Rheumatoid arthritis synovial fluid shows enrichment of T-cells producing GMCSF which are polyfunctional for TNFα and IFNγ

OBJECTIVES

GMCSF+T-cells may be involved in pathogenesis of rheumatoid arthritis (RA), and polyfunctionality may be a marker of pathogenicity. Although, higher frequencies of CD4+GMCSF+ T-cells have been reported, there are no data on CD8+GMCSF+ T-cells or polyfunctionality.Our objective was to enumerate frequencies of CD8+GMCSF+ T cells in RA blood and synovial fluid (SF), and assess their polyfunctionality, memory phenotype and cytotoxic ability.

METHODS

This study included RA patients (blood samples,in some with paired synovial fluid (SF)), healthy controls (HC) (blood) and SpA patients (SF). In some RA patients' blood was sampled twice, before and 16-24 weeks after methotrexate (MTX) treatment. After mononuclear cell isolation from blood and SF, ex-vivo stimulation using PMA/Ionomycin was done, and cells were stained (surface and intracellular after permeabilisation/fixation). Subsequently, frequencies of GMCSF+CD8+ and CD4+ T-cells, polyfunctionality (TNFα, IFNγ, IL-17), phenotype (memory) and perforin/granzyme expression were assessed by flowcytometry.

RESULTS

There was no significant difference in frequencies of GMCSF+CD8+ (3.7, 4.1%, p=0.540) or GMCSF+CD4+ T-cells (4.5, 5.2%, p=0.450) inblood of RA and HC. However, there was significant enrichment of both CD8+GMCSF+ (5.8, 3.9%, p=0.0045) and CD4+GMCSF+ (8.5, 4.5%, p=0.0008) T-cells inSF compared to blood in RA patients. Polyfunctional triple cytokine positive TNFα+IFNγ+GMCSF+CD8+T-cells (81, 36%, p=0.049) and CD4+T-cells (48, 32%, p=0.010) was also higher in SF compared to blood in RA. CD8+ T cells showed higher frequency of effector-memory phenotype and granzyme-B expression in RA-SF. On longitudinal follow-up, blood CD4+GMCSF+ T-cells significantly declined (4.6, 2.9%, p=0.0014) post-MTX.

CONCLUSIONS

We report a novel finding of enrichment of CD8+GMCSF+ in addition to CD4+GMCSF+ T-cells in RA-SF. These cells showed higher polyfunctionality for TNFα and IFNγ, and effector memory phenotype suggesting their involvement in RA pathogenesis.

Ab initio molecular orbital and density functional studies on the ring-opening reaction of oxetene

Electrocyclic ring opening (ERO) reaction of 2H-Oxete (oxetene) has been carried out computationally in the gas phase and ring opening barrier has been computed. When comparing the ERO reaction of oxetene with the parent hydrocarbon (cyclobutene), the ring opening of cyclobutene is found to exhibit pericyclic behavior while oxetene shows mild pseudopericyclic nature. Computation of the nucleus-independent chemical shift (NICS) of oxetene adds evidence for pseudopericyclic behavior of oxetene. By locking of lone pair of electrons by hydrogen bonding, it is seen that the pseudopericyclic nature of the ring opening of oxetene is converted into a pericyclic one. CASSCF(5,6)/6-311+G** computation was carried out to understand the extent of involvement of lone pair of electrons during the course of the reaction. CR-CCSD(T)/6-311+G** computation was performed to assess the energies of the reactant, transition state and the product more accurately.

Preparation and evaluation of celecoxib transdermal patches

Celecoxib Transdermal patches were prepared by using different polymers such as hydroxyl-propylmethylcellulose (HPMC), methylcellulose (MC), Polyvinylpyrolidone (PVP). The in-vitro release of the drug from the formulations were studied using commercial semi permeable membrane. The prepared formulation were subjected to various physicochemical evaluation test, in-vitro dissolution studies, kinetics studies shows diffusion might be one of the prominent mechanism influencing the drug release. To confirm the fact Peppa's plot was drawn, which confirmed that the diffusion mechanism involved in the drug release was of non fickian diffusion type. ex-vivo diffusion studies by using rat skin, guinea pig skin and pig ear skin and finally in-vivo evaluation studies (the patch F4 HPMC 0.75%, PVP 0.25%) were carried out by using rabbits.

