Safety and effectiveness of His-bundle pacing and left bundle branch pacing (conduction system pacing) as a first option for cardiac pacing – results of a single-center

Background

Conduction system pacing (CSP) (His bundle pacing and left bundle pacing) is a group of techniques intended to achieve cardiac pacing with a narrow QRS complex through a lead directly inserted in conduction system structures. The safety and effectiveness of this technique are not yet fully understood.

Purpose

To describe the short-term implant findings and safety profile of CSP as a first option after 4 years in a single center.

Methods

In a period of 42 months, 214 patients were submitted to CSP as a first strategy to restore AV synchrony (pacemakers for AV block or sinus node dysfunction) or as a resynchronization (CRT) strategy (for patients with heart failure and bundle branch block). CSP lead was implanted in lieu of a conventional right ventricular lead in pacemaker cases, and in addition or in lieu of a coronary sinus lead, in CRT cases, depending on the technical and anatomical possibilities.

Results

The mean age was 76.7±16.4 years, 65% males. 162 patients implanted a CSP lead for a dual-chamber pacemaker, 3 patients for a single chamber pacemaker, 32 patients for CRT-D (CSP lead replacing the coronary sinus lead with a defibrillator), and 13 patients for an optimized CRT (CSP lead plus coronary sinus lead). In 16 patients (7.4%) the technique of choice was His bundle pacing, two of them presented with subacute elevated thresholds, requiring new lead implantation at the moment of generator pulse replacement. One patient submitted to left bundle branch pacing (0.4%) had subacute lead dislodgement, being submitted to lead revision. Four patients intended for CRT (1.8%) didn't meet the criteria for His bundle pacing or left bundle branch pacing, being submitted to conventional coronary sinus lead placement. There were 10 cases (4.6%) of confirmed lead perforation during the lead septum insertion, with prompt repositioning, all uneventful. No pericardium effusion related to lead perforation was observed. One patient (0.4%) had a pneumothorax, requiring chest tube drainage.

Conclusion

Conduction system pacing as a first strategy is a feasible, effective and safe technique, both for pacing and for resynchronization purposes, with a complication rate comparable to conventional implantation.

Funding Acknowledgement

Type of funding sources: None.

P3801The impact of the type of response to cardiac resynchronization therapy in the survival of patients with advanced heart failure

Fundamental

Cardiac resynchronization therapy (CRT) reduces total mortality in patients (pt) with advanced heart failure (HF). However, the impact of this reduction is unknown in the different types of response.

Objective

To describe the survival of responders and super responders pt to CRT in a retrospective cohort.

Methods

250 pt who underwent a CRT were retrospectively evaluated. All presented in functional class (FC) III/ IV (NYHA). The criteria of response to CRT were: improvement of FC (>1); increase in ejection fraction (EF) >10% and decrease in left ventricular end-systolic diameter (LVESD) – >15%. They were divided into three groups: Group I – 73/250 pt (33%): responder only by the criterion of FC improvement. Group II - 57/250 pt (24%): responder was defined by three criteria (clinical and echocardiographic). Grupo III - super responder – 48/250 pt (20%): decrease >30% in LVESD and/or EF >45%. The survival and clinical outcomes were analyzed in the 3 groups.

Results

In group I, the mean age was 68.7 years; 75% were male; left bundle branch block (LBBB) was observed in 93% and average QRS duration was 164 ms; EF: 26%; average LVESD and left ventricular end-diastolic diameter (LVEDD): 46 and 57.7 mm, respectively. BIV-ICD was observed in 72% of pt. The mean post-implant survival was 30.8 months (CI95%: 25.06–36.54). In group II, the mean age was 70 years; 82% were male; left bundle branch block (LBBB) was observed in 98% and average QRS duration was 166 ms; EF: 27.5%; average LVESD and LVEDD: 52 and 67 mm, respectively. BIV-ICD was observed in 75% of pt. The mean post-implant survival was 45.4 months (CI95%: 38.96–51.84). In group III, the mean age was 71 years; 65% were male; left bundle branch block (LBBB) was observed in all pt (100%) and average QRS duration was 176 ms; EF: 29.2%; average LVESD and LVEDD: 54 and 68 mm, respectively. BIV-ICD was observed in 70% of pt. The mean post-implant survival was 53 months (CI95%: 45.96–60.04). The total mortality observed was 11%, 17% and 6.25%, respectively (48%: neoplasia; 24%: stroke; 19%: terminal HF; 9%: sepsis).

Conclusion

In the present study, the survival of responders pt to CRT varied according to the type of response, being significantly higher in the super responders and in those who presented echocardiographic criteria of response to CRT. These findings present significant clinical relevance and should be evaluated in future studies.

Abstract P3-05-03: Identification of epigenetically silenced breast cancer driver genes

