Characterization and referral patterns of ST-elevation myocardial infarction patients admitted to chest pain units rather than directly to catherization laboratories. Data from the German Chest Pain Unit Registry.

BACKGROUND: Direct transfer to the catheterization laboratory for primary percutaneous coronary intervention (PCI) is standard of care for patients with ST-segment elevation myocardial infarction (STEMI). Nevertheless, a significant number of STEMI-patients are initially treated in chest pain units (CPUs) of admitting hospitals. Thus, it is important to characterize these patients and to define why an important deviation from recommended clinical pathways occurs and in particular to quantify the impact of deviation on critical time intervals. METHODS AND RESULTS: 1679 STEMI patients admitted to a CPU in the period from 2010 to 2015 were enrolled in the German CPU registry (8.5% of 19,666). 55.9% of the patients were delivered by an emergency medical system (EMS), 16.1% transferred from other hospitals and 15.2% referred by a general practitioner (GP). 12.7% were self-referrals. 55% did not get a pre-hospital ECG. Compared to the EMS, referral by GPs markedly delayed critical time intervals while a pre-hospital ECG demonstrating ST-segment elevation reduced door-to-balloon time. When compared to STEMI patients (n=21,674) enrolled in the ALKK-registry, CPU-STEMI patients had a lower risk profile, their treatment in the CPU was guideline-conform and in-hospital mortality was low (1.5%). CONCLUSIONS: CPU-STEMI patients represent a numerically significant group because a pre-hospital ECG was not documented. Treatment in the CPU is guideline-conform and the intra-hospital mortality is low. The lack of a pre-hospital ECG and admission via the GP substantially delay critical time intervals suggesting that in patients with symptoms suggestive an ACS, the EMS should be contacted and not the GP.

Predictors of outcome in patients with parvovirus B19 positive endomyocardial biopsy.

OBJECTIVE: Primary objective was to establish the prognostic value of the myocardial load of PVB19 genomes in patients presenting for work-up of myocarditis and/or unclear cardiomyopathy in comparison to clinical, and CMR parameters. METHODS: 108 consecutive patients who underwent EMB because of suspected myocarditis and/or unclear cardiomyopathy, and had evidence of myocardial PVB19 genome, were enrolled. Primary endpoint was all-cause mortality; secondary endpoint was a composite of cardiac mortality and hospitalization for heart failure. RESULTS: Mean LV-EF was 40%. We found n = 27 patients to have a viral load ≥ 500 GE (IQR 559-846), n = 72 had 100-499 GE, and n = 9 had <100 GE. Immunohistology revealed chronic myocarditis in n = 66, acute myocarditis in n = 1, DCM in n = 17, PVB19 genome only in n = 13, and other pathologies in n = 11. During follow-up 11 patients died, two suffered SCD but were successfully shocked by ICD, and 21 were hospitalized for heart failure. Interestingly, not the viral load, but functional parameters such as LV-EF, LV-EDV (endpoint 2), as well as the histologic diagnosis of DCM and the presence of LGE (for all endpoints) reached statistical significance. In fact, the presence of LGE yields an odds-ratio for a lethal event of 8.56 (endpoint 1), and of 5.52 for endpoint 2. No patient with normal LV-EF, or the absence of LGE, suffered cardiac death during long-term follow-up. CONCLUSION: The viral load of PVB19 genomes in the myocardium is not related to the long-term outcome. Furthermore, this study suggests a growing role of imaging for risk stratification in non-ischemic myocardial disease.

Coronary vasomotor abnormalities in patients with stable angina after successful stent implantation but without in-stent restenosis.

