Heterogeneity of obstructive sleep apnea phenotypes after ischemic stroke: Outcome variation by cluster analysis

INTRODUCTION

Obstructive sleep apnea (OSA) is common but under-recognized after stroke. The aim of this study was to determine whether post-stroke phenotypic OSA subtypes are associated with stroke outcome in a population-based observational cohort.

METHODS

Ischemic stroke patients (n = 804) diagnosed with OSA (respiratory event index ≥10) soon after ischemic stroke were identified from the Brain Attack Surveillance in Corpus Christi (BASIC) project. Functional, cognitive, and quality of life outcomes were assessed at 90 days post-stroke and long-term stroke recurrence was ascertained. Latent profile analysis was performed based on demographic and clinical features, pre-stroke sleep characteristics, OSA severity, and vascular risk factors. Regression models were used to assess the association between phenotypic clusters and outcomes.

RESULTS

Four distinct phenotypic clusters provided the best fit. Cluster 1 was characterized by more severe stroke; cluster 2 by severe OSA and higher prevalence of medical comorbidities; cluster 3 by mild stroke and mild OSA; and cluster 4 by moderate OSA and mild stroke. Compared to cluster 3 and after adjustment for baseline stroke severity, cluster 1 and cluster 2 had worse 90-day functional outcome and cluster 1 also had worse quality of life. No difference in cognitive outcome or stroke recurrence rate was noted by cluster.

CONCLUSION

Post-stroke OSA is a heterogeneous disorder with different clinical phenotypes associated with stroke outcomes, including both daily function and quality of life. The unique presentations of OSA after stroke may have important implications for stroke prognosis and personalized treatment strategies.

Is myocardial infarction a surrogate endpoint for all-cause mortality? A trial-level meta-analysis of 144 randomized controlled trials enrolling 1.2 million patients from 1972–2020

Background

Nonfatal myocardial infarction (MI) is commonly included as an endpoint in studies of treatment or prevention of coronary artery disease driven by the assumption that MI is a surrogate for downstream mortality and that preventing MI will reduce mortality. Though biologically plausible and frequently associated in epidemiological studies, the validity of MI as a surrogate marker for all-cause mortality in randomized controlled trials (RCTs) has not been previously demonstrated with trial-level meta-analytic evidence.

Purpose

To assess MI as a surrogate endpoint for all-cause mortality in RCTs

Methods

In December 2020, PubMed was searched for all RCTs reporting all-cause mortality and MI published in the New England Journal of Medicine, the Lancet, or the Journal of the American Medical Association. RCTs with a minimum sample size of 1000 patients and 24 months of follow up were included. Trial-level correlation between MI and all-cause mortality was then assessed for surrogacy using the coefficient of determination (R2) between the natural logarithm of the odds ratios for MI and mortality using a weighted linear regression where each study was weighted by the number of observations. Criteria for surrogacy was set at 0.8. Prespecified subgroup analyses based on era of trial enrollment (before 2000, 2000–2009, 2010+), duration of follow up (2–3.9, 4–5.9, or 6+ years), and study subject (revascularization, primary prevention, secondary prevention, mixed primary/secondary prevention) were also assessed.

Results

1025 RCTs were retrieved and reviewed with 144 articles representing 1,211,897 patients ultimately meeting criteria for inclusion in the meta-analysis. Overall, MI had no correlation with all-cause mortality (R2=0.02, 95% CI: 0.00–0.08) (figure 1). In terms of era of trial enrollment, before year 2000 MI had low correlation with all-cause mortality (R2=0.22, 95% CI: 0.08–0.36) and had no correlation for the periods 2000–2009 (R2=0.02, 95% CI: 0.00–0.17) and 2010 and beyond (R2=0.01, 95% CI: 0.00–0.09). By follow-up period, MI had low correlation with all-cause mortality at 6+ years (R2=0.30, 95% CI: 0.01–0.55) and had no correlation with mortality at 2–3.9 years (R2=0.004, 95% CI: 0.00–0.08) or 4–5.9 years (R2=0.06, 95% CI: 0.001–0.16). MI had low correlation with all-cause mortality in revascularization trials (R2=0.21, 95% CI: 0.002–0.50) and no correlation with mortality in primary (R2=0.10, 95% CI: 0.001–0.26), secondary (R2=0.03, 95% CI: 0.00–0.20), and mixed primary/secondary prevention trials (R2=0.001, 95% CI: 0.00–0.08).

Conclusions

MI cannot be validated as a surrogate endpoint for all-cause mortality in RCTs of treatments for or to prevent CAD. Thus, treatments that reduce MI cannot be assumed to reduce mortality. Inclusion of MI as an endpoint in RCTs may still be justified based upon its association with impaired quality of life and increased utilization of health care resources but not based on its surrogacy for mortality.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Overall analysis of 144 trials

P3584Optimal medical therapy improves survival in patients with ischaemic cardiomyopathy: an analysis of the STICH trial

Background

Prior studies have demonstrated underuse of optimal medical therapy (OMT) in patients with coronary artery disease (CAD) after revascularization. However, there are limited studies assessing compliance with OMT on long-term survival in patients with CAD and no studies evaluating the impact of OMT in patients with severe CAD and reduced left ventricular (LV) function. The Surgical Treatment for Ischaemic Heart Failure (STICH) Trial was a randomized clinical trial that compared coronary-artery bypass grafting (CABG) with medical therapy versus medical therapy alone in the treatment of ischemic cardiomyopathy.

Purpose

This study sought to determine compliance with OMT over time and the impact of OMT compliance on survival in patients with or without revascularization.

Methods

STICH was a multicenter, randomized clinical trial of patients with an LV ejection fraction of 35% or less and CAD amenable to CABG who were randomized to CABG plus medical therapy (N=610) or medical therapy alone (N=602). A medication history was obtained at hospital discharge or 30 days after enrollment, 1 year, 5 years, and 10 years. OMT was defined as the combination of at least 1 antiplatelet drug, a statin, a beta-blocker, and an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker. The primary outcome was all-cause mortality. Comparison of mortality between the OMT and non-OMT groups was performed using multivariate Cox regression modeling with OMT as a time-dependent covariate.

Results

Of the 1212 patients randomized, at a median follow-up of 9.8 years, all-cause mortality was 58.9% in the CABG group and 66.1% in the medical therapy group. In the CABG arm, 63.6% of patients were on OMT throughout the study period compared to 66.5% of patients in the medical therapy arm (p=0.3). Those on OMT were younger (59.6 vs. 61.4 years, p<0.001); were more often in NYHA class I-II (67.4% vs. 56%, p<0.001); and lower rates of atrial fibrillation (9.4% vs. 18.1%, p<0.001), current smoking (18.6% vs. 24.5%, p=0.015), and depression (4.8% vs. 8.8%, p=0.005). Those on OMT had higher rates of hyperlipidemia (63.8% vs. 54.4%, p=0.001) and prior myocardial infarction (79.4% vs. 73.1%, p=0.01). There was no difference in sex, diabetes, and hypertension between those on OMT and non-OMT. In multivariate survival analysis, OMT was associated with a significant reduction in mortality (adjusted hazard ratio, 0.69; 95% confidence interval, 0.58–0.81; p<0.001). The treatment effect with OMT (31% relative reduction in mortality over 10 years) was numerically greater than the treatment effect of CABG (24% relative reduction in mortality with CABG versus medical therapy alone).

Conclusions

OMT improves long-term survival in patients with ischaemic cardiomyopathy regardless of revascularization status. Strategies to improve OMT use and adherence in this population is needed to maximize survival.

P3343Association of minority status with mortality and hospital readmission in patients with ischemic cardiomyopathy in the STICH trial

Background

Racial and ethnic minorities with coronary artery disease (CAD) suffer worse outcomes than their non-minority counterparts, including increased mortality and hospital readmissions. Proposed explanations include impaired access to care, reduced quality of care, comorbidity burden and medication access. Study of the outcomes of minorities in randomized controlled trials (RCT) allows controlling for some of these factors.

Purpose

The purpose of the current study was to evaluate the impact of minority status on mortality and hospital readmission in patients enrolled in the Surgical Treatment for Ischaemic Heart Failure (STICH) trial.

Methods

STICH was a multicenter, international RCT of patients with an ejection fraction (EF) of 35% or less and CAD amenable to coronary artery bypass graft surgery (CABG) who were randomized to undergo CABG plus medical therapy or medical therapy alone. Median follow-up was 9.8 years. Minority status was defined by self-reported black race or Hispanic ethnicity. Optimal medical therapy (OMT) was the combination of at least 1 antiplatelet drug, a statin, a beta-blocker, and an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker. The primary outcomes of interest were mortality and hospital readmission. Separate Cox proportional hazards models were constructed to examine the independent associations between minority status and mortality and readmission.

