Comparative prognostic importance of measures of left atrial structure and function in non-ischaemic dilated cardiomyopathy

AIMS

To compare the association between measures of left atrial (LA) structure and function, derived from cardiovascular magnetic resonance (CMR), with cardiovascular (CV) death or non-fatal heart failure (HF) events in patients with non-ischaemic dilated cardiomyopathy (DCM).

METHODS AND RESULTS

CMR studies of 580 prospectively recruited patients with DCM in sinus rhythm (median age 54 [interquartile range 44-64] years, 61% men, median LVEF 42% [30-51%]) were analysed for measures of LA structure (left atrial maximum volume index [LAVImax], left atrial minimum volume index [LAVImin]) and function (left atrial emptying fraction [LAEF], left atrial reservoir strain [LARS], left atrial conduit strain [LACS] and left atrial booster strain [LABS]). Over median follow-up of 7.4 years, 103 patients (18%) met the primary endpoint. Apart from LACS, each measure of LA structure and function was associated with the primary endpoint after adjusting for other important prognostic variables. The addition of each LA metric to a baseline model containing the same important prognostic covariates improved model discrimination, with LAVImin providing the greatest improvement (C-statistic improvement: 0.702 to 0.738; χ2 test comparing likelihood ratio p < 0.0001; categorical net reclassification index: 0.210 (95% CI 0.023-0.392)). Patients in the highest tercile of LAVImin had similar event rates to those with persistent atrial fibrillation. Measures of LA strain did not enhance model discrimination above LA volumetric measures.

CONCLUSION

Measure of left atrial structure and function offer important prognostic information in patients with DCM and enhance prediction of adverse outcomes. LA strain was not incremental to volumetric analysis for risk prediction.

Single cell RNA sequencing sheds light on infiltrating T cells in idiopathic inflammatory myopathies

Idiopathic inflammatory myopathies (IIM), also referred to as "myositis," are a group of heterogeneous autoimmune disorders characterised by muscle weakness, atrophy and progressive reduced mobility (Lundberg et al, 2021). IIM represent a significant health burden in adult populations, affecting individuals at a mean age of 50 with an estimated prevalence of 2.9-34 per 100,000 (Dobloug et al, 2015; Svensson et al, 2017). IIM encompass several subtypes including dermatomyositis, immune-mediated necrotising myopathy, inclusion-body myositis, antisynthetase syndrome and polymyositis, which are characterised by specific clinical features, histopathological findings and autoantibody status (Pinal-Fernandez et al, 2020).

Inventory of landslides triggered by an extreme rainfall event in Marche-Umbria, Italy, on 15 September 2022

Systematic and timely documentation of triggered (i.e. event) landslides is fundamental to build extensive datasets worldwide that may help define and/or validate trends in response to climate change. More in general, preparation of landslide inventories is a crucial activity since it provides the basic data for any subsequent analysis. In this work we present an event landslide inventory map (E-LIM) that was prepared through a systematic reconnaissance field survey in about 1 month after an extreme rainfall event hit an area of about 5000 km² in the Marche-Umbria regions (central Italy). The inventory reports evidence of 1687 triggered landslides in an area of ~550 km². All slope failures were classified according to type of movement and involved material, and documented with field pictures, wherever possible. The database of the inventory described in this paper as well as the collection of selected field pictures associated with each feature is publicly available at figshare.

Genetic Architecture of Acute Myocarditis and the Overlap With Inherited Cardiomyopathy

BACKGROUND

Acute myocarditis is an inflammatory condition that may herald the onset of dilated cardiomyopathy (DCM) or arrhythmogenic cardiomyopathy (ACM). We investigated the frequency and clinical consequences of DCM and ACM genetic variants in a population-based cohort of patients with acute myocarditis.

METHODS

This was a population-based cohort of 336 consecutive patients with acute myocarditis enrolled in London and Maastricht. All participants underwent targeted DNA sequencing for well-characterized cardiomyopathy-associated genes with comparison to healthy controls (n=1053) sequenced on the same platform. Case ascertainment in England was assessed against national hospital admission data. The primary outcome was all-cause mortality.

RESULTS

Variants that would be considered pathogenic if found in a patient with DCM or ACM were identified in 8% of myocarditis cases compared with <1% of healthy controls (P=0.0097). In the London cohort (n=230; median age, 33 years; 84% men), patients were representative of national myocarditis admissions (median age, 32 years; 71% men; 66% case ascertainment), and there was enrichment of rare truncating variants (tv) in ACM-associated genes (3.1% of cases versus 0.4% of controls; odds ratio, 8.2; P=0.001). This was driven predominantly by DSP-tv in patients with normal LV ejection fraction and ventricular arrhythmia. In Maastricht (n=106; median age, 54 years; 61% men), there was enrichment of rare truncating variants in DCM-associated genes, particularly TTN-tv, found in 7% (all with left ventricular ejection fraction <50%) compared with 1% in controls (odds ratio, 3.6; P=0.0116). Across both cohorts over a median of 5.0 years (interquartile range, 3.9-7.8 years), all-cause mortality was 5.4%. Two-thirds of deaths were cardiovascular, attributable to worsening heart failure (92%) or sudden cardiac death (8%). The 5-year mortality risk was 3.3% in genotype-negative patients versus 11.1% for genotype-positive patients (Padjusted=0.08).

CONCLUSIONS

We identified DCM- or ACM-associated genetic variants in 8% of patients with acute myocarditis. This was dominated by the identification of DSP-tv in those with normal left ventricular ejection fraction and TTN-tv in those with reduced left ventricular ejection fraction. Despite differences between cohorts, these variants have clinical implications for treatment, risk stratification, and family screening. Genetic counseling and testing should be considered in patients with acute myocarditis to help reassure the majority while improving the management of those with an underlying genetic variant.

Simultaneous multi-slice steady-state free precession myocardial perfusion with iterative reconstruction and integrated motion compensation

PURPOSE

Simultaneous multi-slice (SMS) balanced steady-state free precession (bSSFP) acquisition and iterative reconstruction can provide high spatial resolution and coverage for cardiac magnetic resonance (CMR) perfusion. However, respiratory motion remains a challenge for iterative reconstruction techniques employing temporal regularisation. The aim of this study is to evaluate an iterative reconstruction with integrated motion compensation for SMS-bSSFP first-pass myocardial stress perfusion in the presence of respiratory motion.

