CYP-450 Epoxygenase Derived Epoxyeicosatrienoic Acid Contribute To Reversal of Heart Failure in Obesity-Induced Diabetic Cardiomyopathy via PGC-1 α Activation

We have previously shown that an Epoxyeicosatrienoic Acid (EET) -agonist has pleiotropic effects and reverses cardiomyopathy by decreasing inflammatory molecules and increasing antioxidant signaling. We hypothesized that administration of an EET agonist would increase Peroxisome proliferator-activated receptor-gamma coactivator (PGC-1α), which controls mitochondrial function and induction of HO-1 and negatively regulates the expression of the proinflammatory adipokines CCN3/NOV in cardiac and pericardial tissues. This pathway would be expected to further improve left ventricular (LV) systolic function as well as increase insulin receptor phosphorylation. Measurement of the effect of an EET agonist on oxygen consumption, fractional shortening, blood glucose levels, thermogenic and mitochondrial signaling proteins was performed. Control obese mice developed signs of metabolic syndrome including insulin resistance, hypertension, inflammation, LV dysfunction, and increased NOV expression in pericardial adipose tissue. EET agonist intervention decreased pericardial adipose tissue expression of NOV, while normalized FS, increased PGC-1α, HO-1 levels, insulin receptor phosphorylation and improved mitochondrial function, theses beneficial effect were reversed by deletion of PGC-1α. These studies demonstrate that an EET agonist increases insulin receptor phosphorylation, mitochondrial and thermogenic gene expression, decreased cardiac and pericardial tissue NOV levels, and ameliorates cardiomyopathy in an obese mouse model of the metabolic syndrome.

Abstract P461: The Association of NOV/CCN3 With Obstructive Sleep Apnea in Severe Morbid Obesity: Preliminary Evidence of a Novel Biomarker in OSA

Background: Obstructive sleep apnea (OSA) is strongly associated with cardiovascular and metabolic abnormalities, although the mechanism driving this association is not well understood. NOV/CCN3, a multifunctional extracellular matrix protein, may play a mechanistic and/or prognostic role in these associations. We hypothesized that patients with OSA will have increased levels of NOV, and that NOV can serve as a biomarker in patients to predict OSA as well as metabolic and cardiac risk.

Materials and Methods: 10 morbidly obese subjects presenting to the sleep laboratory for clinical evaluation of possible OSA and 10 healthy lean controls underwent overnight polysomnography and clinical evaluation. Blood samples were analyzed for NOV levels, adiponectin, and IL-6.

Results: OSA was found in 9 obese subjects and 3 lean subjects. NOV levels were significantly higher in the obese vs lean group (2.2±0.3 vs 1.4±0.2 fold change, p<0.03) while apnea-hypopnea index (AHI) was similarly higher in the obese vs lean group (22.9±6.7 vs 8.4±4.1 events/hr, p<0.03). NOV and AHI were positively correlated (ρ=0.49, p=0.033). IL-6 was elevated while adiponectin was reduced in obese vs lean.

Conclusions: NOV levels and AHI, a measure of OSA severity, were higher in obese subjects vs lean controls and were correlated with each other. NOV may be a marker of OSA severity and a biomarker for cardiovascular and metabolic disease in OSA patients.

The association of NOV/CCN3 with obstructive sleep apnea (OSA): preliminary evidence of a novel biomarker in OSA

Obstructive sleep apnea (OSA) has a strong association with cardiovascular and metabolic abnormalities, although the mechanism driving this association is not well established. NOV/CCN3, a multifunctional extracellular matrix protein, may play a mechanistic and/or prognostic role in these associations. We hypothesized that patients with OSA, which primarily affects obese individuals, will have increased levels of NOV, and that NOV can serve as a biomarker in patients to predict OSA as well as metabolic and cardiac risk. Ten morbidly obese and 10 healthy lean subjects underwent overnight polysomnography (PSG) and clinical evaluation. Blood samples were analyzed for NOV levels, adiponectin and IL-6. OSA was found in nine obese subjects and three lean subjects. NOV levels were significantly higher in the OSA vs. no OSA group (2.1 ± 0.9 vs. 1.3 ± 0.8, p < 0.03). NOV levels were significantly higher in the obese vs. lean group (2.2 ± 0.3 vs. 1.4 ± 0.2-fold change, p < 0.03). Among lean subjects, NOV levels were significantly higher in the OSA vs. no OSA group (2.1 ± 0.9 vs. 1.0 ± 0.4, p < 0.05). NOV and AHI were positively correlated (ρ = 0.49, p = 0.033). IL-6 and adiponectin differences in obese vs. lean and OSA vs. no OSA were consistent with an inflammatory phenotype in obese subjects and OSA subjects. NOV is a novel biomarker of the presence and severity of OSA and a potential marker of future cardiovascular and metabolic disease in OSA patients.