Results

Of 1212 patients randomized, 421 (35%) were members of a minority. CABG was the treatment assignment in 52.5% of minority participants whereas 47.5% were randomized to medical therapy (P=0.27). Minority patients were significantly younger than non-minority patients (57.8 vs 61.6 years, P=0.003). Sex, smoking status, and the prevalence of diabetes, hypertension, stroke and chronic kidney disease did not differ between minority and non-minority patients. Fewer minority patients had hyperlipidemia (49% vs. 66%, P<0.001), prior MI (72% vs 80%, P=0.003), atrial fibrillation (8.1% vs. 15%, P=0.001) or prior percutaneous coronary intervention (9% vs. 15%, P=0.004). Minority patients were less often on OMT at 30 days (56% vs. 66%, P=0.001), 1 year (70% vs. 76%, P=0.048) and 5 years (66% vs. 75%, P=0.002). Crude mortality rates were lower in minority patients (57% vs. 65%, P=0.004). However, minority status was independently associated with an increased hazard of mortality (HR 2.3, 95% CI: 1.5–2.5, P<0.001) but had no effect on rehospitalization (HR 1.01, 95% CI: 0.78–1.31, P=0.97).

Conclusion

Despite being a low risk population, minority status in the STICH trial was associated with a 2.3-fold increased hazard of mortality in patients with ischaemic cardiomyopathy. Additional research is urgently needed to delineate and address the causes of disparate outcomes among minority patients.

Effective equations governing an active poroelastic medium

In this work, we consider the spatial homogenization of a coupled transport and fluid–structure interaction model, to the end of deriving a system of effective equations describing the flow, elastic deformation and transport in an active poroelastic medium. The ‘active’ nature of the material results from a morphoelastic response to a chemical stimulant, in which the growth time scale is strongly separated from other elastic time scales. The resulting effective model is broadly relevant to the study of biological tissue growth, geophysical flows (e.g. swelling in coals and clays) and a wide range of industrial applications (e.g. absorbant hygiene products). The key contribution of this work is the derivation of a system of homogenized partial differential equations describing macroscale growth, coupled to transport of solute, that explicitly incorporates details of the structure and dynamics of the microscopic system, and, moreover, admits finite growth and deformation at the pore scale. The resulting macroscale model comprises a Biot-type system, augmented with additional terms pertaining to growth, coupled to an advection–reaction–diffusion equation. The resultant system of effective equations is then compared with other recent models under a selection of appropriate simplifying asymptotic limits.

Lymphocyte Subsets in the Adrenal Glands of Dogs With Primary Hypoadrenocorticism

Primary hypoadrenocorticism, or Addison's disease, is an autoimmune condition common in certain dog breeds that leads to the destruction of the adrenal cortex and a clinical syndrome involving anorexia, gastrointestinal upset, and electrolyte imbalances. Previous studies have demonstrated that this destruction is strongly associated with lymphocytic-plasmacytic inflammation and that the lymphocytes are primarily T cells. In this study, we used both immunohistochemistry and in situ hybridization to characterize the T-cell subtypes involved. We collected postmortem specimens of 5 dogs with primary hypoadrenocorticism and 2 control dogs and, using the aforementioned techniques, showed that the lymphocytes are primarily CD4+ rather than CD8+. These findings have important implications for improving our understanding of the pathogenesis and in searching for the underlying causative genetic polymorphisms.

Mesenchymal Hamartoma of the Liver in a Late-Term Equine Fetus

Mesenchymal hamartoma of the liver is a rare congenital disorder of biliary tract development. During the necropsy of a late-term equine fetus, a markedly enlarged liver of more than two times normal weight was found. Light microscopic review revealed that the normal hepatic parenchyma had been obliterated, replaced, and expanded by abnormal bile ducts surrounded by abundant, myxoid stroma. The lesion was diagnosed as a mesenchymal hamartoma. Small portions of the liver had bridging septa of fibrosis and proliferations of small-caliber abnormal bile ducts, resembling another congenital biliary abnormality termed congenital hepatic fibrosis.

The pharmacokinetic/pharmacodynamic rationale for administering vancomycin via continuous infusion

WHAT IS KNOWN AND OBJECTIVE

Vancomycin is administered via intermittent infusion (II) almost exclusively in the United States, whereas continuous infusion (CI) dosing methods are used regularly in many European countries. The purpose of this literature analysis is to review current evidence regarding the advantages and disadvantages of CI vancomycin in relation to II, based on the pharmacokinetic and pharmacodynamic aspects of dosing and monitoring therapy, and to identify current practices of CI vancomycin dosing.

METHODS

Medline, Cochrane and GoogleScholar databases were searched using vancomycin as a MeSH term, along with continuous and infusion in all fields, which identified 136 citations. A second search added the terms intermittent and survey, producing nine additional articles. All articles that reported an assessment of CI or II vancomycin administration in adult patients, based on clinical, pharmacokinetic, cost or monitoring considerations, were identified. A total of 43 publications were determined to be suitable for final analysis and possible inclusion in the report.

RESULTS AND DISCUSSION

A meta-analysis of six studies concluded that CI vancomycin was associated with a lower relative risk of kidney injury than II therapy, although other studies reported equivocal findings. The results of several clinical studies suggest that CI vancomycin produces clinical outcomes that are comparable to II. Current vancomycin consensus guidelines promote aggressive dosing to achieve trough levels of 10-15 or 15-20 mg/L, but also include recommendations to target a daily area under the curve (AUC24 ) to minimum inhibitory concentration (MIC) ratio of at least 400. Because vancomycin is a non-concentration-dependent antibiotic, it might be more prudent to monitor steady-state serum concentrations (Css ) during a CI rather than trough concentrations during II, due to the questionable correlation between measured trough concentration and AUC. From a pharmacokinetic/pharmacodynamic perspective, vancomycin dosing and monitoring practices associated with CI offer potentially greater reliability than II. A major disadvantage of CI involves the possibility of having to intravenously co-administer another drug that might not be compatible with vancomycin.

WHAT IS NEW AND CONCLUSION

Continuous infusion vancomycin therapy offers the advantage of Css monitoring, thus avoiding the variabilities associated with the timing of trough levels. Current CI practices include a loading dose of 15-20 mg/kg followed by an infusion of 10-40 mg/kg/day based on the patient's renal function, with a target Css of about 20-30 mg/L. An alternative approach to weight-based (mg/kg) CI dosing is to calculate the dose from an estimation of the patient's vancomycin clearance (in L/h), derived from creatinine clearance (CrCl) via the equation (CrCl∙0·041) + 0·22. The daily dose is then determined by multiplying vancomycin clearance (in L/h) by the desired AUC24 . A new CI vancomycin dosing chart includes clearance-based dosing recommendations for Css values ranging from 17·5 to 27·5 mg/L or AUC24 values ranging from 420 to 660 mg h/L. Although sufficient data already exist to support the use of CI vancomycin as a reasonable therapeutic alternative to II, there is still much to learn about administering the drug in this fashion.

Spinal gene expression profiling and pathways analysis of a CB2 agonist (MDA7)-targeted prevention of paclitaxel-induced neuropathy

AIMS

Patients receiving paclitaxel often develop peripheral neuropathies. We found that a novel selective cannabinoid CB2 receptor agonist (MDA7) prevents paclitaxel-induced mechanical allodynia in rats and mice. Here we investigated gene expression profiling in the lumbar spinal cord after 14-day treatment of MDA7 in paclitaxel animals and analyzed possible signaling pathways underlying the preventive effect of MDA7 on paclitaxel-induced neuropathy.

METHODS

Peripheral mechanical allodynia was induced in rats or mice receiving intraperitoneal (i.p.) injection of paclitaxel at a dose of 1mg/kg daily for four consecutive days. MDA7 was administered at a dose of 15mg/kg 15min before paclitaxel and then continued daily for another 10days. Whole-genome gene expression profiling in the lumbar spinal cord of MDA7 and paclitaxel-treated rats was investigated using microarray analysis. The Ingenuity pathway analysis was performed to determine the potential relevant canonical pathways responsible for the effect of MDA7 on paclitaxel-induced peripheral neuropathy.

RESULTS

We observed that the inflammatory molecular networks including tumor necrosis factor (TNF), nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB), transforming growth factor beta (TGFβ), and mitogen-activated protein kinases (MAPK) signaling are most relevant to the preventive effect of MDA7 on paclitaxel-induced peripheral neuropathy. In addition, genes encoding molecules that are important in central sensitization such as glutamate transporters and N-methyl-d-aspartate receptor 2B (NMDAR2B), and neuro-immune-related genes such as neuronal nitric oxide synthase (nNOS1), chemokine CX3CL1 (a mediator for microglial activation), toll-like receptor 2 (TLR2), and leptin were differentially modulated by MDA7.

CONCLUSION

The preventive effect of MDA7 on paclitaxel-induced peripheral allodynia in rats may be associated with genes involved in signal pathways in central sensitization, microglial activation, and neuroinflammation in the spinal cord.

Haiti's food and drinking water: a review of toxicological health risks

CONTEXT

The Republic of Haiti is a developing country in the Caribbean region with a history that challenges toxicologists, yet the historical panoply of toxicological hazards in Haiti has received little scholarly attention.

