Evaluation of the TIMI risk score for secondary prevention for predicting ischemic and bleeding events in patients with recent myocardial infarction

Background

Patients with acute myocardial infarction (MI) have a substantial risk of ischemic events, which must be balanced against the risk of bleeding imposed by modern antiplatelet agents. Both ischemic and bleeding risk are modified by the presence or absence of several risk factors. The TIMI Risk Score for Secondary Prevention (TRA2°P) is a simple and promising risk stratification scheme for predicting risk of atherothrombotic events at 3 years. It was developed using 8598 placebo-treated patients of the TRA 2°P -TIMI 50 trial and has only been evaluated in small selected cohorts.

Purpose

We evaluated the TRA2°P risk score (age≥75 years, congestive heart failure, hypertension, diabetes mellitus, prior stroke, prior coronary artery bypass surgery, peripheral artery disease, renal dysfunction, current smoking) in a large contemporary cohort of patients with a recent myocardial infarction (MI).

Methods

Nationwide administrative health care data on hospitalizations, procedures, medications, and outcomes were abstracted from the Danish registries. We included all patients ≥30 years hospitalized with a first acute MI between 1 January 2005 and 31 December 2011 who were alive and event-free 30 days after discharge. Patients with an indication for oral anticoagulation were excluded. Data on smoking status were not available. The main outcome was a composite of cardiovascular death, non-fatal MI and ischemic stroke. Bleedings requiring hospitalization were also investigated. Patients were followed until death, emigration, or a total of 3 years; whichever came first.

Results

A total of 34,479 patients were included (mean age 67±14 years, 35% females, 66% had prior revascularization, 90% received aspirin, 79% a P2Y12-inhibitor, 86% lipid-lowering medication and 82% beta-blockers). During 3-year follow-up, the main composite outcome was reached in 4677 patients (cumulative incidence, 13.6% [CI95%, 13.2–13.9%]) and 746 patients (2.2% [2.0–2.3%]) had a bleeding requiring hospitalization.

The TRA2°P risk score demonstrated a robust absolute and relative risk gradient for both the composite ischemic endpoint and bleeding requiring hospitalization (Table 1). The absolute risk of bleedings remained lower than the risk of atherothrombotic events. This is summarized in Figure 1, where results are presented by low, intermediary, and high TRA2°P risk score, as applied in the derivation cohort. The C-statistic of the TRA2°P risk score was 0.69 for the composite outcome, comparable to that of the derivation cohort.

Conclusions

The TRA2°P risk score identified patients at increased risk of atherothrombotic events at 3 years and a pattern of increasing absolute risk difference between ischemic and bleeding events. The role of the TRA2°P risk score in identifying patients who may benefit from extended antiplatelet treatment merits further evaluation. Also, the TRA2°P risk score may have wide applications in register-based research of post MI patients.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Bispebjerg and Frederiksberg University Hospital

Pod and Seed Trait QTL Identification To Assist Breeding for Peanut Market Preferences

Although seed and pod traits are important for peanut breeding, little is known about the inheritance of these traits. A recombinant inbred line (RIL) population of 156 lines from a cross of Tifrunner x NC 3033 was genotyped with the Axiom_Arachis1 SNP array and SSRs to generate a genetic map composed of 1524 markers in 29 linkage groups (LG). The genetic positions of markers were compared with their physical positions on the peanut genome to confirm the validity of the linkage map and explore the distribution of recombination and potential chromosomal rearrangements. This linkage map was then used to identify Quantitative Trait Loci (QTL) for seed and pod traits that were phenotyped over three consecutive years for the purpose of developing trait-associated markers for breeding. Forty-nine QTL were identified in 14 LG for seed size index, kernel percentage, seed weight, pod weight, single-kernel, double-kernel, pod area and pod density. Twenty QTL demonstrated phenotypic variance explained (PVE) greater than 10% and eight more than 20%. Of note, seven of the eight major QTL for pod area, pod weight and seed weight (PVE >20% variance) were attributed to NC 3033 and located in a single linkage group, LG B06_1. In contrast, the most consistent QTL for kernel percentage were located on A07/B07 and derived from Tifrunner.

Rheumatologic manifestations of primary immunodeficiency diseases

In the last 5 years, several hundred articles have been published concerning the link between primary immunodeficiency disease (PID) and rheumatologic diseases. Although rheumatologic complications were originally thought to be at the opposite ends of the spectrum of immunopathologic manifestations, they are now all being considered secondary manifestations of a causative primary "immune derangement." For the rheumatologist, it is important to be able to identify patients who may present with typical rheumatologic findings but who have an underlying PID. In a systematic manner, this overview addresses both the systemic and organ-based rheumatologic diseases which have known associations with primary immunodeficiencies, and explores how immunodeficiency may actually cause these clinical manifestations.

