic model. Moreover, the thermodynamic parameters ΔG⁰, ΔH⁰ and ΔS⁰ showed that the uranium adsorption process by polypyrrole was endothermic and spontaneous.

Numerical study of soap-film flow by nonuniform alternating electric fields

Fluid flow of suspended liquid films induced by non-uniform alternating electric fields has been reported. The electric fields were generated by two rod-like electrodes perpendicular to the fluid surface. The observed fluid flow was explained qualitatively by considering a charge induction mechanism, where the electric field actuates on the charge induced on the film surface. In this paper we perform a numerical study of this fluid flow taking into account the charge induction mechanism. The numerical results are compared with experiments and good agreement is found. Finally, we propose the application of the device as a new kind of two dimensional fluid pump.

The effect of l-arginine supplementation on body composition and performance in male athletes: a double-blinded randomized clinical trial

BACKGROUND/OBJECTIVE

Athletes used a lot of dietary supplements to achieve the more muscle mass and improve their athletic performance. The objective of this study was to investigate the effect of l-arginine supplementation on sport performance and body composition in male soccer players.

SUBJECTS/METHODS

This double-blinded, randomized and placebo-controlled trial was conducted on 56 male soccer players, with age range of 16-35, who referred to sport clubs in Isfahan, Iran. Subjects were randomly assigned to either l-arginine or placebo groups. Athletes received daily either 2 g per day l-arginine supplement or the same amount of placebo (maltodextrin) for 45 days. Sport performance and also body mass index (BMI), body fat mass (BFM) and lean body mass (LBM) were measured at the beginning and end of the study. Also, 3-day dietary records were collected at three different time points (before, in the middle of, and at the end of the study).

RESULTS

The mean age of subjects was 20.85±4.29 years. Sport performance (VO₂ max) significantly increased in l-arginine supplementation group (4.12±6.07) compared with placebo group (1.23±3.36) (P=0.03). This increase remained significant even after adjustment of baseline values, physical activity and usual dietary intake of subjects throughout the study. No significant effect of l-arginine supplementation was found on weight, BMI, BFM and LBM.

CONCLUSIONS

l-arginine supplementation (2 g per day) could increase the sport performance in male athletes, but had no effect on anthropometric measurements, including BMI, BFM and LBM. So, further studies are needed to shed light our findings.

Observed long-term mortality after 18,000 person-years among survivors in a large regional drowning registry

AIM

Long-term outcomes beyond one year after non-fatal drowning are uncharacterized. We estimated long-term mortality and identified prognostic factors in a large, population-based cohort.

METHODS

Population-based prospective cohort study (1974-1996) of Western Washington Drowning Registry (WWDR) subjects surviving the index drowning through hospital discharge. Primary outcome was all-cause mortality through 2012. We tabulated Utstein-style exposure variables, estimated Kaplan-Meier curves, and identified prognostic factors with Cox proportional hazard modeling. We also compared 5-, 10-, and 15-year mortality estimates of the primary cohort to age-specific mortality estimates from United States Life Tables.

RESULTS

Of 2824 WWDR cases, 776 subjects (5[IQR 2-17] years, 68% male) were included. Only 63 (8%) non-fatal drowning subjects died during 18,331 person-years of follow-up. Long-term mortality differed by Utstein variables (age, precipitating alcohol use, submersion interval, GCS, CPR, intubation, defibrillation, initial vital signs, neurologic status at hospital discharge) and inpatient markers of illness severity (mechanical ventilation, vasopressor use, seizure, pneumothorax). Survival differed by age (HR 1.04;95%CI 1.03-1.05), drowning-related cardiac arrest (HR 3.47;95%CI 1.97-6.13), and neurologic impairment at hospital discharge (HR 5.10;95% CI 2.70-9.62). In adjusted analysis, age (HR 1.05;95%CI 1.03-1.06) and severe neurologic impairment at discharge (HR 2.31;95%CI 1.01-5.28) were associated with long-term mortality. Subjects aged 5-15 years had higher mortality risks than those calculated from Life Tables.