OBJECTIVES

The primary objectives of this paper are to review what is known about Haiti's current toxicological hazards, with a focus on chronic food-borne aflatoxin exposure and heavy metal contamination of water resources, and to compare these with previous large-scale, acute exposures to toxic substances: the 1995-1996 diethylene glycol (DEG) intoxications and the 2000-2001 ackee fruit poisonings.

METHODS

MEDLINE/PUBMED and the library website of Cornell University were searched using the terms "Haiti" and either "heavy metals," "aflatoxin", "diethylene glycol", or "ackee". The search was inclusive of articles from 1950 to 2012, and 15 out of the 37 returned were peer-reviewed articles offering original data or comprehensive discussion. One peer-reviewed article in press, two newspaper articles, two personal communications, and one book chapter from the personal databases of the authors were also referenced, making a total of 21 citations.

RESULTS

Elevated concentrations of aflatoxins (greater than 20 μg/kg) were documented for staples of the Haitian food supply, most notably peanut butters and maize. Human exposure to aflatoxin was confirmed with analysis of aflatoxin blood biomarkers. The implications of aflatoxin exposure were reviewed in the light of Haiti's age-adjusted liver cancer risk - the highest in the Caribbean region. Measurement of heavy metals in Port-au-Prince ground water showed contamination of lead and chromium in excess of the US Environmental Protection Agency's 15 μg/L Action Level for lead and 100 μg/L Maximum Contamination Level Goal for total chromium. The DEG contamination of paracetamol (acetaminophen) containing products in 1995-1996 claimed the lives of 109 children and the 2000-2001 epidemic of ackee fruit poisoning resulted in 60 cases of intoxication. Lessons for the Haitian Government. The DEG and ackee epidemics overwhelmed local Haitian public health resources. Yet, periods of 8 and 4 months, respectively, passed before the Haitian government sought assistance following the initial poisonings. To our knowledge, the Haitian government did not enact policy to promote drug safety and prevent future poisonings. This will not likely change in the near future because of the state's finance and personnel crises. While protection of its people remains the prerogative of the Haitian government, it is extremely limited in managing chemical exposure to environmental toxins, including aflatoxin and heavy metals.

CONCLUSIONS

The cases of DEG and ackee fruit poisoning demonstrate that environmental exposures to chemicals have occurred in Haiti. Current low-level exposures to aflatoxin and heavy metals highlight the risk that large-scale poisonings can occur. While awareness of toxicological hazards in Haiti must be acknowledged more widely within the government and non-governmental sectors, the lessons of these exposures are relevant to all developing countries where the capacity to discern and manage toxicological risks is absent or not yet effective.

A review of studies examining the nature of selection-based and topography-based verbal behavior

Selection-based (SB) verbal behavior, in most general terms, consists of selecting stimuli from an array, which presumably has some effect on a listener. Topography-based (TB) verbal behavior consists of responses with unique topographies (e.g. speaking, signing, writing) which is also presumed to have some effect on a listener. This article reviews research examining the nature of these two types of verbal behavior. Overall, TB verbal behavior appears to be more easily acquired and may also function to mediate some SB verbal behavior.

Genetic variation at CR1 increases risk of cerebral amyloid angiopathy

OBJECTIVE

Accumulated evidence suggests that a variant within the CR1 gene (single nucleotide polymorphism rs6656401), known to increase risk for Alzheimer disease (AD), influences β-amyloid (Aβ) deposition in brain tissue. Given the biologic overlap between AD and cerebral amyloid angiopathy (CAA), a leading cause of intracerebral hemorrhage (ICH) in elderly individuals, we investigated whether rs6656401 increases the risk of CAA-related ICH and influences vascular Aβ deposition.

METHODS

We performed a case-control genetic association study of 89 individuals with CAA-related ICH and 280 individuals with ICH unrelated to CAA and compared them with 324 ICH-free control subjects. We also investigated the effect of rs6656401 on risk of recurrent CAA-ICH in a prospective longitudinal cohort of ICH survivors. Finally, association with severity of histopathologic CAA was investigated in 544 autopsy specimens from 2 longitudinal studies of aging.

RESULTS

rs6656401 was associated with CAA-ICH (odds ratio [OR] = 1.61, 95% confidence interval [CI] 1.19-2.17, p = 8.0 × 10(-4)) as well as with risk of recurrent CAA-ICH (hazard ratio = 1.35, 95% CI 1.04-1.76, p = 0.024). Genotype at rs6656401 was also associated with severity of CAA pathology at autopsy (OR = 1.34, 95% CI 1.05-1.71, p = 0.009). Adjustment for parenchymal amyloid burden did not cancel this effect, suggesting that, despite the correlation between parenchymal and vascular amyloid pathology, CR1 acts independently on both processes, thus increasing risk of both AD and CAA.

CONCLUSION

The CR1 variant rs6656401 influences risk and recurrence of CAA-ICH, as well as the severity of vascular amyloid deposition.

Surveillance of female patients with inherited bleeding disorders in United States Haemophilia Treatment Centres

Inherited bleeding disorders are especially problematic for affected girls and women due to the monthly occurrence of menstrual periods and the effects on reproductive health. Although heavy menstrual bleeding (HMB) is the most common manifestation, females with inherited bleeding disorders (FBD) experience other bleeding symptoms throughout the lifespan that can lead to increased morbidity and impairment of daily activities. The purpose of this article is to describe the utility of a female-focused surveillance effort [female Universal Data Collection (UDC) project] in the United States Haemophilia Treatment Centres (HTCs) and to describe the baseline frequency and spectrum of diagnoses and outcomes. All FBD aged 2 years and older receiving care at selected HTCs were eligible for enrollment. Demographic data, diagnoses and historical data regarding bleeding symptoms, treatments, gynaecological abnormalities and obstetrical outcomes were analysed. Analyses represent data collected from 2009 to 2010. The most frequent diagnoses were type 1 von Willebrand's disease (VWD) (195/319; 61.1%), VWD type unknown (49/319; 15.4%) and factor VIII deficiency (40/319; 12.5%). HMB was the most common bleeding symptom (198/253; 78.3%); however, 157 (49.2%) participants reported greater than four symptoms. Oral contraceptives were used most frequently to treat HMB (90/165; 54.5%), followed by desmopressin [1-8 deamino-D-arginine vasopressin (DDAVP)] (56/165; 33.9%). Various pregnancy and childbirth complications were reported, including bleeding during miscarriage (33/43; 76.7%) and postpartum haemorrhage (PPH) (41/109; 37.6%). FBD experience multiple bleeding symptoms and obstetrical-gynaecological morbidity. The female UDC is the first prospective, longitudinal surveillance in the US focusing on FBD and has the potential to further identify complications and reduce adverse outcomes in this population.

Enrollment of women and minorities in NINDS trials

OBJECTIVE

To determine policy-associated changes over time in 1) the enrollment of women and minorities in National Institute of Neurological Disorders and Stroke (NINDS)-funded clinical trials and 2) the trial publication reporting of race/ethnicity and gender.

METHODS

All NINDS-funded phase III trials published between 1985 and 2008 were identified. Percent of African Americans, Hispanic Americans, and women enrolled in the trials was calculated for those trials with available data. Z tests were used to compare reporting and enrollment data from before (period 1) and after (period 2) 1995 when NIH enacted their policies regarding race, ethnicity, and gender. Percent of main trial publications reporting enrollment of African Americans, Hispanic Americans, and women was also calculated.

RESULTS

Of the 56 trials identified, 100%, 48%, and 25% reported enrollment by gender, race, and ethnicity. Women constituted 42.1% of the trial population. Enrollment of women increased over time (36.9% period 1; 49.0% period 2, p < 0.001). African Americans constituted 19.8% of the enrollees in trials with available data and enrollment increased over time (11.6% period 1; 30.7% period 2, p < 0.001). Hispanic Americans constituted 5.8% of subjects in trials with available data and enrollment decreased over time (7.4% period 1; 5.0% period 2, p < 0.001).

CONCLUSIONS

Improvements in reporting of race/ethnicity in publications and enrollment of Hispanics in NINDS trials are needed. While African American representation is above population levels, Hispanic Americans are underrepresented in NINDS trials and representation is declining despite Hispanics' increasing representation in the US population.

Congenital hepatic fibrosis in 5 dogs

Congenital hepatic fibrosis is a disorder of biliary system development histologically characterized by diffuse periportal to bridging fibrosis with numerous small often-irregular bile ducts and reduction in the number of portal vein branches. The condition results from abnormal development of the ductal plate, the embryonic precursor to the interlobular bile ducts. It has rarely been reported in veterinary species, and it has never been reported in dogs. This article describes 5 cases of a ductal plate malformation in dogs consistent with congenital hepatic fibrosis. On light microscopy, all 5 livers had severe bridging fibrosis with a marked increase in the number of small bile ducts, which often had irregular, dilated profiles reminiscent of the developing ductal plate. In addition, 80% (4 of 5) of cases lacked typical portal vein profiles. Cytokeratin 7 and proliferating cell nuclear antigen immunohistochemistry was performed on the 3 cases for which paraffin-embedded tissue was available. The bile duct profiles were strongly positive for cytokeratin 7 in all 3 cases, and they were negative for proliferating cell nuclear antigen or only had rare positive cells. All 5 dogs presented with clinical signs of portal hypertension. Congenital hepatic fibrosis should be considered in the differential diagnosis in young dogs that present with portal hypertension and lesions that may have been interpreted as bridging biliary hyperplasia or extrahepatic biliary obstruction.

