Early surveillance of anthracycline induced cardiotoxicity in children using echocardiography and biomarkers: A prospective study

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): CIHR

Background

Anthracyclines, which are commonly used in cancer treatment can induce myocardial damage, result in heart failure during treatment and have cardiac effects even decades after treatment. Monitoring of cardiotoxicity during treatment is largely based on the use of echocardiographic functional markers like ejection fraction and more recently myocardial strain imaging. Some studies have also looked at the utility of biomarkers like troponin and BNP. The utility of this surveillance strategy remains controversial as larger prospective studies are lacking.

Purpose

The aim of this study was to prospectively describe the impact of anthracycline treatment on echocardiographic functional parameters and cardiac biomarkers (high sensitivity troponin T and NT-Pro BNP) during the treatment period and twelve months after completion of treatment. In the current study we wanted to look at whether monitoring parameters during treatment were predictive of left ventricular function 12 months after treatment.

Methods

This was a prospective multi-centre nested case-control study of 256 children diagnosed with cancer requiring anthracycline therapy. Baseline functional echocardiographic parameters  and cardiac biomarkers were obtained prior to starting anthracycline therapy, during the treatment protocol, and 12 months after treatment completion. Patients were assigned to one of two comparison groups based on the fractional shortening at the12-month echocardiogram: patients in group 1 had normal fractional shortening, (FS ³ 28%) while patients in group 2 had reduced fractional shortening (FS < 28%).

Results

A total of 917 echoes were performed, 376 of these occurred during the treatment period. FS was reduced in 27 (7%) of echoes obtained during the treatment period with 22 patients developing new onset dysfunction. Twelve months after treatment completion 232 patients had normal FS (Group 1), while 24 patients showed reduced FS (Group 2). Both groups had normal systolic function and cardiac biomarkers at baseline, however patients in group 2 were older at diagnosis (13.2 years (11.8-16) vs 6.5 years (3.4-13.2), p = 0.003) and received a higher cumulative anthracycline dose (200 mg/m2 (143-318) vs 125 mg/m2 (75-200), p= 0.005). One third (8/24) of patients in group 2 had at least 1 abnormal echo during the treatment period compared to 7% (16/232) in the normal group P < 0.001. The proportion of patients with at least one abnormal biomarker during this period however, was similar between groups.

 Conclusion(s)

Patients receiving higher accumulative anthracycline doses and those with abnormal FS during the treatment period are at higher risk of having reduced cardiac function 12 months after treatment. High sensitivity troponin and NT-Pro BNP levels during the treatment period fail to discriminate patients at risk of developing early reduced systolic function. The relationship of these early results to long term cardiac function remains to be demonstrated.

1159 Right ventricular electromechanical dyssynchrony in relation to right ventricular remodeling, dysfunction and exercise capacity in Ebstein anomaly

Background

Abnormal atrioventricular conduction and functional right ventricular (fRV) dysfunction are common in patients with Ebstein anomaly (EA). However, the relation of fRV dyssynchrony to fRV function in EA has not been studied.

Purpose

We hypothesized that fRV electromechanical dyssynchrony is associated with fRV remodeling, dysfunction and exercise intolerance in EA patients.

Methods

Non-operated EA patients and age-matched controls prospectively underwent echocardiography, cardiovascular magnetic resonance imaging (CMR) and cardiopulmonary exercise testing to quantify RV remodeling, dysfunction and exercise capacity, respectively. The relation of these to fRV dyssynchrony was investigated. RV mechanical dyssynchrony was defined by early septal activation (right-sided septal flash), RV lateral wall prestretch/late contraction, postsystolic shortening, and the maximal intra-RV delay (difference in time to peak of lateral basal RV and apical septal segments) using 2-dimensional strain echocardiography.

Results

Thirty-five EA patients (age 31.6 ± 17.3 years, 19 female) and 35 age-matched controls were studied. QRS duration and intra-fRV mechanical delay were significantly longer in EA compared with controls. 19/35(54%) of EA patients had early activation of septal segments with simultaneous stretching and consequent late activation and post-systolic shortening of RV lateral segments. QRS duration correlated with fRV end-diastolic (fRVEDVI, r = 0.46, P <0.01) and end-systolic indexed volumes (fRVESVIr = 0.57, P <0.001). Intra-fRV delay correlated with RV global longitudinal strain (GLS, r=-0.45,P <0.05) and RV fractional area change (r=-0.56, P <0.01). Intra-fRV delay was also associated with fRVEDVI (r = 0.43, P <0.05), fRVESVI (r = 0.63, P <0.001), fRVEF (r=-0.46,P <0.05) and predicted peak VO2 (r=-0.39, P < 0.05). EA patients with versus without a septal flash had lower fRVEF (45 ± 11 vs. 54 ± 8%, p < 0.05) and predicted peak VO2 (0.71 ± 0.19 vs. 0.92 ± 0.33, p < 0.05).