CONCLUSION

Most drownings were fatal, but survivors of non-fatal drowning had low risk of subsequent long-term mortality similar to the general population that was independently associated with age and neurologic status at hospital discharge.

Rotation induced by uniform and non-uniform magnetic fields in a conducting fluid carrying an electric current

External magnetic field induces controllable rotation in a conducting fluid carrying an electric current.

Clinical predictors of accurate prehospital stroke recognition

BACKGROUND AND PURPOSE

Prehospital activation of in-hospital stroke response hastens treatment but depends on accurate emergency medical services (EMS) stroke recognition. We sought to measure EMS stroke recognition accuracy and identify clinical factors associated with correct stroke identification.

METHODS

Using EMS and hospital records, we assembled a cohort of EMS-transported suspect, confirmed, or missed ischemic stroke or transient ischemic attack cases. The sensitivity and positive predictive value (PPV) for EMS stroke recognition were calculated using the hospital discharge diagnosis as the gold standard. We used multivariable logistic regression analysis to determine the association between Cincinnati Prehospital Stroke Scale use and EMS stroke recognition.

RESULTS

During a 12-month period, 441 EMS-transported patients were enrolled; of which, 371 (84.1%) were EMS-suspected strokes and 70 (15.9%) were EMS-missed strokes. Overall, 264 cases (59.9%) were confirmed as either ischemic stroke (n=186) or transient ischemic attack (n=78). The sensitivity of EMS stroke recognition was 73.5% (95% confidence interval, 67.7-78.7), and PPV was 52.3% (95% confidence interval, 47.1-57.5). Sensitivity (84.7% versus 30.9%; P<0.0001) and PPV (56.2% versus 30.4%; P=0.0004) were higher among cases with Cincinnati Prehospital Stroke Scale documentation. In multivariate analysis, Cincinnati Prehospital Stroke Scale documentation was independently associated with EMS sensitivity (odds ratio, 12.0; 95% confidence interval, 5.7-25.5) and PPV (odds ratio, 2.5; 95% confidence interval, 1.3-4.7).

CONCLUSIONS

EMS providers recognized 3 quarters of the patients with ischemic stroke and transient ischemic attack; however, half of EMS-suspected strokes were false positives. Documentation of a Cincinnati Prehospital Stroke Scale was associated with higher EMS stroke recognition sensitivity and PPV.

Abstract W P220: Use Of A Prehospital Stroke Scale Increases Accuracy Of Emergency Medical Services Stroke Recognition

Background: Prehospital activation of in-hospital stroke response depends on accurate Emergency Medical Services (EMS) provider stroke recognition. While screening tools such as the Cincinnati Prehospital Stroke Scale (CPSS) have been validated, their real world impact is less clear. We determined the accuracy of prehospital stroke recognition and its relationship to CPSS documentation in a cohort of EMS transported suspect and confirmed stroke patients.

Methods: We identified a prospective cohort of all suspected or confirmed ischemic stroke or transient ischemic attack (TIA) patients transported by EMS to a large primary stroke center. Data on prehospital and hospital care were abstracted from medical records. The sensitivity and positive predictive value (PPV) of EMS stroke recognition were calculated using the final hospital discharge diagnosis of ischemic stroke or TIA as the gold standard. We compared the sensitivity and PPV of EMS recognition among cases with and without a documented CPSS using chi square tests. We performed multivariable logistic regression analysis to determine the independent relationship between CPSS use and the odds of EMS stroke recognition among confirmed stroke and TIA cases.

Results: Over a 12 month period, 434 EMS transported patients met inclusion criteria. The median age was 78 and 60% were female. EMS transported 371 (85.5%) patients as suspect strokes and documented a CPSS in 343 (79.0%). A total of 246 cases (56.7%) were confirmed ischemic strokes (n=186) or TIA (n=60). The sensitivity of EMS stroke recognition was 74.4% (95% CI 68.9 to 79.8) and PPV was 49.3% (95% CI 44.2 to 54.4). Sensitivity was higher among cases with CPSS documentation than without (85.9% vs. 25.5% p<0.0001) as was the PPV (54.3% vs. 21.4%, p<0.0001). After adjustment for age, sex, stroke severity, dispatch reason, and time from symptom onset, CPSS use was associated with substantially higher odds of EMS stroke recognition (OR 19.04, 95% CI: 7.95 to 45.59).