Daily rhythm of nociception in rats

Background

Many behavioral and physiological variables exhibit daily rhythmicity. Few investigations of the daily rhythmicity in nociception have been conducted, and conflicting results have been obtained. The present study evaluated the daily rhythmicity in nociception in Wistar rats.

Methods

Nociception was investigated by Eddy's hot plate method, tail immersion method, and tail clip method. The latency between the noxious stimulus and the animal's response was recorded as reaction time. Separate groups of rats were tested in 4-hour intervals for 24 hours.

Results

There was clear daily variation in response latency. Reaction time was shortest a few hours before lights-on and longest at the light-dark transition.

Conclusion

Nociception exhibits robust daily rhythmicity in rats. Sensitivity to pain is highest late in the dark phase of the light-dark cycle and lowest at the light-dark transition.

Electrical remodeling of the atria associated with paroxysmal and chronic atrial flutter

BACKGROUND

Atrial electrical remodeling may be important for the initiation and perpetuation of atrial arrhythmias. Whether paroxysmal atrial flutter (AFL) and chronic AFL cause electrical remodeling of the atria has not been conclusively determined.

METHODS AND RESULTS

Before radiofrequency ablation of paroxysmal AFL, 15 patients in sinus rhythm were evaluated under autonomic blockade. Lateral right atrial (LRA) effective refractory periods (ERPs) at 600 and 450 ms were measured before and at 1-minute intervals for 10 minutes after spontaneous or pace termination of a 5- to 10-minute period of induced AFL. In 10 patients with chronic AFL, LRA, septal, and coronary sinus (CS) ERPs and corrected sinus node recovery times (cSNRTs) at 600 and 450 ms were measured under autonomic blockade 15 minutes, 30 minutes, and 3 weeks after termination of chronic AFL by ablation. In the paroxysmal AFL group, LRA ERPs decreased by 18% at 600 ms and 12% at 450 ms (P:<0.01) after induced AFL and recovered to baseline over approximately 5 minutes. Atrial fibrillation developed during AFL in 3 patients and during ERP testing in 3 patients when refractoriness was at its nadir. In the chronic AFL group, LRA, septal, and CS ERPs at 3 weeks were significantly greater than at 15 and 30 minutes after termination of chronic AFL at both cycle lengths (P:<0.01). Three weeks after ablation, cSNRT decreased 35% at 600 ms (P:<0.05) and decreased 44% at 450 ms (P:<0. 05). Both ERPs and cSNRTs measured 15 and 30 minutes after ablation of chronic AFL were not significantly different.

CONCLUSIONS

Both paroxysmal AFL and chronic AFL cause reversible electrical remodeling of the atria but demonstrate different time courses of recovery.

Synthesis and conformational studies of peptidomimetics containing furanoid sugar amino acids and a sugar diacid

Furanoid sugar amino acids (1) were synthesized and used as dipeptide isosteres to induce interesting turn structures in small linear peptides. They belong to a new variety of designed hybrid structures that carry both amino and carboxyl groups on rigid furanose sugar rings. Four such molecules, 6-amino-2,5-anhydro-6-deoxy-D-gluconic acid (3, Gaa) and its mannonic (4, Maa), idonic (5, Iaa), and a 3,4-dideoxyidonic (6, ddIaa) congeners were synthesized. The synthesis followed a novel reaction path in which an intramolecular 5-exo S(N)2 opening of the hexose-derived terminal aziridine ring in 2 by the gamma-benzyloxy oxygen with concomitant debenzylation occurred during pyridinium dichromate oxidation of the primary delta-hydroxyl group to carboxyl function, leading to the formation of furanoid sugar amino acid frameworks in a single step. Incorporation of these furanoid sugar amino acids into Leu-enkephalin replacing its Gly-Gly portion gave analogues 8-11. Detailed structural analysis of these molecules by circular dichroism (CD) and various NMR techniques in combination with constrained molecular dynamics (MD) simulations revealed that two of these analogues, 8a and 10a, have folded conformations composed of an unusual nine-membered pseudo beta-turn-like structure with a strong intramolecular H-bond between LeuNH --> sugarC3-OH. This, in turn, brings the two aromatic rings of Tyr and Phe in close proximity, a prerequisite for biological activities of opioid peptides. The analgesic activities of 8a,b determined by mouse hot-plate and tail-clip methods were similar to that of Leu-enkephalin methyl ester. The syn disposition of the beta-hydroxycarboxyl motif on the sugar rings appears to be the driving force to nucleate the observed turn structures in some of these molecules (8 and 10). Repetition of the motif on both sides of a furanose ring resulted in a novel molecular design of sugar diacid, 2,5-anhydro-D-idaric acid (7, Idac). Bidirectional elongation of the diacid moieties of 7 with identical peptide strands led to the formation of a C2-symmetric reverse-turn mimetic 12 which displayed a very ordered structure consisting of identical intramolecular H-bonds at two ends between LeuNH --> sugar-OH, the same as in 8 and 10.