Breast cancer is clinically and molecularly complex disease driven by aberrant genetic and epigenetic alterations. Epigenetic alterations in particular DNA methylation changes are one of the most important events involved in breast cancer initiation and progression. Previous reports identified many aberrant DNA methylation signatures associated with molecular subtypes of breast cancer and over 100 candidate genes with promoter hypermethylation in breast cancer. However, it remains elusive which of these genes with promoter hypermethylation play “driver” role in tumorigenesis. In previous studies, the average gain of DNA methylation across all cancer samples compared to the average DNA methylation in normal samples has been the criterion to select for potential targets. However, known tumor suppressor driver genes regulated by methylation are relatively infrequently altered in target cancers. Therefore, we propose the paradoxical hypothesis that identifying hypermethylated cancer drivers require focusing on infrequent rather than frequent events. Hence, to identify these potential driver genes, we developed an algorithm with two unique properties. First, unlike previous studies we focused on targets that gained DNA methylation relatively infrequently (10-40%) and that lost expression in breast cancer. Second, using this algorithm, we distinguished cancer dependent gain of DNA methylation from age-dependent gain of methylation. To discern age dependent and independent DNA methylation changes, we generated DNA methylation sequencing data on 29 normal purified breast epithelium (age range 33-82 years old). Furthermore, to study the biological effects of the overexpression or downregulation of these genes, we generated DNA methylation sequencing data on 6 breast cancer cell lines. We also used DNA methylation and RNA expression datasets (675 cancer, 100 normal) available through the TCGA. Using our algorithm, we identified 53 genes with age independent promoter hypermethylation and loss of expression in TCGA tumor samples. To begin testing the biological effects of these driver genes, we performed canonical pathway enrichment analyses using Ingenuity Pathway Analysis software. We also investigated the mutational status of these genes and their molecular subtype enrichment. Based on these analyses, we picked 12 genes (C10orf125, RUNX3, YOD1, FXYD5, SMOC1, SLC16A5, RNLS, DKK1, PNPLA3, FZD10, RND2, and PLCB1) for further study. We stably overexpressed these potential driver genes in different breast cancer cell lines. Twelve genes out of the 12 tested, slowed cell proliferation and 9 decreased anchorage independent growth. We further validated these driver genes by knocking them out in normal human mammary epithelial cells using CRISPR/Cas9 tool. The loss of these genes, increased cell proliferation rate in normal human mammary epithelial cells compared to the control cells. In conclusion, based on our preliminary data, using bioinformatics tools as well as functional assays, we identified epigenetically altered breast cancer driver genes. Identifying and deciphering true epigenetic cancer drivers could potentially lead to the development of therapeutic drugs targeting these genes and/or targeting pathway dependence.

Citation Format: Panjarian S, Madzo J, Slater C, Jelinek J, Chen X, Issa J-P. Identification of epigenetically silenced breast cancer driver genes [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-05-03.

Stromal infiltration of CD8 T cells is associated with improved clinical outcome in HPV-positive oropharyngeal squamous carcinoma

Background:

Patients with human papillomavirus (HPV)-positive oropharyngeal squamous cell carcinoma (OPSCC) have a better prognosis than those with HPV-negative tumours. There is interest in de-escalating their treatment but strategies are needed for risk stratification to identify subsets with a poor prognosis. This study investigated tumour-infiltrating lymphocytes (TILs) in relation to HPV tumour status and patient survival.

Methods:

Biopsies from 218 patients diagnosed with OPSCC between 2002 and 2011, who underwent chemo/radiotherapy were analysed for HPV by PCR, in-situ hybridisation and p16 immunohistochemistry (IHC). One hundred and thirty-nine samples with concordant HPV detection were analysed for CD3, CD4, CD8 and FoxP3 expression in tumour and stromal regions using multiplexIHC and multispectral image analysis. Labelling of smooth muscle actin (SMA) identified activated stroma.

Results:

Human papillomavirus-positive compared with HPV-negative OPSCC had higher infiltration in both tumour and stromal areas of CD4 and CD8 T cells but not FoxP3 T regulatory cells. Only CD3+CD8+ stromal and not tumour area infiltration was associated with increased survival (P=0.02). There was significantly higher SMA expression in HPV-positive compared with -negative tumours, which did not correlate with survival.

Conclusions:

Studies of TILs for risk stratification in OPSCC should assess stromal infiltration.

Current issues in determining dietary protein and amino-acid requirements

Pregnancy and the first two years of life are periods of rapid growth and yet the knowledge of requirements for protein and dietary indispensable amino acids is very limited. The development of carbon oxidation methods opens the way to studies that should fill these important gaps in knowledge.

Genital lymphoedema due to ano-genital granulomatosis

A 21-year-old man presented to genitourinary (GU) medicine physicians with (initially) painful penile and scrotal swelling. A diagnosis of ano-genital granulomatosis was confirmed on histological analysis of penile skin. Enquiring about systemic symptoms resulted in the additional diagnosis of gastrointestinal Crohn's disease. The patient is now receiving immunosuppressive therapy to treat both conditions.

Erythrocyte fatty acid composition and insulin sensitivity in daughters of Type 2 diabetic patients and women with no family history of diabetes

BACKGROUND

There is evidence that the impact of environmental factors on insulin sensitivity is modified by the presence of family history of diabetes.

AIM

To compare the association between the erythrocyte phospholipid fatty acid composition (a biomarker of dietary fatty acids) and insulin sensitivity in daughters of Type 2 diabetic patients with the corresponding association in women without family history of diabetes.

MATERIAL/SUBJECTS AND METHODS

Eighteen offspring of Type 2 diabetic patients [age 30+/-6.5 yr; body mass index (BMI) 22.2+/-2.5 kg/m2; body fat 31.8+/-5.1%] and 18 matched women (age 30.1+/-6.8 yr; BMI 22.2+/-1.8 kg/m2; body fat 32.2+/-6.0%) participated in the study.