Conclusion: EMS providers recognized three quarters of all stroke or TIA admissions, while EMS suspicion of stroke was correct only half of the time. Documentation of a CPSS was associated with substantially higher EMS stroke recognition.

The quality of prehospital ischemic stroke care: compliance with guidelines and impact on in-hospital stroke response

BACKGROUND

A number of emergency medical services (EMSs) performance measures for stroke have been proposed to promote early stroke recognition and rapid transportation to definitive care. This study examined performance measure compliance among EMS-transported stroke patients and the relationship between compliance and in-hospital stroke response.

METHODS

Eight quality indicators were derived from American Stroke Association guidelines. A prospective cohort of consecutive, EMS-transported patients discharged from 2 large Midwestern stroke centers with a diagnosis of acute ischemic stroke was identified. Data were abstracted from hospital and EMS records. Compliance with 8 prehospital quality indicators was calculated. Univariate and multivariable logistic regression analysis were performed to measure the association between prehospital compliance and a binary outcome of door-to-computed tomography (CT) time less than or equal to 25 minutes.

RESULTS

Over the 12 month study period, 186 EMS-transported ischemic stroke patients were identified. Compliance was highest for prehospital documentation of a glucose level (86.0%) and stroke screen (78.5%) and lowest for on-scene time less than or equal to 15 minutes (46.8%), hospital prenotification (56.5%), and transportation at highest priority (55.4%). After adjustment for age, time from symptom onset, and stroke severity, transportation at highest priority (odds ratio [OR], 13.45) and hospital prenotification (OR, 3.75) were both associated with significantly faster door-to-CT time. No prehospital quality metric was associated with tissue-plasminogen activator delivery.

CONCLUSIONS

EMS transportation at highest priority and hospital prenotification were associated with faster in-hospital stroke response and represent logical targets for EMS quality improvement efforts.

A simple risk index and thrombolytic treatment response in acute ischemic stroke

IMPORTANCE

The Stroke Prognostication using Age and the NIH Stroke Scale index, created by combining age in years plus a National Institutes of Health (NIH) Stroke Scale score of 100 or higher (and hereafter referred to as the SPAN-100 index), is a simple risk score for estimating clinical outcomes for patients with acute ischemic stroke (AIS). The association between this index and response to intravenous thrombolysis for AIS has not been properly evaluated.

OBJECTIVE

To assess the relationship between SPAN-100 index status and outcome following treatment with intravenous thrombolysis for AIS.

DESIGN, SETTING, AND PARTICIPANTS

Using the Virtual International Stroke Trials Archive (VISTA) database, an international repository of clinical trials data, we assessed the SPAN-100 index among 7093 patients with AIS who participated in 4 clinical trials from 2000 to 2006. The SPAN-100 index is considered positive if the sum of the age and the NIH Stroke Scale (a 15-item neurological examination scale with scores ranging from 0 to 42, with higher scores indicating more severe strokes) score is greater than or equal to 100. Multivariable logistic regression analyses were used to determine the independent association between SPAN-100 index status and 90-day outcomes.

MAIN OUTCOMES AND MEASURES

The primary outcome was a composite of severe disability or death measured 90 days after stroke, and the secondary outcomes were death alone and a composite of no disability/modest disability.