Predicting ischaemic stroke subtype from presenting systolic blood pressure: the BASIC Project

OBJECTIVE

We hypothesized that low presenting systolic blood pressure (SBP) predicted cardioembolic stroke aetiology.

DESIGN

Active and passive surveillance were used to identify all ischaemic strokes as part of the Brain Attack Surveillance in Corpus Christi (BASIC) population-based study. Multinomial logistic regression was used to examine the association between stroke subtype and first documented SBP in the medical record.

SETTING

Nueces County, TX, USA (313,645 residents in 2000). The community is urban with the majority of the population residing in the city of Corpus Christi. The area is served by seven adult acute care hospitals.

PATIENTS

Three hundred and eight cases with completed ischaemic stroke and determined subtype aetiology between January 2000 and December 2002.

RESULTS

Lower presenting SBP was associated with stroke subtype (P = 0.001). This association remained significant in the final model adjusted for age and history of coronary artery disease. The odds of cardioembolic versus small vessel occlusion increased by 20% (OR = 1.20, 95% CI: 1.07-1.35) for every 10 mmHg decrease in presenting SBP. Other covariates including race/ethnicity, gender, history of hypertension, and diabetes were neither significant predictors of stroke subtype, nor did they confound the association of SBP and stroke subtype. A 5 year increase in age increased the odds of cardioembolic subtype by 25% (OR = 1.25, 95% CI: 1.07-1.47).

CONCLUSIONS

Lower initial SBP and older age at ischaemic stroke presentation were associated with cardioembolic stroke. Suspicion of cardioembolic stroke should be increased in those presenting with low SBP.

Performance of automated slidemakers and stainers in a working laboratory environment - routine operation and quality control

The automated slidemaker/stainers of the four Beckman Coulter LH755 hematology systems in our laboratory are operated as analyzers, with similar requirements for setup, maintenance and quality control. A study was performed to confirm that these slide maker/stainers in routine use produce peripheral blood films that are completely satisfactory for microscopy and without cells, particularly abnormal cells, being pulled to the edges or sides of the film outside the usual working area. One hundred and thirty-nine automated blood films that had been produced during routine operation were compared with well-prepared manual films from the same patients. None of the films was unacceptable for microscopy. The distributions of normal white cell types within the counting areas of automated films compared with manual films, for all 139 samples for WBC from 1.0 to 352.8 × 10⁹/l; for blasts and promyelocytes in the 65 samples in which they occurred and for nucleated red blood cells in the 58 samples in which they occurred all fell within the expected limits of 200 cell differential counts of CLSI H20-A. Red cell morphology and the occurrence of WBC clumps, platelet clumps and smudge cells were comparable between the automated and manual films of all samples. We conclude that automated slidemaker/stainers, as typified by those of the Beckman Coulter LH755 system, are capable of producing blood films comparable with well-prepared manual films in routine laboratory use; and that the maintenance and quality control procedures used in our laboratory ensure consistent high quality performance from these systems.

Ethnic disparities in stroke and hypertension among women: the BASIC project

BACKGROUND

Little data exist on stroke burden in Mexican-American (MA) women. The objective of this study was to characterize the burden of stroke in MA and non-Hispanic white (NHW) women and to compare this burden across ethnic groups.

METHODS

Cases of ischemic stroke and intracerebral hemorrhage among women (January 2000-December 2006) were identified as part of the Brain Attack Surveillance in Corpus Christi (BASIC) Project, a stroke surveillance study in a biethnic Texas community. Cumulative incidence of stroke among women was compared by ethnicity and age. Logistic regression was used to compare risk factors and age-adjusted use of antihypertensives between MA and NHW female stroke cases.

RESULTS

MA women had elevated stroke risk compared with NHW women at younger ages (ages 45-59: relative risk (RR) = 2.00 (95% confidence interval (CI): 1.54-2.58); ages 60-74: RR = 1.57 (95% CI: 1.31-1.87); ages > or =75: RR = 1.13 (95% CI: 0.98-1.29)). Stroke severity and stroke type did not differ between ethnic groups. MA female stroke cases were more likely to have hypertension (odds ratio (OR) = 1.41 (95% CI: 1.11-1.80)), diabetes (OR = 3.54 (95% CI: 2.82-4.45)), and the presence of both risk factors (OR = 3.31 (95% CI: 2.61-4.21)) compared with NHW female stroke cases and were more likely to report use of antihypertensives (OR = 1.51 (95% CI: 1.10-2.06)). There was a trend toward greater hypertension awareness among MA female stroke cases (OR = 1.37 (95% CI: 0.98-1.91)).

CONCLUSIONS

MA women have increased risk of stroke at younger ages compared with NHW women. Reasons for this ethnic disparity, including an increased prevalence of hypertension and diabetes, should be explored.

Gender and ethnic differences in subarachnoid hemorrhage

BACKGROUND

Mexican Americans (MAs) comprise the largest component of the largest minority group within the United States. The purpose of this study was to examine ethnic and gender differences in the epidemiology, presentation, and outcomes after subarachnoid hemorrhage (SAH) in a representative United States community. Targeted public health interventions are dependent on accurate assessments of groups at highest disease risk.

METHODS

All patients with nontraumatic SAH older than 44 years were prospectively identified from January 1, 2000, to December 31, 2006, as part of the Brain Attack Surveillance In Corpus Christi project, an urban population-based study in southeast Texas. Risk ratios for cumulative SAH incidence comparing MAs with non Hispanic whites (NHWs) and women with men were calculated. Descriptive statistics for other clinical and demographic variables were computed overall, by gender, and by ethnicity.

RESULTS

A total of 107 patients had a SAH during the time period (7-year cumulative incidence: 11/10,000); of these, 43 were NHW (40% of cases vs 53% of the population) and 64 were MA (60% of cases vs 48% of the population). The overall age-adjusted risk ratio for SAH in MAs compared with NHWs was 1.67 (95% CI: 1.13, 2.47), and in women compared to men was 1.74 (95% CI 1.16, 2.62). Overall in-hospital mortality was 32.2%. No ethnic difference was observed for discharge disability or in-hospital mortality.

CONCLUSIONS

Subarachnoid hemorrhage disproportionately affects Mexican Americans and women. Public health interventions should target these groups to reduce the impact of this severe disease.

Phase I study of frequent low-dose administration of decitabine, alone or in combination with hyperCVAD, in relapsed or refractory acute lymphocytic leukemia (ALL)

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Background: Aberrant DNA methylation is frequent in ALL. Decitabine, a hypomethylating agent, is a potent inducer of apoptosis in lymphoid leukemia cell lines. In vivo, treatment with decitabine results in transient induction of global hypomethylation. Therefore, a more frequent schedule of administration (i.e. every other week (QOW)) may have significant clinical activity. Methods: We have developed a phase I study of low decitabine administered QOW. Patients that do not respond or progress after decitabine can receive the combination of decitabine with hyperCVAD in a sequential phase of the study. Starting doses of decitabine are 10 mg/m2 IV daily×5 every other week, and 5 mg/m2 IV daily×5 concomitant with hyperCVAD. The studies follow a classic “3+3” design. Patients with relapsed/refractory ALL of any age are elegible. Molecular studies include the analysis of global and gene specific DNA methylation and gene expression reactivation. Results: Seven patients have been treated (median age 25, range 8–44). All had refractory disease and had previously completed at least 8 courses of hyperCVAD therapy and 2 years of maintenance therapy or similar. Four patients have been treated at dose level 1 of single agent decitabine, and 3 at dose level 2 (20 mg/m2). Three of these patients have also been treated at dose level 1 of the combination of hyperCVAD and decitabine. No severe drug related toxicites have been observed. Four patients had achieved a response: 1 CR after decitabine and hyperCVAD, and 3 PR (normalization of peripheral blood with bone marrow blasts reduction of more than 50% but above 5%). One PR was achieved after decitabine and hyperCVAD, but two with only decitabine. Two of these patients did not qualify for CR because bone marrow blasts were 6%. Of these four responding patients, 1 in CR received successful alloSCT, 1 progressed after 2 courses of single agent decitabine, and 2 pediatric patients continue on therapy. The study continues. Molecular studies are ongoing. Conclusions: In summary, frequent administration of low dose decitabine, alone or in combination with hyperCVAD, may be clinically safe and active in advanced relapsed/refractory ALL.

No significant financial relationships to disclose.

