Effect of enalapril on myocardial infarction and unstable angina in patients with low ejection fractions

An association between raised renin levels and myocardial infarction has been reported. We studied the effects of enalapril, an angiotensin-converting enzyme (ACE) inhibitor, on the development of myocardial infarction and unstable angina in 6797 patients with ejection fractions < or = 0.35 enrolled into the two Studies of Left Ventricular Dysfunction (SOLVD) trials. Patients were randomly assigned to placebo (n = 3401) or enalapril (n = 3396) at doses of 2.5-20 mg per day in two concurrent double-blind trials with the same protocol. Patients with heart failure entered the treatment trial (n = 2569) and those without heart failure entered the prevention trial (n = 4228). Follow-up averaged 40 months. In each trial there were significant reductions in the number of patients developing myocardial infarction (treatment trial: 158 placebo vs 127 enalapril, p < 0.02; prevention trial: 204 vs 161 p < 0.01) or unstable angina (240 vs 187 p < 0.001; 355 vs 312, p < 0.05). Combined, there were 362 placebo group patients with myocardial infarction compared with 288 in the enalapril group (risk reduction 23%, 95% CI 11-34%; p < 0.001). 595 placebo group patients developed unstable angina compared with 499 in the enalapril group (risk reduction 20%, 95% CI 9-29%, p < 0.001). There was also a reduction in cardiac deaths (711 placebo, 615 enalapril; p < 0.003), so that the reduction in the combined endpoint of deaths, myocardial infarction, and unstable angina was highly significant (20% risk reduction, 95% CI 14-26%; p < 0.0001). Enalapril treatment significantly reduced myocardial infarction, unstable angina, and cardiac mortality in patients with low ejection fractions.

Baseline quality of life as a predictor of mortality and hospitalization in 5,025 patients with congestive heart failure. SOLVD Investigations. Studies of Left Ventricular Dysfunction Investigators

This study examined the independent relation of health-related quality of life (HRQL) to mortality and congestive heart failure (CHF)-related hospitalizations in patients with an ejection fraction of < 0.35 followed for a mean of 36.5 months. A brief HRQL questionnaire was administered at baseline to patients randomized to placebo or enalapril in the Studies of Left Ventricular Dysfunction (SOLVD) trial. Participants had an ejection fraction of < 0.35 and either symptomatic CHF (treatment trial, n = 2,465) or asymptomatic CHF (prevention trial, n = 2,560). Baseline assessment of HRQL predicted mortality and CHF-related hospitalizations in symptomatic and asymptomatic patients randomized to enalapril and placebo treatment. Domains that were the stronger univariate predictors of mortality and CHF-related hospitalizations were activities of daily living (relative risk [RR] for mortality: 1.163, p < 0.000; for hospitalization: 1.215, p < 0.000), general health (RR for mortality: 1.205, p < 0.000; for hospitalization: 1.188, p < 0.000), and social functioning (RR for mortality 1.098, p < 0.000; for hospitalization: RR 1.156, p < 0.000). In the multivariate model, activities of daily living (RR for mortality 1.41, p < 0.000; for hospitalization: RR 1.43, p < 0.002), general health (RR for mortality 1.21, p < 0.000; for hospitalization RR 1.16, p < 0.013) and heart failure symptoms (RR for mortality 1.02, p < 0.025; for hospitalization RR 1.03, p < 0.004) were found to be independent risk factors. HRQL independently predicted mortality and CHF-related hospitalizations after adjustment for ejection fraction, age, treatment, and New York Heart Association classification in patients with an ejection fraction of < 0.35, randomized to enalapril and placebo treatment. HRQL provides additional clinical information regarding disease course and outcome that is not captured by traditional indexes of clinical status.

Apolipoprotein A-I gene polymorphism associated with premature coronary artery disease and familial hypoalphalipoproteinemia