RESULTS

Of 7093 patients, 743 (10.5%) were SPAN-100 positive, and 2731 (38.5%) received intravenous thrombolysis. Compared with SPAN-100-negative patients, SPAN-100-positive patients were more likely to experience a catastrophic outcome (adjusted odds ratio [AOR], 9.03 [95% CI, 6.68-12.21]) or death alone (AOR, 5.03 [95% CI, 4.06-6.23]) and less likely to experience a favorable outcome (AOR, 0.08 [95% CI, 0.06-0.13]). However, there was an interaction between SPAN-100 index status and thrombolysis treatment (P < .001) revealing a reduction in the likelihood of severe disability/death with thrombolytic treatment for SPAN-100-positive (AOR, 0.46 [95% CI, 0.29-0.71]) but not SPAN-100-negative patients (AOR, 0.96 [95% CI, 0.85-1.07]). Similar interactions between SPAN-100 index status and thrombolysis treatment were observed for the 2 secondary outcomes.

CONCLUSION AND RELEVANCE

Compared with the SPAN-100-negative patients with AIS, the SPAN-100-positive patients with AIS seem to have poorer 3-month outcomes but may derive greater benefit when treated with intravenous thrombolysis. The SPAN-100-positive patients are often excluded from AIS clinical trials but should probably not be denied thrombolysis treatment on the basis of such a profile alone.

Abstract T P313: Sensitivity of ICD-9 Discharge Codes to Identify TIA Cases in 4 Community-Based Emergency Departments

Introduction: The diagnosis of TIA is often challenging in the emergency department (ED) setting. ICD-9 discharge code 435 is often used to identify TIA cases; however, its accuracy is unclear. Our objective was to determine the sensitivity of ICD-9 code 435 to identify confirmed TIA cases treated in 4 community-based EDs.

Methods: Over a 12 month period suspect TIA cases were prospectively identified using hot-pursuit mechanisms in 4 EDs. A time-based definition of TIA was used (i.e., acute onset focal unilateral symptoms with duration <24 hours and no alternative diagnosis). All cases had a final clinical diagnosis of TIA confirmed following an independent physician panel review. Data were abstracted from medical charts and the primary ICD-9 discharge code was obtained from the hospital or ED billing records. ICD-9 discharge codes were neither used to identify cases or confirm the final diagnosis.

Results: Of 366 subjects with suspected TIA, 336 (92%) had a confirmed final diagnosis of TIA. Mean age was 66 years, 54% female, 31% non-white and 83% were hospitalized. The relative frequency of primary ICD-9 discharge codes at each of the 4 EDs are shown in the Table. The overall sensitivity of the 435 code was 64.3% (95% CI 58.9-69.4). Alternative codes used included stroke-related (8.0%), other CVD-related (2.7%), miscellaneous (8.3%) and non-specific symptoms codes (16.7%). The frequency of 435 coding varied non-significantly between sites (56% to 72%; p= 0.13); however, sites varied substantially in their use of non-specific symptoms codes (4.8% to 26.7%; p=0.002).

Conclusions: In this series of confirmed TIA cases, more than 1/3 rd would not have been identified if the 435 code was used. These findings suggest that the 435 code should not be relied upon to identify TIA cases. Future studies should determine the causes of the variation in coding between sites, and also measure both sensitivity and specificity of the 435 code.

Abstract T P317: Diagnostic Imaging Performed in TIA Patients Identified in the Emergency Department: Frequency, Yield and Relationship to 90-Day Outcomes

Introduction: Patients who present to the Emergency department (ED) with transient ischemic attack (TIA) receive a wide variety of imaging tests. We describe the use, yield, and prognostic implications of diagnostic imaging undertaken in a cohort of TIA patients.

Methods: Patients with a high clinical suspicion of TIA were prospectively identified over a 12 month period in 4 community-based EDs. A TIA diagnosis was confirmed following independent physician review. Chart data were abstracted and 90-day outcomes (incident stroke, recurrent TIA, cardiovascular-related hospitalization, or death) were collected at telephone follow-up. Relative risk (RR) and 95% confidence intervals (CI) were used to quantify the association between test results and outcomes.

Results: Of 336 confirmed TIA patients, 319 (95%) had 90-day follow up data. The mean age was 66, 46% were male, 32% non-white, and 74% were hospitalized. Overall, 15% had a 90-day outcome event. Nearly all patients (98%) received brain imaging (CT and/or MRI) (Table). An acute or sub-acute infarct was identified in 4.2% of CT and 17.9% of MRI studies. Carotid artery imaging (Doppler, CTA, or MRA) was performed in 87% of patients, and stenosis >50% was found in 17%. Echocardiography (TTE and/or TEE) was performed in 66% of cases and identified potential cardioembolic sources in 12%.

