P5570Contemporary trends and outcomes of percutaneous and surgical mitral valve replacement or repair for mitral insufficiency in cancer patients

Importance

Severe mitral valve insufficiency (MR) is managed using mitral valve replacement or repair. Transcatheter mitral valve repair (TMVR) is an emerging non-invasive treatment option for MR. Cancer patients stand to benefit from non-invasive treatment of MR given the nature of this intervention. Objective:We sought to assess the relative utilization, outcomes, and dispositions associated with TMVR vs. surgical mitral valve procedures (SMVP) in cancer patients.

Methods

The 2012–2015 National Inpatient Sample, a retrospective observational study was queried using ICD-9 codes for adults >18 years with comorbid MR (ICD-9 – 424.0) and cancer without metastatic disease. To maintain a homogenous study population and to limit confounding, those with mitral stenosis, rheumatic disease, infective endocarditis, aortic valve disease, or those undergoing any other vascular or cardiac surgery in the same admission were excluded from the analysis. Multiple in-hospital and disposition outcomes were evaluated. Since the baseline population undergoing SMVP (ICD-9: 35.23, 35.24, 35.12) is quite different from TMVR (ICD-9: 35.97), parallel analyses for outcomes and dispositions were presented but no direct statistical comparisons.

Results

A total of 410,175 out of 2,449,010 patients with mitral insufficiency were found to have non-metastatic cancer (16.7%). A total of 3,600 TMVR procedures were performed during the study period. Over the study period, there has been an increase in the proportion of patients undergoing TMVR among all patients undergoing mitral valve procedures (figure). The increase is higher in cancer patients in the most recent year (14.2% vs. 8.2%, p<0.0001). The four major cancers comprise of 50% of these TMVR patients. TMVR was associated with 1.4% vs. 2.2% in-hospital mortality (p=0.55), 0.7% vs. 0.8% stroke (p=0.87), 9.2% vs. 11.8% major bleeding (p=0.31), 14.1% vs. 16.5% acute kidney injury (p=0.52), 62.0% vs. 64.6% home discharge (p=0.58), and 13.3% vs. 12.0% discharge to nursing home (p=0.58) among cancer vs. non-cancer patients, respectively. On the other hand, SMVP was associated with 3.1% vs. 3.5% in-hospital mortality (p=0.35), 2.6% vs. 3.1% stroke (p=0.16), 35.0% vs. 30.5% major bleeding (p<0.0001), 19.5% vs. 19.6% acute kidney injury (p=0.88), 32.8% vs. 38.6% home discharge (p<0.0001), 37.2% vs. 35.0% home health care use (p<0.0001), and 26.8 vs. 22.8% discharge to nursing home (p=0.05), among cancer vs. non-cancer patients respectively.

TMVR percent in mitral valve procedures

Conclusion

TMVR utilization for MR in cancer has steadily increased in both cancer and non-cancer patients, although it is proportionately higher among cancer patients in recent years. Overall, TMVR was associated with low in-hospital mortality and a similar safety profile in cancer and non-cancer patients, while SMVP appears to have a slightly worse safety profile in cancer patients. Our findings, suggest that TMVR is a reasonable strategy in selective cancer patients with MR.

Shear-induced degradation of linear polyacrylamide solutions during pre-electrophoretic loading

Electrophoretic channels are filled with a polymer matrix prior to their use in DNA separations. This process, called gel-loading, can be accomplished manually, using syringes, or can be automated through the use of small pumps or vacuum. The injection rate is constrained by the desire to minimize shear-induced degradation of the polymer molecules. Currently, the community lacks quantitative data with which to gauge the range of flow rates that prevent polymer degradation. In this study, measurements of the zero shear rate viscosity of linear polyacrylamide (LPA) solutions are used to determine the LPA molecular weight before and after gel-loading. The results indicate molecular degradation in polymer solutions even when injected at minimal flow rates of 1 microL/min. To correlate these rheological observations of shear-induced degradation with subsequent electrophoretic performance, the degraded solutions were used as sieving matrixes for DNA sequencing analysis. The decreases in electrophoretic resolution and increases in peak widths between sheared and nonsheared LPA solutions are related to the degradation in molecular weight experienced by the polymer solutions.