METHODS

Thirty-one patients with suspected coronary artery disease were prospectively recruited and imaged at 1.5 T. A SMS-bSSFP prototype myocardial perfusion sequence was acquired at stress in all patients. All datasets were reconstructed using an iterative reconstruction with temporal regularisation, once with and once without motion compensation (MC and NMC, respectively). Three readers scored each dataset in terms of: image quality (1:poor; 4:excellent), motion/blurring (1:severe motion/blurring; 3:no motion/blurring), and diagnostic confidence (1:poor confidence; 3:high confidence). Quantitative assessment of sharpness was performed. The number of uncorrupted first-pass dynamics was measured on the NMC datasets to classify patients into 'suboptimal breath-hold (BH)' and 'good BH' groups.

RESULTS

Compared across all cases, MC performed better than NMC in terms of image quality (3.5 ± 0.5 vs. 3.0 ± 0.8, P = 0.002), motion/blurring (2.9 ± 0.1 vs. 2.2 ± 0.8, P < 0.001), diagnostic confidence (2.9 ± 0.1 vs. 2.3 ± 0.7, P < 0.001) and sharpness index (0.34 ± 0.05 vs. 0.31 ± 0.06, P < 0.001). Fourteen patients with a suboptimal BH were identified. For the suboptimal BH group, MC performed better than NMC in terms of image quality (3.8 ± 0.4 vs. 2.6 ± 0.8, P < 0.001), motion/blurring (3.0 ± 0.1 vs. 1.6 ± 0.7, P < 0.001), diagnostic confidence (3.0 ± 0.1 vs. 1.9 ± 0.7, P < 0.001) and sharpness index (0.34 ± 0.05 vs. 0.30 ± 0.06, P = 0.004). For the good BH group, sharpness index was higher for MC than NMC (0.34 ± 0.06 vs 0.31 ± 0.07, P = 0.03), while there were no significant differences observed for the other three metrics assessed (P > 0.11). There were no significant differences between suboptimal BH MC and good BH MC for any of the reported metrics (P > 0.06).

CONCLUSIONS

Integrated motion compensation significantly reduces motion/blurring and improves image quality, diagnostic confidence and sharpness index of SMS-bSSFP perfusion with iterative reconstruction in the presence of motion.

High-resolution non-contrast free-breathing coronary cardiovascular magnetic resonance angiography for detection of coronary artery disease: validation against invasive coronary angiography

BACKGROUND

Coronary artery disease (CAD) is the single most common cause of death worldwide. Recent technological developments with coronary cardiovascular magnetic resonance angiography (CCMRA) allow high-resolution free-breathing imaging of the coronary arteries at submillimeter resolution without contrast in a predictable scan time of ~ 10 min. The objective of this study was to determine the diagnostic accuracy of high-resolution CCMRA for CAD detection against the gold standard of invasive coronary angiography (ICA).

METHODS

Forty-five patients (15 female, 62 ± 10 years) with suspected CAD underwent sub-millimeter-resolution (0.6 mm3) non-contrast CCMRA at 1.5T in this prospective clinical study from 2019-2020. Prior to CCMR, patients were given an intravenous beta blockers to optimize heart rate control and sublingual glyceryl trinitrate to promote coronary vasodilation. Obstructive CAD was defined by lesions with ≥ 50% stenosis by quantitative coronary angiography on ICA.

RESULTS

The mean duration of image acquisition was 10.4 ± 2.1 min. On a per patient analysis, the sensitivity, specificity, positive predictive value and negative predictive value (95% confidence intervals) were 95% (75-100), 54% (36-71), 60% (42-75) and 93% (70-100), respectively. On a per vessel analysis the sensitivity, specificity, positive predictive value and negative predictive value (95% confidence intervals) were 80% (63-91), 83% (77-88), 49% (36-63) and 95% (90-98), respectively.

CONCLUSION

As an important step towards clinical translation, we demonstrated a good diagnostic accuracy for CAD detection using high-resolution CCMRA, with high sensitivity and negative predictive value. The positive predictive value is moderate, and combination with CMR stress perfusion may improve the diagnostic accuracy. Future multicenter evaluation is now required.

Quantitative Diffusion and Spectroscopic Neuroimaging Combined with a Novel Early-Developmental Assessment Improves Models for 1-Year Developmental Outcomes

BACKGROUND AND PURPOSE

Preterm infants are at risk for overt and silent CNS injury, with developmental consequences that are difficult to predict. The novel Specific Test of Early Infant Motor Performance, administered in preterm infants at term age, is indicative of later developmental gross motor and cognitive scores at 12 months. Here, we assessed whether functional performance on this early assessment correlates with CNS integrity via MR spectroscopy or diffusional kurtosis imaging and whether these quantitative neuroimaging methods improve predictions for future 12-month developmental scores.

MATERIALS AND METHODS

MR spectroscopy and quantitative diffusion MR imaging data were acquired in preterm infants (n = 16) at term. Testing was performed at term and 3 months using the Specific Test of Early Infant Motor Performance and the Bayley Scales of Infant and Toddler Development, Third Edition, at 12 months. We modeled the relationship of MR spectroscopy and diffusion MR imaging data with both test scores via multiple linear regression.

RESULTS

MR spectroscopy NAA ratios at a TE of 270 ms in the frontal WM and basal ganglia and kurtosis metrics in major WM tracts correlated strongly with total Specific Test of Early Infant Motor Performance scores. The addition of MR spectroscopy and diffusion separately improved the functional predictions of 12-month outcomes.

CONCLUSIONS

Microstructural integrity of the major WM tracts and metabolism in the basal ganglia and frontal WM strongly correlate with early developmental performance, suggesting that the Specific Test of Early Infant Motor Performance reflects CNS integrity after preterm birth. This study demonstrates that combining quantitative neuroimaging and early functional movement improves the prediction of 12-month outcomes in premature infants.

A Multicenter External Validation of a Score Model to Predict Risk of Events in Patients With Brugada Syndrome

A multivariate risk score model was proposed by Sieira et al in 2017 for sudden death in Brugada syndrome; their validation in 150 patients was highly encouraging, with a C-index of 0.81; however, this score is yet to be validated by an independent group. A total of 192 records of patients with Brugada syndrome were collected from 2 centers in the United Kingdom and retrospectively scored according to a score model by Sieira et al. Data were compiled summatively over follow-up to mimic regular risk re-evaluation as per current guidelines. Sudden cardiac death survivor data were considered perievent to ascertain the utility of the score before cardiac arrest. Scores were compared with actual outcomes. Sensitivity in our cohort was 22.7%, specificity was 57.6%, and C-index was 0.58. In conclusion, up to 75% of cardiac arrest survivors in this cohort would not have been offered a defibrillator if evaluated before their event. This casts doubt on the utility of the score model for primary prevention of sudden death. Inherent issues with modern risk scoring strategies decrease the likelihood of success even in robustly designed tools such as the Sieira score model.