Conclusions

In EA, fRV electromechanical dyssynchrony is associated with fRV remodeling, dysfunction and impaired exercise capacity and may constitute a therapeutic target.

Abstract 1159 Figure.

546 Machine-learning based exploration of echocardiographic patterns and clinical parameters to understand their relation to death or transplant in pediatric dilated cardiomyopathy

Background

Pediatric dilated cardiomyopathy (DCM) affects left ventricular (LV) function and carries a high risk of death or heart transplantation. However, the relation of LV regional function and inefficiency to clinical outcomes is underexplored.

Purpose

The aim of this study was to understand the relationship of regional LV mechanics, global LV function and clinical characteristics to the outcomes of death or heart transplant in children with DCM; through the integration of a vast amount of information enabled by unsupervised machine learning techniques.

Methods

DCM was defined by a LV end-diastolic dimension z-score > 2 and LV ejection fraction (EF) <55%. Longitudinal strain curves were sampled at 6 LV lateral wall and septal locations from the 4ch apical view. In addition, we analyzed other echo parameters including the aortic outflow pattern as a measure of LV pump function, QRS duration, LV EF, indexed end-diastolic LV dimension, global longitudinal strain and patient characteristics including age, weight, body surface area and medications (diuretics, ACE inhibitor, beta-blockers, mineralocorticoid receptor antagonist, digoxin, inotropes, antiarrhythmics). We used an unsupervised machine learning algorithm (multiple kernel learning) to reduce the dimensionality of these data, and position patients based on similarities. We subsequently used k-means clustering to recover homogeneous groups of patients. We then interpreted the data patterns associated to each of the groups for the occurrence of death or transplant through non-linear regression analysis (multi-scale kernel regression).

Results

50 children with DCM (age 0 to 18 years) were analyzed. Clustering on the two first dimensions of the low-dimensional space resulted in three clusters (Figure A), with significantly different proportions of the composite outcome of death or heart transplant (Cl1 = 79%, Cl2 = 50%, Cl3 = 20%; p = 0.01). The group with the highest proportion of death or transplant (cluster 1) comprised the oldest and most frequently medicated subjects, with impaired LVEF and GLS, and with the widest QRS duration (p < 0.01) (Figure B). The group with the second highest proportion of death or transplant (cluster 2) comprised patients with the lowest LVEF (p < 0.01) and GLS (p < 0.001), reduced and delayed peak aortic outflow velocity and severely impaired basal and apical LV strain (Figure C). In contrast, the group with highest transplant-free survival (cluster 3) had the highest LVEF and GLS values, the most synchronous LV contraction as assessed by strain and QRS duration and the highest amplitude and earliest peaking aortic flow.

Conclusion

Our results serve as a proof-of-concept that machine-learning based approaches can be useful to explore and understand which regional and global echo parameters in combination with clinical parameters are associated with a higher risk of death or transplant in pediatric DCM.

Abstract 546 Figure

Detection of hepatitis E virus genotypes 3 and 4 in donkeys in northern China

BACKGROUND

Hepatitis E virus (HEV) is the causative agent of acute self-limiting hepatitis in humans in developing countries. Hepatitis E virus RNA was first detected in donkeys in Spain, but little is known about the possible presence of HEV in donkeys in China.

OBJECTIVES

To investigate the prevalence of HEV in donkeys in northern China.

STUDY DESIGN

Investigation of the prevalence of HEV in donkeys using serological, molecular and phylogenetic approaches.

METHODS

A total of 401 donkey serum specimens were tested for serological and molecular detection of HEV via enzyme-linked immunosorbent assay and quantitative reverse transcription polymerase chain reaction. The amplified products were cloned in pMD18-T vector and sequenced. The alignment and phylogenetic analysis of partial HEV ORF2 genes were compared with the corresponding sequences of the obtained HEV representative strains.