Impact of Drug‐Exposure Intensity and Duration of Therapy on the Emergence ofStaphylococcus aureusResistance to a Quinolone Antimicrobial

We have shown previously in animal model and in vitro systems that antimicrobial therapy intensity has a profound influence on subpopulations of resistant organisms. Little attention has been paid to the effect of therapy duration on resistant subpopulations. We examined the influence of therapy intensity (area under the concentration/time curve for 24 h:minimum inhibitory concentration [AUC24:MIC] ratio) and therapy duration on resistance emergence using an in vitro model of Staphylococcus aureus infection. AUC24:MIC ratios of>or=100 were necessary to kill a substantial portion of the total population. Importantly, we demonstrated that therapy duration is a critical parameter. As the duration increased beyond 5 days, the intensity needed to suppress the antibiotic-resistant subpopulations increased, even when the initial bacterial kill was>4 log10 (cfu/mL). These findings were prospectively validated in an independent experiment in which exposures were calculated from the results of fitting a large mathematical model to all data simultaneously. All of the prospectively determined predictions were fulfilled in this validation experiment.

Veterinary aspects and perspectives of nutrigenomics: a critical review

Nutrigenomics examines nutrient-gene interactions on a genome-wide scale. Increased dietary fat or higher non-esterified fatty acids (NEFA) from starvation-induced mobilisation may enhance hepatic oxidation and decrease esterification of fatty acids by reducing the expression of the fatty acid synthase gene. The key factors are the peroxisome proliferator-activated receptors (PPARs). Dietary carbohydrates--both independently and through insulin effect--influence the transcription of the fatty acid synthase gene. Oleic acid or n-3 fatty acids downregulate the expression of leptin, fatty acid synthase and lipoprotein lipase in retroperitoneal adipose tissue. Protein-rich diets entail a shortage of mRNA necessary for expression of the fatty acid synthase gene in the adipocytes. Conjugated linoleic acids (CLAs) are activators of PPAR and also induce apoptosis in adipocytes. Altered rumen microflora produces CLAs that are efficient inhibitors of milk fat synthesis in the mammary gland ('biohydrogenation theory'). Oral zinc or cadmium application enhances transcription rate in the metallothionein gene. Supplemental CLA in pig diets was found to decrease feed intake and body fat by activating PPARgamma-responsive genes in the adipose tissue. To prevent obesity and type II diabetes, the direct modulation of gene expression by nutrients is also possible. Nutrigenomics may help in the early diagnosis of genetically determined metabolic disorders and in designing individualised diets for companion animals.

Early care limitations independently predict mortality after intracerebral hemorrhage

OBJECTIVE

Intracerebral hemorrhage (ICH) is associated with a high early mortality rate. We examined the impact of early do not resuscitate (DNR) orders and other limitations in aggressive care on mortality after ICH in a community-based study.

METHODS

Cases of spontaneous ICH from 2000 to 2003 were identified from the Brain Attack Surveillance in Corpus Christi (BASIC) project, with deaths ascertained through 2005. Charts were reviewed for early (<24 hours from presentation) DNR orders, withdrawal of care, or deferral of other life sustaining interventions, analyzed together as combined DNR (C-DNR). Multivariable Cox-proportional hazards models were used to examine the association between short- and long-term all-cause mortality and early C-DNR, adjusted for demographics and established predictors of mortality after ICH.

RESULTS

Of 18,393 subjects screened for cerebrovascular disease, 270 non-traumatic ICH cases were included. Cumulative mortality risk was 0.43 at 30 days and 0.55 over the study course. Early C-DNR was noted in 34% of cases and was associated with a doubling in the hazard of death both at 30 days (hazard ratio [HR] 2.17, 95% CI 1.38, 3.41) and at end of follow-up (HR 1.92, 95% CI 1.29, 2.87) despite adjustment for age, gender, ethnicity, Glasgow Coma Scale, ICH volume, intraventricular hemorrhage, and infratentorial hemorrhage.

CONCLUSIONS

Early care limitations are independently associated with both short- and long-term all-cause mortality after intracerebral hemorrhage (ICH) despite adjustment for expected predictors of ICH mortality. Physicians should carefully consider the effect of early limitations in aggressive care to avoid limiting care for patients who may survive their acute illness.

Large calcifications in ovaries otherwise normal on ultrasound

OBJECTIVE

To evaluate calcifications >or= 5 mm in length in ovaries that are otherwise normal on ultrasound, and to determine whether such large ovarian calcifications are an indicator of ovarian neoplasm.

METHODS

This was a retrospective study reviewing pelvic ultrasound results at our unit between October 1994 and April 2002 to identify patients with ovarian calcifications that were >or= 5 mm in maximum length in otherwise normal ovaries, and who also had follow-up imaging studies. Patient medical histories were reviewed, calcification characteristics, including number, size, shape and laterality of calcifications, were recorded and follow-up imaging studies were reviewed to assess change in size of the calcification and to see if a neoplasm had developed.

RESULTS

The study group consisted of 28 patients. The mean length of imaging follow-up was 35.2 +/- 30.7 months. The mean size of the calcifications was 7.4 +/- 2.3 (range, 5-13) mm. The calcification remained stable in all 28 patients and no ovarian neoplasms developed in any of the patients. Histological confirmation was available in one patient and this revealed dystrophic calcification in a corpus albicans.

CONCLUSION

Calcifications ranging from 5 to 13 mm in length in otherwise normal ovaries remain stable on follow-up imaging and are not an indicator of current or future ovarian neoplasm. Published by John Wiley & Sons, Ltd.

Projected costs of ischemic stroke in the United States

BACKGROUND

There are barriers to acute stroke care in minority groups as well as a higher incidence of ischemic stroke when compared with non-Hispanic whites.

OBJECTIVE

To estimate the future economic burden of stroke in non-Hispanic whites, Hispanics, and African Americans in the United States from 2005 to 2050.

METHODS

We used U.S. Census estimates of the race-ethnic group populations age 45 years and older. We obtained stroke epidemiology and service utilization data from the Northern Manhattan Stroke Study and the Brain Attack Surveillance in Corpus Christi project and other published data. We estimated costs directly from Medicare reimbursement or from studies that used Medicare reimbursement. Direct and indirect costs considered included ambulance services, initial hospitalization, rehabilitation, nursing home costs, outpatient clinic visits, drugs, informal caregiving, and potential lost earnings.

RESULTS

The total cost of stroke from 2005 to 2050, in 2005 dollars, is projected to be 1.52 trillion dollars for non-Hispanic whites, 313 billion dollars for Hispanics, and 379 billion dollars for African Americans. The per capita cost of stroke estimates are highest in African Americans (25,782 dollars), followed by Hispanics (17,201 dollars), and non-Hispanic whites (15,597 dollars). Loss of earnings is expected to be the highest cost contributor in each race-ethnic group.

CONCLUSIONS

The economic burden of stroke in African Americans and Hispanics will be enormous over the next several decades. Further efforts to improve stroke prevention and treatment in these high stroke risk groups are necessary.

Differences in intracerebral hemorrhage between Mexican Americans and non-Hispanic whites

BACKGROUND

Mexican Americans (MAs) have higher incidence rates of intracerebral hemorrhage (ICH) than non-Hispanic whites (NHWs). The authors present clinical and imaging characteristics of ICH in MAs and NHWs in a population-based study.

METHODS

This work is part of the Brain Attack Surveillance in Corpus Christi (BASIC) project. Cases of nontraumatic ICH were identified from 2000 to 2003. Multivariable logistic regression was used to assess the independent associations between ethnicity and ICH location (lobar vs nonlobar) and volume (> or = 30 vs < 30 mL), adjusting for demographics and baseline clinical characteristics. Logistic regression was also used to determine the association between ethnicity and in-hospital mortality, adjusting for confounders.

RESULTS

A total of 149 MAs and 111 NHWs with ICH were identified. MAs were younger (70 vs 77, p < 0.001), more often male (55% vs 42%, p = 0.04), had a lower prevalence of atrial fibrillation (2.0% vs 13%, p < 0.001), and a higher prevalence of diabetes (39% vs 19%, p < 0.001). MA ethnicity was independently associated with nonlobar hemorrhage (OR 2.08, 95% CI: 1.15, 3.70). MAs had over two times the odds of having small (< 30 mL) hemorrhages compared with NHWs (OR = 2.41, 95% CI: 1.31, 4.46). NHWs had higher in-hospital mortality, though this association was no longer significant after adjustment for ICH volume, location, age, and sex.

CONCLUSIONS

There are significant differences in the characteristics of ICH in MAs and NHWs, with MA patients more likely to have smaller, nonlobar hemorrhages. These differences may be used to examine the underlying pathophysiology of ICH.

Presentation of intracerebral haemorrhage in a community

BACKGROUND

Studies on intracerebral haemorrhage (ICH) from tertiary care centres may not be an accurate representation of the true spectrum of disease presentation.

OBJECTIVE

To describe the clinical and imaging presentation of ICH in a community devoid of the referral bias of an academic medical centre; and to investigate factors associated with lower Glasgow coma scale (GCS) score at presentation, as GCS is crucial to early clinical decision making.