Milestones: a rapid assessment method for the Clinical Competency Committee

INTRODUCTION

Educational milestones are now used to assess the developmental progress of all U.S. graduate medical residents during training. Twice annually, each program's Clinical Competency Committee (CCC) makes these determinations and reports its findings to the Accreditation Council for Graduate Medical Education (ACGME). The ideal way to conduct the CCC is not known. After finding that deliberations reliant upon the new milestones were time intensive, our internal medicine residency program tested an approach designed to produce rapid but accurate assessments.

MATERIAL AND METHODS

For this study, we modified our usual CCC process to include pre-meeting faculty ratings of resident milestones progress with in-meeting reconciliation of their ratings. Data were considered largely via standard report and presented in a pre-arranged pattern. Participants were surveyed regarding their perceptions of data management strategies and use of milestones. Reliability of competence assessments was estimated by comparing pre-/post-intervention class rank lists produced by individual committee members with a master class rank list produced by the collective CCC after full deliberation.

RESULTS

Use of the study CCC approach reduced committee deliberation time from 25 min to 9 min per resident (p < 0.001). Committee members believed milestones improved their ability to identify and assess expected elements of competency development (p = 0.026). Individual committee member assessments of trainee progress agreed well with collective CCC assessments.

CONCLUSIONS

Modification of the clinical competency process to include pre-meeting competence ratings with in-meeting reconciliation of these ratings led to shorter deliberation times, improved evaluator satisfaction and resulted in reliable milestone assessments.

Racing Against the Clock: Internal Medicine Residents' Time Spent On Electronic Health Records

BACKGROUND

Since the late 1980s, resident physicians have spent increasing amounts of time on electronic health record (EHR) data entry and retrieval. Objective longitudinal data measuring time spent on the EHR are lacking.

OBJECTIVE

We sought to quantify the time actually spent using the EHR by all first-year internal medicine residents in a single program (N = 41).

METHODS

Active EHR usage data were collected from the audit logs for May, July, and October 2014 and January 2015. Per recommendations from our EHR vendor (Cerner Corporation), active EHR usage time was defined as more than 15 keystrokes, or 3 mouse clicks, or 1700 "mouse miles" per minute. Active EHR usage time was tallied for each patient chart viewed each day and termed an electronic patient record encounter (EPRE).

RESULTS

In 4 months, 41 interns accumulated 18,322 hours of active EHR usage in more than 33,733 EPREs. Each intern spent on average 112 hours per month on 206 EPREs. Interns spent more time in July compared to January (41 minutes versus 30 minutes per EPRE, P < .001). Time spent on the EHR in January echoed that of the previous May (30 minutes versus 29 minutes, P = .40).

CONCLUSIONS

First-year residents spent a significant amount of time actively using the EHR, achieving maximal proficiency on or before January of the academic year. Decreased time spent on the EHR may reflect greater familiarity with the EHR, growing EHR efficiencies, or other factors.

Increased HO-1 levels ameliorate fatty liver development through a reduction of heme and recruitment of FGF21

OBJECTIVE

Obese leptin deficient (ob/ob) mice are a model of adiposity that displays increased levels of fat, glucose, and liver lipids. Our hypothesis is that HO-1 overexpression ameliorates fatty liver development.

METHODS

Obese mice were administered cobalt protoporphyrin (CoPP) and stannic mesoporphyrin (SnMP) for 6 weeks. Heme, HO-1, HO activity, PGC1α, FGF21, glycogen content, and lipogenesis were assessed.

RESULTS

CoPP administration increased hepatic HO-1 protein levels and HO activity, decreased hepatic heme, body weight gain, glucose levels, and resulted in decreased steatosis. Increased levels of HO-1 produced a decrease in lipid droplet size, Fatty acid synthase (FAS) levels involving recruitment of FGF21, PPARα, and Glut 1. These beneficial effects were reversed by inhibition of HO activity.

CONCLUSION

Increased levels of HO-1 and HO activity reduced the levels of obesity by reducing hepatic heme and lipid accumulation. These changes were manifested by decreases in cellular heme, increases in FGF21, glycogen content, and fatty liver. The beneficial effect of HO-1 induction results from an increase in PPARα and FGF21 levels and a decrease in PGC1α, levels they were reversed by SnMP. Low levels of HO-1 and HO activity are responsible for fatty liver.

Association of corrected QT interval with long-term mortality in patients with syncope

INTRODUCTION

The electrocardiographic parameters QRS duration, QRS-T angle and QTc can predict mortality in patients with cardiovascular disease. The prgnostic value of these parameters in hospitalized patients with syncope needs investigation.

MATERIAL AND METHODS

We retrospectively studied 590 consecutive patients hospitalized with syncope. After excluding patients with baseline abnormal rhythm, QT- prolonging medications, and missing data, 459 patients were analyzed. Baseline demographic characteristics, co-morbidities, medication use, San Francisco Syncope Rule (SFSR) and Osservatorio Epidemiologico sulla Sincope nel Lazio (OESIL) score and data on mortality were collected. The categorical variables and continuous variables of the 2 groups of patients with prolonged QTc and normal QTc interval were analyzed by Fischer's exact test and Mann-Whitney Test. A stepwise Cox regression model was used for time to death analysis.