The strain-7 study: multimodal, multivendor, multifield strength, scan:rescan comparison of global longitudinal and circumferential strain in healthy volunteers

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): National Insitute for Health Research

Background

There is clinical and prognostic evidence for global longitudinal strain (GLS) and circumferential strain (GCS). A range of techniques exist: 2-dimensional echocardiography (2Decho), 3-dimensional echocardiography (3Decho) and Cardiovascular Magnetic Resonance (CMR).

Purpose

To investigate inter-study repeatability and inter-method comparison of GLS and GCS techniques.

Methods

Volunteers underwent same day scan

rescan 2Decho, 3Decho, 1.5T Siemens CMR (Cine imaging and Displacement encoding with stimulated echoes [DENSE]), 3T Siemens CMR (Cine Imaging and DENSE) and 3T Philips CMR (Tagging and Fast strain-encoding [fSENC]) imaging. Strain was quantified for 2Decho (EchoPAC), 3Decho (TomTec), Feature tracking (FT) for cine imaging (CircleCVI), CIM (University of Auckland) for DENSE and Tag, and Myostrain (Myocardial solutions) for fSENC.

Results

20(6F) volunteers, mean age 33 ± 7 years, mean LVEF 62 ± 4%. All GLS and GCS methods had excellent inter-study agreement (ICC &gt; 0.75) with coefficient of variation (CoV) between 4-8% (Table 1). Median and IQR are presented in Figure 1.

Friedman’s test revealed statistically significant inter-method differences for GLS (χ2 = 66.4,p &lt; 0.0001) and GCS (χ2 = 50.9,p &lt; 0.0001). Post hoc analysis using Dunn’s test with Bonferroni correction demonstrated significant differences:

-GLS: 2Decho vs DENSE 1.5T (p = 0.001) and Myostrain 3T (p = 0.0116); 3Decho vs FT 3T (p = 0.049) and DENSE 1.5T (p &lt; 0.0001); FT 1.5T vs DENSE 1.5T (p = 0.001) and Myostrain 3T (p = 0.01); FT 3T vs Myostrain 3T (p &lt; 0.0001); DENSE 1.5T vs Tag 3T (p = 0.0008) and Myostrain 3T (p &lt; 0.0001); Tag 3T vs Myostrain (p = 0.02).

-GCS: 3Decho vs DENSE 1.5T (P = 0.0005), FT 1.5T (p &lt; 0.001), FT 3T (P &lt; 0.001) and Myostrain (p = 0.003); FT 1.5T vs Tag 3T (p = 0.001), FT 3T vs Myostrain 3T (p = 0.04).

Conclusion

There is excellent interstudy agreement for GLS and GCS methods. However, there are important inter-method differences in absolute values, that need to be considered for clinical application as a surveillance method and longitudinal studies.

Table 1 Acquisiton Post processing GLS CoV(%) GLS ICC GCS CoV(%) GCS ICC 2DEcho EchoPAC 4.88 0.80 - - 3DEcho TomTec 4.77 0.86 3.97 0.85 Siemens 1.5T cine FT CircleCVI 8.30 0.79 6.00 0.85 Siemens 3T cine FT CircleCVI 6.21 0.89 4.76 0.94 Philips 3T Tag CIM 6.15 0.89 5.86 0.88 Siemens 1.5T DENSE CIM 4.36 0.90 4.65 0.89 Philips 3T fSENC Myostrain 8.45 0.81 4.06 0.90 Interstudy agreement for the different GLS and GCS methods. Abstract Figure 1

Left ventricular ejection fraction as an imaging biomarker to guide cardiac resynchronisation therapy in heart failure patients: a multimodal comparison of 2D and 3D echocardiography and CMR

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): The authors acknowledge financial support from the Department of Health through the National Institute for Health Research (NIHR) comprehensive Biomedical Research Centre award to Guy’s & St Thomas’ NHS Foundation Trust in partnership with King’s College London and King’s College Hospital NHS Foundation Trust and by the NIHR MedTech Co-operative for Cardiovascular Disease at Guy’s and St Thomas’ NHS Foundation Trust. This work was supported by the Wellcome/EPSRC Centre for Medical Engineering [WT 203148/Z/16/Z]. MSN was funded by a clinical lectureship awarded by the NIHR. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, the DoH, EPSRC, MRC or the Wellcome Trust.

Introduction – Imaging derived left ventricular ejection fraction (LVEF) has an important role to guide initiation of medical therapy and device insertion in patients with heart failure and reduced ejection fraction (HFrEF). Previous studies have reported the correlation and agreement of LVEF in various patient populations, but sparse evidence exists on patients with heart failure referred for Cardiac Resynchronisation Therapy (CRT) using 2D and 3D echocardiography (2DE & 3DE) and cardiovascular magnetic resonance (CMR).

Objectives – To determine the correlation and agreement of LVEF as determined by 2DE, 3DE and CMR in a cohort of HF patients referred for assessment of CRT.

Methods – Patients with suspected HFrEF referred for assessment for CRT therapy were included in this single centre study. Patients underwent 2DE, 3DE and CMR to derive LVEF, LVESV and LVEDV. Correlation was determined with Pearson’s correlation, agreement with Bland-Altman analysis and Cohen’s kappa analysis for agreement using a dichotomous cut off of LVEF ≤35% as a threshold for CRT insertion (Ponikowski, 2016).

Results - 55 patients (mean age 71 ± 9.2, 76% male) were included. The mean LVEF for 2DE, 3DE, CMR and were 32.4 ± 8.6, 32.1 ± 9.6 and 30.3 ± 9.5 respectively. CMR had a significantly lower LVEF compared to 2DE (p = 0.03).

There was good correlation between 3DE & CMR and 2DE & CMR, and excellent correlation between 3DE and 2DE for LVEF (Table 1). There was for trend for CMR to underestimate LVEF compared to 2DE and 3DE, with small biases although wide limits of agreement (Figure 1). There was excellent correlation of LVEDV and LVESV across all 3 techniques. CMR underestimated volumes compared to 2DE and 3DE with large biases and wide LOA.

The kappa coefficient agreement at threshold level for CRT insertion (LVEF ≤35%) was fair for 3DE and CMR (0.379, p = 0.004) and 2DE and CMR (0.462, p = 0.001), and moderate for 3DE and 2DE (0.575, p ≤ 0.001).