Acute or sub-acute infarction on brain imaging and stenosis >50% on carotid imaging were both significantly associated with 90-day outcomes, but cardioembolic sources on echocardiography were not (Table). There was a trend towards positive MRA or Doppler studies being more strongly associated with 90-day outcomes (RR= 2.13 and 1.92, respectively) than CTA (RR= 1.16).

Conclusion: In this TIA cohort, brain, carotid artery, and cardiac imaging were all frequently acquired. Acute or sub-acute brain infarction and carotid artery stenosis were both associated with adverse outcomes at 90 days, whereas echocardiography was not.

Evaluation of seed and seedling emergence enhancement of some population of Sahandy savory (Satureja sahendica) by gibberlic acid, potasium nitrate, pre-cooling, physical and chemical scarification treatment

In greenhouse experiment, the seed samples of 3 populations were treated with treatments including: cold stratification, Gibberlic Acid (50 ppm and 100 ppm), Potassium nitrate (0.2%, 0.4%), physical scarification (sand paper), chemical scarification (Ethylic alcohol 70%) and distilled water (control), then these treated seed samples were sown in pots as randomize design with three replication. The germination characteristics including: germination percentage, speed of germination, length of root and shoot, seedling length, ratio of root length by shoot length, vigor index, fresh weight arid dry weight, ratio of dry weight by fresh weight were evaluated during 45 days of experiment. Comparing between three populations of Sahandy savory, seed germination characteristics of the Ghazvin population was higher than the other two populations. According to effect of treatment on germination seed characteristics, the species of savory and their population, it was concluded that effect of Gibberlic Acid and Potassium nitrate was higher than physical scarification and chemical scarification comparing with control. With more effective of gibberlic acid and KNO3 and cold treatment on seed germination enhancement of the population, it was clarified that the type of dormancy of some population of Sahandy savory was physiological dormancy.

The role of exon 45 and 16 in the pathogenesis of Von Willebrand disease in Iranian Patients

BACKGROUND

Von Willebrand disease (VWD) is an autosomal recessive congenital bleeding disorder with deficiency or dysfunction of von Willebrand factor (VWF). The gene encoding for the VWF is located on chromosome 12, which is 178 Kb with 52 exons. Various mutations of this gene is responsible for the clinical features of VWD, but some single nucleotide polymorphisms make the molecular diagnosis of it very complicated.In this study genetic variations in two exons (45 & 16) of VWF gene in Iranian patients suffer from type 3 VWD from south west of Iran were evaluated.

MATERIALS AND METHODS

Genetic variations in exon 45 and exon 16 of VWF gene were evaluated in 33 patients diagnosed with type 3 VWD from south west of Iran. Two exons with their flanking introns were amplified by PCR and amplicons were analyzed by sequencing for any molecular changes.

RESULTS

No mutation was found in both selected regions. An A/C polymorphism in intron 44 was recognized in all patients in homozygous manner. This SNP reported for the first time from Iranian VWD patients.

CONCLUSION

Mutation of VWF gene is different in various ethnic groups, which finding of is important in the diagnosis of the VWD, especially for prenatal diagnosis. A few mutations are reported for exon 45 and 16 of this gene in Iran and other countries. But, present study didn't find any mutation in these patients. Mutation in other exons or introns should be evaluated in affected individuals from south west of Iran.

The Possible Impact of Obesity on Androgen, Progesterone and Estrogen Receptors (ERα and ERβ) Gene Expression in Breast Cancer Patients

BACKGROUND

Obesity has been associated with increased mortality from hormone dependant cancers such as breast cancer which is the most prevalent cancer in women. The link between obesity and breast cancer can be attributed to excess estrogen produced through aromatization in adipose tissue. The role of steroid hormone receptors in breast cancer development is well studied but how obesity can affect the expression pattern of steroid hormones in patients with different grades of breast cancer was the aim of this study.