RESULTS

Insulin Sensitivity Index (ISI)-Matsuda tended to be lower (p=0.06) in the Offspring than the control group. Weight proportions of erythrocyte phospholipid saturated (SFA), polyunsaturated (PUFA), and monounsaturated fatty acids (MUFA) were similar between the two groups. In the offspring, erythrocyte total SFA were negatively correlated with ISI-Matsuda [r=-0.47, p<0.05), ISI(gly)-Belfiore (r=-0.52, p<0.05) and ISI(ffa)-Belfiore (r=-0.53, p<0.05)], whereas total PUFA were positively correlated with insulin sensitivity [ISI-Matsuda, r=0.46, p<0.05; ISI(gly)-Belfiore, r=0.53, p<0.05; ISI(ffa)-Belfiore, r=0.54, p<0.05]. No significant correlations were observed in the control group.

CONCLUSIONS

The associations between erythrocyte fatty acid composition and insulin sensitivity are distinct between daughters of Type 2 diabetic patients and women without family history of diabetes.

Validation of a fully autonomous phosphate analyser based on a microfluidic lab-on-a-chip

This work describes the design of a phosphate analyser that utilises a microfluidic lab-on-a-chip. The analyser contains all the required chemical storage, pumping and electronic components to carry out a complete phosphate assay. The system is self-calibrating and self-cleaning, thus capable of long-term operation. This was proven by a bench top calibration of the analyser using standard solutions and also by comparing the analyser's performance to a commercially available phosphate monitor installed at a waste water treatment plant. The output of the microfluidic lab-on-a-chip analyser was shown to have sensitivity and linear range equivalent to the commercially available monitor and also the ability to operate over an extended period of time.

Improving the specificity of the [13C]mixed triacylglycerol breath test by estimating carbon dioxide production from heart rate

BACKGROUND

The [13C]mixed triacylglycerol (MTG) breath test is a non-invasive measure of fat digestion and can be used to assess the need for enzyme replacement therapy in children with cystic fibrosis (CF). However, it lacks specificity. Quantitation of cumulative percent dose recovered (cPDR) requires knowledge of carbon dioxide production rate (VCO2). A resting value is assumed, but children are unlikely to remain at rest during the test.

OBJECTIVE

To improve the specificity and therefore the positive predictive value (PPV) of the MTG breath test using calibrated heart rate monitors to estimate non-resting VCO2.

DESIGN

Proof of concept study.

SUBJECTS

Six children with CF, 10 healthy children and eight healthy adults performed [13C]MTG breath tests.

METHODS

Heart rate monitors were worn throughout the test. Non-resting VCO2 was estimated continuously from heart rate. Percentage dose recovered was calculated using predicted resting VCO2, measured resting VCO2 and non-resting VCO2 estimated from heart rate. Physical activity level (PAL) was taken as cPDR calculated using non-resting VCO2 divided by cPDR calculated using measured resting VCO2. The cutoff point was determined using two graph-receiver operator characteristics.

RESULTS

Use of calibrated heart rate monitors to estimate non-resting VCO2 improved the specificity of the test. The PPV increased from 0.67 to 0.99. PAL was 1.3 in adults and children who performed the test in hospital, and 1.7 in children who performed the test at home.

CONCLUSION

Individually calibrated heart rate monitors are useful tools to estimate non-resting VCO2 during the [13C]MTG breath test.

Comparison of accuracy and precision of heart rate calibration methods to estimate total carbon dioxide production during 13C-breath tests

BACKGROUND

13C-breath tests are noninvasive tools to measure gastrointestinal function and nutritional interventions. Calculation of percentage dose recovered of 13C in exhaled breath requires knowledge of CO2 production rate (VC02). A resting value is usually assumed, but this can underestimate VC02 because subjects are unlikely to remain at rest during tests that last for many hours. There is a need for a method to estimate nonresting VC02 during 13C-breath tests.

OBJECTIVE

To calibrate a heart rate monitor to continually estimate VC02 during 13C-breath tests.

DESIGN

Proof of concept study.

SUBJECTS

Eight healthy adults, 10 healthy children and six children with cystic fibrosis.

METHODS

Heart rate and VC02 were measured simultaneously at resting and nonresting levels. A new calibration method (smoothing heart rate and fitting a sigmoid function) was compared with published methods. A [ 3C]acetate breath test was used to demonstrate the range of physical activity during breath tests.

RESULTS

The new calibration method was more accurate than existing methods (mean bias -0.0002%, 95% confidence interval (CI) -0.0007, 0.0003% of the mean measured VC02). Smoothing heart rate gave a more precise estimate of VC02 and a more accurate estimate of resting energy expenditure (mean bias -0.09, 95% Cl -0.22, 0.05 mmol CO2 min-' m-2 body surface area) than using raw data (mean bias -0.21, 95% Cl -0.38, -0.04 mmol CO2 min' m-2 body surface area). Physical activity level ranged from 1.0 to 2.5 in children, and 1.0 to 1.5 in adults.

CONCLUSION

Use of smoothed HR with a sigmoid function provides an accurate method of estimating nonresting VC02 during 13C-breath tests.

The usefulness of stable isotopes in nutrition and human health: the application of mass spectrometry and 13C-breath tests to detect helicobacter pylori infection

The interest in Helicobacter pylori has escalated in recent years. H. pylori may produce a chronic gastric infection which is usually life-long and many epidemiological studies have shown that this is the most common bacterial infection throughout the world involving 50% of the world population. Thus, it is clear that the diagnosis of H. pylori infection represents at least a key step in the management of many of the patients referred to the gastroenterologist. Additionally, due to the wide range and relevance of pathologies possibly related to this infection, from micronutrient malnutrition and co-infections to malignancies, there is the potential for H. pylori to be a major health problem. Improved methods for the diagnosis and follow up treatment of the infection have been developed. Use of stable isotopes as non-invasive and safe diagnostic methods, namely (13C) breath tests, has been the key to a new era of research in H. pylori epidemiology and diagnosis as well as the establishment of eradication therapies. This non-invasive nuclear technique, that is considered the gold standard for the diagnosis of this bacterial infection, has successfully been standardized and implemented along Latin America. Taking into account the high prevalence of this bacterial infection, the impact of this technique in the whole region is very high. In this article we discuss several aspects of this methodology in order to harmonize the application of this method in developing regions.