RESULTS

Serological results showed that 49 donkeys (12.22%, 95% CI: 9.18-15.83%) were positive for anti-HEV-specific antibodies, and 17 donkeys (4.24%, 95% CI: 2.49-6.70%) were positive for HEV viral RNA. On the basis of sequence alignment and phylogenetic analysis, all isolated HEV strains belonged to genotype 3 (HEV-3) or HEV-4, sharing more than 76.2-96.3% identities with 67 other HEV representative strains of HEV-1 to HEV-8.

MAIN LIMITATIONS

Further studies about the prevalence of HEV in organs or faecal samples from donkeys are needed to evaluate the possible role of HEV reservoir and to determine the risk factors associated with the transmission of this zoonotic virus in donkeys in China.

CONCLUSIONS

This is the first report documenting the molecular analysis of donkey HEV strains worldwide and the serological evidence of HEV infection in donkeys in northern China. The results suggest that young donkeys are more susceptible to HEV infection compared with older donkeys. Further investigation is required to determine whether donkeys should be considered reservoirs for zoonotic HEV. The Summary is available in Chinese - see Supporting information.

1471. Medical Claims Analysis as a Tool to Evaluate Empiric and Targeted Antibiotic Therapy in UTIs

Background

Methods

Results

Conclusion

Disclosures

Quality improvement strategies to prevent falls in older adults: a systematic review and network meta-analysis

BACKGROUND

Falls are a common occurrence and the most effective quality improvement (QI) strategies remain unclear.

METHODS

We conducted a systematic review and network meta-analysis (NMA) to elucidate effective quality improvement (QI) strategies for falls prevention. Multiple databases were searched (inception-April 2017). We included randomised controlled trials (RCTs) of falls prevention QI strategies for participants aged ≥65 years. Two investigators screened titles and abstracts, full-text articles, conducted data abstraction and appraised risk of bias independently.

RESULTS

A total of 126 RCTs including 84,307 participants were included after screening 10,650 titles and abstracts and 1210 full-text articles. NMA including 29 RCTs and 26,326 patients found that team changes was statistically superior in reducing the risk of injurious falls relative to usual care (odds ratio [OR] 0.57 [0.33 to 0.99]; absolute risk difference [ARD] -0.11 [95% CI, -0.18 to -0.002]). NMA for the outcome of number of fallers including 61 RCTs and 40 128 patients found that combined case management, patient reminders and staff education (OR 0.18 [0.07 to 0.47]; ARD -0.27 [95% CI, -0.33 to -0.15]) and combined case management and patient reminders (OR, 0.36 [0.13 to 0.97]; ARD -0.19 [95% CI, -0.30 to -0.01]) were both statistically superior compared to usual care.

CONCLUSIONS

Team changes may reduce risk of injurious falls and a combination of case management, patient reminders, and staff education, as well as case management and patient reminders may reduce risk of falls. Our results can be tailored to decision-maker preferences and availability of resources.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO (CRD42013004151).

Comparisons of Interventions for Preventing Falls in Older Adults: A Systematic Review and Meta-analysis

IMPORTANCE

Falls result in substantial burden for patients and health care systems, and given the aging of the population worldwide, the incidence of falls continues to rise.

OBJECTIVE

To assess the potential effectiveness of interventions for preventing falls.

DATA SOURCES

MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Ageline databases from inception until April 2017. Reference lists of included studies were scanned.

STUDY SELECTION

Randomized clinical trials (RCTs) of fall-prevention interventions for participants aged 65 years and older.

DATA EXTRACTION AND SYNTHESIS

Pairs of reviewers independently screened the studies, abstracted data, and appraised risk of bias. Pairwise meta-analysis and network meta-analysis were conducted.

MAIN OUTCOMES AND MEASURES

Injurious falls and fall-related hospitalizations.