A parent training model for toilet training children with autism

BACKGROUND

Azrin & Foxx pioneered an intensive toilet training protocol for individuals with intellectual disability living in a residential setting. Since the development of the Rapid Toilet Training (RTT) protocol, many have replicated the efficacy, most notably in educational and outpatient treatment settings, but often training over longer periods of time. This study presents data from a parent training model that replicates Azrin and Foxx's results and training time.

METHOD

This multiple baseline across subjects design study employs an ABA design where two boys diagnosed with autism were toilet trained using a modified Azrin & Foxx intensive teaching protocol. The first subject, a 4-year-old boy, did not have a history of attempted toilet training. The second subject, a 6-year-old boy, demonstrated a history of failed toilet training attempts in both the home and school settings. The trainings were conducted in the home setting where a novel parent-training approach was implemented.

RESULTS

Participant 1 was continent at the end of the second day of training, and completely toilet trained (including initiation and communication) by day 10 of the intervention. Participant 2 was continent after day 1 and completely toilet trained by day 5 of the intervention.

CONCLUSIONS

Long-term follow-up demonstrates maintenance of skills 3 years post training. Social validity via parent satisfaction was assessed. Limitations to the current study and recommendations for future research were discussed.

6th International Immunoglobulin Symposium: poster presentations

The posters presented at the 6th International Immunoglobulin Symposium covered a wide range of fields and included both basic science and clinical research. From the abstracts accepted for poster presentation, 12 abstracts were selected for oral presentations in three parallel sessions on immunodeficiencies, autoimmunity and basic research. The immunodeficiency presentations dealt with novel, rare class-switch recombination (CSR) deficiencies, attenuation of adverse events following IVIg treatment, association of immunoglobulin (Ig)G trough levels and protection against acute infection in patients with X-linked agammaglobulinaemia (XLA) and common variable immunodeficiency (CVID), and the reduction of class-switched memory B cells in patients with specific antibody deficiency (SAD). The impact of intravenous immunoglobulin on fetal alloimmune thrombocytopenia, pregnancy and postpartum-related relapses in multiple sclerosis and refractory myositis, as well as experiences with subcutaneous immunoglobulin in patients with multi-focal motor neuropathy, were the topics presented in the autoimmunity session. The interaction of dendritic cell (DC)-SIGN and alpha2,6-sialylated IgG Fc and its impact on human DCs, the enrichment of sialylated IgG in plasma-derived IgG, as wells as prion surveillance and monitoring of anti-measles titres in immunoglobulin products, were covered in the basic science session. In summary, the presentations illustrated the breadth of immunoglobulin therapy usage and highlighted the progress that is being made in diverse areas of basic and clinical research, extending our understanding of the mechanisms of immunoglobulin action and contributing to improved patient care.

LMO2-associated clonal T cell proliferation in two patients after gene therapy for SCID-X1

We have previously shown correction of X-linked severe combined immunodeficiency [SCID-X1, also known as gamma chain (gamma(c)) deficiency] in 9 out of 10 patients by retrovirus-mediated gamma(c) gene transfer into autologous CD34 bone marrow cells. However, almost 3 years after gene therapy, uncontrolled exponential clonal proliferation of mature T cells (with gammadelta+ or alphabeta+ T cell receptors) has occurred in the two youngest patients. Both patients' clones showed retrovirus vector integration in proximity to the LMO2 proto-oncogene promoter, leading to aberrant transcription and expression of LMO2. Thus, retrovirus vector insertion can trigger deregulated premalignant cell proliferation with unexpected frequency, most likely driven by retrovirus enhancer activity on the LMO2 gene promoter.

Transurethral microwave thermotherapy for nonbacterial prostatitis: a randomized double-blind sham controlled study using new prostatitis specific assessment questionnaires

PURPOSE

We investigated the effectiveness and durability of transurethral microwave thermotherapy in the treatment of chronic nonbacterial prostatitis using 2 new prostatitis specific assessments in a randomized, double-blind, sham controlled trial.

MATERIALS AND METHODS

Patients with nonbacterial prostatitis were randomly assigned to receive either transurethral microwave thermotherapy or sham therapy. Patients were assessed using a symptom severity index and symptom frequency questionnaire. These 2 new prostatitis symptom assessment tools were validated by applying them to 30 similar patients without prostatitis. All nonresponders received transurethral microwave thermotherapy at 3 months and were reassessed at 6 months. Long-term followup of the responder group averaged 21 months.