Improvement of Herpesvirus saimiri T cell immortalization procedure to generate multiple CD4+ T-cell clones from peripheral blood lymphocytes of AIDS patients

Herpesvirus saimiri (HVS) can infect and immortalize human T lymphocytes of both CD4- and CD8-positive phenotypes. We have previously shown that infection of peripheral blood lymphocytes (PBL) from AIDS patients with HVS predominantly yielded immortalized CD8-positive T cell clones. Here we show that CD4-positive T cells from AIDS patients can be efficiently immortalized by HVS if patient PBL are enriched for CD4-positive T cell subpopulation prior to HVS infection. Such cells can be cloned and maintained in culture for prolonged times, and they exhibit activated T cell phenotype of Th1 class and are susceptible to HIV-1 infection. Several immortalized T cell clones obtained from one out of three AIDS patients tested here were HIV-1 positive and produced infectious virus. This approach permits efficient generation of multiple CD4-positive T cell clones from AIDS patients for functional and virological studies.

Peptide T in the treatment of painful distal neuropathy associated with AIDS: results of a placebo-controlled trial. The Peptide T Neuropathy Study Group

OBJECTIVE

To assess the safety and efficacy of Peptide T in the treatment of painful distal symmetrical polyneuropathy (DSP) associated with human immunodeficiency virus (HIV) infection.

BACKGROUND

Painful DSP is a frequent complication of HIV infection, although its etiology and optimal treatment are unknown. Peptide T (D-(alpha 1)-Peptide T-amide) has been found in phase I trials and anecdotal reports to relieve neuropathic pain in AIDS patients.

DESIGN/METHODS

In this multicentered, double-blind, randomized study, subjects received intranasal Peptide T 6 mg/day or placebo for 12 weeks. The primary outcome measure was change in the modified Gracely pain score. Secondary efficacy variables were results of neurologic examination, neuropsychological and electrophysiologic studies, global evaluation, and CD4 lymphocyte counts.

RESULTS

Of 81 evaluable subjects, 40 received Peptide T and 41 received placebo. The change in pain scores was not significantly different (p = 0.32) in the Peptide T group (-0.24) as compared to placebo (-0.39). Group comparisons were not significantly different for change in any clinical examination or neuropsychologic measure, sural nerve amplitude or conduction velocity, or CD4 lymphocyte count. No significant drug-related adverse effects occurred in either group.

CONCLUSION

Intranasal Peptide T is safe but ineffective in the treatment of painful DSP associated with AIDS.

Human erythrocytes bearing electroinserted CD4 neutralize infection in vitro by primary isolates of human immunodeficiency virus type 1

Human erythrocytes bearing electroinserted full-length CD4 (RBC-CD4) can bind and fuse with a laboratory strain of human immunodeficiency virus type 1 (HIV-1) or with T cells infected by HIV-1. Here we show that RBC-CD4 neutralize primary HIV-1 strains in an assay of cocultivation of peripheral blood mononuclear cells (PBMC) from HIV-1-infected persons with uninfected PBMC. RBC-CD4 inhibited viral p24 core antigen accumulation in these cocultures up to 10,000-fold compared with RBC alone. Viral p24 accumulation was inhibited equally well when measured in culture supernatants or in call extracts. The inhibition was dose-dependent and long-lived. Two types of recombinant CD4 tested in parallel were largely ineffective. The neutralization of primary HIV-1 by RBC-CD4 in vitro was demonstrated in PBMC cultures from 21 of a total of 23 patients tested at two independent sites. RBC-CD4 may offer a route to blocking HIV-1 infection in vivo.

