Acute coronary syndromes in diabetes: Biomarkers of endothelial injury improve risk stratification and help identify predictors of risk.

BACKGROUND AND AIMS: Patients with diabetes mellitus (DM) are at an increased risk of acute coronary syndrome (ACS); however, the factors predicting those at highest risk are not well understood. We identified risk factors in those with DM that best predict high ACS risk based on a multiple endothelial injury biomarker algorithm. METHODS: We studied adults with DM from a clinical registry with measures of a coronary artery disease prediction algorithm (CADPA) score identifying 5-year ACS risk from nine markers. Stepwise logistic regression provided odds ratios for the relationship of age, gender, and individual risk factors not part of the CADPA algorithm with the likelihood of a high risk CADPA score. RESULTS: We studied 1,613 adults with DM (women: 47.3%, ages 22 to 100, mean age 63.2 years). Of these, 6.1% had a low, 13.2% intermediate, and 80.7% high risk CADPA score. From stepwise logistic regression, women were less likely to have a high risk CADPA score (odds ratio [OR] 0.21, 95% confidence intervals [CI] 0.15-0.29, p<.0001), while age (per standard deviation [SD]) (OR 5.04, [4.12-6.17], p<.0001), body mass index (BMI per SD) (OR 1.34, [1.14-1.58], p = 0.004), hypertension (OR 1.60, [1.15-2.24], p = 0.006), current smoking (OR 2.55, [1.56-4.16], p = 0.0002), hsCRP (per SD) (OR 1.24, [1.01-1.53], p = 0.04), and triglycerides (per SD) (OR 1.26, [1.04-1.54], p = 0.02) were more likely to have a high risk CADPA score. CONCLUSIONS: Age, men, hypertension, BMI, current smoking, hsCRP, and triglycerides are key factors in those with DM associated with higher ACS risk.

Novel biomarker panel measuring endothelial injury identifies patients at risk of coronary artery syndrome and discordance with low-density lipoprotein cholesterol.

BACKGROUND: Individuals with no history of coronary artery disease can develop acute coronary syndrome (ACS), often in the absence of major risk factors including low-density lipoprotein cholesterol (LDL-C). We identified risk factors and biomarkers that can help identify those at discordantly high risk of ACS with normal LDL-C using a novel validated coronary artery disease predictive algorithm (CADPA) incorporating biomarkers of endothelial injury. METHODS: Five-year predicted ACS risk was calculated for 6392 persons using CADPA. Persons were classified as low (<3.5%), intermediate (3.5-<7.5%) or high (≥7.5%) CADPA risk and by LDL-C levels <130 mg/dL (low) and ≥130 mg/dL (high) and whether in the discordantly low LDL-C (but high CADPA risk) or high LDL-C (but low/intermediate CADPA risk) group. Multiple logistic regression identified risk factors and biomarkers that predicted discordance. RESULTS: 31% were classified as low (<3.5%), 27% at intermediate (3.5-<7.5%) and 42% were at high risk (≥7.5%). 28% of subjects were identified in the low LDL discordant risk group (LDL-C< 130 mg/dL but 5-year CADPA predicted risk ≥7.5%) and 19% in the high LDL discordant risk group (LDL-C ≥ 130 mg/dL but 5-year CADPA risk of <7.5%). Diabetes (odds ratio [OR], 2.84 [2.21-3.66]), male sex (OR, 2.83 [2.40-3.35]), family history (OR, 2.23 [1.88-2.64]) and active smoking (OR, 1.99 [1.50-2.62]) predicted low LDL risk discordance more than other risk factors (all P < 0.01). Increased serum soluble FAS, hemoglobin A1c and interleukin-16 were the biomarkers most independently associated with increased risk. CONCLUSIONS: Discordance between LDL-C levels and ACS risk is common. Males with diabetes and a family history of myocardial infarction who are actively smoking may be at highest risk of developing ACS despite controlled LDL-C. Future studies should examine whether using the CADPA can help identify individuals that could benefit from earlier targeting of risk factor modification for the prevention of ACS.

A Unique Approach to Building a Learner-Guided Ultrasound Simulator for Central Venous Access Training.