Decreased plasma high-density-lipoprotein (HDL) cholesterol and apolipoprotein A-I levels have been associated with premature coronary artery disease. We identified a PstI restriction-endonuclease site flanking the human apolipoprotein A-I gene at its 3' end that is polymorphic. The absence and presence of this site, as determined by genomic blotting analysis of PstI-digested chromosomal DNA with the use of an apolipoprotein A-I gene probe, were associated with 3.3-kb and 2.2-kb hybridization bands, respectively. The 3.3-kb band appeared in 4.1 percent of 123 randomly selected control subjects and in 3.3 percent of 30 subjects with no angiographic evidence of coronary artery disease. In contrast, among 88 patients who had severe coronary disease before the age of 60, as documented by angiography, the 3.3-kb band occurred in 32 percent (P less than 0.0001). It was also found in 8 of 12 index cases (P less than 0.0001) of kindreds with familial hypoalphalipoproteinemia. In the two patient groups, the allele frequencies of the site that produced the 3.3-kb band were 17 and 42 percent, respectively, as compared with an allele frequency of only 2 percent in the control populations. Within kindreds with familial hypoalphalipoproteinemia and among first-degree relatives of patients with coronary artery disease, the 3.3-kb band was associated with decreased HDL cholesterol levels. Among all patients with coronary artery disease, 58 percent had HDL cholesterol levels below the 10th percentile of normal values; however, this frequency increased to 73 percent when patients with the 3.3-kb band were considered. These findings indicate that the polymorphism in the region between the apolipoprotein A-I and apolipoprotein C-III genes may be a useful marker for the risk of premature coronary artery disease and familial hypoalphalipoproteinemia.

Knot security in simple sliding knots and its relationship to rotator cuff repair: how secure must the knot be?

We sought to determine which simple sliding knot configurations would have adequate strength for rotator cuff repair. Four knot configurations were tied with both No. 1 polydioxanone suture and No. 2 Ethibond suture (Ethicon, Somerville, NJ) using 3 different tying techniques: hand-tie, standard knot pusher, and cannulated double-diameter knot pusher. The knots were then tested to failure on a materials testing system. The weakest standard knot configuration was S=S=S=S. The other 3 knot configurations (S//S//S//S, SxSxSxS, and S//xS//xS//xS) generally failed in the 35 to 50 N range. Ultimate strength in this range can be shown to be adequate to withstand, without suture failure, a maximal contraction of a repaired rotator cuff tear within the rotator crescent, assuming certain conditions are met (suture anchors placed 1 cm apart, 2 sutures per anchor). More complex knots are not necessary for adequate knot security. However, the same configuration with only 1 suture per anchor will not be strong enough because the suture will fail under maximum physiological load. This study shows that we can predict the adequacy of a given knot configuration under maximum physiological loading conditions.

Syncope: current diagnostic evaluation and management

OBJECTIVE

To provide a comprehensive review of the causes, current diagnostic evaluation, and treatment of syncope.

DATA IDENTIFICATION

New data and knowledge in this evolving field were critically analyzed by doing a MEDLINE search on syncope supplemented by selective review of English language literature citations in the Index Medicus before 1980.

STUDY SELECTION

We reviewed approximately 200 published articles on syncope and closely related topics as well as using our own clinical experience. We selected articles if they addressed the pathophysiology of syncope, classification and causes, differential diagnosis, noninvasive and invasive evaluation, and current therapy.

RESULTS OF DATA SYNTHESIS

Syncope is a common clinical problem, occurring in 30% to 50% of the adult population. The prognosis for syncope depends on its cause. Cardiac syncope has the worst prognosis and therefore mandates thorough evaluation and prompt treatment. Diagnostic evaluation is made difficult by the transient nature of the episodes and the many causes. Noninvasive testing reveals the cause of syncope in approximately 50% of cases. More extensive evaluation, including invasive electrophysiologic studies, has assumed a larger role in defining the cause of syncope in selected patients with structural heart disease in whom a noninvasive evaluation has been nondiagnostic. Recently tilt-table studies have been proposed as a clinically useful noninvasive test for vagally mediated syncope.

CONCLUSIONS

A rational stepwise diagnostic and therapeutic approach to patients with syncope can be developed by initially doing a careful history and physical examination followed by a noninvasive evaluation and selective use of additional, more specialized or invasive tests. Future research should focus on defining the validity and utility of current diagnostic testing in syncope and on exploring further the pathophysiology of patients with recurrent, unexplained syncope.

Loop security as a determinant of tissue fixation security

Secure arthroscopic repair of rotator cuff tears and Bankart lesions requires tight knots (knot security). Equally important, but usually overlooked, is the tightness of the suture loop (loop security). This study compared loop security in knots tied with No. 1 PDS suture using three different methods: (1) hand-tied, (2) single-hole standard knot pusher, and (3) cannulated double-diameter knot pusher. The results of this study show that the double-diameter knot pusher maintained tight suture loops that were equivalent in circumference to hand-tied loops and were significantly tighter than suture loops tied with a standard single-hole knot pusher. This study highlights the fact that loop security is equally important to knot security in tissue fixation.