Effects of sho-saiko-to on production of prostaglandin E2 (PGE2), leukotriene B4 (LTB4) and superoxide from peripheral monocytes and polymorphonuclear cells isolated from HIV infected individuals

The effects of Sho-saiko-to (SST), a traditional Chinese medicine, on the production of PGE2 from monocytes, LTB4 and superoxide from polymorphonuclear cells (PMNC) in HIV infected individuals were studied. SST inhibited the production of PGE2 from monocytes stimulated by opsonized zymosan in all groups including the healthy control group and also inhibited the production of superoxide from PMNC after stimulation with FMLP. On the other hand, SST enhanced the production of LTB4 when PMNC were stimulated by the calcium ionophore A23187. These results suggest that SST has different effects on the production of prostanoids or superoxide from monocytes and PMNC. Furthermore, our data indicates that inhibition of PGE2 or superoxide production will lead to indirect suppression of HIV, and enhancement of LTB4 will contribute to the upregulation of the immune reaction in HIV infected individuals.

Conservation of an intact human immunodeficiency virus type 1 vif gene in vitro and in vivo

Replication of vif-negative human immunodeficiency virus type 1 (HIV-1) is attenuated in certain cell lines and highly impaired in peripheral blood lymphocytes in vitro. To determine whether intact vif is positively selected during natural HIV-1 infection and to determine vif sequence variability, we employed PCR amplification, cloning, and sequencing to investigate the vif region of replicating virus in short-term-passage HIV-1 primary isolates from five asymptomatic individuals and from five persons with AIDS. A total of 46 vif clones were obtained and analyzed. Recombinant proviruses were constructed from selected vif clones from one patient and found to be fully infectious. We found that 38 of the 46 clones sequenced carried open vif reading frames and that there was a low degree of heterogeneity of vif genes within isolates from the same individual and among isolates from different donors. The cysteines previously found to be essential for vif protein function were conserved in all clones. A phylogenetic tree constructed from all available vif nucleotide sequences resulted in a virus grouping similar to those of gag and env. Direct sequencing of vif amplified by PCR from uncultured lymphocytes of 15 individuals at various stages of progression toward AIDS demonstrated vif open reading frames in 13 of 15 samples tested. There was no obvious correlation between disease status and the presence of an intact vif within this sample group at the time of sample procurement. The conservation of the vif open reading frame in vitro and in vivo and its limited variability following virus transmission in vitro are consistent with a role for vif in natural HIV-1 infection.

Treatment of acyclovir-unresponsive cutaneous herpes simplex virus infection with topically applied SP-303

The naturally occurring polyphenolic biopolymer SP-303 has in vitro activity against both HSV-1 and HSV-2, including strains that are resistant to acyclovir. Nine AIDS patients with acyclovir-unresponsive mucocutaneous herpes simplex virus infection were treated with thrice daily topical SP-303T ointment in an open-label pilot study. Although a transient decrease in lesion size was observed in 4 patients during study drug therapy, and 3 patients sustained a quantitative decrease in virus burden, neither complete healing nor cessation of virus shedding occurred in any patient. Seven patients complained of pain or burning upon application of the study ointment, causing 1 patient to terminate the study. In summary, application of SP-303T ointment effected no significant improvement in the clinical course of 9 AIDS patients with acyclovir-unresponsive HSV infection.

Modulation of cellular gene expression of HIV type 1 infection as determined by subtractive hybridization cloning: downregulation of thymosin beta 4 in vitro and in vivo

Chronic infection with HIV-1 has profound effects on host cell growth and function. We used subtractive hybridization cloning to identify genes whose expression is modulated by HIV-1 infection in the T leukemia cell line CEM. The gene encoding thymosin beta 4, a ubiquitous polypeptide associated with hematopoietic differentiation, showed two- to threefold reduced transcription in HIV-1-infected CEM cells and other HIV-1-infected T cells and macrophages in vitro. Solid-phase radioimmunoassay revealed about a threefold decrease in the level of thymosin beta 4 protein in lysates of infected cells. Northern blot analysis of RNA samples from lymphocytes of five AIDS patients reveals an up to fivefold reduction in the level of thymosin beta 4 mRNA. These results indicate that HIV-1 infection may directly influence the expression of certain physiologically important proteins.

