Comparison of Rates of Coronary Angiography and Combined Testing Procedures in Patients Seen in the Emergency Room With Chest Pain (But No Objective Acute Coronary Syndrome Findings) Having Coronary Computed Tomography Versus Exercise Stress Testing.

Coronary computed tomography angiography (CCTA) appears comparable to standard care, including exercise stress testing (EST), in diagnosing acute coronary syndrome in emergency department (ED) patients with chest pain but may increase downstream testing. The objective of this study was to investigate rates of post-CCTA versus post-EST testing for (1) invasive angiography and (2) all combined cardiac testing. This was a retrospective cohort study performed at 2 urban Canadian EDs involving patients aged up to 65 years with chest pain but no objective ACS findings that were evaluated with CCTA or EST at the physician's discretion. The primary outcome was the proportion of patients who had 30-day invasive angiography in each group; secondary outcomes included all subsequent 30-day cardiac testing, including nuclear medicine scanning. From July 1, 2012, to June 30, 2014, we collected 1,700 patients: 521 CCTA and 1,179 EST. Demographics and risk factors were similar in both cohorts. In the following 30 days, 30 CCTA (5.8%) and 297 EST (25.2%) patients underwent any type of additional cardiac testing (difference 19.4%, 95% CI 16.0 to 22.6), whereas 12 CCTA (2.3%) and 20 EST patients (1.7%) underwent angiography (difference 0.6%, 95% CI -0.8% to 2.6%). No patients in either group died or had a myocardial infarction within 30 days. For ED patients with chest pain who underwent brief observation, CCTA and EST had similar 30-day angiography rates, but CCTA patients underwent significantly less overall cardiac investigations.

A population-based study of antenatal corticosteroid prophylaxis for preterm birth.

OBJECTIVE: National and international clinical practice guidelines, based on the meta-analysis of randomized trials, recommend antenatal corticosteroid (ACS) prophylaxis for threatened preterm delivery. We carried out a study to determine the extent to which current clinical practice in British Columbia adheres to these guidelines with a focus on preterm deliveries at 33 to 34 weeks of gestation. METHODS: Data were obtained from the British Columbia Perinatal Database Registry, a comprehensive provincial registry containing detailed information on all births in the province. All preterm live births between 2000 and 2009 were included in the study. The rate of ACS administration was assessed in different gestational age groups. Determinants of ACS administration (such as maternal characteristics and obstetric factors) were also studied. The frequency of ACS prophylaxis was estimated using rates and exact 95% confidence intervals, and associations were assessed using odds ratios and 95% confidence intervals. RESULTS: Among 35 862 preterm births in British Columbia, the rate of ACS administration was 56.0% in the 26- to 32-week group (95% CI 54.7% to 57.4%) and 19.4% in the 33- to 34-week group (95% CI 18.5% to 20.4%). Rates were reasonably consistent between 2000 and 2009 and by region of residence in British Columbia. Women with hypertension (OR 1.51; 95% CI 1.32 to 1.72), gestational diabetes (OR 1.21; 95% CI 1.05 t01.40), and iatrogenic deliveries (OR 1.34; 95% CI 1.22 to 1.47) were significantly more likely to receive ACS. CONCLUSION: Despite explicit clinical guidelines, ACS usage in preterm deliveries at 33 to 34 weeks of gestation appears to be suboptimal.

The immunostimulatory activity of unmethylated and methylated CpG oligodeoxynucleotide is dependent on their ability to colocalize with TLR9 in late endosomes.

TLR9 recognizes CpG motifs present in pathogenic DNA and triggers potent immune responses. It is generally accepted that TLR9 distinguishes pathogenic DNA based, in part, on methylation status, where TLR9 binds unmethylated but not methylated CpG. However, we showed that methylated CpG induces potent TLR9-mediated responses when delivered in lipid nanoparticles. In this article, we report that methylation dictates the ability of free CpG DNA to colocalize with TLR9 in late endosomes. However, when delivered in lipid nanoparticles, CpG DNA and TLR9 colocalize, regardless of methylation status. Therefore, it is proposed that the ability of immune cells to distinguish unmethylated pathogenic from methylated mammalian DNA is controlled by a mechanism that regulates TLR9 mobilization and colocalization rather than a differential binding affinity.