METHODS

In this case-control study, 70 women with breast cancer participated with different grades of obesity (36 none obese, BMI < 25 kg/m(2) and 34 obese, BMI ≥ 25 kg/m(2)). The mean age of participants was 44.53 ± 1.79 yr (21-70 yr). The serum level of estrogen, progesterone and androgen determined by ELISA. Following quantitative expression of steroid hormone receptors mRNA in tumor tissues evaluated by Real-time PCR. Patients with previous history of radiotherapy or chemotherapy were excluded. SPSS 16 was used for data analysis and P < 0.05 considered statistically significant.

RESULTS

The difference in ERα, ERβ and PR mRNA level between normal and obese patients was significant (P < 0.001). In addition, the expression of AR mRNA was found to be higher than other steroid receptors. There was no significant relation between ERβ gene expression in two groups (P = 0.68). We observed a significant relationship between ERα and AR mRNA with tumor stage and tumor grade, respectively (P = 0.023, P = 0.015).

CONCLUSION

According to the obtained results, it is speculated that obesity could paly a significant role in estrogen receptors gene expression and also could affect progression and proliferation of breast cancer cells.

Compound KIR-HLA genotype analyses in the Iranian population by a novel PCR-SSP assay

Natural killer (NK) cells eliminate infected and transformed cells while still are self-tolerant. Interactions of the independently segregating Killer cell immunoglobulin-like receptors (KIR) and human leucocyte antigens (HLA) loci play a critical role in NK cell regulation. Different compound KIR-HLA genotypes can impart different thresholds of activation to the NK-cell repertoire and such genotypic variation has been found to confer altered risk in a number of human diseases including viral infections, autoimmune disorders, reproduction abnormalities and cancers. In this study, we presented a novel combined KIR-HLA polymerase chain reaction-sequence-specific primers genotyping assay for simultaneous determination of KIR genes and their three major HLA class I ligand groups (C1, C2, and Bw4). Moreover, known inhibitory and activating KIR + HLA (iKIR + HLA: 2DL2/3 + C1, 2DL1 + C2, 3DL1 + Bw4; and aKIR + HLA: 2DS2 + C1, 2DS1 + C2, 3DS1 + Bw4) combinations as well as co-inheritance of aKIR genes and iKIR + HLA pairs were analysed in a total of 200 unrelated healthy Iranian individuals. All tested subjects had at least one of the three iKIR + HLA pairs and the frequencies of various inhibitory combinations in the study group were: 31.5%, three iKIR + HLA pairs, 53.5%, two iKIR + HLA pairs, and 15%, 0ne iKIR + HLA pair. Furthermore, we revealed that majority of Iranians (69%) carry compound genotypes with greater number of inhibitory pairings than activating combinations (iKIR + HLA > aKIR + HLA). Conversely, iKIR + HLA < aKIR (45%) was dominant genotype in the study group. We conclude that selective evolutionary pressure has propensity to maintain KIR-HLA genotypes with more inhibitory combinations to guarantee self-tolerance. In contrast, existence of activating KIR genes without normal endogenous ligands, potentially arms the NK population for competent immunosurveillance and stronger defense against infections.

Preparation and Characterization of Expandable St/MMA Copolymers Produced by Suspension Polymerization

Free radical suspension copolymerization of styrene (St) with methyl methacrylate (MMA) in the presence of n-pentane was investigated. The batch polymerization was performed in a stirred reactor via a two-stage process. First, free radical suspension polymerization of St and MMA in aqueous media was carried out at about 80—90°C with the aid of a monofunctional initiator to the monomer conversions up to about 70%. Second process, called impregnation stage, consisted of a high temperature—high pressure cycle (110—120°C and 10 bars) in which the blowing agent was charged in the reactor and polymerization was carried out with the aid of a high temperature initiator. Fine particles of micron sizes of St/MMA copolymer were synthesized by manipulation of some experimental parameters governing the copolymerization system. Polymerization was carried out at different agitation rates, suspending agent and aqueous phase initiator concentrations as well as emulsifier amounts, while keeping constant the MMA/St ratio. To reach a desired bead size, the above parameters were optimized using the Taguchi method for experimental design and the relative importance of the mentioned parameters was analyzed. Particles with a spherical shape of 250—350 μm were formed. The obtained copolymers were also characterized in terms of molecular weight, polydispersity index, copolymer composition, morphology of the polymer beads, thermal behavior, and particle size and particle size distribution.