Conclusion – Whilst LVEF is not the only indicator to guide CRT insertion, it remains an important imaging parameter for clinical decision making. We observed large biases in left ventricular volumes between 2D, 3D and CMR. However, whilst the overall bias in LVEF is small, the wide limits of agreement (LOA) observed may represent an area of clinical uncertainty, which may impact on the dichotomous imaging threshold for CRT insertion.

Comparison of indices between modalities LVEF Correlation (r) LVEF Bias & LOA (%±SD) EDV Correlation (r) EDV Bias & LOA (mL ± SD) ESV Correlation (r) ESV Bias & LOA (mL ± SD) 3DE vs CMR 0.676 (p &lt; 0.001) +1.75 ± 15.4 0.896 (p &lt; 0.001) -82.16 ± 42.8 0.937 (p &lt; 0.001) -61.3 ± 34.9 3DE vs 2DE 0.872 (p &lt; 0.001) +0.48 ± 4.5 0.909 (p &lt; 0.001) -10.31 ± 28.3 0.936 (p &lt; 0.001) -8.42 ± 20.5 2DE vs CMR 0.675 (p &lt; 0.001) +2.35 ± 14.6 0.876 (p &lt; 0.001) -67.35 ± 36.3 0.898 (p &lt; 0.001) -51.42 ± 30.1 Abstract Figure. Bland-Altman Plot LVEF by 3DE & CMR

Quantitative analysis of myocardial metabolic heterogeneity is superior to visual assessment for the detection of active cardiac sarcoidosis by F-18 FDG PET-CT imaging

Funding Acknowledgements

Type of funding sources: None.

Background

Myocardial inflammation may occur in the context of a multisystem disease such as sarcoidosis, adversely affecting prognosis. A definitive diagnosis of cardiac sarcoidosis (CS) is essential to implementing life-saving treatment but this is complicated by the invasive nature of endomyocardial biopsy (EMB) and its low accuracy. Positron emission tomography (PET) assists in diagnosis, which relies on visual interpretation of myocardial F-18 FDG uptake. The value of quantitative analysis and its application to clinical practice remain uncertain.

Purpose

To investigate the power of quantitative F-18 FDG PET-CT imaging analysis for detecting CS in patients with suspected disease.

Methods

All patients underwent F-18 FDG PET-CT after a 24-hour low-carbohydrate diet and 15-hour fasting as part of their diagnostic work-up for suspected cardiac inflammation. Cardiovascular magnetic resonance acted as gatekeeper to PET-CT in 8 of every 10 scans. Myocardial F-18 FDG uptake was assessed qualitatively and quantitatively using both manually drawn regions of interest and automatic polar maps to measure global and segmental standardised F-18 FDG uptake values (SUV).  The coefficient of variation (CoV) was calculated to determine uptake heterogeneity. To confirm diagnosis, follow-up data regarding disease progression, further testing and treatment were collected. To allow for sufficient follow-up time, the first 40 consecutive patients from a prospective registry (n= 214; Sep 2017-Jun 2020) were included.

Results

A comprehensive clinical picture was obtained successfully in 37 patients (median [IQR], 17 [13.5] months) and a final diagnosis of CS reached in 7 (disease prevalence, 19%). EMB was performed in 2 patients only while 3 underwent PPM/ICD implantation. Significant predictors of CS were fulfilment of Japanese Ministry of Health and Welfare criteria (Wald, 6.44; p = 0.01) and left ventricular dysfunction (Wald 6.72; p = 0.01). Qualitative F-18 FDG PET-CT had a high negative (95%) but low positive (45%) predictive value for CS (sensitivity, 83%; specificity, 77%). F-18 FDG SUV CoV was the strongest imaging predictor (Wald, 6.77; p = 0.009) and was significantly higher in CS than non-CS (CoV median [quartiles], 0.26 [0.21, 0.36] and 0.12 [0.11, 0.14] respectively; p = 0.004). As per ROC curve analysis (AUC, 0.84), a CoV threshold of 0.20 was highly specific (93%) and sensitive (86%) for CS.

Conclusion

In a referring population with a low prevalence of cardiac sarcoidosis, F-18 FDG PET-CT imaging is sensitive for the detection of myocardial inflammation with active disease unlikely in patients with a negative scan. Quantitative evaluation of metabolic heterogeneity within the myocardium provides a strong, independent marker of active disease and should be considered alongside visual assessment.

Use of glycoprotein IIb/IIIa antagonists to prevent stent thrombosis in morphine-treated patients with ST-elevation myocardial infarction

Morphine can delay absorption of P2Y₁₂-inhibitors in ST-elevation myocardial infarction (STEMI) patients, which has the potential to expose these patients to increased stent thrombosis risk after primary percutaneous coronary intervention (PPCI). Limited evidence exists for pharmacotherapeutic strategies aiming to mitigate this risk. We evaluated the impact of guideline-driven 'routine' glycoprotein IIb/IIIa antagonist (GPI) use in morphine-treated patients undergoing PPCI. A total of 3224 consecutive STEMI patients undergoing PPCI at a large tertiary cardiac center between 2012 and 2017 were evaluated. GPI use and outcomes before and after introduction of a local guideline were compared, and rates of definite stent thrombosis were identified at 24 h and 30 days. GPI use increased from 42.4% to 69.9% after the introduction of the new guideline. Stent thrombosis occurred in 1.3% (26/1947) pre-guideline and 0.6% (7/1244) post-guideline (P = .037). Of the 33 stent thrombosis cases, 90% (27/30) had received morphine, of whom 85.2% (23/27) had not received adjunctive GPI. Complete records for assessing 30-day bleeding rates were only available in 374 patients and, in this subset, there was no significant difference in rates of GUSTO moderate or severe bleeding before vs. after introduction of the local guideline (1.7% vs 2.8%; P = .47) although, in both cohorts combined, any GUSTO bleeding was observed more frequently in GPI-treated patients (21.8%) compared to those not receiving a GPI (10.0%; P = .002). In conclusion, routine GPI use in morphine-treated STEMI patients undergoing PPCI appears to protect against stent thrombosis. Large-scale studies are needed to establish the overall risk-benefit of GPI therapy in morphine-treated PPCI patients and to assess alternative strategies for preventing acute stent thrombosis in these patients.