Reduced total energy expenditure and physical activity in cachectic patients with pancreatic cancer can be modulated by an energy and protein dense oral supplement enriched with n-3 fatty acids

The aim of the study was to assess the total energy expenditure (TEE), resting energy expenditure (REE) and physical activity level (PAL) in home-living cachectic patients with advanced pancreatic cancer. The influence of an energy and protein dense oral supplement either enriched with or without the n-3 fatty acid eicosapentaenoic acid (EPA) and administered over an 8-week period was also determined. In total, 24 patients were studied at baseline. The total energy expenditure was measured using doubly labelled water and REE determined by indirect calorimetry. Patients were studied at baseline and then randomised to either oral nutritional supplement. Measurements were repeated at 8 weeks. At baseline, REE was increased compared with predicted values for healthy individuals (1387(42) vs 1268(32) kcal day⁻¹, P=0.001), but TEE (1732(82) vs 1903(48) kcal day⁻¹, P=0.023) and PAL (1.24(0.04) vs 1.50) were reduced. After 8 weeks, the REE, TEE and PAL of patients who received the control supplement did not change significantly. In contrast, although REE did not change, TEE and PAL increased significantly in those who received the n-3 (EPA) enriched supplement. In summary, patients with advanced pancreatic cancer were hypermetabolic. However, TEE was reduced and this was secondary to a reduction in physical activity. The control energy and protein dense oral supplement did not influence the physical activity component of TEE. In contrast, administration of the supplement enriched with EPA was associated with an increase in physical activity, which may reflect improved quality of life.

Total energy expenditure and physical activity in young Scottish children: mixed longitudinal study

Childhood obesity has been attributed to a decline in total energy expenditure (TEE). We measured TEE, physical activity, and sedentary behaviour in a representative sample of young children from Glasgow, UK, at age 3 years (n=78), and we did a follow-up study at age 5 years (n=72). Mean physical activity level (TEE/resting energy expenditure) was 1.56 (SD 0.39) at age 3 years and 1.61 (0.22) at age 5 years. Median time in sedentary behaviour was 79% of monitored hours at age 3 years (IQR 74-84) and 76% (71-80) at age 5 years. Median time spent in moderate to vigorous physical activity represented only 2% of monitored hours at age 3 years (IQR 1-4) and 4% at age 5 years (2-6). Modern British children establish a sedentary lifestyle at an early age.

A comparison of the rate of recovery of 13CO2 in exhaled breath with 2H in body water following ingestion of [2H/13C]octanoic acid in a dog

The objective of this study was to assess post-gastric processing of octanoic acid (OA) by comparing the rate of recovery of 13C in breath with the rate of recovery of 2H in saliva following ingestion of [2H/13C]OA. A test meal with 100mg [13C]OA and 750 mg [2H]OA was ingested on two separate occasions by one dog. Exhaled breath and saliva samples were collected at set time points for 6h following ingestion of the test meal. Two indices were computed, half recovery time (t(1/2)) and the time of peak excretion (t(max)). Recovery of 2H in saliva was quicker than recovery of 13C in breath as determined by the difference in the indices for each isotope; 1.33 and 1.59 h for t(1/2) and t(max), respectively. These findings suggest that the post-gastric processing of OA imposes a delay on the recovery of 13C in breath in the dog, as occurs in man and in the horse.

Production of 13C labelled pea flour for use in human digestion and fermentation studies

Stable isotope breath tests offer a new approach to the study of digestion and fermentation of carbohydrates in man. In this study, 13C labelled peas were grown by pulsing 250 ml 13CO2 into a sealed growth chamber. A second pulse was added to a portion of the peas to increase the 13C enrichment. This generated pea flour with an enrichment of 2.36 at.% excess (range 2.09-2.71 n = 3) and 8.64 atom % excess (range 7.37-9.78 n = 3) respectively. This represented incorporation of an absolute yield of 3.8% of the 13CO2 into peas in the 'once-labelled' treatment and 7.5% in the 'twice-labelled' treatment. Ingestion of a mixture of the labelled pea flour (300 mg) by two volunteers generated measurable 13CO2 excretion for breath test analysis. The profile of breath 13CO2 enrichment increased to a maximum within three hours after consuming the pea flour followed by a decrease almost back to baseline by 13 hours. Breath 13CO2 appeared to rise again after this apparent nadir at 13 hours until the end of the sampling period. Mathematical analysis of the data suggested that two peaks best described the profile of breath 13CO2 up to 13 hours. A third peak was necessary to describe the late rise in breath 13CO2 enrichment. This use of 13C enriched pea flour may provide a useful non invasive method for measurement of digestion and fermentation in vivo.