RESULTS

A total of 283 RCTs (159 910 participants; mean age, 78.1 years; 74% women) were included after screening of 10 650 titles and abstracts and 1210 full-text articles. Network meta-analysis (including 54 RCTs, 41 596 participants, 39 interventions plus usual care) suggested that the following interventions, when compared with usual care, were associated with reductions in injurious falls: exercise (odds ratio [OR], 0.51 [95% CI, 0.33 to 0.79]; absolute risk difference [ARD], -0.67 [95% CI, -1.10 to -0.24]); combined exercise and vision assessment and treatment (OR, 0.17 [95% CI, 0.07 to 0.38]; ARD, -1.79 [95% CI, -2.63 to -0.96]); combined exercise, vision assessment and treatment, and environmental assessment and modification (OR, 0.30 [95% CI, 0.13 to 0.70]; ARD, -1.19 [95% CI, -2.04 to -0.35]); and combined clinic-level quality improvement strategies (eg, case management), multifactorial assessment and treatment (eg, comprehensive geriatric assessment), calcium supplementation, and vitamin D supplementation (OR, 0.12 [95% CI, 0.03 to 0.55]; ARD, -2.08 [95% CI, -3.56 to -0.60]). Pairwise meta-analyses for fall-related hospitalizations (2 RCTs; 516 participants) showed no significant association between combined clinic- and patient-level quality improvement strategies and multifactorial assessment and treatment relative to usual care (OR, 0.78 [95% CI, 0.33 to 1.81]).

CONCLUSIONS AND RELEVANCE

Exercise alone and various combinations of interventions were associated with lower risk of injurious falls compared with usual care. Choice of fall-prevention intervention may depend on patient and caregiver values and preferences.

A scoping review identifies multiple emerging knowledge synthesis methods, but few studies operationalize the method

OBJECTIVES

To systematically identify, define, and classify emerging knowledge synthesis methods through a scoping review.

STUDY DESIGN AND SETTING

MEDLINE, CINAHL, EMBASE, PsycINFO, the Cochrane Methodology Register, the Cochrane Database of Systematic Reviews, Social Sciences Abstracts, Library and Information Science Abstracts, Philosopher's Index, and Education Resources Information Center were searched to identify articles reporting emerging knowledge synthesis methods across the disciplines of health, education, sociology, and philosophy. Two reviewers independently selected studies and abstracted data for each article.

RESULTS

In total, 409 articles reporting on 25 knowledge synthesis methods were included after screening of 17,962 titles and abstracts and 1,010 potentially relevant full-text articles. Most of the included articles were an application of the method (83.9%); only 3.7% were seminal articles that fully described the method (i.e., operationalized the steps). Most of the included articles were published after 2005. The methods were most commonly used across the fields of nursing, health care science and services, and health policy.

CONCLUSION

We found a lack of guidance on how to select a knowledge synthesis method. We propose convening an international group of leaders in the knowledge synthesis field to help clarify emerging approaches to knowledge synthesis.

Seeking effective interventions to treat complex wounds: an overview of systematic reviews

BACKGROUND

Numerous, often multi-faceted regimens are available for treating complex wounds, yet the evidence of these interventions is recondite across the literature. We aimed to identify effective interventions to treat complex wounds through an overview of systematic reviews.

METHODS

MEDLINE (OVID interface, 1946 until October 26, 2012), EMBASE (OVID interface, 1947 until October 26, 2012), and the Cochrane Database of Systematic Reviews (Issue 10 of 12, 2012) were searched on October 26, 2012. Systematic reviews that examined adults receiving care for their complex wounds were included. Two reviewers independently screened the literature, abstracted data, and assessed study quality using the Assessment of Multiple Systematic Reviews (AMSTAR) tool.

RESULTS

Overall, 99 systematic reviews were included after screening 6,200 titles and abstracts and 422 full-texts; 54 were systematic reviews with a meta-analysis (including data on over 54,000 patients) and 45 were systematic reviews without a meta-analysis. Overall, 44% of included reviews were rated as being of high quality (AMSTAR score ≥ 8). Based on data from systematic reviews including a meta-analysis with an AMSTAR score ≥ 8, promising interventions for complex wounds were identified. These included bandages or stockings (multi-layer, high compression) and wound cleansing for venous leg ulcers; four-layer bandages for mixed arterial/venous leg ulcers; biologics, ultrasound, and hydrogel dressings for diabetic leg/foot ulcers; hydrocolloid dressings, electrotherapy, air-fluidized beds, and alternate foam mattresses for pressure ulcers; and silver dressings and ultrasound for unspecified mixed complex wounds. For surgical wound infections, topical negative pressure and vacuum-assisted closure were promising interventions, but this was based on evidence from moderate to low quality systematic reviews.

