External validation of Cardiac disease, Hypertension, and Logarithmic Left anterior descending coronary artery radiation dose (CHyLL) for predicting major adverse cardiac events after lung cancer radiotherapy.

Background and purpose: Major adverse cardiac events(MACE) are prevalent in patients with locally advanced-non-small cell lung cancer(LA-NSCLC) following radiotherapy(RT). The CHyLL model, incorporating coronary heart disease(CHD),Hypertension(HTN),Logarithmic LADV15 was developed and internally-validated to predict MACE among LA-NSCLC patients. We sought to externally validate CHyLL to predict MACE in an independent LA-NSCLC cohort. Patients and methods: Patients with LA-NSCLC treated with RT were included. CHyLL score was calculated:5.51CHD + 1.28HTN + 1.48ln(LADV15 + 1)-1.36CHD*ln(LADV15 + 1). CHyLL performance in predicting MACE was assessed and compared to mean heart dose(MHD) using Cox-proportional hazard(PH) analyses and Harrel's concordance(C)-indices. MACE and overall survival(OS) among low-vs high-risk groups(CHyLL < 5 vs ≥ 5) were compared. Results: In the external validation cohort(N = 102), the median age was 71 years and 55% were females. Most(n = 74,73%), had clinical Stage III disease and 35(34%) underwent surgery. CHyLL demonstrated good MACE prediction with C-index of 0.73(95% Confidence Interval(CI):0.58-0.89), while MHD did not (C-index = 0.46 (95% CI:0.30-0.62)). Per CHyLL, 32(31%) and 70(69%) patients were considered low-and high-risk for MACE, respectively. CHyLL consistently identified lower MACE rates in the low-vs high-risk group(log-rank p = 0.108):0 vs 8%(12 months),5 vs 16%(24 months),5 vs 16%(36 months),and 5 vs 19%(48 months) post-RT. In the pooled internal and external validation cohort(N = 303), MACE rates in low-vs high-risk groups were statistically significantly different(log-rank p = 0.01):1 vs 6%(12 months),3 vs 12%(24 months),6 vs 19%(36 months),and 6 vs 21%(48 months). Conclusions: CHyLL was externally validated and superior to MHD in predicting MACE. CHyLL has the potential to identify high-risk patients who may benefit from cardio-oncology optimization and to estimate personalized LADV15 constraints based on cardiac risk factors and acceptable MACE thresholds.

Endotelina-1 y tono vascular en sujetos con factores de riesgo aterogénico / Endothelin-1 and vascular tone in subjects with atherogenic risk factors

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Sequential hypoglycemia, hyperglycemia, and the carcinoid syndrome arising from a plurihormonal neuroendocrine neoplasm.

OBJECTIVE: To describe the first patient with a neuroendocrine tumor secreting serotonin, insulin, and glucagon and having the corresponding clinical syndromes. METHODS: We present a detailed case report, including serial laboratory and clinical findings, in a man with type 2 diabetes, symptomatic hypoglycemia, and the carcinoid syndrome and in whom a plurihormonal metastatic neuroendocrine neoplasm was ultimately diagnosed. RESULTS: In a 58-year-old man with type 2 diabetes, which was treated effectively with a sulfonylurea for 7 years, episodes of hypoglycemia developed. After discontinuation of the orally administered agent, the hypoglycemic episodes initially resolved but then recurred and were associated with inappropriately increased plasma insulin concentrations. In addition, the patient had symptoms and biochemical evidence of the carcinoid syndrome. Computed tomography of the abdomen showed multiple hypodense lesions in the liver, and ultrasound-guided fine-needle aspiration of a liver mass was performed. Undifferentiated neuroendocrine tumor with hepatic metastatic involvement was diagnosed. After a hepatic artery embolization procedure, the hypoglycemia was alleviated, but hyperglycemia soon recurred, associated with inappropriately increased serum glucagon concentrations. The patient's course strongly suggested the presence of a plurihormonal tumor secreting serotonin, insulin, and glucagon. CONCLUSION: To our knowledge, this is the first reported case of a patient with a neuroendocrine neoplasm secreting serotonin, glucagon, and insulin, manifested by the carcinoid syndrome, hyperglycemia, and hypoglycemia.