A Tat antagonist inhibits HIV-1 induction in naturally infected and experimentally infected T cells

Ro 5-3335, a novel antagonist of human immunodeficiency virus type 1 (HIV-1) Tat activity, inhibits acute and chronic HIV-1 infection in T lymphocytes. Here we describe the effects of Ro 5-3335 on the accumulation of viral DNA during primary infection, the induction of virus from a latently infected cell line, and the expression of virus upon activation of naturally infected T cells. Ro 5-3335 permitted initial DNA synthesis during primary infection, but inhibited the subsequent increase in viral DNA copy number. The induction of HIV-1, as determined by the synthesis of p24 core antigen, was inhibited by 99% by Ro 5-3335 in both the model cell line and naturally infected T cells.

Flow stimulates endothelial cells to release a nitrovasodilator that is potentiated by reduced thiol

We designed a novel system to study flow-mediated endothelium-dependent vasodilation. Vascular rings of rabbit thoracic aorta were mounted for isometric tension recording in a flow chamber filled with physiological saline solution. The flow chamber contained a stir bar and was mounted on a magnetic stirrer to induce vortical flow. Norepinephrine (NE, 10(-6) M) induced contraction of the vascular rings. Bovine endothelial cells on microcarrier beads added to the chamber had little effect on contraction to NE in the absence of flow. Flow induced endothelium-dependent relaxation of the vascular rings that was dependent on the flow rate. Relaxations were annulled or reversed to a contraction with methylene blue, bovine hemoglobin, or N-monomethyl-L-arginine. Conversely, N-acetyl-L-cysteine augmented the flow-mediated relaxation. Furthermore, in the presence of N-acetyl-L-cysteine, the half-life of the endothelium-dependent relaxing factor was increased. In conclusion, the stimulus of flow induces the release by endothelial cells of a diffusible, short-lived factor with the attributes of a nitrovasodilator. The action of this endogenous vasodilator is augmented by the reduced thiol N-acetyl-L-cysteine.

Effect of azidothymidine (AZT) on HIV P24 antigen, beta 2-microglobulin, neopterin, soluble CD8, soluble interleukin-2 receptor and tumor necrosis factor alpha levels in patients with AIDS-related complex or AIDS

Circulating HIV P24 antigen, beta 2-microglobulin, neopterin, soluble CD8, soluble interleukin-2 receptor and TNF alpha levels were measured in 20 patients (9 with ARC and 11 with AIDS) treated with azidothymidine (AZT) and in 12 patients (3 with ARC and 9 with AIDS) who were in a placebo group. Mean levels of HIV P24 antigen, beta 2-microglobulin, neopterin and SCD8 decreased significantly (P less than 0.05) after 12 to 16 weeks of AZT administration. SIL-2R and TNF alpha serum levels did not appear to change in association with AZT therapy. No changes were observed in the placebo group except that TNF alpha levels appeared to increase after 12 to 16 weeks. These results suggest that AZT administration may have led to reduced HIV P24 antigen, beta 2-microglobulin, neopterin and SCD8 mean levels in these patients.

Effect of azidothymidine (AZT) on P24 antigen levels in patients with AIDS-related complex and AIDS

Circulating HIV P24 antigen levels at baseline and following AZT therapy were measured in 9 patients with ARC and 11 patients with AIDS. Eight of these patients had no detectable levels of P24. The P24 antigen levels in the remaining 12 patients decreased significantly after AZT treatment. Following discontinuation of AZT treatment in 2 patients, the P24 antigen levels went up. These results clearly demonstrate the efficacy of AZT in reducing P24 antigen levels in circulation.

In vitro susceptibilities of Aeromonas hydrophila, Aeromonas sobria, and Aeromonas caviae to 22 antimicrobial agents

MICs of 22 antimicrobial agents for 60 strains of three Aeromonas species were determined by a microdilution method. The newer cephalosporins such as moxalactam, cefotaxime, and cefoperazone, the aminoglycosides, and chloramphenicol, tetracycline, nitrofurantoin, and trimethoprim-sulfamethoxazole inhibited most of the strains studied. Within the genus, A. hydrophila was more resistant than either A. caviae or A. sobria to the antibiotics tested.

