The 2023 Duke-International Society for Cardiovascular Infectious Diseases Criteria for Infective Endocarditis: Updating the Modified Duke Criteria

The microbiology, epidemiology, diagnostics, and treatment of infective endocarditis (IE) have changed significantly since the Duke Criteria were published in 1994 and modified in 2000. The International Society for Cardiovascular Infectious Diseases (ISCVID) convened a multidisciplinary Working Group to update the diagnostic criteria for IE. The resulting 2023 Duke-ISCVID IE Criteria propose significant changes, including new microbiology diagnostics (enzyme immunoassay for Bartonella species, polymerase chain reaction, amplicon/metagenomic sequencing, in situ hybridization), imaging (positron emission computed tomography with 18F-fluorodeoxyglucose, cardiac computed tomography), and inclusion of intraoperative inspection as a new Major Clinical Criterion. The list of "typical" microorganisms causing IE was expanded and includes pathogens to be considered as typical only in the presence of intracardiac prostheses. The requirements for timing and separate venipunctures for blood cultures were removed. Last, additional predisposing conditions (transcatheter valve implants, endovascular cardiac implantable electronic devices, prior IE) were clarified. These diagnostic criteria should be updated periodically by making the Duke-ISCVID Criteria available online as a "Living Document."

Angiopoietin 2 and hsCRP are associated with pulmonary hemodynamics and long-term mortality respectively in CTEPH-Results from a prospective discovery and validation biomarker study

INTRODUCTION

Chronic thromboembolic pulmonary hypertension (CTEPH) is an underdiagnosed disease of uncertain etiology. Altered endothelial homeostasis, defective angiogenesis and inflammation are implicated. Angiopoietin 2 (Ang2) impairs acute thrombus resolution and is associated with vasculopathy in idiopathic pulmonary arterial hypertension.

METHODS

We assessed circulating proteins associated with these processes in serum from patients with CTEPH (n = 71) before and after pulmonary endarterectomy (PEA), chronic thromboembolic pulmonary disease without pulmonary hypertension (CTEPD, n = 9) and healthy controls (n = 20) using Luminex multiplex arrays. Comparisons between groups were made using multivariable rank regression models. Ang2 and high-sensitivity C-reactive protein (hsCRP) were measured in a larger validation dataset (CTEPH = 277, CTEPD = 26). Cox proportional hazards models were used to identify markers predictive of survival.

RESULTS

In CTEPH patients, Ang2, interleukin (IL) 8, tumor necrosis factor α, and hsCRP were elevated compared to controls, while vascular endothelial growth factor (VEGF) c was lower (p < 0.05). Ang2 fell post-PEA (p < 0.05) and was associated with both pre- and post-PEA pulmonary hemodynamic variables and functional assessments (p < 0.05). In the validation dataset, Ang2 was significantly higher in CTEPH compared to CTEPD. Pre-operative hsCRP was an independent predictor of mortality.

CONCLUSIONS

We hypothesize that CTEPH patients have significant distal micro-vasculopathy and consequently high circulating Ang2. Patients with CTEPD without pulmonary hypertension have no discernible distal micro-vasculopathy and therefore have low circulating Ang2. This suggests Ang2 may be critical to CTEPH disease pathogenesis (impaired thrombus organization and disease severity).

A Case of Thrombotic Microangiopathy and Acute Sarcoidosis

Although sarcoidosis is an established cause of multiorgan dysfunction, acute presentation with thrombotic microangiopathy resulting in severe renal and hematological sequelae has not been reported. We describe the case of a patient presenting with hypercalcemia, pancreatitis, and acute renal failure, followed by microangiopathic hemolytic anemia. Although there were no significant respiratory symptoms, thoracic radiology and mediastinal lymph node biopsy results were in keeping with sarcoidosis as the underlying cause of this multisystem presentation. Corticosteroids were commenced with clinical and biochemical improvement. This novel case highlights the need to consider sarcoidosis as part of the differential diagnosis for unusual multiorgan presentations and for early multidisciplinary involvement in such cases to permit optimal treatment.