Quality of care for patients hospitalized with heart failure at academic medical centers.

BACKGROUND: The purpose of this study was to determine the standard of care provided by academic medical centers for the management of congestive heart failure (CHF). METHODS AND RESULTS: The standard of care was estimated by assessing adherence to the treatment guidelines published by the US Agency for Health Care Policy and Research among 522 patients hospitalized at 7 university hospitals with a diagnosis of CHF. Data were abstracted by retrospective chart review. Of the 522 patients analyzed, 435 (83%) had a left ventricular ejection fraction (LVEF) measured or documented. Among these patients, 192 were considered "ideal" candidates for angiotensin-converting enzyme (ACE) inhibitor therapy (ie, with systolic dysfunction [LVEF <40%] and no contraindications to ACE inhibitors). In this cohort of "ideal" candidates, 138 (72%) were receiving ACE inhibitors at hospital discharge, including 60 (44%) who were prescribed doses recommended in large clinical trials. Compliance with patient education guidelines was assessed in all 487 patients who were alive at the time of discharge. Of these patients, 365 (75%) received dietary counseling, 404 (83%) were educated about exercise, 54 (11%) were instructed to follow daily weights, and 468 (96%) were counseled regarding medication compliance. Among the 87 smokers who were alive at time of discharge, 8 (9%) had documented advice to quit smoking. CONCLUSIONS: This study indicates that academic medical centers performed fairly well on the assessment of LVEF, the prescription of ACE inhibitors at discharge, and on education regarding diet, exercise, and compliance with medications. However, the results suggest opportunities for improvement in ACE inhibitor dosing and patient education regarding the importance of monitoring daily weights and smoking cessation.

Optimum maintenance trough levels of cyclosporine in heart transplant recipients given corticosteroid-free regimen.

BACKGROUND: Standard immunosuppressive therapy for heart transplant recipients consists of cyclosporine, azathioprine, and corticosteroids. Long-term use of steroids results in serious side effects. Steroid-free maintenance immunosuppressive regimens have been shown to be safe and effective in selected heart transplant recipients. Cyclosporine is the cornerstone of immunosuppressive therapy in such regimens. The ideal dose of cyclosporine, providing adequate immunosuppression while minimizing toxicity, remains controversial in the standard triple immunosuppressive regimen. This study attempted to define the optimal level of cyclosporine (whole blood radioimmunoassay) for heart transplant recipients given a steroid-free regimen. METHODS: We retrospectively analyzed data from 583 endomyocardial biopsies and corresponding cyclosporine trough levels obtained from 48 orthotopic heart transplant recipients maintained without steroids. We used maximum likelihood probit techniques to examine the correlation between cyclosporine level and the probability of rejection (International Society for Heart and Lung Transplantation [ISHLT] grades higher than 1A). The data were adjusted for age at the time of transplantation, sex, race, time elapsed since transplantation, and azathioprine dose. RESULTS: Higher cyclosporine levels were associated with a lower probability of acute cellular rejection (p < .03). The lowest probability of rejection, ISHLT grades higher than 1A (1.7%), was associated with a cyclosporine level of 322 ng/mL. In this database, higher levels of cyclosporine were not associated with higher serum creatinine levels (p = .6). CONCLUSIONS: Cyclosporine trough levels of 300 to 350 ng/mL (whole blood radioimmunoassay) are associated with the lowest probability of cellular rejection in patients given a steroid-free regimen of cyclosporine and azathioprine. There was no association between cyclosporine levels and serum creatinine.

Gender differences in mortality after myocardial infarction. Why women fare worse than men.

Several studies have indicated that women sustaining a myocardial infarction have a higher unadjusted short-term (i.e., in-hospital or 30-day) mortality than men. The advanced age of women at the time of presentation appears to be the major factor contributing to their worse prognosis relative to men. Controlling for age eliminates the association between female gender and increased mortality in most, but not all studies. This article reviews the data on age and other factors that might explain why women with a myocardial infarction fare worse then men.

Cytokines as potential vaccine adjuvants.