Commercial central line vascular access trainers are available but have significant limitations including cost, size, and limited durability when used for the complete procedure. A unique central venous access trainer was constructed using silicone loaf pan, ballistic gel, copper pipe and aluminum rods as vessels conduits, with varying inserts including latex and silicone to simulate different vascular structures, and the use of camouflage. This trainer is inexpensive, portable, reusable, allows the complete procedure to be simulated, and may be customized to the specific needs of the learner. The assembled simulator demonstrated excellent ultrasound visualization, including varying size and vessel character, allowed modification to specific learner needs, while at the same time being light-weight, portable, inexpensive, and reusable. A moderate-fidelity central venous access simulator can be constructed in a cost-effective manner, which can be optimized to the learner skill level and allows the entire procedure to be completed on the simulator.

Usefulness of a Coronary Artery Disease Predictive Algorithm to Predict Global Risk for Cardiovascular Disease and Acute Coronary Syndrome.

Traditional global risk assessment for cardiovascular disease fails to identify a significant percentage of the population initially classified at low or intermediate risk of cardiovascular disease that are actually at high risk for acute coronary syndrome (ACS). We examined a coronary artery disease predictive algorithm (CADPA) that includes 9 biomarkers involved in the pathogenesis of atherosclerosis initiated by endothelial damage and repair (hepatocyte growth factor, soluble FAS, Fas ligand, eotaxin, cutaneous T cell-attracting chemokine, monocyte chemotactic protein-3, interleukin-16, hemoglobin A1c, high-density lipoprotein-cholesterol), in addition to age, gender, diabetes, and family history of myocardial infarction that more accurately predicts 5-year risk of ACS to identify the patient population at discordantly high risk. We found that 34% of patients at low risk by global risk assessment and 72% of patients at intermediate risk by global risk assessment were actually at discordantly high risk for ACS. This patient population was disproportionately male and older in age. The biomarkers (per standard deviation) that most predicted the odds (95% confidence levels) of discordance were interleukin-16 (2.59 [2.21 to 3.03]), Fas Ligand (0.50 [0.43 to 0.57]), hepatocyte growth factor (1.72 [1.50 to 1.98]), soluble FAS (2.19 [1.86 to 2.58]), cutaneous T cell-attracting chemokine (0.46 [0.40 to 0.53]), and eotaxin (1.78 [1.56 to 2.03]), in addition to age, HbA1c, low-density lipoprotein-cholesterol, and glycated hemoglobin. In conclusion, although future prospective study validation is needed to establish a causal relation between CADPA and cardiovascular events, our study defines a patient population considered low to intermediate risk by conventional clinical evaluation, but who is at discordantly high risk indicated by the endothelial injury serum biomarker algorithm CADPA and may benefit from further evaluation and medical management.

Clinical utility of a novel coronary heart disease risk-assessment test to further classify intermediate-risk patients.

BACKGROUND: Current coronary heart disease (CHD) risk assessments inadequately assess intermediate-risk patients, leaving many undertreated and vulnerable to heart attacks. A novel CHD risk-assessment (CHDRA) tool was developed for intermediate-risk stratification using biomarkers and established risk factors to significantly improve CHD risk discrimination. HYPOTHESIS: Physicians will change their treatment plan in response to more information about a patient's CHD risk level provided by the CHDRA test. METHODS: A Web-based survey of cardiology, internal medicine, family practice, and obstetrics/gynecology physicians (n = 206) was conducted to assess the CHDRA clinical impact. Each physician was shown 3 clinical vignettes representing community-based cohort participants randomly selected from 8 total vignettes. For each, the physicians assessed the individual's CHD risk and selected preferred therapies based on the individual's comorbidities, physical examination, and laboratory results. The individual's CHDRA score was then provided and the physicians were queried for changes to their initial treatment plans. RESULTS: After obtaining the CHDRA result, 70% of the physician responses indicated a change to the patient's treatment plan. The revised lipid-management plans agreed more often (74.6% of the time) with the current Adult Treatment Panel III guidelines than did the original plans (57.6% of the time). Most physicians (71.3%) agreed with the statement that the CHDRA result provided information that would impact their current treatment decisions. CONCLUSIONS: The CHDRA test provided additional information to which physicians responded by more often applying appropriate therapy and actions aligned with guidelines, thus demonstrating the clinical utility of the test.

Analytical performance validation of a coronary heart disease risk assessment multi-analyte proteomic test.