Analysis of 13C-mixed triacylglycerol in stool by bulk (EA-IRMS) and compound specific (GC/MS) methods

This paper was presented in poster form at the 17th International Congress of Nutrition, August 27-31, Vienna, Austria (Annals of Nutrition & Metabolism 2001; 45(Suppl.1):349). Some of the data were also presented in poster form at the British Society of Gastroenterology Meeting, March 18-21, Glasgow, UK (Gut 2001; 48(Suppl.1):A91). The 13C-mixed triacylglycerol (MTG) breath test is used to measure intraluminal fat digestion. In normal digestion, 20-40% of the ingested 13C label is recovered in breath CO2. We aimed to identify the proportions of ingested label excreted in stool, as well as breath following ingestion of 13C-MTG by children with impaired exocrine pancreatic function and healthy controls. 13C enrichment of breath samples was measured by continuous flow isotope ratio mass spectrometry (IRMS) and cumulative percent dose recovered (cPDR) in 10 h was calculated. Total 13C of a faecal fat extract from each stool was measured by elemental analyser-IRMS, and 13C enrichment and concentration of the TBDMS derivative of octanoic acid was measured by GC/MS after hydrolysis of the fat extract. Stool 5-day cPDR was calculated. Mean breath cPDR was 35%. Mean cPDR in stool by combustion-IRMS and GC/ MS, respectively, was 0.8% and 1.0%. Therefore, the remaining 64% of the 13C label must remain in the body and variability in breath cPDR is due to postabsorptive rather than predigestive factors.

End-plate gamma- and epsilon-subunit mRNA levels in AChR deficiency syndrome due to epsilon-subunit null mutations

Acetylcholine receptor (AChR) deficiency is the most common of the congenital myasthenic syndromes (CMS). Typically, the number of AChRs, measured by alpha-bungarotoxin binding, is reduced to 10-30% of normal levels, the miniature end-plate potentials are correspondingly reduced, and there are morphological changes at the motor end-plates. The majority of these syndromes are due to either missense or frameshift mutations within the gene encoding the adult-specific epsilon-subunit. These are often null mutations, but some mutant epsilon-subunits can be incorporated, at low levels, into functional AChRs in transfected cell lines. It is not clear, therefore, whether upregulation of the mutant epsilon-subunit mRNA could generate sufficient AChR to support neuromuscular transmission, albeit at a reduced level. Conversely, it might be that the mutant epsilon-subunit transcripts are subject to mRNA surveillance and 'nonsense-mediated' loss, leading to reduced epsilon-subunit mRNA expression. In either case, it is thought that neuromuscular transmission may be provided partly or entirely by incorporation of the foetal-specific gamma-subunit into end-plate AChR. gamma-Subunit mRNA is expressed at low levels in normal human muscle, but might be upregulated in CMS. The study of mRNA levels for AChR subunits should improve our understanding of genotype-phenotype relationships in CMS. Here we have defined homozygous epsilon-subunit mutations in four unrelated families with AChR deficiency and studied the steady-state levels of mRNA for AChR subunits at the motor end-plates by in situ hybridization. Although we demonstrated that each mutation would lead to almost complete absence of surface adult AChR expression, we detected similar robust expression of alpha- and epsilon-subunit mRNAs at end-plates of patient and control muscles, suggesting that mRNA transcripts for the epsilon-subunit are neither upregulated nor degraded preferentially. Interestingly, we were unable to detect any increase in gamma-subunit mRNA expression at CMS end-plates. Transgenic mice lacking the epsilon-subunit die 2-3 months after birth, suggesting that alpha(2)betadelta(2) pentamers cannot sustain neuromuscular transmission. Therefore, we tentatively conclude that the persistent low level expression of the gamma-subunit, which is present in normal human muscles as well as in AChR deficiency syndromes, is sufficient to enable patients with epsilon-subunit null alleles to survive.

Stable isotopes and the international system of units

It is now over 60 years since Nier built the first isotope ratio mass spectrometer. The introduction of continuous-flow techniques heralded a huge expansion in the use of stable isotopes in biomedical and environmental sciences, yet there is no consensus on the appropriate units, especially in the biomedical field. Most isotope ratio mass spectrometry (IRMS) instruments calculate isotopic abundance in terms of delta notation (delta, per thousand, per mil), which is a convention determined by geochemistry, because most of the original IRMS instruments were developed in isotope geochemistry laboratories to measure natural abundance variations. Delta units are not SI units. This paper considers the appropriate units for studies using stable isotopes based on the International System of Units (SI). The SI base unit for concentration is the mol, from which atom fraction and mol fraction are derived. The units of stable isotope abundance, atom % and mol %, are the atom and mol fractions expressed as percentages. Atom % excess and mol % excess are the SI units of enrichment and are to be recommended for use in tracer studies.

Carcinogenicity of estrogens in human breast epithelial cells

Epidemiological and clinical evidences indicate that breast cancer risk is associated with prolonged ovarian function that results in elevated circulating levels of steroid hormones. Principal among these is estrogen, which is associated with two important risk factors, early onset of menarche and late menopause. However, up to now there is no direct experimental evidence that estrogens are responsible of the initiation of human breast cancer. We postulate that if estrogens are causative agents of this disease, they should elicit in human breast epithelial cells (HBEC) genomic alterations similar to those exhibited by human breast cancers, such as DNA amplification and loss of genetic material representing tumor suppressor genes. These effects could result from binding of the hormone to its nuclear receptors (ER) or from its metabolic activation to reactive metabolites. This hypothesis was tested by treating with the natural estrogen 17beta-estradiol (E2) and the synthetic steroid diethylstilbestrol (DES) MCF-10F cells, a HBEC line that is negative for ER. Cells treated with the chemical carcinogen benzo (a) pyrene (BP) served as a positive control of cell transformation. BP-, E2-, and DES-treated MCF-10F cells showed increases in survival efficiency and colony efficiency in agar methocel, and loss of ductulogenic capacity in collagen gel. The largest colonies were formed by BP-treated cells, becoming progressively smaller in DES- and E2-treated cells. The loss of ductulogenic capacity was maximal in BP-, and less prominent in E2- and DES-treated cells. Genomic analysis revealed that E2- and DES-treated cells exhibited loss of heterozygosity in chromosomes 3 and 11, at 3p21, 3p21-21.2, 3p21.1-14.2, and 3p14.2 14.1, and at 11q23.3 and 11q23.1-25 regions, respectively. It is noteworthy that these loci are also affected in breast lesions, such as ductal hyperplasia, carcinoma in situ, and invasive carcinoma. Our data are the first ones to demonstrate that estrogens induce in HBEC phenotypic changes indicative of cell transformation and that those changes are associated with significant genomic alterations that might unravel new pathways in the initiation of breast cancer.