There is a compelling clinical need for adjuvants suitable for human use to enhance the efficacy of vaccines in the prevention of life-threatening infection. Candidate populations for such vaccine-adjuvant strategies include normal individuals at the two extremes of life, as well as the ever increasing population of immunocompromised individuals. In addition, adjuvants that would increase the efficiency of vaccination with such vaccines as those directed against hepatitis B and Streptococcus pneumoniae would have an even greater general use. Cytokines, as natural peptides intimately involved in the normal immune response, have great appeal as potential adjuvants. An increasing body of work utilizing recombinant versions of interleukin-1, -2, -3, -6, -12, gamma-interferon, tumor necrosis factor, and granulocyte-monocyte-colony stimulating factor has shown that cytokines do have vaccine adjuvant activity. However, in order to optimize adjuvant effect and minimize systemic toxicity, strategies in which the cytokine is fused to the antigen, or the cytokine is presented within liposomes or microspheres appear to be necessary to make this a practical approach suitable for human use. There is much promise in this approach, but there is much work to be accomplished in order to optimize the pharmacokinetics of cytokine administration as well as its side effect profile.

Neocartilage formation in vitro and in vivo using cells cultured on synthetic biodegradable polymers.

Cartilaginous implants for potential use in reconstructive or orthopedic surgery were created using chondrocytes grown on synthetic, biodegradable polymer scaffolds. Chondrocytes isolated from bovine or human articular or costal cartilage were cultured on fibrous polyglycolic acid (PGA) and porous poly(L)lactic acid (PLLA) and used in parallel in vitro and in vivo studies. Samples were taken at timed intervals for assessment of cell number and cartilage matrix (sulfated glycosaminoglycan [S-GAG], collagen). The chondrocytes secreted cartilage matrix to fill the void spaces in the polymer scaffolds that were simultaneously biodegrading. In vitro, chondrocytes grown on PGA for 6 weeks reached a cell density of 5.2 x 10(7) cells/g, which was 8.3-fold higher than at day 1, and equalled the cellularity of normal bovine articular cartilage. In vitro, the cell growth rate was approximately twice as high on PGA as it was on PLLA; cells grown on PGA produced S-GAG at a high steady rate, while cells grown on PLLA produced only minimal amounts of S-GAG. These differences could be attributed to polymer geometry and biodegradation rate. In vivo, chondrocytes grown on both PGA and PLLA for 1-6 months maintained the three-dimensional (3-D) shapes of the original polymer scaffolds, appeared glistening white macroscopically, contained S-GAG and type II collagen, and closely resembled cartilage histologically. These studies demonstrate the feasibility of culturing isolated chondrocytes on biodegradable polymer scaffolds to regenerate 3-D neocartilage.

Identification and characterization of gamma-giardin and the gamma-giardin gene from Giardia lamblia.

The giardins are abundant cytoskeletal proteins that range in size from 29-38 kDa and are specific to the ventral disk of the intestinal protozoan parasite Giardia lamblia. The 29-kDa (beta and beta-1; refs. 8-10) and the 33-kDa (alpha-1 and alpha-2; refs. 3 and 7) giardins have been characterized previously. In this paper we extend the analysis of the giardins to include the 38-kDa giardin, which we have named gamma-giardin. After purifying gamma-giardin by two-dimensional electrophoresis, we raised polyclonal antibodies to the protein and used them to demonstrate that gamma-giardin shares at least one epitope with 9 other giardin polypeptides and that it localizes to the ventral disk of the parasite. We also determined an internal peptide sequence of 12 amino acid residues and used this information to construct oligonucleotide probes for the gamma-giardin gene. After cloning the gene, we determined the nucleotide sequence of its 933-bp open reading frame and 866 bp of 5' and 3' flanking sequence. We found the downstream AGTPuAAPy motif typical of all G. lamblia genes sequenced to date, and determined that the single copy of the gamma-giardin gene localizes to the same chromosome or chromosomal cluster as the alpha-giardins. Finally, we demonstrated by primer extension analysis that gamma-giardin transcripts contain a short untranslated leader characteristic of G. lamblia messenger RNAs.