RESULTS

Of 459 patients, prolonged QTc interval was observed in 122 (27%). Mean follow-up was 41 months. Patients with prolonged QTc interval had higher prevalence of cardiovascular disease, OESIL score, high risk SFSR, hypertension, dyslipidemia, coronary artery disease, congestive heart failure, and increased mortality. Stepwise Cox regression analysis showed that significant independent prognostic factors for time to death were prolonged QTc interval (p = 0.005), age (p = 0.001), diabetes mellitus (p = 0.001) and history of malignancy (p = 0.006). QRS duration and QRS-T angle were not independent predictors of mortality.

CONCLUSIONS

A prolonged QTc interval is an independent predictor of long-term mortality in hospitalized patients with syncope.

Predictors of in-hospital mortality and acute myocardial infarction in thrombotic thrombocytopenic purpura

BACKGROUND

Despite the widespread availability of plasmapheresis as a therapy, thrombotic thrombocytopenic purpura is associated with significant morbidity and mortality. There is a paucity of data on the predictors of poor clinical outcome in this population. Acute myocardial infarction is a recognized complication of thrombotic thrombocytopenic purpura. Little is known about the magnitude of this problem, its risk factors, and its influence on mortality in patients hospitalized with thrombotic thrombocytopenic purpura.

METHODS

We used the 2001-2010 Nationwide Inpatient Sample database to identify patients aged ≥18 years with the diagnosis of thrombotic thrombocytopenic purpura (International Classification of Diseases, 9th Revision, Clinical Modification [ICD-9-CM] code 446.6) who also received therapeutic plasmapheresis (ICD-9-CM code 99.71) during the hospitalization. Patients with acute myocardial infarction were identified using the Healthcare Cost and Utilization Project Clinical Classification Software code 100. Stepwise logistic regression was used to determine independent predictors of in-hospital mortality and acute myocardial infarction in thrombotic thrombocytopenic purpura patients.

RESULTS

Among the 4032 patients (mean age 47.5 years, 67.7% women, and 36.9% white) with thrombotic thrombocytopenic purpura who also underwent plasmapheresis, in-hospital mortality was 11.1%. Independent predictors of increased in-hospital mortality were older age (odds ratio [OR] 1.03; 95% confidence interval [CI], 1.02-1.04; P <.001), acute myocardial infarction (OR 1.89; 95% CI, 1.24-2.88; P = .003), acute renal failure (OR 2.75; 95% CI, 2.11-3.58; P <.001), congestive heart failure (OR 1.66; 95% CI, 1.17-2.34; P = .004), acute cerebrovascular disease (OR 2.68; 95% CI, 1.87-3.85; P <.001), cancer (OR 2.49; 95% CI, 1.83-3.40; P <.001), and sepsis (OR 2.59; 95% CI, 1.88-3.59; P <.001). Independent predictors of acute myocardial infarction were older age (OR 1.03; 95% CI, 1.02-1.04; P <.001), smoking (OR 1.60; 95% CI, 1.14-2.24; P = .007), known coronary artery disease (OR 2.59; 95% CI, 1.76-3.81; P <.001), and congestive heart failure (OR 2.40; 95% CI, 1.71-3.37; P <.001).

CONCLUSION

In this large national database, patients with thrombotic thrombocytopenic purpura had an in-hospital mortality rate of 11.1% and an acute myocardial infarction rate of 5.7%. Predictors of in-hospital mortality were older age, acute myocardial infarction, acute renal failure, congestive heart failure, acute cerebrovascular disease, cancer, and sepsis. Predictors of acute myocardial infarction were older age, smoking, known coronary artery disease, and congestive heart failure.

Abstract 374: EET Agonist Improves Cardiac Energy Metabolism and Heart Function by Regulating Fatty Acid Oxidation and Oxidative Stress in Infarcted Myocardium

Introduction: Myocardial Ischemia (MI), one of the major causes of heart failure, is associated with cardiac remodeling, insufficient angiogenesis and enhanced oxidative stress. Cytochrome P450 epoxygenase metabolites of arachidonic acid, EETs, have multiple cardiovascular effects, including vasodilation, inhibition of inflammatory response and stimulation of epithelial cell growth. In addition, emerging studies indicate a role of these unique lipid mediators in the regulation of metabolic homeostasis. We propose that EET agonists reduce post infarcted cardiac remodeling by improving cardiac dysfunction through increased angiogenesis improved cardiac energy metabolism and a reduction in oxidative stress.

Methods: C57B16 mice were divided into 3 groups: sham, mice with myocardial infarction (MI) via LAD ligation and mice with MI treated with an EET-agonist (NUDSA). NUDSA was administered after 5 days of MI (0.5 mg/kg) in C57B16 mice. Myocardial echocardiography was performed 30 days after MI to assess the cardiac function. Capillary density, oxidative stress and cardiac energy metabolism markers were compared among the groups.