Detection and Characteristics of Temporal Encephaloceles in Patients with Refractory Epilepsy

BACKGROUND AND PURPOSE

Temporal encephaloceles are increasingly visualized during neuroimaging assessment of individuals with refractory temporal lobe epilepsy, and their identification could indicate an intracranial abnormality that may be related to a potential seizure focus. Careful review by an experienced neuroradiologist may yield improved detection of TEs, and other clinical, neurophysiologic, and radiologic findings may predict their presence.

MATERIALS AND METHODS

Data were reviewed retrospectively in patients at our institution who were presented at a multidisciplinary conference for refractory epilepsy between January 1, 2010, and December 31, 2016. Clinical, neurophysiologic, and imaging data were collected. An expert neuroradiologist reviewed the latest MR imaging of the brain in patients for whom one was available, noting the presence or absence of temporal encephaloceles as well as other associated imaging characteristics.

RESULTS

A total of 434 patients were reviewed, 16 of whom were excluded due to unavailable or poor-quality MR imaging. Seven patients had temporal encephaloceles reported on initial imaging, while 52 patients had temporal encephaloceles identified on expert review. MR imaging findings were more often initially normal in patients with temporal encephaloceles (P < .001), and detection of temporal encephaloceles was increased in patients in whom 3T MR imaging was performed (P < .001), the T2 sampling perfection with application-optimized contrasts by using different flip angle evolutions sequence was used (P < .001), or the presence of radiologic findings suggestive of idiopathic intracranial hypertension was noted. Seizure onset by scalp electroencephalogram among patients with temporal encephaloceles was significantly more likely to be temporal compared with patients without temporal encephaloceles (P < .001). A significant correlation between intracranial electroencephalogram seizure onset and patients with temporal encephaloceles compared with patients without temporal encephaloceles was not observed, though there was a trend toward temporal-onset seizures in patients with temporal encephaloceles (P = .06).

CONCLUSIONS

Careful review of MR imaging in patients with refractory temporal lobe epilepsy by a board-certified neuroradiologist with special attention paid to a high-resolution T2 sequence can increase the detection of subtle temporal encephaloceles, and certain clinical and neurophysiologic findings should raise the suspicion for their presence.

Development of High Signal Intensity within the Globus Pallidus and Dentate Nucleus following Multiple Administrations of Gadobenate Dimeglumine

BACKGROUND AND PURPOSE

Previous studies have evaluated various gadolinium based contrast agents and their association with gadolinium retention, however, there is a discrepancy in the literature concerning the linear agent gadobenate dimeglumine. Our aim was to determine whether an association exists between the administration of gadobenate dimeglumine and the development of intrinsic T1-weighted signal in the dentate nucleus and globus pallidus.

MATERIALS AND METHODS

In this single-center, retrospective study, the signal intensity of the globus pallidus, dentate nucleus, thalamus, and middle cerebellar peduncle was measured on unenhanced T1-weighted images in 29 adult patients who had undergone multiple contrast MRIs using exclusively gadobenate dimeglumine (mean, 10.1 ± 3.23 doses; range, 6-18 doses). Two neuroradiologists, blinded to the number of prior gadolinium-based contrast agent administrations, separately placed ROIs within the globi pallidi, thalami, dentate nuclei, and middle cerebellar peduncles on the last MR imaging examinations. The correlations between the globus pallidus:thalamus and the dentate nucleus:middle cerebellar peduncle signal intensity ratios with the number of gadolinium-based contrast agent administrations and cumulative dose were tested with either 1-tailed Pearson or Spearman correlations. A priori, P < .05 was considered statistically significant.

RESULTS

Both the globus pallidus:thalamus and dentate nucleus:middle cerebellar peduncle ratios showed significant correlation with the number of gadolinium-based contrast agent administrations (r = 0.39, P = .017, and r = 0.58, P = .001, respectively). Additionally, the globus pallidus:thalamus and dentate nucleus:middle cerebellar peduncle ratios showed significant correlation with the cumulative dose of gadobenate dimeglumine (r = 0.48, P = .004, and r = 0.43, P = .009, respectively). Dentate nucleus hyperintensity was qualitatively present on the last MR imaging in 79.3%-86.2% of patients and in all patients who had received >10 doses.

CONCLUSIONS

At high cumulative doses (commonly experienced by patients, for example, with neoplastic disease), gadobenate dimeglumine is associated with an increase in the globus pallidus:thalamus and dentate nucleus:middle cerebellar peduncles signal intensity ratios.

Pediatric Patients Demonstrate Progressive T1-Weighted Hyperintensity in the Dentate Nucleus following Multiple Doses of Gadolinium-Based Contrast Agent

BACKGROUND AND PURPOSE

While there have been recent reports of brain retention of gadolinium following gadolinium-based contrast agent administration in adults, a retrospective series of pediatric patients has not previously been reported, to our knowledge. We investigated the relationship between the number of prior gadolinium-based contrast agent doses and increasing T1 signal in the dentate nucleus on unenhanced T1-weighted MR imaging. We hypothesized that despite differences in pediatric physiology and the smaller gadolinium-based contrast agent doses that pediatric patients are typically administered based on weighted-adjusted dosing, the pediatric brain would also demonstrate dose-dependent increasing T1 signal in the dentate nucleus.

MATERIALS AND METHODS

We included children with multiple gadolinium-based contrast agent administrations at our institution. A blinded reader placed ROIs within the dentate nucleus and adjacent cerebellar white matter. To eliminate reader bias, we also performed automated ROI delineation of the dentate nucleus, cerebellar white matter, and pons. Dentate-to-cerebellar white matter and dentate-to pons ratios were compared with the number of gadolinium-based contrast agent administrations.

RESULTS

During 20 years at our institution, 280 patients received at least 5 gadolinium-based contrast agent doses, with 1 patient receiving 38 doses. Sixteen patients met the inclusion/exclusion criteria for ROI analysis. Blinded reader dentate-to-cerebellar white matter ratios were significantly associated with gadolinium-based contrast agent doses (r_s = 0.77, P = .001). The dentate-to-pons ratio and dentate-to-cerebellar white matter ratios based on automated ROI placement were also significantly correlated with gadolinium-based contrast agent doses (t = 4.98, P < .0001 and t = 2.73, P < .02, respectively).

CONCLUSIONS

In pediatric patients, the number of prior gadolinium-based contrast agent doses is significantly correlated with progressive T1-weighted dentate hyperintensity. Definitive confirmation of gadolinium deposition requires tissue analysis. Any potential clinical sequelae of gadolinium retention in the developing brain are unknown. Given this uncertainty, we suggest taking a cautious stance, including the use, in pediatric patients, of higher stability, macrocyclic agents, which in both human and animal studies have been shown to be associated with lower levels of gadolinium deposition, and detailed documentation of dosing. Most important, a patient should not be deprived of a well-indicated contrasted MR examination.