Diagnosis of myocardial infarction at autopsy: AECVP reappraisal in the light of the current clinical classification

Ischemic heart disease is one of the leading causes of morbidity and death worldwide. Consequently, myocardial infarctions are often encountered in clinical and forensic autopsies, and diagnosis can be challenging, especially in the absence of an acute coronary occlusion. Precise histopathological identification and timing of myocardial infarction in humans often remains uncertain while it can be of crucial importance, especially in a forensic setting when third person involvement or medical responsibilities are in question. A proper post-mortem diagnosis requires not only up-to-date knowledge of the ischemic coronary and myocardial pathology, but also a correct interpretation of such findings in relation to the clinical scenario of the deceased. For these reasons, it is important for pathologists to be familiar with the different clinically defined types of myocardial infarction and to discriminate myocardial infarction from other forms of myocardial injury. This article reviews present knowledge and post-mortem diagnostic methods, including post-mortem imaging, to reveal the different types of myocardial injury and the clinical-pathological correlations with currently defined types of myocardial infarction.

Genomic evidence supports a clonal diaspora model for metastases of esophageal adenocarcinoma

The poor outcomes in esophageal adenocarcinoma (EAC) prompted us to interrogate the pattern and timing of metastatic spread. Whole-genome sequencing and phylogenetic analysis of 388 samples across 18 individuals with EAC showed, in 90% of patients, that multiple subclones from the primary tumor spread very rapidly from the primary site to form multiple metastases, including lymph nodes and distant tissues-a mode of dissemination that we term 'clonal diaspora'. Metastatic subclones at autopsy were present in tissue and blood samples from earlier time points. These findings have implications for our understanding and clinical evaluation of EAC.

Chronic thromboembolic pulmonary hypertension following long-term peripherally inserted central venous catheter use

A 36-year-old woman presented with recurrent pulmonary emboli (PE) despite oral anticoagulation. She was a type I diabetic with severe gastroparesis requiring insertion of multiple long-term peripherally inserted central catheters (PICC) over a 10-year period. Imaging at presentation demonstrated a PICC-associated mobile mass in the right atrium and signs of pulmonary hypertension (PH). She was thrombolyzed and fully anticoagulated, and diabetic management without PICC strongly recommended. PH persisted, however, and she developed chronic thromboembolic pulmonary hypertension (CTEPH), for which successful pulmonary endarterectomy (PEA) surgery led to symptomatic and hemodynamic improvement. This was the first case of CTEPH reported related to long-term PICC use outside the setting of malignant disease, and a novel observation that the PEA specimen contained multiple plastic fragments. Long-term PICC placement increases the risk of CTEPH, a life-threatening, albeit treatable, complication.

A hypercoagulable state leading to venous limb gangrene associated with occult lung adenocarcinoma

We report a case of lung adenocarcinoma-associated hypercoagulability leading to venous limb gangrene, managed successfully with argatroban and then dabigatran. Use of idarucizumab permitted diagnostic investigations, leading to targeted antineoplastic therapy with crizotinib, surgical resection with curative intent, and continued survival over 2 years after the index event.

Surgical resection of a massive primary mediastinal liposarcoma with cervical extension

A 73-year-old man was referred for surgical excision of a massive mediastinal and cervical liposarcoma following neoadjuvant chemotherapy. Surgery was performed via a cervical incision, sternotomy and right posterolateral thoracotomy. The tumour arose from the oesophagus, which underwent extensive dissection and was oversewn with pleura after tumour resection. Histology confirmed a completely excised grade 2 de-differentiated liposarcoma with complete macroscopic excision. The patient made an excellent recovery. Oesophageal liposarcomas are rare and, unlike in this case, often extend intraluminally, necessitating oesophagectomy. To our knowledge, this is the largest such tumour found in the literature.

Phenotypic Characterization of EIF2AK4 Mutation Carriers in a Large Cohort of Patients Diagnosed Clinically With Pulmonary Arterial Hypertension

BACKGROUND

Pulmonary arterial hypertension (PAH) is a rare disease with an emerging genetic basis. Heterozygous mutations in the gene encoding the bone morphogenetic protein receptor type 2 (BMPR2) are the commonest genetic cause of PAH, whereas biallelic mutations in the eukaryotic translation initiation factor 2 alpha kinase 4 gene (EIF2AK4) are described in pulmonary veno-occlusive disease/pulmonary capillary hemangiomatosis. Here, we determine the frequency of these mutations and define the genotype-phenotype characteristics in a large cohort of patients diagnosed clinically with PAH.