RESULTS

The symptom severity index and symptom frequency questionnaire were confirmed to be valid for symptom assessment in prostatitis patients. The transurethral microwave thermotherapy group benefited from therapy compared to the sham group. Of the sham group 50% had a favorable response after subsequent transurethral microwave thermotherapy. The 7 responders in the treatment group continued to improve during the subsequent 21 months.

CONCLUSIONS

Transurethral microwave thermotherapy appears to be an effective, safe and durable treatment for some patients with nonbacterial prostatitis unresponsive to traditional therapy.

Case report: steroid sparing effect of intravenous gamma globulin in a child with necrotizing vasculitis

This article reports the case of a boy aged 2 years 6 months, who had fever, arthritis, and necrotizing cutaneous vasculitis. Evaluation revealed no evidence of direct infectious causes. However, high anti-streptolysin and streptozyme titers during the acute phase support the possibility that streptococcal infection played an important role in the pathogenesis of this disease. The patient's condition improved significantly with the administration of prednisone. However, several attempts to diminish the prednisone dose resulted in relapses. Subsequently, the prednisone was successfully tapered and discontinued after intravenous gamma globulin administration. It is recommended that intravenous gamma globulin should be considered before immunosuppressive therapy in the treatment of necrotizing vasculitis.

Blockade by dendrotoxin homologues of voltage-dependent K+ currents in cultured sensory neurones from neonatal rats

1. Homologues of dendrotoxin (Dtx) were isolated from the crude venom of Green and Black Mamba snakes and examined for K+ channel blocking activity in neonatal rat dorsal root ganglion cells (DRGs) by whole-cell patch clamp recording. 2. Outward potassium current activated by depolarization was composed of two major components: a slowly inactivating current (SIC, tau decay approximately 50 ms, 200 ms and 2s), and a non-inactivating current (NIC, tau decay > 2 min). Tail current analysis revealed two time constants of deactivation of total outward current, 3-12 ms and 50-150 ms (at -80 mV) which corresponded to SIC and NIC, respectively. 3. All the homologues (alpha-, beta-, gamma- and delta-Dtx and toxins I and K) blocked outward current activated by depolarization in a dose-dependent manner. The most potent in blocking total outward current was delta-Dtx (EC50 of 0.5 +/- 0.2 nM), although there were no statistically significant differences in potency between any of the homologues. 4. Qualitative differences in the nature of the block were noted between homologues. In particular, the block by delta-Dtx was time-dependent, whereas that by alpha-Dtx was not. 5. alpha-Dtx was a much better blocker of SIC (EC50 = 1.0 +/- 0.4 nM) than was delta-Dtx (EC50 = 17.6 +/- 5.8 nM). Furthermore, delta-Dtx was selective for NIC (EC50 +/- 0.24 +/- 0.03 nM) over SIC and reduced the slow component of tail currents (NIC), preferentially. On the other hand, a-Dtx did not significantly distinguish between SIC and NIC although tail current analysis showed that a-Dtxpreferentially reduced the fast component of tail currents (SIC).6. The results confirm, using direct electrophysiological methods, that homologues of dendrotoxins from Mamba snake venom block K+ channels in rat sensory neurones. Furthermore, a-Dtx and 6-Dtx distinguish between sub-types of K+ channels in these cells and may thus be useful pharmacological tools in other neuronal K+ channel studies.

Quantitation of soluble HLA class I heterodimers and beta 2-microglobulin in patients with active pulmonary tuberculosis

Beta 2m serum levels have been shown to be increased in patients with tuberculosis and HIV infection. We determined the stability of beta 2m and of sHLA-I dimers in serum, and then determined the levels of both molecules in 60 non-HIV-infected patients with active pulmonary tuberculosis and in 55 adult controls. The levels of sHLA-I in samples kept at room temperature declined by 8% at 30 minutes, 16% at 60 minutes, and 36% at 120 minutes. Beta 2m levels remained stable at all times tested. Mean sHLA-I levels were 0.99 +/- 0.16 micrograms/ml in controls and 1.34 +/- 0.11 micrograms/ml in patients with tuberculosis (P < 0.0001). Beta 2m levels were 1.23 +/- 0.26 micrograms/ml in controls and 2.26 +/- 0.64 micrograms/ml in patients with tuberculosis (P < 0.0001). All patients with tuberculosis had elevation of sHLA-I and/or beta 2m above 1 standard deviation of normal values. However, there was no correlation between sHLA-I and beta 2m levels in individual samples. Evaluation of sHLA-I holds the promise of further understanding of the biology and genetic regulation of the immune response to mycobacterial infection.