CONCLUSIONS

Numerous interventions can be utilized for patients with varying types of complex wounds, yet few treatments were consistently effective across all outcomes throughout the literature. Clinicians and patients can use our results to tailor effective treatment according to type of complex wound. Network meta-analysis will be of benefit to decision-makers, as it will permit multiple treatment comparisons and ranking of the effectiveness of all interventions. Please see related article: http://dx.doi.org/10.1186/s12916-015-0326-3.

Expression and significance of SATB1 in the development of breast cancer

Special AT-rich sequence binding protein 1 (SATB1) is a recently discovered gene regulator that can promote the growth and metastasis of breast cancer. However, its expression in different stages of breast cancer development have not been examined. We explored the role of SATB1 in the development of breast cancer by detecting SATB1 expression levels in different stages of breast cancer. SATB1 expression was determined using an immunohistochemical streptavidin peroxidase method; the relationship between clinicopathological features of breast cancer and SATB1 expression was analyzed using the X(2) test. Positive rates of SATB1 protein in normal breast tissue, normal breast ductal hyperplasia tissue, precancerous lesions of breast cancer, non-invasive cancer, early invasive carcinoma, and invasive breast cancer tissue were, respectively, 6.25 (2/32), 6.4 (3/47), 20.4 (10/49), 45.0 (9/20), 52.9 (9/17), and 76.6% (72/94). SATB1 in the latter 3 groups was significantly higher than in the first 3 groups (P < 0.05). The positive rate of SATB1 protein in invasive non-special types of breast cancer (88.5%, 54/61) was significantly higher than in the special type of invasive breast cancer (54.5%, 18/33) and early invasive breast cancer (52.9%, 9/17) (P < 0.05). SATB1 protein expression in breast cancer with lymph node metastasis was generally increased, and the difference was statistically significant (P < 0.05). SATB1 protein expression showed an increasing trend in different stages of breast cancer development. Overexpression indicated poor prognosis.

Interventions to decrease the risk of adverse cardiac events for patients receiving chemotherapy and serotonin (5-HT3) receptor antagonists: a systematic review

Background

Patients may experience nausea and vomiting when undergoing chemotherapy or surgery requiring anesthesia. Serotonin 5-hydroxytryptamine 3 (5-HT3) receptor antagonists are effective antiemetics, yet may cause adverse cardiac events, such as arrhythmia. We aimed to identify interventions that mitigate the cardiac risk of 5-HT3 receptor antagonists.

Methods

Electronic databases, trial registries, and references were searched. Studies on patients undergoing chemotherapy or surgery examining interventions to monitor cardiac risk of 5-HT3 receptor antagonists were included. Search results were screened and data from relevant studies were abstracted in duplicate. Risk of bias of included studies was assessed using the Cochrane Effective Practice and Organisation of Care (EPOC) group’s risk-of-bias tool. Due to a dearth of included studies, meta-analysis was not conducted.

Results

Two randomized clinical trials (RCT) and 1 non-randomized clinical trial (NRCT) were included after screening 7,637 titles and abstracts and 1,554 full-text articles. Intravenous administration of different dolasetron doses was examined in the NRCT, while dolasetron versus ondansetron and palonosetron versus ondansetron were examined in the RCT. Electrocardiogram (ECG) was the only intervention examined to mitigate cardiac harm. No differences in ECG evaluations were observed between dolasetron or palonosetron versus ondansetron after 15 minutes, 24 hours, and 1 week post-administration in the 2 RCTs. Four deaths were observed in one RCT, which were deemed unrelated to palonosetron or ondansetron administration. Minor increases in PR and QT intervals were observed in the NRCT for dolasetron dosages greater than 1.2 mg/kg 1–2 hours post-administration, but were deemed not clinically relevant.

Conclusions

ECG monitoring of chemotherapy patients administered with 5-HT3 receptor antagonists did not reveal clinically significant differences in arrhythmia between the medications at the examined time periods. The usefulness of ECG to monitor chemotherapy patients administered with 5-HT3 receptor antagonists remains unclear, as all patients received ECG monitoring.

Trial registration

PROSPERO registry number: CRD42013003565

Electronic supplementary material

The online version of this article (doi:10.1186/2050-6511-16-1) contains supplementary material, which is available to authorized users.

Application value of ICU nursing scoring system in nurse allocation

AIM

The aim of this paper was to investigate the application value of the intensive care nursing scoring system (ICNSS) in intensive care unit (ICU) nursing resources allocation.