Diagnosing acute cardiac ischemia in the emergency department: a systematic review of the accuracy and clinical effect of current technologies

STUDY OBJECTIVE

Acute cardiac ischemia (ACI) encompasses the diagnoses of unstable angina pectoris and acute myocardial infarction (AMI). Accurate diagnosis and triage of patients with ACI in the emergency department should increase survival for these patients and reduce unnecessary hospital admissions.

METHODS

We conducted a systematic review of the English-language literature published between 1966 and December 1998 on the accuracy and clinical effect of diagnostic technologies for ACI. We evaluated prospective and retrospective studies of adult patients who presented to the ED with symptoms suggesting ACI. Outcomes were diagnostic performance (test sensitivity and specificity) and measures of clinical effect. Meta-analyses were performed when appropriate. A decision and cost-effectiveness analysis was conducted that investigated various diagnostic strategies used in the diagnosis of ACI in the ED.

RESULTS

We screened 6,667 abstracts, reviewed 407 full articles, and included 106 articles articles in the main analysis. Single measurements of biomarkers at presentation to the ED have low sensitivity for AMI, although they have high specificity. Serial measurements greatly increase the sensitivity for AMI while maintaining their excellent specificity. Diagnostic technologies to evaluate ACI in selected populations, such as electrocardiography, sestamibi perfusion imaging, and stress ECG, may have very good to excellent sensitivity; however, they have not been sufficiently studied. The Goldman Chest Pain Protocol has good sensitivity (about 90%) for AMI but has not been shown to result in any differences in hospitalization rate, length of stay, or estimated costs in the single clinical effect study performed. Its applicability to patients with unstable angina pectoris has not been evaluated. The use of an Acute Cardiac Ischemia-Time-Insensitive Predictive Instrument led to the appropriate triage of 97% of patients with ACI presenting to the ED and reduced unnecessary hospitalizations.

CONCLUSION

Many of the current technologies remain underevaluated, especially regarding their clinical effect. The extent to which combinations of tests may provide better accuracy than any single test needs further study.

Cycloplegic refractions in infants and young children

We studied groups of normal infants and infants with amblyopia and esoropia to determine the incidence of infantile astigmatism. Under cycloplegia, 19% of normal infants had astigmatism; this was at least twice the incidence in adults, but less than one-hale that found by noncycloplegic refractions of infants. During the first three postnatal years the incidence of astigmatism and distributions of spherical equivalents and anisometropia did not distinguish normal patients from most of those with esotropia and amblyopia.

Accuracy of biomarkers to diagnose acute cardiac ischemia in the emergency department: a meta-analysis

STUDY OBJECTIVE

We sought to evaluate quantitatively the evidence on the diagnostic performance of presentation and serial biochemical markers for emergency department diagnosis of acute cardiac ischemia (ACI), including acute myocardial infarction (AMI) and unstable angina.

METHODS

We conducted a systematic review and meta-analysis of the English-language literature published between 1966 and December 1998. We examined the diagnostic performance of creatine kinase, creatine kinase-MB, myoglobin, and troponin I and T testing. Diagnostic performance was assessed by using estimates of test sensitivity and specificity and was summarized by summary receiver-operating characteristic curves.

RESULTS

Only 4 studies were found that evaluated all patients with ACI; 73 were found that focused only on a diagnosis of AMI. To diagnose ACI, presentation biomarker tests had sensitivities of 16% to 19% and specificities of 96% to 100%; serial biomarker tests had sensitivities of 31% to 45% and specificities of 95% to 98%. Considering only the diagnosis of AMI, presentation biomarker tests had summary sensitivities of 37% to 49% and summary specificities of 87% to 97%; serial biomarker tests had summary sensitivities of 79% to 93% and summary specificities of 85% to 96%. Variation of test sensitivity was best explained by test timing. Longer symptom duration or time between serial tests yielded higher sensitivity.

CONCLUSION

The limited evidence available to evaluate the diagnostic accuracy of biomarkers for ACI suggests that biomarkers have very low sensitivity to diagnose ACI. Thus, biomarkers alone will greatly underdiagnose ACI and will be inadequate to make triage decisions. For AMI diagnosis alone, multiple testing of individual biomarkers over time substantially improves sensitivity, while retaining high specificity, at the expense of additional time. Further high-quality studies are needed on the clinical effect of using biomarkers for patients with ACI in the ED and on optimal timing of serial testing and in combination with other tests.