BACKGROUND: Coronary angiography is often performed in patients with recurrent or ongoing angina after successful percutaneous coronary intervention (PCI) in search of an in-stent restenosis (ISR). However, in many of these patients, no significant ISR can be detected. We speculate that enhanced coronary vasoconstriction represents an alternative explanation for angina in these patients. METHODS: From 1,285 patients with angiographically unobstructed coronaries (no stenosis ≥50 %) who underwent intracoronary acetylcholine provocation testing (ACH-test) between 2008 and 2011, we consecutively recruited 104 patients (42 female (40 %), mean age 64 ± 11 years) who fulfilled the following inclusion criteria: previous stent implantation due to obstructive coronary artery disease (CAD), ongoing/recurrent exertional angina, no significant (<50 %) ISR. RESULTS: In fifty-one patients with previous PCI (49 %), the ACH-test elicited enhanced epicardial vasoconstriction (≥75 % diameter reduction with reproduction of the patient's symptoms) and microvascular vasoconstriction (reproduction of symptoms, ischemic ECG-changes and no epicardial vasoconstriction) was seen in 18 additional patients (17 %). The ACH-test was uneventful in the remaining 35 patients (34 %). Epicardial vasoconstriction in patients with previous PCI was most often distal and diffuse (31/51, 61 %, p < 0.01). CONCLUSION: Enhanced epicardial and microvascular coronary vasoconstrictions are frequently found in patients with stable angina after successful PCI but without significant ISR. Intracoronary acetylcholine provocation testing may be useful in these patients to determine the cause of angina and initiate appropriate medical treatment.

Performance evaluation of the Sysmex XE-5000 hematology analyzer for white blood cell analysis in cerebrospinal fluid.

CONTEXT: The newest generation hematology analyzer, Sysmex XE-5000 (Sysmex Corporation, Kobe, Japan) is equipped with an improved body fluid analysis mode. OBJECTIVE: To evaluate the applicability of the XE-5000 analyzer to white blood cell (WBC) analysis in cerebrospinal fluid (CSF). DESIGN: A total of 425 routinely collected, consecutive CSF samples were included in the study. For a comparison of total WBC counts, the results of routine chamber counts were grouped into categories of 0 to 5 (n  =  330), >5 to 10 (n  =  36), >10 to 50 (n  =  39), >50 to 200 (n  =  15), and >200 (n  =  5) WBC/µL. Microscopic differential counts were performed using cytospins from 276 samples. Results were grouped according to the percent content of polymorphonuclear (PMN) cells, 0% to 25% (n  =  263), >25% to 50% (n  =  7), >50% to 75% (n  =  3), and >75% to 100% (n  =  3) of WBC. Corresponding results of XE-5000 analysis were matched to these particular count categories. RESULTS: For total WBC counts, the proportions of samples correctly classified by the XE-5000 from the percentage groups described above were 88%, 47%, 72%, 93%, and 100%, respectively. After the two lowest count categories were combined into one range of 0 to 10 WBC/µL, matches increased to 95%. For PMN counts in the 0% to 25% group, 37% of samples were misclassified by the XE-5000. Conversely, for samples with microscopic PMN counts of more than 25%, there was a trend toward underestimation by the XE-5000. Mismatches were most pronounced in samples with fewer than 10 WBC/µL. CONCLUSIONS: The Sysmex XE-5000 hematology analyzer yields valid total CSF cell counts and may be considered an acceptable alternative to the traditional chamber method, even for samples with low WBC counts. However, it cannot be recommended as a suitable alternative for manual differential cytologic workup.

Identification of oncostatin M as a STAT5-dependent mediator of bone marrow remodeling in KIT D816V-positive systemic mastocytosis.

Systemic mastocytosis is a neoplastic disease of mast cells harboring the activating KIT mutation D816V. In most patients, mast cell infiltration in the bone marrow is accompanied by marked microenvironment alterations, including increased angiogenesis, osteosclerosis, and sometimes fibrosis. Little is known about the mast cell-derived molecules contributing to these bone marrow alterations. We show here that neoplastic mast cells in patients with systemic mastocytosis express oncostatin M (OSM), a profibrogenic and angiogenic modulator. To study the regulation of OSM expression, KIT D816V was inducibly expressed in Ba/F3 cells and was found to up-regulate OSM mRNA and protein levels, suggesting that OSM is a KIT D816V-dependent mediator. Correspondingly, KIT D816V(+) HMC-1.2 cells expressed significantly higher amounts of OSM than the KIT D816V(-) HMC-1.1 subclone. RNA interference-induced knockdown of STAT5, a key transcription factor in KIT D816V(+) mast cells, inhibited OSM expression in HMC-1 cells, whereas a constitutively activated STAT5 mutant induced OSM expression. Finally, OSM secreted from KIT D816V(+) mast cells stimulated growth of endothelial cells, fibroblasts, and osteoblasts, suggesting that mast cell-derived OSM may serve as a key modulator of the marrow microenvironment and thus contribute to the pathology of systemic mastocytosis.