Thromboembolic prophylaxis in total hip replacement: a comparison between the low molecular weight heparinoid Lomoparan and heparin-dihydroergotamine

In a prospective, randomized, assessor-blind multicentre study two antithrombotic subcutaneous regimens were compared in patients undergoing total hip replacement. Group 1 (154 patients) received 750 anti-Xa units of a new low molecular weight heparinoid (Lomoparan) subcutaneously twice a day and group 2 (155 patients) received 5000 units heparin and 0.5 mg dihydroergotamine (heparin-DHE 5000) twice a day. The incidence of deep vein thrombosis, assessed by routine bilateral venography on day 10 (+/- 1), was 17 and 32 per cent in groups 1 and 2 respectively (risk reduction 47 per cent; P = 0.007). One patient in each group developed a symptomatic pulmonary embolism confirmed by lung scanning. Major bleeding complications occurred in one patient in each group and no significant difference was observed between the two groups with respect to minor bleeding complications. Subcutaneous Lomoparan appears to be as safe as heparin-DHE 5000 at the above doses with regard to bleeding complications, and is more efficacious with respect to venous thrombosis.

Cloning of the low-affinity murine granulocyte-macrophage colony-stimulating factor receptor and reconstitution of a high-affinity receptor complex

A cDNA clone (clone 71) that encodes a low-affinity receptor for murine granulocyte-macrophage colony-stimulating factor (GM-CSF) has been isolated by direct expression. This molecule is the homologue of the human GM-CSF receptor alpha subunit, although homology between these molecules is surprisingly low (less than 35% amino acid identity). The cDNA encodes a polypeptide of 387 amino acids, which contains the conserved features of the hematopoietin receptor superfamily. When expressed in COS-7 cells, this clone encodes a protein that binds radiolabeled murine GM-CSF with low affinity. Coexpression of clone 71 with a cDNA corresponding to a low-affinity interleukin 3 (IL-3) receptor (AIC2A) did not alter the affinity of binding of either GM-CSF or IL-3. However, coexpression of clone 71 with the IL-3 receptor-related cDNA AIC2B generated high-affinity binding sites for murine GM-CSF but not murine IL-3. These studies show that clone 71 and AIC2B are capable of forming an alpha beta complex capable of binding murine GM-CSF with high affinity, while AIC2A appears not to be a component of the murine GM-CSF receptor.

Tetanus toxin and neuronal membranes: the relationship between binding and toxicity

Tetanus toxin labeled by the Bolton-Hunter technique possesses high specific activity and retains substantial biological activity. This material can be used to characterize tetanus toxin binding to receptors in brain membrane preparations. In experiments aimed at measuring the absorption of labeled toxin, the displacement of labeled toxin by unlabeled toxin and the on-rate and off-rate constants, the data revealed two binding sites. The high affinity site had a Kd of 0.033 to 0.070 nM and a Bmax of 0.26 to 0.4 pmol/mg of protein; the low affinity site had a Kd of 0.89 to 6.9 nM and a Bmax of 1.55 to 3.0 pmol/mg of protein. The binding of tetanus toxin to brain membranes was enhanced greatly by low pH and ionic strength. Similarly to tetanus toxin, botulinum neurotoxin could be labeled by the Bolton-Hunter technique, and its binding to brain membranes was also enhanced by low pH and ionic strength. In studies with a neutralizing monoclonal antibody against tetanus toxin, the antigen-antibody interaction was not significantly altered by media with low ionic strength and pH. On the other hand, the ability of the antibody to block toxin binding to brain membranes was reduced substantially in nonphysiologic media. In a bioassay aimed at determining the effect of pH and tonicity on tissue association by toxin, low pH and ionic strength did not enhance toxicity. The biological activity of tetanus toxin was unaffected and that of botulinum neurotoxin was greatly diminished. The present findings confirm the widely reported observation that low pH and ionic strength promote tissue association by tetanus toxin, but they challenge the premise that this binding is relevant to the normal process of cell poisoning.

Control of renovascular hypertension by renal embolization

Two cases with medically well-controlled renovascular hypertension due to unilateral contracted kidney were treated by percutaneous renal embolization. One of the patients had two aneurysms of the renal artery in addition to the stenosis. Both patients remained normotensive without medication after follow-ups of 6 and 24 months, respectively.

Adverse reactions in treatment with lithium carbonate and haloperidol

Hospital records of 425 patients who had been treated simultaneously with lithium carbonate and haloperidol were examined. Adverse reactions in these patients were the same as in patients given lithium alone or haloperidol alone. None of the patients developed a syndrome resembling that described by others in patients treated with a lithium and haloperidol combination.