Accuracy and clinical effect of out-of-hospital electrocardiography in the diagnosis of acute cardiac ischemia: a meta-analysis

STUDY OBJECTIVE

We sought to evaluate quantitatively the evidence on the diagnostic performance of out-of-hospital ECG for the diagnosis of acute cardiac ischemia (ACI) and acute myocardial infarction (AMI) and the clinical effect of out-of-hospital thrombolysis.

METHODS

We conducted a systematic review and meta-analysis of the English-language literature published between 1966 and December 1998 on the diagnostic accuracy of out-of-hospital ECG and the clinical effect of out-of-hospital thrombolysis. Both prospective and retrospective studies qualified for the assessment of diagnostic performance. For clinical effect, data from prospective nonrandomized studies were synthesized separately from data from randomized trials. Diagnostic performance was assessed by using estimates of test sensitivity, specificity, and diagnostic odds ratios and was summarized by using summary receiver-operating characteristic curves. Measures of clinical effect included time savings, early ventricular function, early mortality, and long-term survival.

RESULTS

Diagnostic accuracy was evaluated in 11 studies with a total of 7,508 patients. Data were available for ACI in 5 studies and for AMI in 8 studies. For ACI, the random-effects pooled sensitivity was 76% (95% CI, 54% to 89%), the specificity was 88% (95% CI, 67% to 96%), and the diagnostic odds ratio was 23 (95% CI, 6.3 to 85). The respective figures for AMI were sensitivity of 68% (95% CI, 59% to 76%), specificity of 97% (95% CI, 89% to 92%), and diagnostic odds ratio of 104 (95% CI, 48 to 224). Both in nonrandomized (n=4, total 1,531 patients) and randomized (n=9, total 6,643 patients) studies, out-of-hospital thrombolysis shortened the time from onset of symptoms to thrombolytic treatment by 40 to 60 minutes. Data on short-term ejection fraction were sparse. Hospital mortality was reduced by 16% (95% CI, 2% to 27%) among randomized trials, and a similar estimate of effect was seen in nonrandomized studies. There was no clear effect on long-term mortality, but data were sparse.

CONCLUSION

Out-of-hospital ECG has excellent diagnostic performance for AMI and very good performance for ACI. Out-of-hospital thrombolysis achieves time savings and improves short-term mortality, but the effect on long-term mortality is unknown.

Giving and receiving help: interpersonal transactions in mutual-help meetings and psychosocial adjustment of members

The helping transactions that occur in group meetings have been theorized to be important therapeutic mechanisms within mutual-help (or self-help) groups. Hypothesized links between giving and receiving help and psychosocial adjustment were examined in a mutual-help group for individuals with serious mental illness (GROW). Participants' adjustment was assessed at two time points and helping behaviors were measured with observational coding of weekly group interactions during the period between assessments. Frequencies of helping behaviors were used to predict Time 2 adjustment after controlling for initial adjustment. Consistent with the helper therapy principle, giving help to others predicted improvements in psychosocial adjustment; giving advice was a unique predictor. Total amount of help received was not associated with adjustment, but receiving help that provided cognitive reframing was associated with better social adjustment. A predicted interaction suggested that receiving help was related to better functioning when members experienced high levels of group integration.

Immune regulatory abnormalities produced by procainamide

The pathogenesis of procainamide-induced autoantibody production is unknown. To test the effect of procainamide on the immune system, we studied in vitro suppressor cell function and immunoglobulin G (IgG) secretion in 11 patients who developed autoantibodies while taking procainamide. The procainamide group was compared with patients with spontaneous systemic lupus erythematosus (n = 15) and a normal control population (n = 40). Impaired in vitro suppressor cell function was found in 11 of 14 patients with spontaneous systemic lupus erythematosus but in none of the patients taking procainamide. However, total in vitro IgG secretion was significantly increased in the procainamide group with regard to the control and systemic lupus erythematosus groups. There was a direct correlation between the circulating anti-SS DNA antibody titer and in vitro IgG secretion. Furthermore, T cells isolated from the procainamide-treated patients stimulated IgG secretion by normal allogeneic peripheral blood lymphocytes. The added T cells did not affect in vitro suppressor cell function. We postulate that autoantibody production in patients taking procainamide is due to enhanced helper T cell function and not to impaired suppression. However, the development of clinical disease requires the participation of additional genetic or immunologic factors.