Abstract P6-05-11: DEPArray™ enables recovery of pure tumor cells from heterogeneous fine needle aspirates for routine downstream NGS analysis

Introduction: We have previously shown reliability in isolating pure populations of cells from complex tissues using the DEPArray™. Fine Needle Aspiration (FNA) is a quick and simple procedure often performed to make a diagnosis or rule out conditions such as cancer. Although FNA is also used to assess response to treatment, the procedure is often deemed insufficient in yield and purity of tumor cells. Here we provide preliminary results showing 100% efficiency in recovering pure tumor cell populations from FNA samples of patients affected by Metastatic Breast Cancer and known to have low tumor burden (&lt;20%) prior to using the DEPArray™ platform.

Method: FNA paraffin embedded sections (50 microns thickness) from metastases originating from breast (n=3) primary tumors were evaluated. Each FFPE curl was processed to yield single cells followed by DEPArray™ sorting based on cytokeratin (Ker), vimentin (Vim) and nuclear staining. The recovered cell populations were directly lysed in the collection tube prior to PCR-based target enrichment for next generation sequencing using Ion AmpliSeq™ CHPv2.

Results: DEPArray™ analysis allowed identification of 3 well separated cell populations, including tumor (Ker+/Vim-), stromal (Vim+/Ker) and putative EMT (Ker+/Vim+) cells. Overall, only 21% (4.3% to 42.7% range) of the total (mean of 6335) cells analyzed were of tumor (KER+/Vim-) origin. Groups of pure cells (mean 105 cells, range 15-200) for each population were recovered for sequence analysis. In one breast cancer FNA sample, we observed TP53 LoH but only in the recovered tumor (KER+) cells and not in the unsorted, stromal (VIM+), or EMT (KER+/VIM+) populations. In addition, a PIK3CA missense somatic heterozygous variant was identified in both the tumor and putative EMT populations but not in stromal cells, confirming this as a somatic mutation.

Conclusion: DEPArray™ allows resolution of two main limitations associated with FNA samples obtained for genomic analysis: too few target cells and unwanted admixture of normal cells. DEPArray™ allows for phenotypic distinction between the sorted cells prior to recovery; thus, enabling sequence analysis that is suitable for detecting genomic aberrations such as CNVs and LoH, which cannot be evaluated as precisely in an unsorted sample. Clearly, the DEPArray™ platform brings precision to detection, quantification and recovery of pure target cells that are suitable for subsequent downstream molecular analysis that can improve cancer diagnosis and personalized treatment strategies for breast cancer patients.

Citation Format: Sero V, Forcato C, Bolognesi C, Buson G, Medoro G, Yazdani M, Blevins A, Manaresi N, Bischoff FZ. DEPArray™ enables recovery of pure tumor cells from heterogeneous fine needle aspirates for routine downstream NGS analysis. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-05-11.

Abstract P2-02-19: Somatic genetic profiling of circulating tumor cells (CTC) in metastatic breast cancer (MBC) patients

Introduction: Somatic mutations, including those in TP53, PIK3CA, and estrogen receptor alpha (ESR1), are key to the biology of cancer and response to therapy. Recently, somatic cancer-associated mutations have been identified in circulating cell free plasma tumor DNA (ptDNA). Less is known about the mutation profile of DNA extracted from CTC (CTC-DNA). Since CTC-DNA provides mutational information of single cells, we hypothesize CTC-DNA will complement ptDNA to give greater insight into tumor heterogeneity.

Methods: Patients with ER positive MBC who were enrolled in the Mi CTC-ONCOSEQ, a companion trial to Mi-ONCOSEQ (the Michigan Oncology Sequencing Program), and who had ≥5CTC/7.5 ml whole blood were included. CTC were enriched from white blood cells (WBC) with CellSearch© (CXC kit). CTC and WBC were then purified using DEPArrayTM. DNA from individual CTC and WBC was isolated and subjected to whole genomic amplification (Ampli 1TM WGA). Genetic analysis was performed on individual CTC, pooled CTC and pooled WBC DNA by multiplexed PCR based targeted next generation sequencing (NGS) using the Oncomine Comprehensive Panel (targeting ∼130 onco- and tumor suppressor genes) and the Ion Torrent Proton. All patients had exome sequencing performed on research biopsies of metastases using an Illumina HiSeq 2500 platform.

Results: This pilot study was conducted using high quality DNA from two patients assessed to date. Both patients had lobular carcinoma and as expected harbored somatic, deleterious CDH1 (E-cadherin) mutations (frameshift and non-sense) in both research biopsy and CTC-DNA. These data supported our approach. Patient #1 was TP53 wild type in her research biopsy, but multiple CTC harbored somatic TP53 frame-shift mutations (Table). Patient #2 harbored an ESR1 Y537S mutation in her research biopsy. However, only 4 of 7 CTC also harbored this somatic, heterozygous mutation.

Prioritized mutations in CTCPt#Cell Type (CTC vs WBC), numberGeneMutationVariant fraction (expected 1=homozygous; 0.5=heterozygous)Found in research biopsy?1CTC_A2CDH1p.I584fs1YES CTC_A4  1  CTC_A7  0.54  CTC_pool*  0.74  WBC_pool  0  CTC_A2TP53p.152_156del1NO CTC_A4  1  CTC_A7  0.51  CTC_pool*  0.88  WBC_pool  0 2CTC_A9ESR1p.Y537S0.52YES CTC_D1  0.34  CTC_D2  0.46  CTC_D6  0.65  CTC_pool*  0.35  WBC_pool  0  CTC_A12  0  CTC_D3  0  CTC_D7  0  CTC_A12CDH1p.Q641X1YES CTC_A9  1  CTC_D1  1  CTC_D3  1  CTC_D6  1  CTC_pool*  1  WBC_pool  0 * pool of all CTC

Conclusions: We demonstrate the ability to purify CTC, isolate, and amplify DNA of suitable quality for genetic analysis using a comprehensive targeted sequencing panel. Both known and novel alterations were identified in comparison to research biopsy specimens. This approach allows single cell analysis demonstrating heterogeneity of mutational status in different single cells. Studies of CTC-ESR1 and other genetic abnormalities in patients with known tissue mutations who participated in Mi CTC-ONCOSEQ are now underway.