Pain Affects Health-Related Quality of Life in Kidney Transplant Recipients

BACKGROUND

Chronic pain is prevalent in end-stage renal disease patients undergoing chronic hemodialysis. We do not fully know the intensity of chronic pain experienced by kidney recipients in comparison to those on chronic hemodialysis and healthy controls. Moreover, the effect of chronic pain on kidney recipients' health-related quality of life (HRQoL) is yet to be comprehensively addressed. We designed this study to find an answer to these questions.

METHODS

In this case control study, we studied 205 kidney recipients, 69 hemodialysis patients, and 100 healthy controls, who were matched for age, sex, monthly family income, and educational level. The patients were evaluated for the intensity of chronic pain by Visual Analogue Scale (VAS). HRQoL was measured with Short Form 36 (SF-36) in the kidney recipients. Chronic pain intensity was compared in the study groups, and in the kidney recipients the correlation between SF-36 subscores and severity of pain was assessed.

RESULTS

Severity of pain in the kidney recipients was lower than the hemodialysis patients, but more than the healthy controls (P=.001). The VAS pain score negatively correlated with the scores of SF- 36 total (r=-.329, P=01), mental health (r=-.190, P=07), physical health (r=-.275, P=.001), physical function (r=-.339, P=.001), role limitation due to physical problems (r=-.478, P=.001), role limitation due to emotional problems (r=-.326, P=.001), and bodily pain (r=-.894, P=.001).

DISCUSSION

The intensity of chronic pain experienced by the kidney recipients is less than that experienced by patients under chronic hemodialysis, but higher than healthy subjects. Focusing on chronic pain as a cause of post-renal transplantation morbidity is expected to improve post-renal transplantation quality of life.

Effects of passive smoking on common respiratory symptoms in young children

AIM

To observe the effects of fathers' smoking on respiratory symptoms in children between the ages of 6 mo and 5 y living in Tehran during the period January to December 2001.

METHODS

The caregivers of 622 children attending resident-based clinics in two university hospitals were interviewed about the respiratory illnesses incurred by the child during the previous 12 mo and the smoking habits of those living with the child. Children who lived in households in which any person, other than the father, smoked were excluded.

RESULTS

The analysis included 595 children, 40.6% of whom were living in homes where fathers smoked cigarettes. About 35% of smokers admitted to unrestricted smoking at home. In children not living with a smoker, 81.6% had experienced at least one episode of upper respiratory tract infection (URTI) during the previous year and the rate increased to 95.2% in passive smokers whose fathers were not restricted from smoking in front of the children, (p-value <0.01). A similar pattern was found for otitis media and asthma (p-value <0.05 and <0.01, respectively). The average number of URTI episodes during the previous year was significantly higher in children exposed to unrestricted smoking (p <0.01).

CONCLUSION

The study outlines the detrimental effects of paternal smoking on the respiratory health of children from a part of world in which this problem has not been studied previously, and highlights the importance of educating fathers to alter their smoking habits so that even if they do not stop smoking altogether, they should discontinue smoking indoors.