Accuracy of imaging technologies in the diagnosis of acute cardiac ischemia in the emergency department: a meta-analysis

STUDY OBJECTIVE

We sought to quantitatively evaluate the evidence on the diagnostic performance of imaging technologies (including rest and stress echocardiography and technetium-99m sestamibi scanning) for the diagnosis of acute cardiac ischemia and acute myocardial infarction in the emergency department.

METHODS

We conducted a systematic review and meta-analysis of the English-language literature published between 1966 and December 1998. Both prospective and retrospective studies qualified for the assessment of diagnostic performance. Diagnostic performance was assessed by means of random-effect estimates of test sensitivity, specificity, and the diagnostic odds ratio and was summarized by using summary receiver-operating characteristic curves.

RESULTS

Diagnostic accuracy was evaluated in 10 studies of rest echocardiography, 2 studies of dobutamine stress echocardiography, and 6 studies of technetium-99m sestamibi scanning. However, only 3 rest echocardiography and 5 technetium-99m sestamibi studies evaluated patients strictly in the ED setting. Patient populations were often highly selected to represent low- or moderate-risk groups. When limited to ED studies, rest echocardiography showed excellent sensitivity of 93% (95% CI, 81% to 97%) and good specificity of 66% (95% CI, 43% to 83%). The results were similar when all studies were considered, including data from reports of admitted patients and patients sent to the cardiac care unit. There was insufficient literature on stress echocardiography in the ED to properly assess the technology. Technetium-99m sestamibi scanning also showed excellent sensitivity (range, 91.5% to 100%) and good specificity (range, 49.3% to 84.4%) for acute myocardial infarction; for acute cardiac ischemia, the random-effects pooled sensitivity was 89% (95% CI, 73% to 96%), and the pooled specificity was 77% (95% CI, 63% to 87%).

CONCLUSION

For selected low- and moderate-risk patient groups, echocardiography and technetium-99m sestamibi imaging appear to have very good diagnostic performance with a similar sensitivity and specificity profile. More evidence should be accumulated on their performance specifically in the ED setting.

Cycloplegic refractions of premature infants

Cyclopentolate refractions of 146 premature infants disclosed higher incidences of myopia and anisometropia than those reported for full-term infants. Also, more than 70% of the premature infants had I diopter or more of astigmatism; 83% of the astigmatism was against-the-rule. Infants with shorter gestational periods had more severe myopia and astigmatism. Infants born very prematurely should undergo follow-up refractions to determine whether they retain refractive errors large enough to interfere with visual function.

Antiphospholipid antibody-mediated effects in an arterial model of thrombosis are dependent on Toll-like receptor 4

Patients with antiphospholipid syndrome (APS) produce antiphospholipid antibodies (aPL) and develop vascular thrombosis that may occur in large or small vessels in the arterial or venous beds. On the other hand, many individuals produce aPL and yet never develop thrombotic events. Toll-like receptor 4 (TLR4) appears to be necessary for aPL-mediated prothrombotic effects in venous and microvascular models of thrombosis, but its role in arterial thrombosis has not been studied. Here, we propose that aPL alone are insufficient to cause thrombotic events in an arterial model of APS, and that a concomitant trigger of innate immunity (e.g. TLR4 activation) is required. We show specifically that anti-β2-glycoprotein I (anti-β2GPI) antibodies, a subset of aPL, accelerated thrombus formation in C57BL/6 wild-type, but not TLR4-deficient, mice in a ferric chloride-induced carotid artery injury model. These aPL bound to arterial and venous endothelial cells, particularly in the presence of β2GPI, and to human TLR4 by enzyme-linked immunoassay. Arterial endothelium from aPL-treated mice had enhanced leukocyte adhesion, compared to control IgG-treated mice. In addition, aPL treatment of mice enhanced expression of tissue factor (TF) in leukocytes induced by the TLR4 ligand lipopolysaccharide (LPS). aPL also enhanced LPS-induced TF expression in human leukocytes in vitro. Our findings support a mechanism in which aPL enhance TF expression by leukocytes, as well as augment adhesion of leukocytes to the arterial endothelium. The activation of TLR4 in aPL-positive individuals may be required to trigger thrombotic events.