METHODS

The English version of ICNSS scale was translated into Chinese by nursing experts, and was consistently revised and improved based on China's actual conditions. A total of 105 cases were randomly divided into the observation group (N.=55) and the control group (N.=50). In the observation group, the nursing workload was estimated and the nurses were allocated using ICNSS; in the control group, the sickbeds were equally distributed to the nurses and each nurse was equally in charge of managing patients. The ICU duration, medical charge, incidence of complications, nursing quality control scoring and nurses' satisfaction to their resource allocations were compared between the two groups.

RESULTS

The ICU duration, medical charge and incidence of complications in the observation group were significantly lower than those in the control group (P=0.032, P=0.024, P=0.006 respectively); while quality control scoring and nurses' satisfaction to their resources allocation in the observation group were significantly higher than those in the control group (P=0.045, P=0.004 respectively).

CONCLUSION

The nursing quality and the nurses' satisfaction could be improved using ICNSS to evaluate ICU nursing workload and allocate resources.

The association of antihypertensive medication use with risk of cognitive decline and dementia: a meta-analysis of longitudinal studies

The association of antihypertensive medication use with cognitive decline (including mild cognitive impairment) or dementia (including Alzheimer's disease (AD), vascular dementia (VD) and any dementia) has still been an area of controversy. This study examined the association of antihypertensive medication use with cognitive decline or dementia using a quantitative meta-analysis of longitudinal studies. EMBASE and MEDLINE were searched for articles published up to Feb 2011. All studies that examined the relationship between antihypertensive medication use and the incidence of dementia or cognitive decline were included. Pooled relative risk (RR) was calculated using fixed and random-effects models. Fourteen studies met our inclusion criteria for this meta-analysis. All subjects were without dementia or cognitive impairment at baseline. There were subjects with (32,658) and without (36,905) antihypertensive medication use. The quantitative meta-analysis showed that there was no significant difference in incidence of AD (RR: 0.90, 95% confidence interval (CI): 0.79-1.03), cognitive decline (RR: 0.97; 95% CI: 0.92-1.03) and cognitive impairment (RR: 0.97; 95% CI: 0.92-1.03). The quantitative meta-analysis showed that the subjects with antihypertensive medication use were lower incidence of VD (RR: 0.67, 95% CI: 0.52-0.87) and any dementia (RR: 0.87; 95% CI: 0.77-0.96) than those without. The quantitative meta-analysis showed that antihypertensive medication use could decrease risk of the development of VD and any dementia, but could not decrease that of AD, cognitive decline and cognitive impairment.

Incidence and management of bevacizumab associated hypertension in outpatient oncology clinic

e20677

Background: Bevacizumab, a vascular endothelial growth factor (VEGF) inhibitor is utilized to treat a wide range of cancers. However, clinical trials of bevacizumab reported the incidence of hypertension (HTN) up to 36%. A national guideline has not been established to manage bevacizumab-induced HTN. The incidence and management of bevacizumab associated HTN were evaluated in an outpatient oncology clinic. Methods: A randomized, retrospective chart review of 100 patients who received at least one dose of bevacizumab from 1/1/07 to 12/31/07 was conducted. The overall incidence and management of hypertension were evaluated. Other bevacizumab associated toxicities were compared in patients with or without hypertension. Results: The overall incidence of bevacizumab-induced HTN was 31% (95%CI: 22%-40%) with CTC (v 3.0) grade 3 HTN rate of 10%. The number of patients with a history of HTN or uncontrolled BP prior to bevacizumab therapy was significantly different across the four HTN grade groups (p= 0.0019). Out of 31 patients who had grade 1–3 HTN, 8 patients (26%) were managed by the oncologists, 8 patients (26%) by the primary care physicians, and 15 patients (48%) had no management. Bevacizumab was held in 3 patients due to high blood pressure (BP) resulting in one patient discontinuing bevacizumab therapy. The odds of other bevacizumab associated adverse events in patients with grades 1–3 HTN was 2.776 times than that of patients with grade 0 HTN (p=0.0201). Conclusions: Bevacizumab was associated with HTN in 31% of patients. Patients with history of HTN or uncontrolled BP prior to initiating bevacizumab were at an increased risk to develop a higher grade of HTN. Management of bevacizumab-induced HTN could be improved since BP of 63% of patients with grades 2 and 3 HTN was not adequately controlled.

No significant financial relationships to disclose.