Results: Echocardiography showed that left ventricle dilatation, measured as end diastolic area (EDA), was reduced in NUDSA treated groups compared to the MI group (C57, EDA: MI: 0.413 ±0.02 cm 2 ; MI+NUDSA: 0.217±0.03 cm 2 ; p<0.05). Cardiac Index, decreased by MI, was restored by NUDSA in C57 mice. Cardiac histological examination revealed an increase in myocardial angiogenesis and capillary density in mice treated with NUDSA (p<0.01 vs. MI). Cardiac tissue showed an increased expression of ETS-1, phosphorylated Acetyl CoA Carboxylase (pACC) and Carnitine Palmitoyl Transferase I (CPT-1) along with a decrease in 3NT and gpphox 91 expression in mice treated with NUDSA as compared to the MI group (p<0.05).

Conclusion: This is the first study to demonstrate that EET improves cardiac energy metabolism in infarcted heart by regulating fatty acid oxidation and ameliorating oxidative stress and cardiac remodeling. Thus pharmacological induction of EET may open new avenues in the treatment of patients with post infarcted heart failure.

Abstract 397: HMOX1 Ameliorates Fatty Liver and Metabolic Syndrome by Reduction of Hepatic Heme and PGC1a

Introduction: Nonalcoholic fatty liver (NAFLD) occurs in a setting of high fat diets, insulin resistance, obesity and dyslipidemia. Individuals with NAFLD have an increased risk of developing metabolic syndrome. Heme oxygenase-1 (HMOX1), a major cytoprotective enzyme, attenuates oxidative stress and obesity and increases insulin sensitivity. The antioxidant effect of HMOX1 is due to an increase in ferritin, and bilirubin and a decrease in heme, a pro-oxidant. The aim of this study was to examine the role of increased hepatic HMOX activity in decreasing steatosis, adiposity and vascular dysfunction and to determine the mechanism underlying these metabolic changes in obese mice.

Methods: Obese mice were administered cobalt protoporphyrin (CoPP) and HMOX activity inhibitor stannous mesoporphyrin (SnMP) for 6 weeks. Blood pressure, body weight and blood glucose levels were measured in all the groups. Glycogen content, hepatic fibrosis, heme levels, fatty acid synthase (FAS) and lipid droplet size in liver were also assessed.

Results: CoPP administration increased hepatic HMOX1 protein levels and HMOX activity, decreased blood pressure, body weight, blood glucose levels, hepatic heme content (p<0.05) as compared to obese mice. Our results also showed that HMOX1 induction causes a significant decrease in lipid steatosis ( lipid droplet size and FAS levels; p<0.01) as compared to obese mice. Densitometry analysis showed increased expression of PPARα and Glut 1 along with decreased expression of PGC1α in hepatic tissue. These beneficial effects were reversed by administration of SnMP.

Conclusion: This novel study demonstrates the role of hepatic HMOX1 in attenuating the fatty liver and metabolic homeostasis by decreasing PGC1α and heme content and enhancing glycogen levels. Pharmacological agents that increase HMOX1 levels or gene targeting of HMOX1 offer a promising therapeutic target for NAFLD and suggest the existence of a significant link between the heme-HMOX system and the extent and severity of heme-dependent fatty liver.

HO-1 induction improves the type-1 cardiorenal syndrome in mice with impaired angiotensin II-induced lymphocyte activation

Type-1 cardiorenal syndrome, characterized by acute kidney dysfunction secondary to cardiac failure and renal arteriolar vasoconstriction, is mediated by the renin-angiotensin-aldosterone axis and sympathetic nervous system activation. Previous reports indicate that angiotensin II modulates immune function and causes recruitment and activation of T-lymphocytes. The goal of this study was to evaluate the effects of postischemic heart failure on renal morphology and circulation and the beneficial effects of heme oxygenase-1 (HO-1) induction in T-lymphocyte-suppressed severe combined immune deficiency (SCID) mice. Mice were divided into 4 groups: sham, myocardial infarction (MI), MI treated with an HO-1 inducer, cobalt protoporphyrin, and with or without stannous mesoporphyrin, an inhibitor of HO activity. Heart and kidney function were studied 30 days after surgery. Fractional area change was reduced 30 days after surgery in both the C57 and SCID MI-groups as compared with their respective controls (P<0.01). Renal Pulsatility Index and renal injury were increased in C57 and SCID MI-groups compared with the sham group. HO-1 induction improved renal vasoconstriction as well as ameliorated renal injury in both the SCID and C57 MI-groups (P<0.01). However, improvement was more evident in SCID mice. In addition, our results showed that plasma creatinine, angiotensin II, and renin were significantly increased in the C57 and SCID MI-groups as compared with their respective controls. HO-1 induction decreased these parameters in both MI groups. Stannous mesoporphyrin reversed the beneficial effect of cobalt protoporphyrin in both mouse strains. The study demonstrates that T-lymphocyte suppression facilitated the HO-1-dependent improvement in the attenuation of type-1 cardiorenal syndrome.