Reproductive hazards of lead exposure among urban Egyptian men

Fifty-five urban Egyptian males, aged 20-40, were assigned to two main groups to study the effects of their exposure to lead (Pb). Group I, infertile men (INF, n = 30), was divided into environmentally exposed (INF-E, n = 15) and environmentally and occupationally exposed (INF-EO, n = 15). A matching group (II) of fertile men (F, n = 25) was divided into fertile, environmentally exposed (F-E, n = 10), which was the control group, and fertile, environmentally and occupationally exposed (F-EO, n = 15). Semen parameters (i.e., count, morphology, motility, and volume), blood and semen Pb levels, and reproductive hormonal indices (i.e., serum testosterone, FSH, and LH) were measured in all subjects. Lead levels were always higher in blood than semen. Semen lead levels were significantly higher in all groups vs. the control (F-E) group. While no changes were observed in testosterone levels across groups, variable effects on LH and FSH levels were observed. Infertile-EO subjects showed a definite pattern of impaired semen parameters in comparison with infertile-E. No abnormalities were detected in hematologic, hepatic or renal function.

External cardiac programmed stimulation for noninvasive termination of sustained supraventricular and ventricular tachycardia

To examine the feasibility of using a noninvasive temporary pacemaker for termination of well-tolerated supraventricular (SVT) and ventricular tachycardia (VT), a standard external demand pacemaker was modified to allow stimulation with single or multiple extrastimuli and overdrive pacing. To evaluate the efficacy, safety and tolerance of external cardiac programmed stimulation, a standard arrhythmia termination protocol was used in 223 tachycardias in 22 patients. The technique of external cardiac programmed stimulation was used in 209 episodes of SVT in 13 patients. It terminated 95% of the episodes with success in 19 of 20 episodes of atrioventricular nodal reentrant tachycardia and 179 of 189 episodes of atrioventricular reciprocating tachycardia. Of 198 episodes of SVT terminated by the technique 168 (85%) were terminated by a single extrastimulus and 28 (14%) by double extrastimuli. Only 2 episodes of SVT required overdrive pacing for termination. External cardiac programmed stimulation did not result in atrial fibrillation or arrhythmia acceleration. Of 14 episodes of sustained monomorphic VT 5 were terminated by external cardiac programmed stimulation. One tachycardia was terminated by a single extrastimulus, 1 by double extrastimuli and 3 by overdrive pacing. Arrhythmia acceleration occurred once and was terminated by endocardial pacing. On 27 separate occasions patient evaluation of maximal discomfort included 4 ratings of mild, 10 of moderate, 11 of severe and 2 of intolerable discomfort. External cardiac programmed stimulation is effective and safe in patients with well-tolerated sustained supraventricular or ventricular arrhythmias.

Serum glutamate was elevated in children aged 3-10 years with autism spectrum disorders when they were compared with controls

AIM

This study aimed to see whether measuring serum glutamate in children with autism spectrum disorder (ASD) could provide a biological marker that could allow early intervention.

METHODS

Serum glutamate was measured in 30 patients aged 3-10 years presenting with ASD to the Abou El Reesh Hospitals, Cairo University, Egypt and 30 matched controls without ASD in 2015. The Vineland Social Maturity Scale was applied to assess social competence, self- help skills and adaptive behaviour in both groups. The severity of autism was measured with the Childhood Autism Rating Scale test.

RESULTS

The patients' group showed higher mean values of serum glutamate (5.888) than the control group (2.521) and the statistical difference was significant (p = 0.00021). There was no significant difference (p = 0.151) in the serum level of glutamate between patients receiving 1-2 mg of risperidone (6.519 ± 2.851) and those who were free from any medication for at least six weeks (5.157 ± 2.184).