BACKGROUND: Coronary heart disease (CHD) remains prevalent despite efforts to improve CHD risk assessment. The authors developed a multi-analyte immunoassay-based CHD risk assessment (CHDRA) algorithm, clinically validated in a multicenter study, to improve CHDRA in intermediate risk individuals. OBJECTIVE: Clinical laboratory validation of the CHDRA biomarker assays' analytical performance. METHODS: Multiplexed immunoassay panels developed for the seven CHDRA assays were evaluated with donor sera in a clinical laboratory. Specificity, sensitivity, interfering substances and reproducibility of the CHDRA assays, along with the effects of pre-analytical specimen processing, were evaluated. RESULTS: Analytical measurements of the CHDRA panel proteins (CTACK, Eotaxin, Fas Ligand, HGF, IL-16, MCP-3 and sFas) exhibited acceptable accuracy (80 - 120%), cross-reactivity (< 1%), interference (< 30% at high concentrations of bilirubin, lipids, hemoglobin and HAMA), sensitivity and reproducibility (< 20% CV across multiple runs, operators and instruments). Recoveries from donor sera subjected to typical clinical laboratory pre-analytical conditions were within 80 - 120%. The pre-analytical variables did not substantively impact the CHDRA scores. CONCLUSIONS: The CHDRA panel analytical validation in a clinical laboratory meets or exceeds the specifications established during the clinical utility studies. Risk score reproducibility across multiple test scenarios suggests the assays are not susceptible to clinical laboratory pre-analytical and analytical variation.

Seroepidemiologic investigation of an outbreak of pandemic influenza A H1N1 2009 aboard a US Navy vessel--San Diego, 2009.

BACKGROUND: During summer 2009, a US Navy ship experienced an influenza-like illness outbreak with 126 laboratory-confirmed cases of pandemic influenza A (H1N1) 2009 virus among the approximately 2000-person crew. METHODS: During September 24-October 9, 2009, a retrospective seroepidemiologic investigation was conducted to characterize the outbreak. We administered questionnaires, reviewed medical records, and collected post-outbreak sera from systematically sampled crewmembers. We used real-time reverse transcription-PCR or microneutralization assays to detect evidence of H1N1 virus infection. RESULTS: Retrospective serologic data demonstrated that the overall H1N1 virus infection attack rate was 32%. Weighted H1N1 virus attack rates were higher among marines (37%), junior-ranking personnel (34%), and persons aged 19-24 years (36%). In multivariable analysis, a higher risk of illness was found for women versus men (odds ratio [OR] = 2.2; 95% confidence interval [CI]: 1.1-4.4), marines versus navy personnel (OR = 1.7; 95% CI, 1.0-2.9), and those aged 19-24 versus ≥ 35 years (OR = 3.9; 95% CI, 1.2-12.8). Fifty-three percent of infected persons did not recall respiratory illness symptoms. Among infected persons, only 35% met criteria for acute respiratory illness and 11% for influenza-like illness. CONCLUSIONS: Approximately half of H1N1 infections were asymptomatic, and thus, the attack rate was higher than estimated by clinical illness alone. Enhanced infection control measures including pre-embarkation illness screening, improved self-reporting of illness, isolation of ill and quarantine of exposed contacts, and prompt antiviral chemoprophylaxis and treatment might be useful in controlling shipboard influenza outbreaks.

Mechanism of action of the Adiana(®) device: a histologic perspective.

BACKGROUND: The study was conducted to confirm the mechanism of action of the Adiana permanent contraception device by means of histologic analysis of long-term specimens. STUDY DESIGN: Fifteen specimens were obtained from eight subjects undergoing hysterectomy 2 to 4 years after the Adiana procedure. Serial sections were stained with hematoxylin and eosin, as well as epithelial membrane antigen immunostain. RESULTS: A normal foreign body reaction with minimal chronic inflammatory changes was observed in all specimens. Immunostaining for epithelial membrane antigen was absent in the interstitial tissue surrounding the matrix. CONCLUSION: Histologic analysis of long-term specimens supports the mechanism of action of the Adiana permanent contraception device.

Enhanced accuracy and reliability of HER-2/neu immunohistochemical scoring using digital microscopy.