Dual demand pacing using retriggerable refractory periods for ventricular rate control during paroxysmal supraventricular tachyarrhythmias in patients with dual chamber pacemakers

The use of dual chamber pacing in patients with atrioventricular block and paroxysmal supraventricular tachyarrhythmias may present a clinical dilemma because of the rapid and erratic triggering of ventricular pacing. To avoid this, a variety of pacing methods have now been described, including the use of retriggerable atrial refractory periods or dual demand pacing. This review details the use, advantages, and limitations of this poorly understood algorithm referred to as "pseudo-mode switching."

Electrical remodeling of the atria following loss of atrioventricular synchrony: a long-term study in humans

BACKGROUND

Evidence suggests that an increased incidence of atrial fibrillation occurs in patients undergoing single-chamber ventricular pacing (VVI) when compared with those undergoing single-chamber atrial pacing (AAI) or those having dual-chamber atrioventricular pacing (DDD). The mechanism for this is unknown. We hypothesized that long-term loss of atrioventricular (AV) synchrony leads to atrial electrical remodeling: a potential explanation for this difference.

METHODS AND RESULTS

The study was a prospective, randomized comparison between 18 patients paced in VVI mode and 12 patients paced in DDD mode for 3 months. Under autonomic blockade, effective refractory periods (ERPs) from the lateral right atrium (RA), RA appendage, RA septum, and coronary sinus-corrected sinus node recovery times (cSNRTs), as well as P-wave duration (PWD), and biatrial diameters were measured at baseline and 3 months. The VVI group was then programmed to DDD pacing and reevaluated after a further 3 months. After long-term VVI pacing, ERPs at all 4 atrial sites increased significantly in a nonuniform fashion in association with biatrial dilatation. PWD and cSNRTs also prolonged significantly. With the reestablishment of AV synchrony, ERPs, PWD, cSNRTs, and biatrial dimensions returned to baseline levels. In the 12 patients who underwent long-term DDD pacing from baseline, no significant changes in atrial electrophysiology or biatrial dimensions were demonstrated.

CONCLUSIONS

Long-term loss of AV synchrony induced by VVI pacing is associated with atrial electrical remodeling, which is reversible after the reestablishment of AV synchrony with DDD pacing. This process may be partly responsible for the higher incidence of atrial fibrillation in patients undergoing VVI pacing compared with AV sequential pacing.

Left atrial mechanical function after brief duration atrial fibrillation

OBJECTIVES

This study examined the effect of brief duration atrial fibrillation on left atrial and left atrial appendage mechanical function in humans with structural heart disease.

BACKGROUND

Left atrial dysfunction and the development of spontaneous echo contrast (SEC) may follow the cardioversion of atrial fibrillation (AF) to sinus rhythm. This phenomenon has been termed "stunning" and is implicated in the development of atrial thrombus and embolic stroke. The effects of brief duration AF on left atrial mechanical function in humans are unknown.