CONCLUSION

We found higher levels of serum glutamate in subjects with ASD and this might reflect altered glutamatergic neurotransmission which may aid early ASD detection. Further investigations are needed with a large number of participants to further clarify the possibility of using glutamate as a biomarker for ASD.

alpha-1,4-Glucosidase activity in infertile oligoasthenozoospermic men with and without varicocele

This work aimed to assess seminal alpha-1,4-glucosidase activity in infertile oligoasthenozoospermic men associated with and without scrotal varicocele. Eighty men were investigated. They were divided into three groups: group 1 (n = 20), fertile normozoospermic men; group 2 (n = 30), oligoasthenozoospermia with varicocele; and group 3 (n = 30), oligoasthenozoospermia without varicocele. The patients underwent medical history, clinical examination, conventional semen analysis and estimation of seminal plasma alpha-1,4-glucosidase activity by double-beam spectrophotometer method and serum testosterone by radioimmunoassay method. There was a significant decrease in the mean seminal alpha-1,4-glucosidase activity levels in infertile men versus controls (mean +/- SD; 7.66 +/- 0.433, 2.088 +/- 0.565, 5.384 +/- 0.85 mU ml(-1) respectively). Mean serum testosterone levels demonstrated nonsignificant differences between studied groups. Seminal alpha-1,4-glucosidase activity levels demonstrated significant correlation with sperm count, sperm motility percentage and serum testosterone in oligoasthenozoospermia with varicocele group and demonstrated nonsignificant correlation in other groups. It is concluded that varicocele-induced hypoxia is the adverse effect that causes both oligoasthenozoospermia and decreased seminal alpha-1,4-glucosidase levels.

The dual role of innate immunity in antiphospholipid syndrome and systemic lupus erythematosus

Antiphospholipid syndrome (APS), as a primary disease or a secondary syndrome in systemic lupus erythematosus (SLE), is characterized by the presence of antiphospholipid antibodies (aPL) and a clinical event. It is likely that both genetic and environmental factors lead to the development of aPL and progression to disease. However, the precise mechanisms are not known. We hypothesize that innate immune activation plays a dual role in APS and SLE, both in the production of aPL (i.e. “initiation” phase) and in the development of a clinical event (i.e. “effector” phase). We have shown that mice immunized with certain phospholipid-binding proteins (e.g. β2-glycoprotein I (β2GPI)), plus a concomitant trigger of innate immunity (e.g. a toll-like receptor 4 (TLR4) ligand), produce a strong β2GPI-reactive T cell response, resulting in high levels of aPL as well as other SLE autoantibodies. We propose that β2GPI, through its interaction with apoptotic cells, permits B cell epitope spread to multiple SLE autoantibodies. Innate immune activation is also implicated in a murine model of aPL-enhanced thrombus formation. This dual role of innate immune activation provides new insight into the mechanisms involved in the initiation of aPL and other SLE-related autoantibodies, as well as the development of aPL-mediated disease.

Translumbar coronary arteriography

Selective coronary angiography, using a catheter sheath placed across the lumbar region and into the abdominal aorta, has been performed for a patient with lack of other arterial access due to severe occlusive atherosclerosis in the abdominal aorta and innominate and left subclavian arteries. This approach is quick and facile, but care must be taken to prevent possible bleeding complications.

Cutaneous Melanoma: Mutational Status and Potential Links to Tertiary Lymphoid Structure Formation

Recent advances in immunotherapy have enabled rapid evolution of novel interventional approaches designed to reinvigorate and expand patient immune responses against cancer. An emerging approach in cancer immunology involves the conditional induction of tertiary lymphoid structures (TLS), which are non-encapsulated ectopic lymphoid structures forming at sites of chronic, pathologic inflammation. Cutaneous melanoma (CM), a highly-immunogenic form of solid cancer, continues to rise in both incidence and mortality rate, with recent reports supporting a positive correlation between the presence of TLS in melanoma and beneficial treatment outcomes amongst advanced-stage patients. In this context, TLS in CM are postulated to serve as dynamic centers for the initiation of robust anti-tumor responses within affected regions of active disease. Given their potential importance to patient outcome, significant effort has been recently devoted to gaining a better understanding of TLS neogenesis and the influence these lymphoid organs exert within the tumor microenvironment. Here, we briefly review TLS structure, function, and response to treatment in the setting of CM. To uncover potential tumor-intrinsic mechanisms that regulate TLS formation, we have taken the novel perspective of evaluating TLS induction in melanomas impacted by common driver mutations in BRAF, PTEN, NRAS, KIT, PRDM1, and MITF. Through analysis of The Cancer Genome Atlas (TCGA), we show expression of DNA repair proteins (DRPs) including BRCA1, PAXIP, ERCC1, ERCC2, ERCC3, MSH2, and PMS2 to be negatively correlated with expression of pro-TLS genes, suggesting DRP loss may favor TLS development in support of improved patient outcome and patient response to interventional immunotherapy.