Comparison of conventional and miniaturized biochemical techniques for identification of animal streptococcal isolates

Human clinical streptococcal isolates can be identified rapidly by means of commercially available miniaturized biochemical systems, in contrast to animal and environmental isolates which may require extensive characterization using conventional methods. Streptococcal isolates (n=548) from fresh animal feces of cattle, swine, and broiler chickens were tested by means of conventional biochemical and physiological techniques, and also with a miniaturized technique in which conventional formulations were dispensed in 0.1 ml volume into microtiter plates. Agreement of the positive feature frequencies of the two methods were compared. Results from the tolerance tests in the two methods were generally in good agreement. However, the miniaturized method tended to give false negative results in some carbohydrate fermentation tests. Agreement between the 2 methods ranged from 100% for bile esculin tests to 71% for raffinose fermentation. Cluster analysis of the conventional method data indicated that there were 11 biochemically related groups of isolates, 2 of which were identified asStreptococcus faecalis, andS. morbillorum. Half of the isolates biochemically resembledS. faecium. Errors of miniaturized tests occurred mainly in certain tests and in certain biochemically related clusters of isolates. The data indicate that further investigation of experimental conditions such as medium formulation and inoculum size could lead to a successful miniaturized technique for testing animal streptococcal isolates.

Growth of coagulase-negative staphylococci on colistin-nalidixic acid agar and susceptibility to polymyxins

Colistin-nalidixic acid agar, although recently recommended as a replacement for blood agar for primary plating of urine specimens ( Fung et al., J. Clin. Microbiol. 16:632-636, 1982), has also been reported to suppress the growth of some strains of staphylococci that are susceptible to colistin (polymyxin E). The susceptibility of 11 species of staphylococci to polymyxins was determined, and the ability of these species to grow on colistin-nalidixic acid agar was examined. Although the MICs for most of the strains tested were 8 micrograms/ml or less, only a few coagulase-negative staphylococci grew on or were inhibited by colistin-nalidixic acid agar. This descrepancy was explained by the antagonistic effects that medium components, such as physiological concentrations of magnesium and calcium and 5% sheep blood, had on the activity of polymyxin. Colistin-nalidixic acid agar is still recommended for routine urine processing; however, the poor growth of 13% of the Staphylococcus saprophyticus strains tested suggests that blood agar should be included in the primary plating battery of urine specimens obtained from female outpatients.

Effect of different media on determination of novobiocin resistance for differentiation of coagulase-negative staphylococci

Species identification of coagulase-negative staphylococci often requires the determination of novobiocin susceptibility. Although previous investigators have recommended the use of P agar for this purpose, most clinical laboratories do not routinely utilize this medium. For this reason, studies were performed to compare novobiocin susceptibility results obtained with 11 different species of staphylococci (10 isolates of each species), using P agar, Trypticase soy agar with 5% sheep blood, and Mueller-Hinton agar. Tests performed on 70 susceptible isolates (minimal inhibitory concentration less than 1.6 micrograms/ml) resulted in zones of inhibition around 5-micrograms novobiocin disks ranging from 19.6 to 33.9, 16.2 to 26.6, and 21.3 to 36.4 mm on P agar, Trypticase soy agar with 5% sheep blood, and Mueller-Hinton agar, respectively. Forty resistant isolates (minimal inhibitory concentration greater than or equal to 1.6 micrograms/ml) exhibited zones of inhibition ranging from 6.0 to 11.3 mm on P agar, 6.0 to 11.6 mm on Trypticase soy agar with 5% sheep blood, and 6.0 to 13.5 mm on Mueller-Hinton agar. Using the established cut off of 16 mm to define novobiocin resistance for the identification of coagulase-negative staphylococci, we correctly identified 100% of the strains tested, regardless of the media utilized.