Structure of the acidic microcapsular glycan from the reference strain (C.D.C. 6320-58) for Serratia marcescens serotype O14:K12

The acidic polysaccharide from Serratia marcescens serogroup O14:K12 was analyzed by means of chemical studies and NMR spectroscopy and its repeating unit structure found to be carbohydrate sequence [see text] O-Acetyl groups are proposed to be present in non-stoichiometric amounts on O-6 on one of the hexose residues in the main chain.

Liver export protein synthetic rates are increased by oral meal feeding in weight-losing cancer patients

We have demonstrated previously that, in the fasting state, whereas albumin synthesis is similar in cachectic cancer patients compared with controls, fibrinogen synthesis is increased. Whether synthesis of these proteins is altered after an oral meal was examined in eight weight-losing pancreatic cancer patients and six healthy controls by use of an intravenous flooding dose of [(2)H(5)]- or [(2)H(8)]phenylalanine. Cancer patients had a median weight loss of 19%, a significantly lower serum albumin concentration, and a significantly higher plasma fibrinogen concentration than controls (P < 0.005). Fasting albumin synthesis rates were similar between cancer patients and controls (median total synthesis rate 11.3 vs. 13.9 g/day, respectively) and rose on feeding by a similar degree (median 29 and 24%). The fasting fibrinogen total synthetic rate was significantly higher in cancer patients than in controls (median 3.3 vs. 1.0 g/day, P = 0.0019). In cancer patients in the fed state, fibrinogen synthetic rate rose by a median of 38% (P = 0.012), whereas in controls there was no significant change. These findings demonstrate significant upregulation by feeding of acute-phase protein synthesis in cachectic cancer patients.

Liver disease does not affect lipolysis as measured with the 13C-mixed triacylglycerol breath test in children with cystic fibrosis

BACKGROUND

Liver disease associated with cystic fibrosis may not only limit the solubilisation and absorption of the products of fat digestion, but also may depress the activity of pancreatic lipase. The purpose of this study was to measure the effect of liver disease on triacylglycerol lipolysis using the 13C-mixed triacylglycerol breath test.

METHODS

Forty children with cystic fibrosis took 13C-mixed triacylglycerol with a standard breakfast and the child's normal pancreatic enzyme replacement therapy. Breath samples were collected before and every 30 minutes after ingestion for 6 hours. The cumulative percentage dose of 13C recovered at 6 hours was calculated from sequential measurements of 13C enrichment of breath CO2, measured by isotope ratio mass spectrometry. Liver abnormalities and portal hypertension were defined by ultrasound scan and clinical examination.

RESULTS

Twenty-four children had liver abnormalities, including 5 with portal hypertension. No difference was found between cumulative percentage dose of 13C recovered at 6 hours in 16 children with no liver abnormality (mean, 21.4%+/-11.1%), 19 children with liver abnormalities (22.2%+/-10.0%) and 5 children with portal hypertension (20.9%+/-7.1%).

CONCLUSION

Intestinal lipolysis is not reduced in cystic fibrosis liver disease when measured using the 13C mixed triacylglycerol breath test. These findings affirm the test's use as an indirect measure of fat digestion that is not affected by inadequate intraluminal bile salts or liver disease.

(13)C natural abundance in the British diet: implications for (13)C breath tests

Surprisingly little information is available on the natural abundance of the minor isotope of carbon, (13)C, in common foodstuffs in the British diet. This study therefore aimed to examine the (13)C natural abundance of foodstuffs from a small cross-section of the British diet. The isotopic abundance, delta per mil, was calculated by measurement of the isotope ratio (13)C:(12)C by isotope ratio mass spectrometry. Results from this study were also compared with results from a North American study to highlight the difference in isotopic abundance between Northern European foodstuffs and North American foodstuffs. Such data should prove useful to those planning tracer studies using the stable isotope (13)C where enrichment is measured against a large and variable natural abundance in the body. Minimisation of this basal variation, for example in breath CO(2), can be achieved by controlling dietary intake of foods naturally abundant in (13)C.