METHODS

Twenty-four patients (23 men, aged 59.1+/-12.7 years) with significant structural heart disease (ejection fraction 31.2+/-9.0%, left atrial diameter 4.9+/-0.4 cm) undergoing implantation of a ventricular cardiodefibrillator underwent transesophageal echocardiography to evaluate left atrial appendage emptying velocities (LAAeV) and SEC before, during and after a 15-min period of AF induced by rapid right atrial pacing. Atrial fibrillation was then permitted to terminate spontaneously within 5 min or was reverted with an endocardial direct current shock. Velocities and SEC were assessed in sinus rhythm pre-AF, during AF and immediately, 5 and 10 min after reversion to sinus rhythm.

RESULTS

Atrial fibrillation terminated spontaneously in 10 patients after 16.1+/-1.0 min. Endocardial direct current (DC) cardioversion of 10.4+/-6.4 J was required in 14 patients after AF lasting 20 min. Mean LAAeV pre-AF (50.0 +/- 17.5 cm/s) was not significantly different to LAAeV immediately (52.8 +/- 16.7 cm/s), 5 min (54.3 +/- 16.4 cm/s) or 10 min (53.7 +/- 15.7 cm/s) after reversion to sinus rhythm. Atrial stunning defined as a reduction in LAAeV of >20% was not observed in any patient. Fourteen of 24 patients (58%) developed SEC during AF, which resolved within 30 s of AF termination. There were no significant differences between LAAeV in those patients reverting with DC shock (pre-AF 50.6+/-16.2 cm/s vs. immediately post-AF 54.7+/-16.6 cm/s) or in those patients with spontaneous reversion (pre-AF 48.9+/-20.2 cm/s vs. immediately post-AF 49.8+/-17.3 cm/s).

CONCLUSIONS

Significant left atrial stunning was not observed after brief duration AF in humans with structural heart disease. Transient left atrial SEC develops in a significant proportion of these patients during AF but resolves rapidly on reversion to sinus rhythm. These findings suggest that the risk of thromboembolism may be low after brief duration AF that terminates either spontaneously or with an endocardial DC shock even in patients with significant structural heart disease. These findings have important implications for recipients of implantable devices that are capable of atrial defibrillation in response to AF.

Transvenous ventricular pacing options in Ebstein's anomaly

Transvenous pacing in patients with Ebstein's anomaly is challenging due to anatomical abnormalities of the tricuspid valve and right heart chambers. This paper describes the various transvenous ventricular lead placement options for permanent pacing in patients with Ebstein's anomaly. In Ebstein's anomaly, stable long-term ventricular pacing can be achieved by positioning the lead either in the atrialised right ventricle, true right ventricle or the cardiac venous system. The pitfalls and advantages of pacing from these sites with the electrocardiographic and chest X-ray appearances are described.

Left atrial "stunning" following radiofrequency catheter ablation of chronic atrial flutter

OBJECTIVES

This study examined the effect of radiofrequency ablation (RFA) on left atrial (LA) and left atrial appendage (LAA) function in humans with chronic atrial flutter (AFL).

BACKGROUND

Atrial stunning and the development of spontaneous echocardiographic contrast (SEC) is a consequence of electrical cardioversion of AFL to sinus rhythm. This phenomenon has been termed "stunning" and is associated with thrombus formation and embolic stroke. Radiofrequency ablation is now considered to be definitive treatment for chronic AFL, but whether this procedure is complicated by LA stunning is unknown.

METHODS

Fifteen patients with chronic AFL undergoing curative RFA underwent transesophageal echocardiography to evaluate LA and LAA function and SEC before and immediately, 30 minutes and 3 weeks after RFA. To control for possible direct effects of RFA on atrial function, seven patients undergoing RFA for paroxysmal AFL were also studied. In this group, RF energy was delivered in sinus rhythm and echocardiographic parameters were assessed before and immediately and 30 minutes following RFA.

RESULTS

Chronic AFL: Mean arrhythmia duration was 17.2 +/- 13.3 months. Twelve patients (80%) developed SEC following RF energy application and reversion to sinus rhythm. LAA velocities decreased significantly from 54.0 +/- 14.2 cm/s in AFL to 18.0 +/- 7.1 cm/s in sinus rhythm after arrhythmia termination (p < 0.01). These changes persisted for 30 minutes. Following 3 weeks of sustained sinus rhythm, significant improvements in LAA velocities (68.9 +/- 23.6 vs. 18.0 +/- 7.1 cm/s, p < 0.01) and mitral A-wave velocities (49.8 +/- 10.3 vs. 13.4 +/- 11.2 cm/s, p < 0.01) were evident and SEC had resolved in all patients. Paroxysmal AFL: Radiofrequency energy delivered in sinus rhythm had no significant effect on any of the above indexes of LA or LAA function and no patient developed SEC following RFA.