Abstract 287: Association of Primary Payer Status and In-Hospital Mortality After Heart Transplant: A Nationwide Inpatient Sample Study

Background: Medicaid enrollment and expenditures are projected to increase sharply with the Affordable Care Act’s eligibility expansions. However, the impact of these changes on outcomes after heart transplant procedure has not been studied before. The aim of this study was to analyze the relationship between payment source and outcomes following heart transplant in a national database.

Methods: We used the Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) to evaluate patients who obtained a heart transplant (ICD 9 procedure codes 37.51). Discharge weights were used to obtain nationwide estimates. A total of 2,329 heart transplant procedures were identified in the NIS database, corresponding to an estimated 11,536 nationwide heart transplant procedures between 2005 and 2010. Patients were stratified on the basis of payer status: Medicare (30%), Medicaid (17%), private insurance (52%), and uninsured (1.5%). Multivariable logistic regression models were used to assess the effect of primary payer status on in-hospital mortality.

Results: Patients had a mean age of 47 (±19) years, 26% were women and 55% were whites. Among insured patients, compared with private insurance, a higher unadjusted in-hospital mortality rate was found among patients with Medicare (4.3% vs. 6.4%; OR, 1.57; 95% CI, 1.31-1.89; P <0.001), and Medicaid (5.3%; OR, 1.30; 95% CI, 1.03-1.63; P=0.028). After controlling for patient demographics, comorbidities, income, hospital features and hospital region, Medicaid (OR, 1.41; 95% CI, 1.09-1.83; P=0.009) and Medicare (OR, 1.60; 95% CI, 1.31-1.96; P<0.0001) payer status were independently associated with higher in-hospital mortality. Length of stay was longest for Medicaid patients (48 ± 52 days) and shortest for Medicare patients (33 ± 38 days, P <0.001). Medicaid patients also accrued the highest unadjusted hospital charges (USD 518,233 ± 314,717, P <0.001).

Conclusion: In this national study of hospitalized patients undergoing heart transplant, uninsured payer status was rare. Medicaid or Medicare payer status was associated with increased risk adjusted in-hospital mortality, while Medicaid payer status was also associated with increased length of stay and increased hospital charges. Further prospective studies are needed to elucidate factors that are responsible for such disparities in outcomes by payer status.

Abstract 90: Ten-year Trends in Mechanical Revascularization, Intra-Aortic Balloon Pump Use and In-Hospital Mortality in Patients With Acute Myocardial Infarction Complicated by Cardiogenic Shock

Background: Early mechanical revascularization with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock is associated with improved survival. The current guidelines also recommend (Class IIa) the use of intra-aortic balloon pump (IABP) in patients with cardiogenic shock. However, the evidence supporting this recommendation is controversial.

Objectives: To examine the trends (2001-2010) in mechanical revascularization, IABP use and in-hospital mortality in patients with cardiogenic shock complicating AMI and to determine if IABP use is associated with improved in-hospital survival among these patients.

Methods: We conducted a retrospective trend analysis of the Healthcare Cost and Utilization Project’s Nationwide Inpatient Sample (NIS) database from 2001-2010. All patients ≥ 40 years of age with AMI and cardiogenic shock were identified using ICD-9-CM diagnosis codes. Trends in mechanical revascularization (PCI or CABG), IABP use and in-hospital mortality were analyzed. We used logistic regression analysis to determine the association between IABP use and in-hospital mortality.

Results: From 2001-2010, among 6,670,347 patients aged ≥ 40 years admitted with AMI, 287,256 (4.3%) had cardiogenic shock. The proportion of patients with cardiogenic shock complicating AMI increased from 3.7% in 2001 to 5.1% in 2010 (P trend < 0.001). There was a significant increase in mechanical revascularization rates (49.7% in 2001 to 66.3% in 2010, P trend < 0.001) as well as IABP use (38.7% in 2001 to 47.8% in 2010, P trend < 0.001) in these patients over the 10-year period. The overall in-hospital mortality among patients with AMI and cardiogenic shock decreased from 48.6% in 2001 to 32.7% in 2010 (P trend < 0.001). When adjusted for demographics, cardiovascular risk factors and mechanical revascularization status, IABP use was associated with higher in-hospital mortality (adjusted OR 1.14, 95% CI 1.11-1.16, P<0.001). Similarly, in the subgroup of patients who underwent mechanical revascularization, in-hospital mortality was higher among those with IABP placement (adjusted OR 1.39, 95% CI 1.35-1.43, P <0.001).

Conclusion: Mechanical revascularization rates in patients with cardiogenic shock complicating AMI have increased during the past decade. This is also associated with a decrease in in-hospital mortality during this period. IABP use has also increased over the past 10 years; however, IABP use is associated with higher in-hospital mortality among patients with AMI and cardiogenic shock.