Functional roles of chromosomes 11 and 17 in the transformation of human breast epithelial cells in vitro

Genomic alterations in primary breast cancer play a role in the initiation and progression of the disease. We have analyzed the molecular events involved in the initiation and progression of the neoplastic process in an in vitro experimental system. Immortalization of human breast epithelial cells (HBEC) is associated with 3:9 translocation, p53 mutation and microsatellite instability (MSI) of chromosomes 11p13, and 17p. BP1-E cells, derived from the immortalized MCF-10F cells transformed by the carcinogen benzo(a)pyrene (BP), express in vitro growth advantage, anchorage independence, enhanced chemoinvasiveness, loss of ductulogenic capabilities and tumorigenesis in a heterologous host. This neoplastic progression is also associated with mutations and/or amplification of c-H-ras, int-2, c-neu, c-myc and MDM2, MSI at 11q25 and 13q12-q13 and loss of heterozygosity at 17p. In order to test whether chromosomes 11 or 17 play a functional role in the phenotypic expression of transformation of BP1E cells, we utilized microcell-mediated chromosome transfer (MMCT) technique for inserting the corresponding normal chromosomes to these transformed cells. BP1E cells were transfected with PsV2neo plasmid and fused with microcells obtained from the mouse cell line A9, containing a normal chromosome 11 or 17 (A9-11neo and A9-17neo cells, selected in G418 and cloned. Sixteen primary microcell hybrids from each chromosome transfer, designated BP1E-11neo and BP1E-17neo survived selection in G-418 containing medium. A single clone from each group, BP1E-11neo #145 and BP1E-17neo D100, survived subcloning and were utilized for a detailed panel of analyses. The presence of a donor chromosome was confirmed by dual color fluorescence in situ hybridization (FISH), southern blot analysis of the marker vector pSV2neo, and microsatellite polymorphism analysis. The transfer of the normal chromosomes 11 and 17 resulted in a 50% and 90% inhibition of cell growth respectively, and reduced both colony efficiency and colony size. Telomerase activity was significantly reduced only by chromosome 17 insertion, providing a possible explanation for the more significant senescence observed in BP1E-17neo D100 cells. Microsatellite polymorphism analysis revealed that three loci, 11q13-23, 11q23.1, and 11q23.3 (markers D11S911, DRD2, and D11S29) were retained in BP1E-11neo #145 cells, and two, 17q24.2-25.2, 17q25.2 (markers D17S515 and D17S785 were retained in BP1E-17neo D100 cells. We conclude that the specific regions of normal chromosomes 11 and 17 transferred play a functional role in the expression of immortal and transformed phenotypes of HBEC in vitro.

Analysis of tert.-butyldimethylsilyl [1-13C]palmitic acid in stool samples by gas chromatography-mass spectrometry with electron impact ionisation: comparison with combustion isotope-ratio mass spectrometry

The use of 13C-labelled compounds to study lipid metabolism is increasing. Typically less than 40% of the orally administered label is recovered in breath CO2. The remainder must be either absorbed and not oxidised or not absorbed and remain in the faeces. Two methods of determining how much tracer passes through the body, and is present in the stool, were compared. Compound specific analysis of tert.-butyldimethylsilyl [13C]hexadecanoic acid by gas chromatography-mass spectrometry (GC-MS) with electron impact ionisation was compared with bulk analysis of whole stool and lipid extract by continuous flow isotope ratio mass spectrometry (CF-IRMS) with a combustion interface. The mean difference between the IRMS and GC-MS methods was -0.02 mmol 13C d(-1) with a mean excretion of 14.2 mmol 13C d(-1). Combustion IRMS is both simpler and cheaper, when the objective is to determine how much administered dose appears in stool, and information about the form of the label is not required.

Fibrinogen synthesis is elevated in fasting cancer patients with an acute phase response

The unusual amino acid composition of acute phase proteins may be relevant to our understanding of the mechanism of tissue wasting in chronic inflammatory disease. During periods in which demand for amino acids outstrips dietary supply, skeletal muscle protein may be mobilized to meet this demand. An imbalance in the amino acid composition of these proteins may thus be detrimental to the body's nitrogen economy. To address this problem, we have measured the synthetic rate of fibrinogen (perhaps the major acute phase protein) and plasma amino acid profiles in a group of patients with adenocarcinoma of the pancreas and an ongoing inflammatory response (serum C-reactive protein >10 mg/L in the absence of any other obvious infective or inflammatory cause). These were also measured in a control group with no evidence of inflammation. Fibrinogen synthesis was measured after an overnight fast, using a flooding dose of 2H5-phenylalanine. The fractional rate of fibrinogen synthesis was significantly elevated in the cancer group compared with healthy controls [39.3 (20.0-49.9) and 21.9 (13.2-37.7) %/d, respectively; median (range), P < 0.05]. The absolute rate of fibrinogen synthesis was also elevated [84 (33-143) and 26 (15-43) mg/(kg.d), respectively; median (range), P < 0.01]. We calculated that, in cancer patients with anorexia-cachexia (i.e., documented ongoing weight loss in the absence of an obvious cause such as obstruction or malabsorption), aromatic amino acid supply (predominantly tryptophan) most limits fibrinogen synthesis from skeletal muscle reserves. Demand for the nonessential amino acids serine and glycine was elevated. Assuming that tryptophan is limiting, up to 2.6 g muscle protein ( approximately 12 g skeletal muscle tissue) may be wasted to synthesize 1 g fibrinogen. Interpretation of the observation that circulating free tryptophan concentrations were significantly reduced in the cancer patients will have to await flux measurements. The metabolic changes accompanying the inflammatory response suggest that down-regulation of this process may be beneficial.

Albumin synthesis rates are not decreased in hypoalbuminemic cachectic cancer patients with an ongoing acute-phase protein response

OBJECTIVE

To determine whether suppression of albumin synthesis contributes to the hypoalbuminemia observed in weight-losing cancer patients with evidence of an ongoing acute-phase protein response (APPR).

BACKGROUND DATA

Proinflammatory cytokines such as tumor necrosis factor (TNF) and interleukin 6 (IL-6) are known to downregulate albumin synthesis and increase acute-phase protein production in isolated hepatocytes. However, whether albumin synthesis is suppressed in hypoalbuminemic cancer patients with evidence of an ongoing acute-phase response is unknown.