CONCLUSIONS

Radiofrequency ablation of chronic AFL is associated with significant LA stunning and the development of SEC. Left atrial stunning is not secondary to the RF energy application itself. Sustained sinus rhythm for 3 weeks leads to resolution of these acute phenomena. Left atrial stunning occurs in the absence of direct current shock or antiarrhythmic drugs, suggesting that its mechanism may be a function of the preceding arrhythmia rather than the mode of reversion.

Atrial fibrillation and anticoagulation in patients with permanent pacemakers: implications for stroke prevention

Several large prospective randomized trials have demonstrated that anticoagulation with warfarin reduces the risk of thromboembolic stroke in high risk patients with chronic AF by approximately 70%. Large numbers of patients with permanent pacemakers have AF, and anticoagulation rates in this population have not been described. In a prospective analysis of 110 consecutive patients attending the pacemaker clinic of a large university hospital we assessed the number of patients with AF and the proportion of these patients who were receiving anticoagulation to prevent thromboembolic stroke. Where necessary, temporary pacemaker reprogramming to low ventricular rates was utilized to facilitate the diagnosis of AF. Fifty-three of the 110 patients (48%) were diagnosed with AF, all of whom (100%) had accepted high risk factors for thromboembolic stroke. Only eight of the 53 (15%) had been anticoagulated with warfarin. Thirty-six of the 53 patients (68%) diagnosed with AF had no prior documented diagnosis of chronic AF, and the majority had no symptoms suggesting AF. A single lead II ECG was insufficient in 67 of the 110 patients (61%) to diagnose the underlying atrial rhythm; the remainder required 12-lead ECGs or temporary pacemaker reprogramming to low ventricular rates to diagnose the underlying atrial rhythm. AF is common in patients with permanent pacemakers. It is commonly asymptomatic, and anticoagulation is markedly underutilized in reducing stroke risk in these patients. Attention to the possibility of AF in paced patients should allow prompt diagnosis and allow both the initiation of anticoagulation in order to reduce thromboembolic stroke risk and consideration for cardioversion of AF to sinus rhythm.

Effect of direct current shocks on left atrial mechanical function in patients with structural heart disease

OBJECTIVES

This study examined the effect of endocardial and transthoracic direct current (DC) shocks on left atrial and left atrial appendage function in humans with structural heart disease.

BACKGROUND

DC cardioversion of atrial fibrillation (AF) to sinus rhythm is associated with transient left atrial and left atrial appendage dysfunction and the development of spontaneous echo contrast (SEC). This phenomenon has been termed atrial "stunning" and may be associated with thrombus formation and embolic stroke. To what extent the shock itself contributes to atrial stunning is unclear.

METHODS

Thirteen patients in sinus rhythm undergoing implantation of a ventricular implantable cardioverter defibrillator (ICD) were prospectively evaluated. All patients had significant structural heart disease. To evaluate the effects of DC shocks on left atrial and left atrial appendage function, biphasic R wave synchronized endocardial shocks of 1, 10 and 20 J were delivered between the right ventricular electrode and the left pectoral generator of the ICD in sinus rhythm. R wave synchronized transthoracic shocks of 360 J were also delivered between anteriorly and posteriorly positioned chest electrodes. Transesophageal echocardiography was performed to evaluate left atrial appendage velocities, mitral inflow velocities and the presence of SEC before and immediately after each DC shock.

RESULTS

There were no significant changes in left atrial or left atrial appendage function after endocardial or transthoracic DC shocks. Left atrial SEC did not develop after endocardial or transthoracic DC shocks.

CONCLUSIONS

Endocardial and transthoracic DC shocks are not directly responsible for left atrial and left atrial appendage stunning and do not contribute to the stunning that is observed after the cardioversion of AF to sinus rhythm.