METHODS

The study formed part of the BASIC project (Brain Attack Surveillance in Corpus Christi), a population based stroke surveillance study in a bi-ethnic Texas community. Cases of first non-traumatic ICH were identified from years 2000 to 2003, using active and passive surveillance. Clinical data were collected from medical records by trained abstractors, and all computed tomography (CT) scans were reviewed by a study physician. Multivariable linear regression was used to identify clinical and CT predictors of a lower GCS score.

RESULTS

260 cases of non-traumatic ICH were identified. Median ICH volume was 11 ml (interquartile range 3 to 36) with hydrocephalus noted in 45%. Median initial GCS score was 12.5 (7 to 15). Hydrocephalus score (p = 0.0014), ambient cistern effacement (p = 0.0002), ICH volume (p = 0.014), and female sex (p = 0.024) were independently associated with lower GCS score at presentation, adjusting for other variables.

CONCLUSIONS

ICH has a wide range of severity at presentation. Hydrocephalus is a potentially reversible cause of a lower GCS score. Since early withdrawal of care decisions are often based on initial GCS, recognition of the important influence of hydrocephalus on GCS is warranted before withdrawal of care decisions are made.

Vascularized tissue‐engineered chambers promote survival and function of transplanted islets and improve glycemic control

We have developed a chamber model of islet engraftment that optimizes islet survival by rapidly restoring islet-extracellular matrix relationships and vascularization. Our aim was to assess the ability of syngeneic adult islets seeded into blood vessel-containing chambers to correct streptozotocin-induced diabetes in mice. Approximately 350 syngeneic islets suspended in Matrigel extracellular matrix were inserted into chambers based on either the splenic or groin (epigastric) vascular beds, or, in the standard approach, injected under the renal capsule. Blood glucose was monitored weekly for 7 weeks, and an intraperitoneal glucose tolerance test performed at 6 weeks in the presence of the islet grafts. Relative to untreated diabetic animals, glycemic control significantly improved in all islet transplant groups, strongly correlating with islet counts in the graft (P<0.01), and with best results in the splenic chamber group. Glycemic control deteriorated after chambers were surgically removed at week 8. Immunohistochemistry revealed islets with abundant insulin content in grafts from all groups, but with significantly more islets in splenic chamber grafts than the other treatment groups (P<0.05). It is concluded that hyperglycemia in experimental type 1 diabetes can be effectively treated by islets seeded into a vascularized chamber functioning as a "pancreatic organoid."

Emergency department evaluation of ischemic stroke and TIA: the BASIC Project

OBJECTIVE

To identify demographic and clinical variables of emergency department (ED) practices in a community-based acute stroke study.

METHODS

By both active and passive surveillance, the authors identified cerebrovascular disease cases in Nueces County, TX, as part of the Brain Attack Surveillance in Corpus Christi (BASIC) Project, a population-based stroke surveillance study, between January 1, 2000, and December 31, 2002. With use of multivariable logistic regression, variables independently associated with three separate outcomes were sought: hospital admission, brain imaging in the ED, and neurologist consultation in the ED. Prespecified variables included age, sex, ethnicity, insurance status, NIH Stroke Scale score, type of stroke (ischemic stroke or TIA), vascular risk factors, and symptom presentation variables. Percentage use of recombinant tissue plasminogen activator (rt-PA) was calculated.

RESULTS

A total of 941 Mexican Americans (MAs) and 855 non-Hispanic whites (NHWs) were seen for ischemic stroke (66%) or TIA (34%). Only 8% of patients received an in-person neurology consultation in the ED, and 12% did not receive any head imaging. TIA was negatively associated with neurology consultations compared with completed stroke (odds ratio [OR] 0.35 [95% CI 0.21 to 0.57]). TIA (OR 0.14 [0.10 to 0.19]) and sensory symptoms (OR 0.59 [0.44 to 0.81]) were also negatively associated with hospital admission. MAs (OR 0.58 [0.35 to 0.98]) were less likely to have neurology consultations in the ED than NHWs. Only 1.7% of patients were treated with rt-PA.

CONCLUSIONS

Neurologists are seldom involved with acute cerebrovascular care in the emergency department (ED), especially in patients with TIA. Greater neurologist involvement may improve acute stroke diagnosis and treatment efforts in the ED.

Human immunodeficiency and hepatitis virus infections and their associated conditions and treatments among people with haemophilia

Treatment with contaminated plasma products before 1990 resulted in extraordinary prevalence rates of human immunodeficiency virus (HIV) and hepatitis B and C viruses (HBV, HCV). In the Second Multicentre Haemophilia Cohort Study (MHCS-II) during 2001-03, 30% of HCV-seropositive survivors had HIV and 4.6% were HBV carriers. Highly active antiretroviral therapy (HAART) radically altered the consequences of HIV/HCV coinfection. Whereas opportunistic infections predominated previously, current major complications are liver failure and bleeding (exacerbated by decreased clotting factor synthesis, hypersplenic thrombocytopenia, and oesophageal varices). Most HIV-positives in MHCS-II were HIV RNA-negative and had > 200 CD4(+) cells microL(-1), but only 59% were on HAART. With HIV, especially after 41 years of age, liver disease was apparent (jaundice in 5%, ascites 7%, hepatomegaly 9%, splenomegaly 19%). HAART increases survival but may contribute to various comorbidities. Without HIV, sustained HCV clearance is obtained in > 50% with combined pegylated interferons plus ribavirin, but data in haemophilic populations, especially with HIV, are limited. In MHCS-II, HCV RNA negativity was 41% following standard interferon plus ribavirin; among interferon-naive participants (implying spontaneous HCV clearance), HCV RNA negativity was 12% with and 25% without HIV. Without HIV, spontaneous HCV clearance was much more likely with early age at infection and particularly with recent birth (late 1970s or early 1980s) but not with bleeding propensity or its treatment. Most (72%) participants had received no anti-HCV therapy. Hepatic and haematological conditions are likely to increase during the coming years unless most adult haemophiliacs are successfully treated for HIV, HCV or both.

Predictors of noninvasive ventilation tolerance in patients with amyotrophic lateral sclerosis

Noninvasive ventilation (NIV) appears to improve survival and quality of life in patients with amyotrophic lateral sclerosis (ALS), but little is known about predictors of NIV tolerance. NIV use was assessed and clinical predictors of tolerance were investigated, using predictive modeling, in ALS patients diagnosed and followed in our clinic until death over a 4-year time period. Patients were prescribed NIV based on current practice parameters when respiratory symptoms were present or forced vital capacity was less than 50%. We prescribed NIV in 52% (72) of patients. For those prescribed NIV, information regarding tolerance was available for 50 patients, with 72% (36) tolerant to its use. Tolerance was six times more likely in limb-onset than bulbar-onset ALS patients, with a trend toward reduced tolerance in those with lower forced vital capacity at NIV initiation. Age, gender, and duration of disease were not predictors of NIV tolerance. We conclude that a majority of ALS patients who are prescribed NIV can successfully become tolerant to its use.

Incubation of European yew (Taxus baccata) with white-tailed deer (Odocoileus virginianus) rumen fluid reduces taxine A concentrations

Yew ( Taxus baccata) foliage was co-incubated with rumen fluid (RF) taken from fistulated cattle (Bos taurus), anesthetized white-tailed deer (Odocoileus virginianus) and O. virginianus killed by bow hunters. The first trial with live deer resulted in statistically significant 59% reduction of taxine A by deer RF and no reduction by cattle RF. The second intubation trial, in which half the samples were stopped after 12 h, resulted in slightly less taxine A reduction by deer (46%) and 12% reduction by cattle RF. RF obtained by hunters eQuipped with thermos bottles and trained to collect RF immediatey upon field dressing their deer caused the most (88-96%) taxine A destruction: cattle RF reduced 68-88% the toxin. Obtaining RF from freshly killed deer was less expensive and more consistently successful than taking RF by intubation of anesthetized deer. The greater ability of white-tailed deer RF to detoxify yew taxines may not entirely explain the advantage white-tailed deer have over cattle to surviveyew ingestions without toxic effects.

A common mutation, Arg457-->Gln, links prothrombin deficiencies in the Puerto Rican population

Five unrelated families with Puerto Rican ancestry were identified as having at least one member with bleeding due to a prothrombin deficiency. Genetic prothrombin deficiencies are extremely rare, but at the University of Puerto Rico Hemophilia Center, prothrombin deficiency is the third most common congenital coagulation factor deficiency. Because Puerto Rico is relatively isolated, there was a reasonable expectation of a founder effect. Prothrombin genes from probands and their parents were directly sequenced from PCR amplified exons using forward and reverse primers. Four novel prothrombin mutations were identified. The first, a G-->A substitution at DNA position 10150 predicting an Arg457-->Gln (R457Q) replacement, is common to all five families. In two of the families, the proband children are homozygous for R457Q. In the other three families, the probands are compound heterozygotes for R457Q and one of the other three mutations, which include another point mutation (gamma16Q), a deletion and a splice junction mutation. The two point mutations have been designated Puerto Rico I and Puerto Rico II. The crystal structure of alpha-thrombin predicts that the R457Q mutation removes a salt bridge that links the A- and B-chains of thrombin. The primary effect of this defect appears to be destabilization of the circulating prothrombin, creating a moderate hypoprothrombinemia. However, prothrombin antigen/activity ratios indicate a dysprothrombinemia as well, most likely due to the inability of R457Q prothrombin to activate fully to thrombin.