Citation Format: Paoletti C, Cani AK, Aung K, Darga EP, Cannell EM, Hovelson DH, Yazdani M, Blevins AR, Tokudome N, Larios JM, Thomas DG, Brown ME, Gersch C, Schott AF, Robinson DR, Chinnaiyan AM, Bischoff F, Hayes DF, Rae JM, Tomlins SA. Somatic genetic profiling of circulating tumor cells (CTC) in metastatic breast cancer (MBC) patients. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-02-19.

Effectiveness of stress management training on the psychological well-being of the nurses

Objective: an appropriate psychological intervention to promote the level of the public health and mental well-being of nurses has a great importance. This investigation was aimed to study the effectiveness of stress management training on the psychological welfare of nurses in Imam Khomeini Hospital. Methodology: this study was quasi-experimental with pretest-posttest that used a control group. Hence, 40 of the nurses in Imam Khomeini Hospital were selected by using a convenience sampling method and placed in the experimental group and the control group. Both groups were pretested by using psychological well-being 84-question scale. Afterwards, the experimental group was trained for ten sessions under stress management skill exercise, and the check group got no intervention. Next, both societies were post-tested, and the acquired data were analyzed by using inferential and descriptive statistical methods accompanied by SPSS 21 software. Findings: the results indicated that stress management training significantly led to the promotion of psychological well-being in nurses (p < 0.001). Conclusion: it was found from the research that due to the high level of effectiveness of stress management training, its low cost, and its high acceptability by the patients, especially when it was performed in a group, had a significant positive impact on the promotion of psychological well-being in nurses.

Brown adipose tissue genes in pericardial adipose tissue of newborn sheep are downregulated by maternal nutrient restriction in late gestation

BACKGROUND

Brown adipose tissue (BAT) thermogenesis is essential for newborn survival. Pericardial adipose tissue is a visceral depot that promotes metabolic and cardiovascular adaptations. We determined whether BAT is present in pericardial adipose tissue in newborns and whether maternal nutrition during late gestation compromises BAT in the postnatal period.

METHODS

We measured uncoupling protein 1 (UCP1) and other BAT-specific genes (e.g., β3-adrenergic receptor (β3ADR) and deiodinase type 2 (DIO2)), together with markers of white adipose tissue (WAT) in sheep on either the first or 30th day after birth. These were twin offspring born to mothers fed with either 100% or nutrient restricted (NR) to 60% of their total metabolizable requirements from 110 d gestation to term.

RESULTS

Gene expression of UCP1 and other BAT-related genes decreased significantly with age. In newborns, maternal nutrient restriction downregulated gene expression of DIO2 and the β3-adrenergic receptor with reduced UCP1 but had no effect on genes predominantly expressed in WAT.

CONCLUSION

BAT is present around the heart in newborns. Exposure to a suboptimal maternal diet in late gestation specifically compromises BAT development and has the potential to place these offspring at increased risk of hypothermia after birth without effects on the subsequent appearance of WAT.

Subcutaneous nephrovesical bypass in kidney transplanted patients

BACKGROUND

Renal transplant ureteral stricture or obstruction is a rare but devastating complication after renal transplantation.

OBJECTIVE

To determine the efficacy and complications of subcutaneous prosthetic ureters as a salvage procedure in transplanted kidneys with recurrent ureteral obstruction.

METHODS

5 subcutaneous prosthetic ureters were inserted in 5 kidney recipients who had recurrent ureteral stenosis and failed endoscopic and open reconstructive surgeries. The prosthetic ureter consisted of an internal silicone tube covered by a coiled PTFE tube. The proximal end of the tube was introduced in the transplanted kidney percutaneously, the tube was passed through a subcutaneous tunnel, and the distal end was inserted in the bladder through a small suprapubic incision.

RESULTS

The mean follow-up of patients was 11.3 months. One of the patients re-operated two days after the procedure because of urinary leakage from the distal end of the prosthetic ureter. No infection or tube encrustation was encountered.

CONCLUSION

Subcutaneous prosthetic ureter is a safe alternative for permanent percutaneous nephrostomy in transplanted kidneys with obstructed ureter and failed endoscopic and open procedures.

The risk factors and laboratory diagnostics for post renal transplant tuberculosis: a case-control, country-wide study on definitive cases

BACKGROUND

Tuberculosis (TB) is an important cause of morbidity and mortality in renal transplant recipients and, because of its infrequency and the lack of medical awareness, it is usually misdiagnosed. This study was carried out to determine frequency and weight of multiple risk factors for post kidney transplantation TB.

METHODS

A total of 44 cases (0.3%), out of 12,820 patients from 12 major kidney transplantation centers in Iran from 1984 to 2003, were compared with 184 healthy transplant subjects who were transplanted by the same surgical team.

RESULTS

The mean age of cases and controls was 37.7 (13-63) and 35.6 (8-67) years (P=0.3), respectively. The mean duration of pre-transplantation hemodialysis was 30.3 (3-168) months in cases and 18.2 (1-180) months in controls (P=0.03). A positive past history of TB was detected in 2 cases and 1 control (P=0.3). The mean doses of initial and maintenance immunosuppressive drugs in cases and controls were not significantly different. A total of 25 cases (56.8%) and 60 controls (32.6%) had rejection before diagnosis of TB (P=0.004; OR=2.7, CI(95%): 1.3-5.6).

CONCLUSIONS

To our knowledge, this is the first study that demonstrated an increase in the risk of post-transplant TB by increasing the duration of pre-transplant hemodialysis and the number of post-transplant rejection episodes as 2 immunocompromised states. Further study is needed to clarify our new findings, specifically in relation to different immunosuppressive regimens.

Cadaveric kidney transplantation: five years experience at a single center

BACKGROUND

In the past, the majority of renal transplantations in Iran were from living donors, but recently cadaveric donation of organs is increasing. We reviewed our experience on kidney transplantation from cadaveric donors for the past 5 years in our center.

METHODS

Between July 1998 and September 2004, 122 kidneys were removed from 61 cases of brain-dead patients and transplanted in 114 patients with end-stage renal disease in our center. Two kidneys had tumoral involvement and were discarded. Three kidneys were transplanted in other centers and three patients received en bloc kidney transplantations. In addition, we performed nine cases of heart, one case of liver, and one case of lung transplantations. All the recipients were followed for at least 1 year and posttreatment renal function and graft survival were determined.