We evaluated the HER-2/neu status of 129 invasive breast cancer specimens for gene amplification by fluorescence in situ hybridization (FISH) and protein overexpression by immunohistochemical analysis. Each immunohistochemically stained slide was interpreted on a standard microscope independently by 10 pathologists. Separately, each pathologist reviewed the same slide set with the assistance of digital microscopy. A total of 1,258 manual immunohistochemical scores and 1,269 digital microscopy immunohistochemical scores were completed. When the same 10 pathologists scored the same immunohistochemical slides with the assistance of digital microscopy, each reviewer improved concordance with FISH, and overall concordance with immunohistochemical analysis improved significantly, to 93% (P < .001). The interrater kappa was used to compare interobserver agreement in HER-2 immunohistochemical scoring for manual and digital microscopy interpretation. Significant improvement in interobserver agreement (kappa = 0.51 vs 0.86; P < .001) was achieved when HER-2 immunohistochemical analysis was scored with the assistance of the digital microscope. The assistance of digital microscopy improves the accuracy and reliability of HER-2 immunohistochemical analysis. These data suggest that documented discrepancies between HER-2 immunohistochemical analysis and FISH reflect predominantly errors in manual immunohistochemical interpretation as opposed to immunohistochemical reagent limitations.

Computer detection of cognitive impairment and associated neuropsychiatric dimensions from the content analysis of verbal samples.

This is a report of a study testing the capacity of a computerized measure of the content analysis of five minute verbal samples to detect and measure cognitive impairment and comorbid neuropsychiatric dimensions in 117 drug-abusing inpatients. The cognitive impairment scores obtained from the computerized procedure correlated significantly with independent scores from the Trails B and Stroop Color and Word test as well as with ANAM (Automated Neuropsychiatric Assessment Metric) neuropsychological tests, including the Matching to Sample Efficiency and Accuracy, the Code Substitution Efficiency, the Continuous Performance Task Efficiency and Accuracy, the Code Substitution Delayed Recall Accuracy, and the Simple Reaction Time Efficiency. When the computerized verbal-content-analysis-derived cognitive impairment scores were combined with scores of selected other ANAM measures, more and higher intercorrelations occurred with Trails A, Trails B, the Stroop Color and Word test, and the Wisconsin Card Sort test. In addition, validated measures of a broad range of associated neuropsychiatric dimensions can be obtained simultaneously from the same five minute verbal samples providing the cognitive impairment scores. No significant effects were found on the cognitive impairment scores of age, education, gender, race, and duration of drug-abuse abstinence.

Detection of circulating cytokeratin-positive cells in the blood of breast cancer patients using immunomagnetic enrichment and digital microscopy.

PURPOSE: To examine the feasibility for identifying and enumerating cytokeratin positive (CK+) cells in the peripheral blood of breast cancer patients. EXPERIMENTAL DESIGN: Blood specimens from 34 normal donors (negative controls), 15 samples to which carcinoma cells were added (positive controls), and 84 breast cancer patients [27 node-negative (N-), 29 node-positive (N+), and 28 metastatic] were studied. RBCs were lysed with ammonium chloride and the resulting cell suspension incubated with anti-EpCAM-conjugated immunomagnetic beads for carcinoma cell enrichment. Immunomagnetically selected cells were placed on slides; stained for CKs 8, 18, and 19; and evaluated with an automated digital microscopy system that rapidly scanned the slide and collected images of cells meeting predefined staining and cytomorphological criteria. A montage of the CK+ cells was reviewed to confirm tumor cell morphology. RESULTS: Eighteen specimens (9 normal, 2 N-, 4 N+, and 3 metastatic) were excluded because of poor cytomorphology or staining artifact. All 15 of the positive controls [95% confidence interval (CI), 78-100%] and none of the 25 negative controls (95% CI, 0-14%) demonstrated CK+ cells. Twenty-one of the 75 (28%; 95% CI, 18-40%) samples from breast cancer patients demonstrated CK+ cells including 76% of patients with metastatic disease (95% CI, 55-91%), 8% with N+ disease (95% CI, 1-26%), and none of those with N- disease (95% CI, 0-14). The mean number of CK+ cells detected in the 21 CK+ patients was 18.4 (range, 1-120). CONCLUSIONS: Breast carcinoma cells can be detected in the blood from a significant fraction of metastatic breast cancer patients using immunomagnetic cell enrichment and digital microscopy. The incidence of CK+ cells was low in those with resected N+ disease (at most 26%) and those with resected N- breast cancer (at most 14%). This technique could be used in large prospective studies of patients with breast cancer to learn whether the detection of rare carcinoma cells is a useful predictive or prognostic factor.