Abstract 201: Predictors of Stroke in Hospitalized Patients with Thrombotic Thrombocytopenic Purpura

Background: Stroke may be the presenting symptom of thrombotic thrombocytopenic purpura (TTP), but the predictors of stroke in patients with TTP are unknown. We sought to seek the differences in characteristics in TTP patients presenting with and without stroke.

Methods: The study examined data from the Nationwide Inpatient Sample (NIS), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality for the years 2001 to 2010. Patients aged ≥ 18 years with the diagnosis of TTP (ICD-9 code 446.6) who received therapeutic plasmapheresis (ICD-9 code 99.71) were included for analysis. Patients with stroke among the group were identified using the HCUP clinical classification Software code (109 for stroke). Data on baseline characteristics and mortality were analyzed.

Results: A total of 4032 patients were identified to have TTP. Among these patients, 329 (8.16%) had the diagnosis of stroke. The independent predictors of stroke in this population by logistic regression analysis were age (OR 1.017; 95% CI 1.008 -1.026 p<0.001), white race (OR 0.704; 95% CI 0.536-0.926 p=0.012), dyslipidemia (OR 1.876; 95% CI 1.309-2.689 p= 0.001) and acute myocardial infarction (AMI) (OR 3.108; 95% CI 2.090-4.621 p<0.001). Independent predictors of in-hospital mortality in patients with TTP who developed stroke were hypertension (OR 0.399; 95% CI 0.190-0.839 p= 0.015), acute renal failure (OR 2.178; 95% CI 1.063-4.461 p=0.033), atrial fibrillation (OR 17.170; 95% CI 3.349-88.030 p=0.001), and ventricular tachycardia/ ventricular fibrillation/cardiac arrest (OR 12.748; 95% CI 1.982-81.979 p=0.007).

Conclusion: Stroke develops in 8.16% of patients admitted with TTP. The independent predictors of stroke in this group of patients are age, white race, dyslipidemia, and AMI.

Operationalizing the internal medicine milestones-an early status report

BACKGROUND

The internal medicine milestones were developed to advance outcomes-based residency training and will play an important role in the next accreditation system.

INNOVATION

As an element of our program's participation in the internal medicine educational innovations project, we implemented a milestones-based evaluation process in our general medicine and pulmonary-critical care rotations on July 1, 2010.

MEASURES

Outcomes assessed included survey-rated acceptability to participating faculty, residents, and clinical competency committee members.

RESULTS

Faculty and residents agreed that the milestones promoted a common understanding of what knowledge, skills, and attitudes should be displayed at particular points in residents' professional development and enhanced evaluators' ability to provide specific performance feedback. Most residents and faculty members agreed that the milestones promoted fairness and uniformity in the evaluation process. Clinical competency committee members agreed the milestones improved the quality of information available for deliberations and resulted in more uniform promotion standards. Faculty rated the use of too many milestones per form/tool at a mean of 7.3 (where 1 was minimally problematic, and 10 was maximally problematic) and the potential for evaluator fatigue (mean, 8.2) as the most significant challenges to the use of milestones. Eight of 12 faculty members would recommend milestones in other programs; 4 were uncertain.

CONCLUSIONS

Despite logistical challenges, educators and trainees found that milestones promoted a common understanding of what knowledge, skills and attitudes should be displayed at particular stages of training; permitted greater specificity in performance feedback; and enhanced uniformity and fairness in promotion decisions.

Peroxisome proliferator-activated receptor delta agonist attenuates nicotine suppression effect on human mesenchymal stem cell-derived osteogenesis and involves increased expression of heme oxygenase-1

Smoking has long been associated with osteoporosis, decreased bone mineral density, increased risk of bone fracture, and increased health costs. Nicotine, the main component of cigarette smoke, has major negative effects on bone metabolism and skeletal remodeling in vivo. Although osteoblasts and osteoblast-like cells have been used extensively to study the impact of nicotine, few studies have been performed on human mesenchymal stem cells (hMSCs). In this context, we examined the impact of nicotine on (a) hMSCs proliferation, (b) osteoblastic differentiation, (c) alkaline phosphatase (ALP) activity, and (d) expression of canonical genes during differentiation of hMSCs. MSCs isolated from human bone marrow were treated with different concentrations (0, 0.1, 1 and 10 μM) of nicotine for 7 days. Nicotine caused a dose-dependent decrease in cell proliferation, decreased heme oxygenase-1 (HO-1) expression (p < 0.05) and attenuated osteogenesis (p < 0.05) in hMSCs (45 % reduction at day 14). In addition, nicotine caused a dose-dependent decrease in alizarin red staining for calcium and staining for ALP. Induction of HO-1 by peroxisome proliferator-activated receptor delta agonist (GW0742) prevented the effect of nicotine. Nicotine caused a dose-dependent reduction in the expression of BMP-2, a well-known marker for bone formation; however, this was prevented by GW0742 treatment. Therefore, induction of HO-1 prevents the deleterious effects of nicotine on osteogenesis in hMSC. This offers insight into both how nicotine affects bone remodeling and a therapeutic approach to prevent fracture and osteoporosis in smokers.