METHODS

Whole-genome sequencing was performed on DNA from patients with idiopathic and heritable PAH and with pulmonary veno-occlusive disease/pulmonary capillary hemangiomatosis recruited to the National Institute of Health Research BioResource-Rare Diseases study. Heterozygous variants in BMPR2 and biallelic EIF2AK4 variants with a minor allele frequency of <1:10 000 in control data sets and predicted to be deleterious (by combined annotation-dependent depletion, PolyPhen-2, and sorting intolerant from tolerant predictions) were identified as potentially causal. Phenotype data from the time of diagnosis were also captured.

RESULTS

Eight hundred sixty-four patients with idiopathic or heritable PAH and 16 with pulmonary veno-occlusive disease/pulmonary capillary hemangiomatosis were recruited. Mutations in BMPR2 were identified in 130 patients (14.8%). Biallelic mutations in EIF2AK4 were identified in 5 patients with a clinical diagnosis of pulmonary veno-occlusive disease/pulmonary capillary hemangiomatosis. Furthermore, 9 patients with a clinical diagnosis of PAH carried biallelic EIF2AK4 mutations. These patients had a reduced transfer coefficient for carbon monoxide (Kco; 33% [interquartile range, 30%-35%] predicted) and younger age at diagnosis (29 years; interquartile range, 23-38 years) and more interlobular septal thickening and mediastinal lymphadenopathy on computed tomography of the chest compared with patients with PAH without EIF2AK4 mutations. However, radiological assessment alone could not accurately identify biallelic EIF2AK4 mutation carriers. Patients with PAH with biallelic EIF2AK4 mutations had a shorter survival.

CONCLUSIONS

Biallelic EIF2AK4 mutations are found in patients classified clinically as having idiopathic and heritable PAH. These patients cannot be identified reliably by computed tomography, but a low Kco and a young age at diagnosis suggests the underlying molecular diagnosis. Genetic testing can identify these misclassified patients, allowing appropriate management and early referral for lung transplantation.

Consensus statement on surgical pathology of the aorta from the Society for Cardiovascular Pathology and the Association for European Cardiovascular Pathology: I. Inflammatory diseases

Inflammatory diseases of the aorta include routine atherosclerosis, aortitis, periaortitis, and atherosclerosis with excessive inflammatory responses, such as inflammatory atherosclerotic aneurysms. The nomenclature and histologic features of these disorders are reviewed and discussed. In addition, diagnostic criteria are provided to distinguish between these disorders in surgical pathology specimens. An initial classification scheme is provided for aortitis and periaortitis based on the pattern of the inflammatory infiltrate: granulomatous/giant cell pattern, lymphoplasmacytic pattern, mixed inflammatory pattern, and the suppurative pattern. These inflammatory patterns are discussed in relation to specific systemic diseases including giant cell arteritis, Takayasu arteritis, granulomatosis with polyangiitis (Wegener's), rheumatoid arthritis, sarcoidosis, ankylosing spondylitis, Cogan syndrome, Behçet's disease, relapsing polychondritis, syphilitic aortitis, and bacterial and fungal infections.

Cardiopulmonary exercise testing suggests a beneficial response to pulmonary endarterectomy in a patient with chronic thromboembolic obstruction and normal preoperative pulmonary hemodynamics

Pulmonary endarterectomy offers a symptomatic and survival benefit in patients with chronic thromboembolic pulmonary hypertension through sustained improvement in right ventricular function. However, its role in patients with symptom limitation, chronic thrombotic obstruction, and a normal pulmonary hemodynamic profile is less clear. Cardiopulmonary exercise testing (CPET) stresses the cardiopulmonary system and has a characteristic response in pulmonary hypertension. CPET may therefore reveal abnormalities in patients with chronic thrombotic obstruction where hemodynamic investigations conducted at rest are reassuring. Using incremental CPET, we demonstrated improvements in right ventricular performance and ventilatory efficiency following pulmonary endarterecomy in a patient with preoperative exercise limitation and normal pulmonary hemodynamics. Careful evaluation of exercise responses may extend the potential benefit offered by pulmonary endarterectomy in patients with chronic thromboembolic obstruction irrespective of their resting hemodynamic profile.