Deaths associated with platelet glycoprotein IIb/IIIa inhibitor treatment

BACKGROUND

The glycoprotein (GP) IIb/IIIa inhibitors are potent antagonists of platelet aggregation that are approved to prevent thrombotic complications of percutaneous coronary intervention and for medical treatment of patients with acute coronary ischaemic syndromes. From safety data obtained from clinical trials, these agents appear to be associated with a definite but well tolerated increase in non-fatal bleeding complications. However, the bleeding risk of patients enrolled in clinical trials may not be representative of the population actually being treated with these agents.

OBJECTIVE

To conduct a review of the adverse events related to GP IIb/IIIa inhibitors reported to the Food and Drug Administration (FDA).

METHODS

450 reports of death related to treatment with GP IIb/IIIa inhibitors were submitted to the FDA between 1 November 1997 and 31 December 2000. These were reviewed and a standard rating system for assessing causation was applied to each event.

RESULTS

Of the 450 deaths, 44% were considered to be definitely or probably related to the use of GP IIb/IIIa inhibitors. The mean age of patients who died was 69 years and 47% of deaths occurred in women. All of the deaths deemed to be definitely or probably related to GP IIb/IIIa inhibitor treatment were associated with excessive bleeding. The central nervous system was the most common site of fatal bleeding.

CONCLUSIONS

Treatment with GP IIb/IIIa inhibitors may result in fatal bleeding complications in some patients. These findings suggest that patients treated in normal clinical practice may be at greater risk than those treated in clinical trials. Judicious use of these agents is therefore appropriate.

Dose responses for adaption to low doses of (60)Co gamma rays and (3)H beta particles in normal human fibroblasts

The dose response for adaption to radiation at low doses was compared in normal human fibroblasts (AG1522) exposed to either (60)Co gamma rays or (3)H beta particles. Cells were grown in culture to confluence and exposed at either 37 degrees C or 0 degrees C to (3)H beta-particle or (60)Co gamma-ray adapting doses ranging from 0.1 mGy to 500 mGy. These cells, and unexposed control cells, were allowed to adapt during a fixed 3-h, 37 degrees C incubation prior to a 4-Gy challenge dose of (60)Co gamma rays. Adaption was assessed by measuring micronucleus frequency in cytokinesis-blocked, binucleate cells. No adaption was detected in cells exposed to (60)Co gamma radiation at 37 degrees C after a dose of 0.1 mGy given at a low dose rate or to 500 mGy given at a high dose rate. However, low-dose-rate exposure (1-3 mGy/min) to any dose between 1 and 500 mGy from either radiation, delivered at either temperature, caused cells to adapt and reduced the micronucleus frequency that resulted from the subsequent 4-Gy exposure. Within this dose range, the magnitude of the reduction was the same, regardless of the dose or radiation type. These results demonstrate that doses as low as (on average) about one track per cell (1 mGy) produce the same maximum adaptive response as do doses that deposit many tracks per cell, and that the two radiations were not different in this regard. Exposure at a temperature where metabolic processes, including DNA repair, were inactive (0 degrees C) did not alter the result, indicating that the adaptive response is not sensitive to changes in the accumulation of DNA damage within this range. The results also show that the RBE for low doses of tritium beta-particle radiation is 1, using adaption as the end point.

Sex-based differences in early mortality of patients undergoing primary angioplasty for first acute myocardial infarction

BACKGROUND

Morbidity and mortality after an acute myocardial infarction (AMI) has been reported to be higher in women than men. However, in some prior reports, women were not treated as aggressively as men, suggesting a treatment bias. We sought to determine whether sex influenced short-term outcomes in a cohort of AMI patients, all of whom underwent primary angioplasty.

METHODS AND RESULTS

We conducted a retrospective cohort study of all patients undergoing primary angioplasty for a first AMI in New York State in 1995. A total of 1044 patients, 317 women and 727 men, were identified. Mean age was 59+/-12 years in men and 65+/-12 years in women (P<0.05). Women had a higher prevalence of hypertension (59% versus 44%, P<0.05), diabetes (19% versus 14%, P<0.05), and peripheral vascular or carotid disease (9.5% versus 5.5%, P<0.05) than men. Men were more likely to be treated earlier (within 6 hours) from the time of symptom onset than women (74% versus 63%, P<0.05). Women had a higher incidence of shock or hemodynamic instability than men (25% versus 17%, P<0.05). The unadjusted in-hospital mortality rate was 7.9% in women and 2.3% in men (P<0.05). After multivariate logistic regression analysis, women maintained a 2.3-fold higher risk of in-hospital death compared with their male counterparts (95% confidence interval [CI], 1.2 to 4.6, P=0.016).

CONCLUSIONS

After correcting for age and baseline risk differences, women undergoing primary angioplasty for AMI have a significantly higher in-hospital mortality rate than men.

Coronary stenting in diabetic patients: Results from the ROSETTA registry

OBJECTIVE

Diabetes mellitus is associated with high rates of restenosis and adverse outcomes after percutaneous transluminal coronary angioplasty (PTCA). It is unclear whether coronary stenting reduces adverse events in diabetic patients after PTCA. Our purpose was to determine whether coronary stenting improves clinical event rates in diabetic patients after PTCA.

METHODS

The Routine Versus Selective Exercise Treadmill Testing After Angioplasty (ROSETTA) registry was a prospective multicenter observational study examining functional testing and adverse outcomes after successful PTCA.

RESULTS

Among the 791 patients enrolled, 180 were diabetic. A total of 90 diabetics received stents while the remaining 90 patients did not. Baseline clinical characteristics were similar between the 2 groups of patients. However, patients with stents were more likely to have complex lesions, whereas those without stents were more likely to undergo atherectomy and have greater residual coronary stenosis. At 6-month follow-up, the composite end point defined as cardiac death, unstable angina, myocardial infarction, need for repeat PTCA, or coronary artery bypass graft surgery (CABG) occurred in 25.0% of stented and 22.2% of nonstented diabetic patients (P not significant [NS]). A multivariate logistic regression analysis showed that coronary stenting was not associated with a reduced incidence of the composite end point among diabetic patients (odds ratio 0.97, 95% CI 0.46-2.05, P NS).

CONCLUSION

Coronary stenting does not improve clinical event rates in diabetic patients after PTCA.

A randomized trial of stenting with or without balloon predilation for the treatment of coronary artery disease

BACKGROUND

Stent placement has historically been preceded by predilation of the target lesion with percutaneous transluminal coronary angioplasty. Direct stent implantation, without predilation, has the potential to have a favorable impact on procedure cost by reducing the number of devices used, contrast administered, and procedure time.

METHODS AND RESULTS

We conducted a prospective randomized trial to compare the economic outcome of stenting with or without predilation. Inclusion criteria included intention to treat a single lesion with a coronary stent in a vessel with a reference diameter >2.4 mm. Exclusion criteria included total occlusions, culprit lesion within a saphenous vein graft, lesion length >25 mm, patients within 48 hours of an acute myocardial infarction, and patients unable to be treated with aspirin and clopidogrel. From September 1999 to March 2000, 77 patients were randomized to direct stent implantation (n = 37) or balloon-facilitated stenting (n = 40). Stent placement was successful in all patients. Crossover to predilation was required in 2 patients in the direct stent group because of inability to deliver the stent. Compared with balloon-facilitated stenting, direct stenting used fewer catheter devices (1.4 +/- 0.7 vs 2.5 +/- 0.8, P <.001), less contrast (92.7 +/- 43.1 mL vs 117.4 +/- 61.0 mL, P =.04), and less fluoroscopy time (7.5 +/- 3.9 minutes vs 11.6 +/- 8.3 minutes, P =.006). No difference in procedural complications or predischarge outcome was found. No difference in major adverse cardiovascular events was found at 6-month follow-up.

CONCLUSION

Direct stenting is a safe and successful procedure that reduces the number of devices used, fluoroscopy time, and contrast administration.

Volume-outcome relation for physicians and hospitals performing angioplasty for acute myocardial infarction in New York state

BACKGROUND

An inverse relation exists between the number of coronary angioplasty procedures performed by physicians or hospitals and short-term mortality. It is not known, however, whether a similar relation holds for physicians and hospitals that perform primary angioplasty for acute myocardial infarction.

METHODS AND RESULTS

We analyzed data from the 1995 New York State Coronary Angioplasty Reporting System Registry to determine the relation between the number of primary angioplasty procedures performed by physicians and hospitals and in-hospital mortality. Patients who underwent angioplasty procedures within 23 hours of onset of acute myocardial infarction without preceding thrombolytic therapy were included (n=1342). In-hospital mortality was reduced 57% among patients who underwent primary angioplasty by high-volume as opposed to low-volume physicians (adjusted relative risk 0.43; 95% CI 0.21 to 0.83). When patients with acute myocardial infarction were treated with primary angioplasty in high-volume hospitals rather than low-volume institutions, the relative risk reduction for in-hospital mortality was 44% (adjusted relative risk 0.56; 95% CI 0.29 to 1.1). Compared with patients treated at low-volume hospitals by low-volume physicians, patients treated at high-volume hospitals by high-volume physicians had a 49% reduction in the risk of in-hospital mortality (adjusted relative risk 0.51; 95% CI 0.26 to 0.99).