Abstract 61: Adipose Tissue Specific HO-1 Induction Regulates the Crosstalk between Wnt and β-catenin Pathways and Leads to Restoration of Vascular Endothelial Function in Mice Fed a High Fat Diet

The principal goal of the present study is to examine the contributions of adipocyte specific over expression of the cytoprotective gene heme oxygenase-1 (HO-1) in modulating vascular function in an animal model of diet induced obesity. A lentiviral construct of the human HO-1 was synthesized under the control of an aP2-activated promoter so as to ensure HO-1 targeting to murine adipocytes. Lentiviruses (50 μl, 2x109 TU/ml in saline) were injected into the C57BL/6 mice by a single intracardiac injection. Mice (6-7 wks old) were divided into 4 groups: Control, high fat diet (HF) mice receiving the control Lenti-aP2-GFP (HF-GFP) and high fat diet mice receiving the lenti-aP2-HO-1 (HF-HO-1) with and without treatment with SnMP. Transduction of lenti-aP2-HO-1 increased human HO-1 expression in adipose tissues without affecting endogenous mice HO-1 (p<0.01). In mice fed a HF diet, lenti-aP2-HO-1 transduction attenuated the increases in body weight (from 52.0±1.0 g to 35.6±2.1g; p<0.01), blood glucose (from 255±3.5 g to 140±2.9mg/dl), blood pressure (from 135±2.8mmHg to 101±2.2mmHg; p<0.01) and inflammatory cytokines as well as the content of both visceral (from 5.5±0.15g to 2.9±0.22g; p<0.05) and subcutaneous fat (p<0.05). Transduction of lenti-aP2-HO-1 increased the numbers of adipocytes of small cell size (p<0.05), insulin sensitivity (p<0.05), adiponectin levels (from 32.4±1.9μg/ml to 19.9±2.1μg/ml; p<0.05) as well as vascular relaxation to acetylcholine ( p<0.05) compared to HF mice administered the lenti-aP2- GFP. Adipocytes of mice fed a HF diet expressed high levels of PPARγ, aP2, C/EBP and Wnt5b proteins and displayed marked increases in Peg1/Mest (p<0.03). Lenti-aP2-HO-1 transduction lowered the elevated levels of these proteins and increased Shh, Wnt10b and β-catenin (p<0.05). Inhibition of HO activity by administration of tin mesoporphyrin (SnMP) to HF-fed mice transduced with the lenti-aP2-HO-1 reversed the decrease in Peg 1/Mest, TNFα and MCP-1 levels. This novel study demonstrate that adipocyte-specific overexpression of HO-1 attenuates HF-mediated adiposity and vascular dysfunction, increases insulin sensitivity and improves adipocyte function by increasing adiponectin, Shh and WNT10b and decreasing inflammatory cytokines.

Abstract 648: Heme-oxygenase-1 Gene Expression Ameliorates Cardiac Dysfunction Following Myocardial Infarction In C57 Mice By Recruitment Of Angiogenic Factors And Angiogenesis In C57 Mice

Rational: Angiogenesis is essential in order to increase blood circulation in infarcted tissue of MI (Myocardial infarction). Increased Heme-Oxygenase (HO)-1 gene expression increases angiogenic proteins, e.g. VEGF, bFGF, EGF, angiopoietin and adiponectin.

Objective: To investigate whether increased levels of HO-1, after the occurrence of a MI, improves angiogenesis and capillary formation in ischemic myocardium, thereby improving cardiac function.

METHODS: Experimental MI was induced by LAD (Left anterior descending artery) ligation. C57BL6 mice were divided into 4 groups: Sham; MI; 5 days after MI treated with the HO-1 inducer, cobalt protoporphyrinIX (CoPP); and, CoPP in the presence of the HO activity inhibitor, Stannous Mesoporphyrin (SnMP). HO-1 downstream signaling proteins were determined including VEGF, CD31 and adiponectin. Echocardiography was performed weekly for 4 weeks after surgery.

Results: 5 days after MI, CoPP treatment significantly increased VEGF (p<0.05 vs.MI), CD31 (p<0.05 vs.MI), and adiponectin levels (p<0.05 vs.MI). These findings were associated with a significant increase in capillary formation and blood flow in CoPP-treated animals (p<0.05 vs.MI). Echocardiography showed that left ventricle dilatation, measured as end diastolic area (EDA), was significantly reduced in CoPP- treated animals compared to MI groups (EDA: MI: 0.216±0.02cm2; MI+CoPP: 0.172±0.03 cm2; (-13%) p<0.01). This was associated with a significant decrease in apoptosis and fibrosis (P<0.05). These beneficial effects were reversed by SnMP administration.