Factors Affecting Stream Nutrient Loads: A Synthesis of Regional SPARROW Model Results for the Continental United States

We compared the results of 12 recently calibrated regional SPARROW (SPAtially Referenced Regressions On Watershed attributes) models covering most of the continental United States to evaluate the consistency and regional differences in factors affecting stream nutrient loads. The models - 6 for total nitrogen and 6 for total phosphorus - all provide similar levels of prediction accuracy, but those for major river basins in the eastern half of the country were somewhat more accurate. The models simulate long-term mean annual stream nutrient loads as a function of a wide range of known sources and climatic (precipitation, temperature), landscape (e.g., soils, geology), and aquatic factors affecting nutrient fate and transport. The results confirm the dominant effects of urban and agricultural sources on stream nutrient loads nationally and regionally, but reveal considerable spatial variability in the specific types of sources that control water quality. These include regional differences in the relative importance of different types of urban (municipal and industrial point vs. diffuse urban runoff) and agriculture (crop cultivation vs. animal waste) sources, as well as the effects of atmospheric deposition, mining, and background (e.g., soil phosphorus) sources on stream nutrients. Overall, we found that the SPARROW model results provide a consistent set of information for identifying the major sources and environmental factors affecting nutrient fate and transport in United States watersheds at regional and subregional scales.

The Regionalization of National-Scale SPARROW Models for Stream Nutrients

This analysis modifies the parsimonious specification of recently published total nitrogen (TN) and total phosphorus (TP) national-scale SPAtially Referenced Regressions On Watershed attributes models to allow each model coefficient to vary geographically among three major river basins of the conterminous United States. Regionalization of the national models reduces the standard errors in the prediction of TN and TP loads, expressed as a percentage of the predicted load, by about 6 and 7%. We develop and apply a method for combining national-scale and regional-scale information to estimate a hybrid model that imposes cross-region constraints that limit regional variation in model coefficients, effectively reducing the number of free model parameters as compared to a collection of independent regional models. The hybrid TN and TP regional models have improved model fit relative to the respective national models, reducing the standard error in the prediction of loads, expressed as a percentage of load, by about 5 and 4%. Only 19% of the TN hybrid model coefficients and just 2% of the TP hybrid model coefficients show evidence of substantial regional specificity (more than ±100% deviation from the national model estimate). The hybrid models have much greater precision in the estimated coefficients than do the unconstrained regional models, demonstrating the efficacy of pooling information across regions to improve regional models.

Cerebral amyloid angiopathy in the aetiology and immunotherapy of Alzheimer disease

Amyloid is deposited in the walls of arteries and capillaries as cerebral amyloid angiopathy (CAA) in the brains of older individuals and of those with Alzheimer disease (AD). CAA in AD reflects an age-related failure of elimination of amyloid-beta (Abeta) from the brain along perivascular lymphatic drainage pathways. In the absence of conventional lymphatic vessel in the brain, interstitial fluid and solutes drain from the brain to cervical lymph nodes along narrow basement membranes in the walls of capillaries and arteries, a pathway that is largely separate from the cerebrospinal fluid. In this review we focus on the pathology and pathogenesis of CAA, its role in the aetiology of AD and its impact on immunotherapy for AD. The motive force for lymphatic drainage of the brain appears to be generated by arterial pulsations. Failure of elimination of Abeta along perivascular pathways coincides with a reduction in enzymic degradation of Abeta, reduced absorption of Abeta into the blood and age-related stiffening of artery walls that appears to reduce the motive force for lymphatic drainage. Reduced clearances of Abeta and CAA are associated with the accumulation of insoluble and soluble Abetas in the brain in AD and the probable loss of homeostasis of the neuronal environment due to retention of soluble metabolites within the brain. Tau metabolism may also be affected. Immunotherapy has been successful in removing insoluble plaques of Abeta from the brain in AD but with little effect on cognitive decline. One major problem is the increase in CAA in immunised patients that probably prevents the complete removal of Abeta from the brain. Increased knowledge of the physiology and structural and genetic aspects of the lymphatic drainage of Abeta from the brain will stimulate the development of therapeutic strategies for the prevention and treatment of AD.

Geriatric surgery is about disease, not age

Maintaining life span and quality of life remains a valid aim of surgery in elderly people. Surgery can be an effective way of restoring both length and quality of life to older people. Minimally invasive techniques and surgery under local anaesthesia make fewer demands on geriatric physiology; given that co-morbidity is a stronger predictor of outcome from surgery than age, this is a significant consideration.