RESULTS

All cadaveric donors were brain dead due to car (30%) and motocycle (70%) accidents, with ages ranging from 5 to 56 years (mean, 24/4 years). The mean warm and total cold ischemia times were 7 minutes and 8.1 hours, respectively. The mean distance between harvesting center and our hospital was 65 km. The 1-year graft survival was 92.3%, with mean serum creatinine of 1.76 +/- 0.79 at 1 year. Of other transplanted organs, the liver and lung recipients died 24 hours and 45 days after operation. Among heart recipients, four are still alive.

CONCLUSION

Cadaveric donors in developing countries including Iran can be excellent sources of organ donation.

Effect of the Immunoregulatory Cytokines on Successful Pregnancy Depends Upon the Control of Graft Rejection Mechanisms

Successful outcomes in allopregnant women depend upon control of graft rejection mechanisms. An understanding of how the fetus escapes the maternal immune system may be relevant for the prevention of transplant rejection. It has been suggested that the same immunosuppressive cytokines contribute to successful pregnancy and transplantation. Recent reports suggest a role for transforming growth factor beta (TGF-beta) in the generation of T-regulatory lymphocytes. In contrast, production of proinflammatory cytokines accompanying intrauterine infection has been associated with fetal rejection or preterm labor. Interleukin-12 (IL-12) is the unique stimulator for differentiation of T-helper lymphocytes (Th) to Th1 cells. It rapidly induces transcription of Th1 cytokines such as interferon-gamma. This study was performed in 70 pregnant women at 21 to 36 weeks gestation, and in 32 healthy nonpregnant controls. An indirect enzyme-linked immunosorbent assay was used to estimate TGF-beta1, and IL-12 in serum. The results showed that TGF-beta1 levels were higher in all pregnant women compared with the nonpregnant controls. No significant changes in serum levels of IL-12 were observed in pregnant compared with the normal control women. The results suggested that the cytokine milieu of the placenta appeared to play a critical role in the maternal acceptance of the fetus, and that TGF-beta1 may function as a regulatory factor in fetal allograft survival during pregnancy.

Preliminary Report of a Nationwide Case-Control Study for Identifying Risk Factors of Tuberculosis Following Renal Transplantation

BACKGROUND

Tuberculosis (TB) is an important infection encountered posttransplantation, especially among patients in developing countries, where there are high incidences of morbidity and mortality.

MATERIALS AND METHODS

One hundred and twenty subjects (1%) from 15 major kidney transplantation centers in Iran from 1984 to 2003 were compared with 440 controls who were matched for operative time, treatment center, and surgical team.

RESULTS

Mean ages of research subjects and controls were 38.6 and 36.6 years (P = .04), respectively. The mean duration of pretransplantation hemodialysis was 29 months (range, 2 to 192 months) in research subjects and 20 months (range, 1 to 180 months) in controls (P = .003). Positive past history of tuberculosis was detected in 4 (3.3%) research subjects and in 7 (1.5%) controls (P = .2). Fifty-two research subjects (43.3%) and 241 controls (54.8%) had pretransplantation purified protein derivative of tuberculin less than 5 mm (P = .02). Mean dosages of initial and maintenance immunosuppressive drugs in research subjects and in controls were not significantly different. Sixty research subjects (50%) and 152 controls (34.5%) had rejection prior to diagnosis of TB (P = .03).

CONCLUSION

To our knowledge, this is the first study that demonstrates an increased risk of posttransplant TB by prolonged duration of pretransplant hemodialysis and number of posttransplant rejection episodes. Further study is needed to clarify these findings specifically with respect to various immunosuppressive regimens.

Successful treatment of cervical aplasia using a peritoneal graft

OBJECTIVE

To evaluate the efficacy of a peritoneal graft for the treatment of cervical aplasia.

METHOD

Four patients with cervical aplasia who had a functioning endometrium and hematometra were recruited for this clinical trial. Through an abdominoperineal approach a plastic stent was inserted between the endometrial cavity and the upper part of the vagina; then, a graft of peritoneum was applied over the stent. In the absence of a vagina, grafts of skin or amniotic membrane were also used. The plastic stent was removed after 1 month in 2 patients and after 1 week in the 2 other patients.

RESULT

After more than 1 year of observation the 4 patients had regular menstrual cycles with normal menstruation. Sonographic examinations also showed empty uterine cavities.

CONCLUSION

Traditional gynecology textbooks recommend hysterectomy in cases of cervical aplasia. This report presents a new technique with 2 variations using a peritoneal graft. Although both variations were successful in the treatment of cervical aplasia in 4 women, more trials are needed to determine which one should be developed.

Caffeine enhances the expression of the angiotensin II Type 2 receptor mRNA in BeWo cell culture and in the rat placenta

Although chronic caffeine exposure during pregnancy has been shown to affect fetal growth, adverse effects of caffeine on embryogenesis are not only well understood, but also controversial. We have used gene chip technology in an attempt to identify to what extent, if any, caffeine could possibly alter gene expressions in the cytotrophoblast-like cell line BeWo. Few down-regulated genes were found; most of the genes were up-regulated, suggesting that chronic caffeine exposure during the gestational period could exert certain influences on embryogenesis. The highest up-regulated gene expression of BeWo cells by caffeine was angiotensin II type 2 (AT(2)) receptor gene. We focused the genes of the renin-angiotensin system (RAS), angiotensin II type 1 (AT(1)) and AT(2)receptors and angiotensin I converting enzyme, for study on caffeine's responsive gene expression in BeWo cells and in the placentae of pregnant rats that were fed a diet supplemented with caffeine (2 mg/100 g body weight) during gestation, and analysed the gene expressions using RT-PCR and LightCycler system. A significantly increased AT(2)receptor gene expression and a slight decreased AT(1)receptor gene expression demonstrated the caffeine's effect to the placental RAS.

Effects of caffeine on heart mitochondria in newborn rats

Caffeine consumption has been implicated in the development of cardiovascular disease. Therefore, in the present study, litters of rats were combined upon birth, and 8 pups were randomly assigned to each dam. Dams with pups were divided into 2 groups: group 1 received a 20% protein diet as a control, and group 2 received the 20% protein diet supplemented with caffeine (4 mg/100 g body weight). Pups from both groups were killed on days 11 and 15. Transmission electron microscopy revealed swollen, disrupted, degenerating mitochondria and intracellular edema in the hearts of rats in the caffeine groups when compared with those of the controls. Plasma Cu concentration was significantly decreased. These results indicate that early exposure to caffeine through maternal milk adversely affects cardiac mitochondria of rat pups and may be associated with decreased plasma Cu levels. It is unclear whether these results apply to the human infant. Interspecies extrapolation from rat to human must be made with caution.