Conclusion: HO-1 improved cardiac function and enhanced angiogenesis via the recruitment of pro-angiogenic factors.

Abstract 357: Targeting Vascular Endothelium with HO-1 Gene Promotes Release of Positive Regulators of Adipocyte Function

Vascular endothelium is a secretory organ which not only regulates vascular function but also secretes bioactive compounds to modulate tissue homeostasis. We aimed to characterize the physiological effects of up regulating endothelial heme oxygenase-1 (HO-1) on adipogenesis in mesenchymal stem cells (hMSCs). Human microvessel endothelial cells (hMEC-1) were cultured along with a lentiviral construct expressing human HO-1 under the control of endothelium specific promoter VE-cadherin (VECAD-HO1) with VECAD-GFP used as a negative control. In complementary experiments hMEC-1 cells were cultured in the presence or absence of siRNA-HO-1 with scrambled siRNA as a negative control. Three days post-transfection, the conditioned media (CM) from hMEC-1 cells was used, along with adipogenic growth factors, to promote adipogenesis in hMSCs. Supporting in vivo experiments were conducted in SD rats injected with either VECAD-HO-1 or VECAD-GFP construct via the tail vein. Transduction efficiency was confirmed in hMEC-1 cells by demonstrating over expression (p<0.05) of HO-1 or GFP in respectively treated cells. hMSCs exposed to CM from VECAD-HO-1 transfected cells demonstrated reduced (p<0.05) adipogenesis (0.16± 0.008 vs 0.12±0.006 ) as compared to hMSCs exposed to CM from VECAD-GFP cells. On the contrary, CM from hMEC-1 cells treated with siRNA for HO-1 promoted higher adipogenesis (p<0.05) with increased adipocyte hypertrophy as opposed to hMSCs treated with CM from hMEC-1 cells transfected with the control siRNA (p<0.05) (0.17±0.008 vs 0.14±0.04). These effects on hMSCs were corroborated by immunoblot analysis demonstrating reduced expression (p<0.05) of positive regulators of adipogenesis, PPARγ, and increased levels (p<0.05) of negative regulators, β-catenin, Wnt 5b and hedgehog in cells treated with CM from hMEC-1 transfected with VECAD-HO1. In SD rats transfected with VECAD-HO-1, plasma adiponectin levels were enhanced (p<0.05) along with increased (p<0.05) adipose tissue levels of pAKT and pAMPK. In conclusion, we show here that a crosstalk between the vascular endothelium and its microenvironment has the potential to regulate adipogenesis and improve adipocyte function via HO-1-depndent pathways.

Abstract 636: Angiotensin II-Mediated Endothelial Cell Dysfunction Contributes to Adipocyte Stem Cell Dysfunction and Adiposity

Rationale: Crosstalk between perivascular adipose tissue and endothelial cells has been proposed to modulate vascular homeostasis. However, paracrine regulatory effects of the stressed endothelium on adipose tissue are relatively unknown.

Objective: We examined the hypothesis that redox mechanisms in endothelial cells can regulate adipocyte function, in a paracrine fashion, via suppression of the Wnt10b/β-catenin-dependent pathways.

METHODS: Human umbilical vein endothelial cells (HUVEC) were treated with AngII (1-50 μM) in the absence and in the presence of the heme oxygenase (HO-1) inducer_cobalt protoporphyrin (CoPP)_or to HO-1 activity inhibitor_stannous mesoporphyrin (SnMP). Adipogenesis was then induced in mesenchymal stem cells, in the presence (10%) or absence of conditioned media (CM) from HUVECs.

Results: MSCs exposed to CM from AngII-treated HUVEC displayed enhanced adipogenesis (0.026±0.001 vs. 0.031±0.001, n=6, p<0.0405). This effect was reversed in MSCs supplemented with CM from HUVECs treated with AngII and CoPP (0.021±0.001, n=6, p<0.0024). This beneficial effect of CoPP in MSCs exposed to CM is reversed by SnMP (0.030±0.001, n=6, p<0.0462) and corroborates the ability of HO-1 in attenuating AngII-dependent adipocyte dysfunction. Complementary immunoblot analysis showed an attenuative effect of AngII on Wnt10b and β-catenin expression (p<0.05). Additionally, AngII enhanced the expression of adipogenic regulators including PPARY, CEBPα, and aP2, which was decreased by CoPP and increased by SnMP.

Conclusion: Our results show that EC dysfunction, as a result of treatment with AngII, contributes to increased adipogenesis in MSCs by the release of negative regulators of adipogenesis. We also show that up-regulation of antioxidant HO-1 ameliorates these effects of AngII. This novel observation suggests that paracrine crosstalk between HUVECs and adipocytes increases endothelial stress to affect adipocyte structure and function. These phenomena might contribute to the metabolic imbalance frequently encountered in conditions associated with chronic endothelial dysfunction and adiposity.