Effects of anticipatory stress on decision making in a gambling task

Recent research has highlighted the fact that emotion that is intrinsic to a task benefits decision making. The authors tested the converse hypothesis, that unrelated emotion disrupts decision making. Participants played the Iowa Gambling Task, during which only experimental participants anticipated giving a public speech (A. Bechara, D. Tranel, & H. Damasio, 2000). Experimental participants who were anticipating the speech learned the contingencies of the choices more slowly, and there was a gender interaction later in the game, with stressed female participants having more explicit knowledge and more advantageous performance and stressed male participants having poorer explicit knowledge and less advantageous performance. Effects of anticipatory stress on decision making are complex and depend on both the nature of the task and the individual.

Capillary and arterial cerebral amyloid angiopathy in Alzheimer's disease: defining the perivascular route for the elimination of amyloid beta from the human brain

Accumulation of amyloid beta (Abeta) in the extracellular spaces of the cerebral cortex and in blood vessel walls as cerebral amyloid angiopathy is a characteristic of Alzheimer's disease (AD) and the ageing human brain. Studies in animals suggest that Abeta is eliminated from the brain either directly into the blood or along perivascular interstitial fluid drainage channels. The aim of the present study is to define the perivascular route for the drainage of Abeta from the human brain. Smears and paraffin sections of post-mortem cortical tissue from 17 cases of AD and from two controls were stained with thioflavin and for Abeta by immunohistochemistry. Histology and confocal microscopy showed that deposits of Abeta in the cortical parenchyma were continuous with Abeta in capillary walls but Abeta in artery walls was not in continuity with Abeta in brain parenchyma. Quantitative studies supported these observations. The results of this study suggest that when Abeta is eliminated from the extracellular spaces of the human brain by the perivascular route, it enters pericapillary spaces and from there drains along the walls of cortical arteries to leptomeningeal arteries. Factors such as overproduction of Abeta, entrapment of Abeta in drainage pathways and poor drainage of Abeta due to functional changes in ageing arteries might result in the failure of elimination of Abeta from the ageing brain and play a major role in the pathogenesis of AD. Such factors might affect therapies for AD that entail administration of anti-Abeta antibodies to eliminate Abeta from the human brain.

A hydrologic network supporting spatially referenced regression modeling in the Chesapeake Bay Watershed

The U.S. Geological Survey has developed a methodology for statistically relating nutrient sources and land-surface characteristics to nutrient loads of streams. The methodology is referred to as SPAtially Referenced Regressions On Watershed attributes (SPARROW), and relates measured stream nutrient loads to nutrient sources using nonlinear statistical regression models. A spatially detailed digital hydrologic network of stream reaches, stream-reach characteristics such as mean streamflow, water velocity, reach length, and travel time, and their associated watersheds supports the regression models. This network serves as the primary framework for spatially referencing potential nutrient source information such as atmospheric deposition, septic systems, point-sources, land use, land cover, and agricultural sources and land-surface characteristics such as land use, land cover, average-annual precipitation and temperature, slope, and soil permeability. In the Chesapeake Bay watershed that covers parts of Delaware, Maryland, Pennsylvania, New York, Virginia, West Virginia, and Washington D.C., SPARROW was used to generate models estimating loads of total nitrogen and total phosphorus representing 1987 and 1992 land-surface conditions. The 1987 models used a hydrologic network derived from an enhanced version of the U.S. Environmental Protection Agency's digital River Reach File, and course resolution Digital Elevation Models (DEMs). A new hydrologic network was created to support the 1992 models by generating stream reaches representing surface-water pathways defined by flow direction and flow accumulation algorithms from higher resolution DEMs. On a reach-by-reach basis, stream reach characteristics essential to the modeling were transferred to the newly generated pathways or reaches from the enhanced River Reach File used to support the 1987 models. To complete the new network, watersheds for each reach were generated using the direction of surface-water flow derived from the DEMs. This network improves upon existing digital stream data by increasing the level of spatial detail and providing consistency between the reach locations and topography. The hydrologic network also aids in illustrating the spatial patterns of predicted nutrient loads and sources contributed locally to each stream, and the percentages of nutrient load that reach Chesapeake Bay.