Prevalence of Helicobacter pylori vacuolating cytotoxin and its allelic mosaicism as a predictive marker for Iranian dyspeptic patients

Helicobacter pylori infects the majority of the population in the developing countries. However, the rate of gastrointestinal complications such as peptic ulcers and gastric malignancies has no parallel with the infection. In order to determine whether cytotoxin (vacA) and its allelic polymorphism can serve as screening markers for such a population, H. pylori strains were isolated from one hundred and thirty two dyspeptic patients. H. pylori genomic DNA was extracted and underwent PCR-amplification for the cytotoxin alleles. Genotyping of the signal sequence region of the vacA gene identified 68% (70 out of 103) of patients with non ulcer dyspepsia (NUD) and 79% (23 out of 29) of the patients with peptic ulcer disease (PUD) possessing the s1 genotype. S1 strains were significantly more prevalent among patients with PUD as compared to the NUD (p < 0.05). In regard to the middle region, 55% of the patient isolates belonged to the m2 genotype with no correlation to disease. The s1m2 genotype was the most prevalent among all patients and significantly correlated with the PUD group (p < 0.05).

Enzyme-linked immunosorbent assay for the specific detection of the mercapturic acid metabolites of naphthalene

The measurement of metabolites constitutes a useful tool for detection of exposure and in pharmacokinetic studies. Epoxidation with subsequent glutathione conjugation and mercapturic acid formation is an important deactivation pathway for naphthalene, a toxin which presumably causes lung disease. The mercapturic acid conjugates of naphthalene [NaphMA (1), N-acetyl-S-(1,2-dihydro-1-hydroxy-2-naphthyl)cysteine (1a), and N-acetyl-S-(1,2-dihydro-2-hydroxy-1-naphthyl)cysteine (1b)], its most important urinary metabolites, and other structurally related derivatives, such as N-acetyl-S-(1,2,3,4-tetrahydro-2-hydroxy-1-naphthyl) cysteine (2), N-acetyl-S-(3-hydroxy-1,2,3,4-tetrahydro-2-naphthyl)cysteine (3), and N-acetyl-S-(2-hydroxy-1-phenylethyl)cysteine (4a) and N-acetyl-S-(2-hydroxy-2-phenylethyl)cysteine (4b) as an isomeric mixture, were synthesized to develop an ELISA (enzyme-linked immunosorbent assay) for the specific detection of NaphMA (1). Compound 1, as an isomeric mixture, was used to raise antibodies by immunizing six rabbits with the corresponding KLH (keyhole limpet hemocyanin) and BSA (bovine serum albumin) derivatives (1KLH and 1BSA). The remaining compounds were covalently attached to BSA, conalbumin, and ovalbumin to be used as coating antigens. The best assay was obtained in a homologous system combining serum Ab2357 (1KLH) and 1BSA as coating antigen. The immunoassay has an I50 of 4-6 ng/mL and a detection limit of 1-2 ng/mL. Because of the known instability of the mercapturic acid conjugate of naphthalene 1, leading to the fully aromatic compound 20, a system involving HPLC is described to check the stability of the NaphMA stock solutions used in the assay. Cross-reactivity studies show high specificity toward the NaphMA. Other related compounds as well as the dehydrated derivative 20 are not recognized by the antibody in this ELISA system.

Application of ELISA techniques to metabolic disposition studies for 1,3-dinitrobenzene: comparison with HPLC and radiochemical methods

An enzyme-linked immunosorbent assay (ELISA) is reported for the detection and quantitation of 1,3-dinitrobenzene, a widely used chemical intermediate in industrial syntheses and potent testicular toxicant in rats. Radiolabeled [14C]-1,3-dinitrobenzene (25 mg/kg, ip) was administered to rats, and the blood disappearance curve generated with the ELISA assay was compared with HPLC separation and quantitation by using both UV and radiochemical methods. An excellent correlation was found between the two methods. Matrix effects from the blood samples were minimal. Cross reactivity with metabolites of 1,3-dinitrobenzene occurred only at levels that were 3 orders of magnitude greater than for the parent compound. The specificity of the ELISA for 1,3-dinitrobenzene was further demonstrated with a variety of other nitroaromatic compounds, of which only 2,4-dinitrotoluene showed significant cross reactivity. The sensitivity and specificity of the 1,3-dinitrobenzene ELISA demonstrate the usefulness of an approach which, if verified with conventional analytical methods, allows rapid and inexpensive measurement of xenobiotic levels in biological samples.