Increased total cytokeratin-18 serum and urine levels in chronic kidney disease.

BACKGROUND: Increased cell death in chronic kidney disease (CKD) by either necrosis or apoptosis has been confirmed by a variety of studies. Possible sources are an inadequate persistent inflammation and ischemia as a consequence of CKD or caused by the underlying renal disease. Detection of total or caspase cleaved cytokeratin 18 (CK-18) is a novel and elegant method to determine necrosis or apoptosis of epithelial cells in the patients' sera and urine. METHODS: 120 patients with CKD stages 1 to 5 were included in the study. Twenty healthy volunteers served as controls. Total and caspase cleaved CK-18 urine and serum concentrations were determined by ELISA. RESULTS: The concentration of serum total CK-18 was significantly higher in CKD stages 3-5 as compared to the healthy controls. Urinary total CK-18 excretion was increased in patients with CKD 5 compared to controls. A significant correlation between urine total CK18 and urine protein and albumin levels was found. Moreover, ROC curve analysis showed the potential of serum and especially urine total CK-18 levels to predict various CKD stages. CONCLUSIONS: We provide evidence for increased total CK-18 serum and urine levels in CKD patients, possibly indicating that epithelial cell necrosis is prevalent in CKD.

Interference of Mycoplasma infection in a gene expression study: it was the environment and not the gene.

We show that short-term exposure to doxycycline, as used in tetracycline-inducible gene expression models, protects cells from stress-induced death in cultures infected with Mycoplasma arginini. Coinciding with the expected maximum level of gene activity, antimicrobial effects of tetracyclines might be mistaken for antiapoptotic properties of the expressed gene product.

Cardiac glycosides induce cell death in human cells by inhibiting general protein synthesis.

BACKGROUND: Cardiac glycosides are Na(+)/K(+)-pump inhibitors widely used to treat heart failure. They are also highly cytotoxic, and studies have suggested specific anti-tumor activity leading to current clinical trials in cancer patients. However, a definitive demonstration of this putative anti-cancer activity and the underlying molecular mechanism has remained elusive. METHODOLOGY/PRINCIPAL FINDINGS: Using an unbiased transcriptomics approach, we found that cardiac glycosides inhibit general protein synthesis. Protein synthesis inhibition and cytotoxicity were not specific for cancer cells as they were observed in both primary and cancer cell lines. These effects were dependent on the Na(+)/K(+)-pump as they were rescued by expression of a cardiac glycoside-resistant Na(+)/K(+)-pump. Unlike human cells, rodent cells are largely resistant to cardiac glycosides in vitro and mice were found to tolerate extremely high levels. CONCLUSIONS/SIGNIFICANCE: The physiological difference between human and mouse explains the previously observed sensitivity of human cancer cells in mouse xenograft experiments. Thus, published mouse xenograft models used to support anti-tumor activity for these drugs require reevaluation. Our finding that cardiac glycosides inhibit protein synthesis provides a mechanism for the cytotoxicity of CGs and raises concerns about ongoing clinical trials to test CGs as anti-cancer agents in humans.

Comparison of multiplex ligation-dependent probe amplification and real-time PCR accuracy for gene copy number quantification using the beta-defensin locus.

The reliable quantification of gene copy number variations is a precondition for future investigations regarding their functional relevance. To date, there is no generally accepted gold standard method for copy number quantification, and methods in current use have given inconsistent results in selected cohorts. In this study, we compare two methods for copy number quantification. beta-defensin gene copy numbers were determined in parallel in 80 genomic DNA samples by real-time PCR and multiplex ligation-dependent probe amplification (MLPA). The pyrosequencing-based paralog ratio test (PPRT) was used as a standard of comparison in 79 out of 80 samples. Realtime PCR and MPLA results confirmed concordant DEFB4, DEFB103A, and DEFB104A copy numbers within samples. These two methods showed identical results in 32 out of 80 samples; 29 of these 32 samples comprised four or fewer copies. The coefficient of variation of MLPA is lower compared with PCR. In addition, the consistency between MLPA and PPRT is higher than either PCR/MLPA or PCR/PPRT consistency. In summary, these results suggest that MLPA is superior to real-time PCR in beta-defensin copy number quantification.