Cerebrovascular disease is a major factor in the failure of elimination of Abeta from the aging human brain: implications for therapy of Alzheimer's disease

Alzheimer's disease (AD) is characterized by the intracellular deposition of ubiquitinated tau and by the extracellular accumulation of soluble, insoluble, and fibrillary Abeta. Previous studies suggest that Abeta is normally eliminated from the brain along perivascular pathways that may become blocked in the aging brain, resulting in cerebral amyloid angiopathy. As age is a major risk factor for AD and for cerebrovascular disease (CVD), we test the hypothesis that CVD inhibits the elimination of Abeta from the aging human brain. Sections from 100 aged and AD brains were stained for Abeta by immunohistochemistry and by reticulin and Masson trichrome techniques. Early deposition of Abeta in brain parenchyma was related to individual arterial territories in the cortex. In areas of more extensive accumulation of Abeta, there was an inverse relationship between capillary amyloid angiopathy and plaques of Abeta. Thus, arterial territories with extensive capillary amyloid angiopathy were devoid of Abeta plaques, whereas in areas with abundant diffuse plaques there was no capillary amyloid angiopathy. Serial sections showed that cortical arteries feeding capillary beds with Abeta angiopathy were occluded by thrombus. We conclude that CVD inhibits the elimination of Abeta along capillary walls and changes the distribution of Abeta in the cerebral cortex. Loss of pulsations in thrombosed or arteriosclerotic arteries may thus abolish the motive force necessary for the drainage of Abeta and inhibit the elimination of Abeta. Therapies to increase elimination of Abeta in AD need to consider the effects of CVD on the elimination of Abeta from the aging human brain.

Network 12 hepatitis B vaccination quality improvement program: an educational program directed at physicians, staff, and patients

Hepatitis B is easily spread via contact with infected blood. Hemodialysis patients and staff are particularly at risk for acquiring hepatitis B. Consequently, vaccination of hemodialysis patients and staff is strongly recommended. However, the vaccination rate among dialysis patients in this country remains below 50%. End-Stage Renal Disease (ESRD) Network 12 developed a quality improvement project directed at increasing patient vaccination by regular surveys, reports, and education of physicians, staff, and patients. Seventy-seven percent of facilities in the 4-state Network participated. Overall vaccination rate increased from 66.9% to 73.2% over 18 months (P <.05). The greatest improvement was seen among units with less than 60% of patients vaccinated initially, with mean facility vaccination rate increasing from 31.2 +/- 20.5% to 57.5 +/- 30.1% in the last available data period (P <.001). Only 3 of these 29 units failed to improve. The 90 units that had 60% to 97% vaccination rates initially improved significantly from 79.8 +/- 9.6% to 82.4 +/- 15% (P =.015). Three quarters of these units showed improvement. Only units with 100% vaccination deteriorated, but still maintained vaccination rates of 74.5 +/- 25.6%. An education-based quality improvement project can improve the hepatitis B vaccination rate of hemodialysis patients.

Heart rate responses to social interactions in free-moving rhesus macaques (Macaca mulatta): a pilot study

Heart rate telemetry was explored as a means to access animal emotion during social interactions under naturalistic conditions. Heart rates of 2 middle-ranking adult females living in a large group of rhesus macaques (Macaca mulatta) were recorded along with their behavior. Heart rate changes during 2 types of interactions were investigated, while controlling for the effects of posture and activity. The risk of aggression associated with the approach of a dominant individual was expected to provoke anxiety in the approachee. This prediction was supported by the heart rate increase after such an approach. No increase was found when the approacher was a kin or a subordinate individual. The tension-reduction function of allogrooming was also supported. Heart rate decelerated faster during the receipt of grooming than in matched control periods.

Strength, physical activity, and body mass index: relationship to performance-based measures and activities of daily living among older Japanese women in Hawaii

OBJECTIVES

Remaining strong, lean, and physically active may contribute to successful aging, both by maintaining function and by enabling more independent living. The study objective was to investigate this hypothesis among a long-lived population of older Japanese women.

DESIGN

A cross-sectional study.

SETTING

The island of Oahu, Hawaii.

PARTICIPANTS

A total of 705 community-dwelling women (mean age, 74; range, 55-93).

MEASUREMENTS

As outcomes, 7 physical performance measures including walking speed, the Get Up and Go test, chair stands, functional reach, and hand and foot reaction times, and 8 questions regarding activities of daily living (ADL). As possible predictors, physical activity, body mass index, and quadriceps, grip, and triceps strength.