Differential Toll-like receptor-dependent collagenase expression in chondrocytes

OBJECTIVES

To characterise the catabolic response of osteoarthritic chondrocytes to Toll-like receptor (TLR) ligands.

METHODS

Induction of the collagenases, matrix metalloproteinase (MMP)1 and MMP13, by TLR ligands was assessed in chondrocytes by real-time reverse transcriptase (RT)-PCR. TLR signalling pathway activation and their involvement in collagenase induction were confirmed by immunoblotting and use of pathway inhibitors and siRNA. TLR expression was compared in the femoral head cartilage of normal controls and patients with osteoarthritis (OA) by real-time RT-PCR.

RESULTS

Ligands for TLR6/2 and TLR3 showed the greatest upregulation of MMP1 and MMP13 respectively, although all TLR ligands upregulated these MMPs. MMP1 and MMP13 induction by TLR3 and TLR1/2 or TLR6/2 ligands were dependent on Trif and MyD88, respectively. These inductions were dependent upon the nuclear factor (NF)kappaB pathway, but were differentially inhibited by various mitogen-activated protein kinase inhibitors, with MMP13 induction most reliant on the extracellular signal-regulated kinase pathway. In addition, ligands for TLR1/2 and TLR6/2, but not TLR3, induced significant collagenolysis in a cartilage resorption assay. Finally, TLR2 was significantly downregulated and TLR3 upregulated in OA, compared to normal, cartilage.

CONCLUSIONS

Activation of chondrocyte TLRs leads to differential collagenase gene activation. Treatment of chondrocytes with TLR1/2 or TLR6/2 ligands resulted in collagen resorption. The modulated expression of chondrocyte TLR2 and TLR3 in OA cartilage, compared to normal, may reflect a response to repair cartilage or prevent further extracellular matrix destruction. These data suggest modulation of TLR-mediated signalling as a potential therapeutic strategy for the treatment of OA.

Androgen activates PEG10 to promote carcinogenesis in hepatic cancer cells

The molecular mechanism of striking higher prevalence of hepatocellular carcinoma (HCC) in male subjects has not yet been fully elucidated. Here, we report that androgen receptor (AR) is differentially expressed in different HCC cell lines. AR agonist dihydrotestosterone (DHT) enhances HCC cell growth and apoptotic resistance. Antagonist flutamide (FLU) blocks the effects of DHT on the HCC cell lines. Paternally expressed gene 10 (PEG10) is expressed in HCC cell lines at substantial high level. Using small interfering RNAs against AR and PEG10 in AR- and PEG10-expressing BEL-7404 hepatoma cells and HuH7 hepatoma cells (HuH7) cells, and AR-transfection technique in AR-lacking and PEG10-expressing HepG2 cells, we have confirmed that through upregulation and activation of PEG10, DHT enhances HCC cell growth and apoptotic resistance. We have further demonstrated that DHT upregulates expression of human telomerase reverse transcriptase (hTERT) in HCC cell lines in a PEG10-dependent manner. Moreover, AR directly interacts in vivo with androgen-responsive elements in the regions of promoter and exon 2 of PEG10 gene in HCC cell lines. DHT promotes the hepatoma formation in vivo nude mice through PEG10 activation. AR antagonists (FLU and valproate) inhibit the hepatoma formation. These findings suggest that PEG10 plays an essential role in hepatocarcinogenesis. The PEG10 inhibition can be a novel approach for therapy of HCC.

Pulmonary and caval blood flow patterns in patients with intracardiac and extracardiac Fontan: a magnetic resonance study

AIMS

We compared in vivo blood flow and pulsatility after different types of Fontan operation using magnetic resonance imaging.

MATERIAL AND METHODS

A total of 37 consecutive patients (mean age 19+/-7.9 years, 7.3+/-3.2 years after Fontan operation), 7 with atriopulmonary anastomosis (APC), 18 with intra-atrial lateral tunnel (LTFO) and 12 with extracardiac Fontan (ECFO) were studied using magnetic resonance phase-contrast velocity mapping. Blood flow (volume flow) in the superior vena cava (SVC), inferior vena cava (IVC) and both pulmonary arteries were measured and a pulsatility index was calculated for each vessel.