METHODS

Albumin synthesis rates were determined in six healthy controls and in six weight-losing pancreatic cancer patients with an ongoing APPR using a flooding dose technique with [2H5]-phenylalanine. The presence of an APPR was defined as a serum C-reactive protein concentration >10 mg/L. Serum cytokines (TNF, IL-6) and soluble TNF receptors (sTNF-R 55 and 75), along with serum cortisol and insulin, were also measured in both groups.

RESULTS

Cancer patients had reduced serum albumin (median 32 [range, 23-36] vs. 42 g/L [40-45]; p < 0.01) and increased serum C-reactive protein concentrations (72 [23-126] vs. <5 mg/L; p < 0.01) when compared with controls. TNF was not detected in either group. sTNF-R 55 levels were significantly elevated in the cancer patients (3.8 [1.9-8.1] vs. 1.2 pg/mL [0.9-2.2]; p < 0.01). Circulating IL-6, insulin, and cortisol concentrations were not significantly different between the groups. The intravascular albumin mass was lower (88 [56-93] vs. 133 g [105-177]; p < 0.01), but the intravascular albumin fractional synthetic rate was higher (13.9 [13.5-18.5] vs. 10.3%/d [71-11.3]; p < 0.01) in the cancer patients compared with the controls. The total intravascular albumin synthetic rate was, however, similar between the two groups (12.7 [7.7-15.7] vs. 11.7 g/d [8.5-18.7]; p NS).

CONCLUSIONS

In weight-losing pancreatic cancer patients with evidence of an ongoing APPR, hypoalbuminemia is not caused by a decreased rate of albumin synthesis.

Audit of prenatal diagnosis for haemoglobin disorders in the United Kingdom: the first 20 years

OBJECTIVES

To audit services for prenatal diagnosis for haemoglobin disorders in the United Kingdom.

DESIGN

Comparison of the annual number of cases recorded in a United Kingdom register of prenatal diagnoses for haemoglobin disorders, with the annual number of pregnancies at risk of these disorders, by ethnic group and regional health authority. The number of pregnancies at risk was estimated using data on ethnic group from the 1991 census and data from the United Kingdom thalassaemia register, which records the number of babies born with thalassaemia.

SETTING

The three national prenatal diagnosis centres for haemoglobin disorders.

SUBJECTS

2068 cases of prenatal diagnosis for haemoglobin disorders in the United Kingdom from 1974 to 1994.

MAIN OUTCOME MEASURES

Utilisation of prenatal diagnosis by risk, ethnic group, and regional health authority. Proportion of referrals in the first trimester and before the birth of any affected child.

RESULTS

National utilisation of prenatal diagnosis for haemoglobin disorders was around 20%. During the past 10 years it has remained steady at about 50% for thalassaemias and risen from 7% to 13% for sickle cell disorders. Utilisation for sickle cell disorders varies regionally from 2% to 20%. Utilisation for thalassaemias varies by ethnic group. It is almost 90% for Cypriots and ranges regionally for British Pakistanis from 0% to over 60%. About 60% of first prenatal diagnoses are done for couples without an affected child. Less than 50% of first referrals are in the first trimester.

CONCLUSIONS

National utilisation of prenatal diagnosis for haemoglobin disorders is far lower than expected, and there are wide regional variations. A high proportion of referrals are still in the second trimester and after the birth of an affected child. The findings point to serious shortcomings in present antenatal screening practice and in local screening policies and to inadequate counselling resources, especially for British Pakistanis.

Simultaneous measurement of albumin and fibrinogen synthetic rates in normal fasted subjects

Albumin and fibrinogen synthesis appear to account for the majority of protein exported by the liver and therefore make a substantial contribution to that of whole-body protein synthesis. However, data on the protein synthetic rates of albumin and fibrinogen in normal subjects are limited. Albumin and fibrinogen synthetic rates were measured simultaneously over a 120-min period in normal subjects (n = 6) by using a flooding dose of 2H5-phenylalanine. Tracer incorporation into proteins was measured by gas chromatography/mass spectrometry. Body mass index, circulating concentrations of insulin, albumin, fibrinogen, C-reactive protein, and plasma volumes of the subjects were all within the normal reference range. There was a small and transient rise in circulating insulin concentrations following the flooding dose of phenylalanine. The median fractional synthetic rate and absolute synthetic rate for albumin was 10.3%/d and 208 mg.kg-1.d-1, respectively. The median fractional synthetic rate and absolute synthetic rate for fibrinogen was 19.5%/d and 28 mg.kg-1.d-1. In the context of the current interest in manipulating the inflammatory response of patients with various disease states, we introduce the concept of an acute phase protein quotient (APPQ). The APPQ is defined as the absolute rate of fibrinogen synthesis divided by that of albumin. In this group of normal subjects, the median APPQ was 0.14.

Reactive angioendotheliomatosis. Case report and review of the literature

Angioendotheliomatosis is an uncommon disease characterized histologically by proliferation of cells within vascular lumina with secondary intravascular thrombi resulting in obliteration of the involved vessels. While angioendotheliomatosis was initially thought to be a single disease entity, recent studies show that the disease may be divided into benign (reactive) and malignant variants, with the malignant variant representing intravascular malignant lymphoma. The reactive variant is rare, with only 16 cases reported in the literature, and is characterized histologically by proliferating endothelial cells within vessel lumina. In this report we present a case of reactive angioendotheliomatosis and review the literature on this rare entity.