CONCLUSIONS

Among hospitals in New York State, a higher volume of primary angioplasty procedures performed by physicians and/or hospitals was associated with a lower mortality rate.

Congenital insensitivity to pain with anhidrosis (CIPA): novel mutations of the TRKA (NTRK1) gene, a putative uniparental disomy, and a linkage of the mutant TRKA and PKLR genes in a family with CIPA and pyruvate kinase deficiency

Congenital insensitivity to pain with anhidrosis is an autosomal recessive hereditary disorder characterized by recurrent episodic fever, anhidrosis (inability to sweat), absence of reaction to noxious stimuli, self-mutilating behavior, and mental retardation. The human TRKA gene (NTRK1), located on chromosome 1q21-q22 encodes the receptor tyrosine kinase for nerve growth factor. We reported that TRKA is the gene responsible for CIPA and we developed a comprehensive strategy to screen for TRKA mutations and polymorphisms, as based on the gene's structure and organization. Here we report eight novel mutations detected as either a homozygous or heterozygous state in nine CIPA families from five countries. Mendelian inheritance of the mutations was confirmed in seven families for which samples from either parent were available. However, non-mendelian inheritance seems likely for the family when only samples from the mother and siblings, (but not from the father) were available. A paternal uniparental disomy for chromosome 1 is likely to be the cause of reduction to homozygosity of the TRKA gene mutation in this family. Interestingly, a Hispanic patient from the USA has two autosomal genetic disorders, CIPA and pyruvate kinase deficiency, whose genetic loci are both mapped to a closely linked chromosomal region. A splice mutation and a missense mutation were detected in the TRKA and PKLR genes from the homozygous proband, respectively. Thus, concomitant occurrence of two disorders is ascribed to a combination of two separate mutant genes, not a contiguous gene syndrome. This finding suggests a mechanism responsible for two autosomal genetic disorders in one patient. All these data further support findings that TRKA defects can cause CIPA in various ethnic groups. This will aid in diagnosis and genetic counseling of this painless but severe genetic disorder.

Long-term comparative experience with tolcapone and entacapone in advanced Parkinson's disease

The objective of this study was to compare the long-term tolerability and efficacy of tolcapone and entacapone in patients with fluctuating Parkinson's disease (PD). Tolcapone and entacapone are two currently available catechol- O -methyltransferase inhibitors that have demonstrated efficacy in the treatment of advanced PD. There are little published data on long-term experience and no direct comparisons. We compared the results of two separate, simultaneous, long-term open label extensions, one for tolcapone and the other for entacapone. The inclusion/exclusion criteria were similar. Data were collected prospectively at 6, 12, 24, and 36 months. Efficacy measures included the Unified Parkinson's Disease Rating Scale (UPDRS) total score, subscores, items 32 (duration of dyskinesia) and 39 (duration of "off" time), and levodopa dose. The two groups were compared using a Mann-Whitney U test for change from baseline and analysis of variance. Tolerability was defined as the ability of patients to maintain therapy and was compared using a Kaplan-Meier analysis. Eleven patients enrolled in the entacapone study and 14 in the tolcapone study. The tolcapone group had more severe disease with significantly higher UPDRS motor score, duration of "off," and levodopa dose requirement. Tolcapone was more effective in lowering UPDRS motor and complication subscores, duration of "off" time, and levodopa doses. UPDRS motor scores and change in levodopa dose in the tolcapone group remained below baseline level for 36 months; however, they were above baseline in the entacapone group from 6 months on. Tolerability was the same for both treatments. Tolcapone appears to have greater and longer efficacy with regard to motor symptoms, "off" time, and change in levodopa requirements than entacapone. These findings indicate that tolcapone continues to have a place in the treatment of advanced PD. However, the risks associated with this drug, particularly hepatic injury, and the requirement for rigorous blood monitoring, need to be considered when choosing an appropriate treatment for patients with advanced PD.

The GRIP domain is a specific targeting sequence for a population of trans-Golgi network derived tubulo-vesicular carriers

Vesicular carriers for intracellular transport associate with unique sets of accessory molecules that dictate budding and docking on specific membrane domains. Although many of these accessory molecules are peripheral membrane proteins, in most cases the targeting sequences responsible for their membrane recruitment have yet to be identified. We have previously defined a novel Golgi targeting domain (GRIP) shared by a family of coiled-coil peripheral membrane Golgi proteins implicated in membrane trafficking. We show here that the docking site for the GRIP motif of p230 is a specific domain of Golgi membranes. By immuno-electron microscopy of HeLa cells stably expressing a green fluorescent protein (GFP)-p230GRIP fusion protein, we show binding specifically to a subset of membranes of the trans-Golgi network (TGN). Real-time imaging of live HeLa cells revealed that the GFP-p230GRIP was associated with highly dynamic tubular extensions of the TGN, which have the appearance and behaviour of transport carriers. To further define the nature of the GRIP membrane binding site, in vitro budding assays were performed using purified rat liver Golgi membranes and cytosol from GFP-p230GRIP-transfected cells. Analysis of Golgi-derived vesicles by sucrose gradient fractionation demonstrated that GFP-p230GRIP binds to a specific population of vesicles distinct from those labelled for beta-COP or gamma-adaptin. The GFP-p230GRIP fusion protein is recruited to the same vesicle population as full-length p230, demonstrating that the GRIP domain is solely proficient as a targeting signal for membrane binding of the native molecule. Therefore, p230 GRIP is a targeting signal for recruitment to a highly selective membrane attachment site on a specific population of trans-Golgi network tubulo-vesicular carriers.

Sonographic and Doppler characteristics of the corpus luteum: can they predict pregnancy outcome?

OBJECTIVE

To determine whether there is a relationship between gray scale or Doppler characteristics of the corpus luteum and first-trimester pregnancy outcome.

METHODS

We conducted a prospective study of patients with spontaneous singleton pregnancies between 5 and 8 weeks' gestation. The corpus luteum size, sonographic appearance, resistive index, and peak systolic velocity were measured on transvaginal sonography. Maternal use of exogeneous progesterone was recorded. Only patients with known first-trimester outcome were included.

RESULTS

There were 201 study patients. The corpus luteum could be visualized in 197 (98%) and had a mean +/- SD size of 1.9 +/- 0.6 cm, a mean resistive index of 0.50 +/- 0.08, and a peak systolic velocity of 20.5 +/- 11.2 cm/s. There were 151 first-trimester survivors (75.1 %) and 50 spontaneous losses (24.9%). In a comparison of the survivors and losses, there was no significant difference in mean corpus luteum size (1.9 versus 1.7 cm; P = .10, t test), mean resistive index (0.50 versus 0.50; P = .71, t test), peak systolic velocity (21 versus 19 cm/s; P = .29, t test), or sonographic appearance (P = .78, chi2 test). The lack of association between corpus luteum characteristics and outcome persisted when cases were stratified by progesterone use and the presence or absence of a heartbeat on the study sonogram.

CONCLUSION

There is no apparent relationship between the characteristics of the corpus luteum and first-trimester pregnancy outcome.

Dual trafficking of Slit3 to mitochondria and cell surface demonstrates novel localization for Slit protein

Drosophila slit is a secreted protein involved in midline patterning. Three vertebrate orthologs of the fly slit gene, Slit1, 2, and 3, have been isolated. Each displays overlapping, but distinct, patterns of expression in the developing vertebrate central nervous system, implying conservation of function. However, vertebrate Slit genes are also expressed in nonneuronal tissues where their cellular locations and functions are unknown. In this study, we characterized the cellular distribution and processing of mammalian Slit3 gene product, the least evolutionarily conserved of the vertebrate Slit genes, in kidney epithelial cells, using both cellular fractionation and immunolabeling. Slit3, but not Slit2, was predominantly localized within the mitochondria. This localization was confirmed using immunoelectron microscopy in cell lines and in mouse kidney proximal tubule cells. In confluent epithelial monolayers, Slit3 was also transported to the cell surface. However, we found no evidence of Slit3 proteolytic processing similar to that seen for Slit2. We demonstrated that Slit3 contains an NH(2)-terminal mitochondrial localization signal that can direct a reporter green fluorescent protein to the mitochondria. The equivalent region from Slit1 cannot elicit mitochondrial targeting. We conclude that Slit3 protein is targeted to and localized at two distinct sites within epithelial cells: the mitochondria, and then, in more confluent cells, the cell surface. Targeting to both locations is driven by specific NH(2)-terminal sequences. This is the first examination of Slit protein localization in nonneuronal cells, and this study implies that Slit3 has potentially unique functions not shared by other Slit proteins.