Radiofrequency ablation for cure of atrial flutter

BACKGROUND

Atrial flutter is a common arrhythmia which frequently recurs after cardioversion and is relatively difficult to control with antiarrhythmic agents.

AIMS

To evaluate the success rate, recurrence rate and safety of radiofrequency, (RF) ablation for atrial flutter in a consecutive series of patients with drug refractory chronic or paroxysmal forms of the arrhythmia.

METHODS

Electrophysiologic evaluation of atrial flutter included activation mapping with a 20 electrode halo catheter placed around the tricuspid annulus and entrainment mapping from within the low right atrial isthmus. After confirmation of the arrhythmia mechanism with these techniques, an anatomic approach was used to create a linear lesion between the inferior tricuspid annulus and the eustachian ridge at the anterior margin of the inferior vena cava. In order to demonstrate successful ablation, mapping techniques were employed to show that bi-directional conduction block was present in the low right atrial isthmus.

RESULTS

Successful ablation was achieved in 26/27 patients (96%). In one patient with a grossly enlarged right atrium, isthmus block could not be achieved. Of the 26 patients with successful ablation, there has been one recurrence of typical flutter (4%) during a mean follow-up period of 5.5 +/- 2.7 months. This patient underwent a successful repeat ablation procedure. Of eight patients with documented clinical atrial fibrillation (in addition to atrial flutter) prior to the procedure, five continued to have atrial fibrillation following the ablation. There were no procedural complications and all patients had normal AV conduction at the completion of the ablation.

CONCLUSIONS

RF ablation is a highly effective and safe procedure for cure of atrial flutter. In patients with chronic or recurrent forms of atrial flutter RF ablation should be considered as a first line therapeutic option.

Inappropriate sinus tachycardia (IST): management by radiofrequency modification of sinus node

BACKGROUND

Inappropriate sinus tachycardia (IST) is a rare form of supraventricular arrhythmia. It can cause disabling symptoms and may be refractory to medical treatment. In symptomatic drug refractory patients, sinus node excision or total ablation of the sinus node with permanent pacemaker implantation was the only therapeutic option. Recently, radiofrequency (RF) modification of the sinus node has been reported to be an effective treatment for this condition.

AIM

To present our experience with sinus node modification using RF energy in the management of IST.

METHODS

Between 1989 to 1996 three patients (two females and one male), aged 28-36 years were diagnosed with symptomatic IST. All had failed multiple drugs and hence underwent sinus node modification using RF. In the first two patients, the site of RF application was guided by anatomical landmarks using fluoroscopy to localise the presumed most superior portion of the crista terminalis and also the earliest site of atrial activation. In the third patient, a 20 pole electrode catheter was used to map the crista terminalis and guide the ablation. Success was defined by 20-30% reduction in the heart rate with normal atrial activation sequence after ablation.

RESULTS

The three patients described here had IST by clinical, electrocardiographic and electrophysiological criteria and were refractory to multiple antiarrhythmic drugs. The number of RF applications were 11, 15, and three applied at the site of earliest atrial activation for the control of heart rates. Patient 3 had a early recurrence at one month and underwent repeat sinus node modification (five RF applications). All three patients who underwent RF modification of the sinus node had a successful outcome. The procedure was uncomplicated and the patients remain asymptomatic during follow up (20, 12 and three months) with satisfactory control of heart rate, although one patient requires atenolol which was previously ineffective.

CONCLUSIONS

RF modification of the sinus node is feasible and effective for IST, and should be the treatment of choice in patients refractory to medical therapy.

Variables predictive of the need for placement in a long-term structured setting for adolescents

A retrospective study of 113 adolescent patients admitted to a short-term unit revealed that family history of drug abuse, behavior problems in females, history of previous inpatient hospitalization diagnosed under a DSM-III category of disorders usually first evident in childhood or adolescence, grade level, symptom of drug experimentation, elopement, and family involvement in treatment were significant variables distinguishing the patients who returned to the community at the end of short-term stay versus those who required continued treatment in a structured residential setting.

Multi-factorial assessment of hospitalized children who set fires

The authors examine the incidence of fire setting among hospitalized children according to age, and also compare the characteristics of the fire-setter group to a control group.