RESULTS

In multivariable models, one or more of the strength tests was associated positively with six of the seven performance-based measures. Among the significant associations, 1-SD increases in strength were associated with 2 to 4% increases in performance compared with the sample mean. Physical activity was independently, and positively associated with the most complex of the tests, the Get Up and Go test. Body mass index (BMI), in contrast to strength and physical activity, was negatively associated with five of the seven performance tests. Among the significant associations, 1-SD increases in BMI were associated with 3 to 8% reductions in performance. In multivariable models strength was also associated positively with seven of the eight ADLs. In the same models, physical activity was positively associated with five and BMI was negatively associated with six of the ADLs.

CONCLUSION

The results suggest that remaining strong, lean, and physically active provided wide-ranging benefits for this population of older Japanese women.

Diagnosis of prostatic carcinoma: the yield of serum prostate specific antigen, digital rectal examination and transrectal ultrasonography

Three tests are commonly used to diagnose prostate carcinoma to date: serum prostate specific antigen (PSA), digital rectal examination and transrectal ultrasonography. We evaluated these 3 tests in 1,001, 6-sector prostate needle biopsies to rule out prostate carcinoma. Of the biopsies 253 (25.3%) revealed prostate cancer. As a single test, PSA was superior to digital rectal examination or transrectal ultrasonography in predicting cancer in this patient population using difference of proportions tests. Receiver operating characteristic analysis also showed PSA to be the superior test. The combinations of PSA plus transrectal ultrasonography and PSA plus digital rectal examination were superior to digital rectal examination plus transrectal ultrasonography. We found cancer in 35 of 188 patients (18.6%) with intermediate PSA levels of 4.1 to 10.0 ng./ml. and normal or asymmetric nonindurated rectal examinations. Only 5 of 79 patients (6.3%) with a normal digital rectal examination and PSA level of less than 4.0 ng./ml. demonstrated carcinoma on biopsy. Of the 5 patients 4 had annual increases in PSA of 40% or greater. While hypoechoic sectors were more than twice as likely as isoechoic sectors of the prostate to contain malignancy on biopsy, nearly 37.6% of the cancers were found in isoechoic sectors. A strategy of performing biopsy of only hypoechoic sectors would have misdiagnosed 24.6% of the patients with prostate cancer. We conclude that serum PSA is the most accurate of the 3 diagnostic tests evaluated. We also recommend a systematic sextant biopsy technique.

Predictors of pathologic stage in prostatic carcinoma. The role of neovascularity

BACKGROUND

Prostate adenocarcinoma is a significant cause of morbidity and mortality in older men. However, the histologic prevalence far exceeds clinically manifest disease. Increased screening has resulted in the detection of a large number of carcinomas of unknown malignant potential. The authors investigated tumor angiogenesis to predict pathologic stage in prostatic tumors. Angiogenesis in prostatic intraepithelial neoplasia (PIN), a putative premalignant lesion, also was investigated.

METHODS

Immunohistochemistry was used to highlight the tumor vasculature. Vessels were quantified using computerized image analysis. A minimum of five randomly selected microscopic fields were measured from each tumor. To investigate PIN, the authors measured vessels per millimeter of gland perimeter, compared with benign glands in the same patient.

RESULTS

Vessel density (vessels per millimeter squared [vv/mm2]) correlated with pathologic stage. The mean vessel density of organ-confined tumors was 80.2 vv/mm2 (95% confidence interval [CI], 71.4-91.0), compared with 110.4 vv/mm2 (95% CI, 97.9-122.8) for tumors with capsular penetration or positive lymph nodes. Logistic regression analysis and modeling showed vessel density superior to histologic grade and preoperative prostate-specific antigen (PSA) level in distinguishing organ-confined tumors from those having extracapsular extension or pelvic lymph node metastasis. PIN in acini and ductules had increased microvascularity relative to benign epithelium in 18 of 25 tumors (P < 0.05).

CONCLUSIONS

Neovascularity has been demonstrated to be a prerequisite for tumor progression. These data demonstrate that microvessel density in prostatic carcinoma is an independent predictor of pathologic stage and, presumably, malignant potential. Quantification of tumor angiogenesis may allow stratification of patients to type of treatment and may allow selection of expectant management for men with low tumor microvessel density.