RESULTS

For all modifications, the blood flow distribution between the SVC and IVC was normal (1:2). Patients with APC had a normal pulsatility, a dilated right atrium, partial backward flow in the IVC and physiological blood flow distribution between the pulmonary arteries. LTFO and ECFO patients had no retrograde flow in the IVC, equal blood flow distribution between the pulmonary arteries and very low or absent pulsatility.

CONCLUSIONS

MRI allows hemodynamic quantification and characterization of various types of Fontan modifications and may be a valuable tool to predict Fontan failure. Despite showing normal pulsatility, patients with APC have right atrial dilatation and partial backward flow in the IVC, demonstrating suboptimal Fontan circulation. LTFO and ECFO both produce unidirectional antegrade flow in the IVC but pulsatility is very low or absent, which may promote poor pulmonary artery growth and increase of pulmonary vascular resistance contributing to late Fontan failure.

Matrix metalloproteinase 10 promotion of collagenolysis via procollagenase activation: implications for cartilage degradation in arthritis

OBJECTIVE

We have previously reported the up-regulation of matrix metalloproteinase 10 (MMP-10) following treatment with the procatabolic stimulus of interleukin-1 (IL-1) and oncostatin M (OSM) in chondrocytes. Although MMP-10 is closely related to MMP-3, little is known about the role of MMP-10 in cartilage catabolism. The purpose of this study was to determine whether MMP-10 is expressed in connective tissue cells and to assess how it may contribute to cartilage collagenolysis.

METHODS

MMP gene expression was assessed by real-time polymerase chain reaction using RNA from human articular chondrocytes and synovial fibroblasts stimulated with IL-1 plus OSM or tumor necrosis factor alpha (TNFalpha) plus OSM. Synovial fluid levels of MMP-10 were determined by specific immunoassay. Recombinant procollagenases were used in activation studies. Immunohistochemistry assessed MMP-10 expression in diseased joint tissues.

RESULTS

MMP-10 expression was confirmed in both chondrocytes and synovial fibroblasts following stimulation with either IL-1 plus OSM or TNFalpha plus OSM, and MMP-10 was detected in synovial fluid samples from patients with various arthropathies. Exogenous MMP-10 significantly enhanced collagenolysis from IL-1 plus OSM-stimulated cartilage, and MMP-10 activated proMMP-1, proMMP-8, and proMMP-13. Immunohistochemistry revealed the presence of MMP-10 in the synovium and cartilage of an IL-1 plus OSM-induced model of arthritis as well as in samples of diseased human tissues.

CONCLUSION

We confirm that both synovial fibroblasts and articular chondrocytes express MMP-10 following treatment with procatabolic stimuli. Furthermore, the detectable levels of synovial fluid MMP-10 and the histologic detection of this proteinase in diseased joint tissues strongly implicate MMP-10 in the cartilage degradome during arthritis. The ability of MMP-10 to superactivate procollagenases that are relevant to cartilage degradation suggests that this activation represents an important mechanism by which this MMP contributes to tissue destruction in arthritis.

Comparison of modified short axis view and apical four chamber view in evaluating right ventricular function after repair of tetralogy of Fallot

BACKGROUND

In clinical settings an easy and reliable method for following up right ventricular (RV) function in patients after repair of tetralogy of Fallot (TOF) is needed. It is, however, unclear whether the novel modified short axis view from echocardiography is superior to the apical four chamber view in this aspect.

MATERIALS AND METHODS

Thirty postoperative TOF patients with median age 17 years (range 6-45 years) and follow up period of 10 years (range 0.5-40 years) were examined echocardiographically using the apical four chamber view and the novel modified short axis view. RV areas in end-systole (Amin) and end-diastole (Amax) were measured and an area fraction [(Amax - Amin)/Amax * 100%] was calculated from the respective view. RV ejection fraction was assessed through magnetic resonance imaging (MRI). The RV area fractions from echocardiography were compared to the RV ejection fraction.

RESULTS

The right ventricular area fraction derived from the modified short axis view was significantly lower than that from the apical four chamber view (34.3+/-9.1% vs. 42.5+/-10.2%, p=0.007). Both the RV area fractions obtained from the modified short axis view (r=0.674, p<0.001) and from the apical four chamber view (r=0.512, p=0.025) correlated significantly with the MRI derived RV ejection fraction.

CONCLUSION

The novel modified short axis view from echocardiography may be superior to the apical four chamber view for routine follow up of patients after TOF repair, in whom the right ventricular outflow tract plays an important role in the right ventricular systolic function.