Rational design of cationic lipids for siRNA delivery.

We adopted a rational approach to design cationic lipids for use in formulations to deliver small interfering RNA (siRNA). Starting with the ionizable cationic lipid 1,2-dilinoleyloxy-3-dimethylaminopropane (DLinDMA), a key lipid component of stable nucleic acid lipid particles (SNALP) as a benchmark, we used the proposed in vivo mechanism of action of ionizable cationic lipids to guide the design of DLinDMA-based lipids with superior delivery capacity. The best-performing lipid recovered after screening (DLin-KC2-DMA) was formulated and characterized in SNALP and demonstrated to have in vivo activity at siRNA doses as low as 0.01 mg/kg in rodents and 0.1 mg/kg in nonhuman primates. To our knowledge, this represents a substantial improvement over previous reports of in vivo endogenous hepatic gene silencing.

Synthetic methylated CpG ODNs are potent in vivo adjuvants when delivered in liposomal nanoparticles.

Although it is well documented that the immunological activity of cytosine-guanine (CpG) motifs is abrogated by 5' methylation of the cytosine residue, encapsulation within stabilized lipid nanoparticles endows these methylated cytosine-guanine- (mCpG-) containing oligonucleotides (ODNs) with potent immunostimulatory activity in murine animal models. Surprisingly, not only do liposomal nanoparticulate (LN) mCpG ODN possess immunostimulatory activity, their potency is found to be equivalent and often greater than the equivalent unmethylated form, as judged by a number of ex vivo innate and adaptive immune parameters and anti-tumor efficacy in murine models. Preliminary data indicate that both methylated and unmethylated CpG ODN act through a common receptor signaling pathway, specifically via toll-like receptor (TLR) 9, based on observations of up-regulated TLR9 expression, induction of nitric oxide and dependence on endosomal maturation. This is confirmed in TLR9 knockout animals which show no immunostimulatory activity following treatment with LN-mCpG ODN. These data, therefore, indicate that the mCpG DNA is fully competent to interact with TLR9 to initiate potent immune responses. Furthermore, this work implicates an as yet unidentified mechanism upstream of TLR9 which regulates the relative activities of free methylated versus unmethylated CpG ODN that is effectively bypassed by particulate delivery of CpG ODN.

The combination of stabilized plasmid lipid particles and lipid nanoparticle encapsulated CpG containing oligodeoxynucleotides as a systemic genetic vaccine.

BACKGROUND: DNA vaccines offer unique potential for generating protective and therapeutic immunity against infectious and malignant diseases. Unfortunately, rapid degradation and poor cellular uptake has significantly limited the efficacy of 'naked' plasmid DNA vaccines. We have previously described stabilized plasmid lipid particles (SPLP) as effective nonviral gene delivery vehicles for the transfection of tumours at distal sites following intravenous administration. Based on their low toxicity and favourable transfection profile following systemic administration, we investigate SPLP as gene delivery vehicles for the generation of a systemically administered genetic vaccine. METHODS: The uptake of SPLP and their ability to transfect splenic antigen presenting cells (APC) following systemic administration is assessed through fluorescently-labelled SPLP in combination with phenotype markers and a very sensitive flow cytometry-based assay for the detection of the transgene, beta-galactosidase. The priming of antigen-specific adaptive and humoural immune responses following vaccination with SPLP alone or in combination with liposomal nanoparticle encapsulated CpG-ODN containing oligodeoxynucleotides (LN CpG-ODN) is characterized through the use of antigen-specific cytotoxicity assays, interferon-gamma secretion assays and enzyme-linked immunosorbant assay. RESULTS: We demonstrate that SPLP are taken up by and transfect APC in the spleen following intravenous administration and that, in the presence of a strong immunostimulatory signal provided by LN CpG-ODN, are able to prime transgene-specific humoural and cellular immune responses. CONCLUSIONS: SPLP represent an effective candidate for the nonviral delivery of a systemic genetic vaccine when combined with additional immune stimulation provided by LN CpG-ODN.