Predictors of pathologic stage in prostatic carcinoma. The role of neovascularity

BACKGROUND

Prostate adenocarcinoma is a significant cause of morbidity and mortality in older men. However, the histologic prevalence far exceeds clinically manifest disease. Increased screening has resulted in the detection of a large number of carcinomas of unknown malignant potential. The authors investigated tumor angiogenesis to predict pathologic stage in prostatic tumors. Angiogenesis in prostatic intraepithelial neoplasia (PIN), a putative premalignant lesion, also was investigated.

METHODS

Immunohistochemistry was used to highlight the tumor vasculature. Vessels were quantified using computerized image analysis. A minimum of five randomly selected microscopic fields were measured from each tumor. To investigate PIN, the authors measured vessels per millimeter of gland perimeter, compared with benign glands in the same patient.

RESULTS

Vessel density (vessels per millimeter squared [vv/mm2]) correlated with pathologic stage. The mean vessel density of organ-confined tumors was 80.2 vv/mm2 (95% confidence interval [CI], 71.4-91.0), compared with 110.4 vv/mm2 (95% CI, 97.9-122.8) for tumors with capsular penetration or positive lymph nodes. Logistic regression analysis and modeling showed vessel density superior to histologic grade and preoperative prostate-specific antigen (PSA) level in distinguishing organ-confined tumors from those having extracapsular extension or pelvic lymph node metastasis. PIN in acini and ductules had increased microvascularity relative to benign epithelium in 18 of 25 tumors (P < 0.05).

CONCLUSIONS

Neovascularity has been demonstrated to be a prerequisite for tumor progression. These data demonstrate that microvessel density in prostatic carcinoma is an independent predictor of pathologic stage and, presumably, malignant potential. Quantification of tumor angiogenesis may allow stratification of patients to type of treatment and may allow selection of expectant management for men with low tumor microvessel density.

The inability of prostate specific antigen index to enhance the predictive the value of prostate specific antigen in the diagnosis of prostatic carcinoma

The prostate specific antigen (PSA) level has become an important but imperfect means of detecting prostatic carcinoma. PSA index (serum PSA normalized to estimated gland volume) has been suggested to improve the performance characteristics of PSA alone. In an attempt to confirm this observation, we compared serum PSA alone to the PSA index in 218 men undergoing systematic random prostatic needle biopsy. Total gland PSA index as well as nontransition zone PSA index were calculated using several constants for the estimated contribution to the serum PSA from the transition zone. The Mann-Whitney nonparametric analysis was performed to account for differences in variances within the data set. For the patient population as a whole, all methods of testing were approximately equivalent in the ability to provide a statistically significant (p < 0.01) stratification between patients with benign and malignant biopsies. In patients with a serum PSA level of 4.1 to 10.0 ng./ml. none of the tests was able to distinguish those with carcinoma from those with a benign biopsy. In men with a normal prostate on digital rectal examination serum PSA was superior to other tests in predicting biopsy results. We conclude that PSA index does not enhance the ability of serum PSA alone to predict the presence of carcinoma.

Screening for prostatic carcinoma with prostate specific antigen: results of the second year

Prostate specific antigen (PSA) has been shown to be useful alone and in conjunction with other tests in the diagnosis of prostatic carcinoma. Previously, we demonstrated that a PSA level of greater than 4.0 ng./ml. as the initial diagnostic test in a screening population results in a detection rate of 2.6 and positive predictive value of 30.5. In the present investigation we performed digital rectal examination and transrectal ultrasound as well as ultrasound guided biopsy in men who in the initial year of the screening study had a PSA level of less than 4.0 ng./ml. but on evaluation 1 year later they had a 20% increase in the PSA level. A total of 701 subjects returned for year 2 of the protocol and 260 (37.1%) demonstrated more than a 20% increase in PSA value. Biopsy was performed in 82 men and carcinoma was detected in 14 (17.1%). Of the men with carcinoma 12 had a second year PSA level of less than 4.0 ng./ml. Radical prostatectomy was performed in 8 patients, 7 of whom had organ confined disease or tumor penetrating the capsule with negative margins. We conclude that a 20% annual change in PSA level may identify men at significant risk for prostatic carcinoma and that patients so identified have favorable pathological stage.