Significance of mild thrombocytopenia in maintenance hemodialysis patients; a retrospective cohort study

Platelet activation in the hemodialysis (HD) circuit often causes thrombocytopenia. However, its clinical and pathophysiological significance has rarely been explored. Herein, we investigated the predictive value of thrombocytopenia for cardiovascular events (CVE) in maintenance HD patients and attempted to explore its mechanistic background considering recent knowledge of platelet dynamics. We conducted a retrospective cohort study on HD patients with the composite primary endpoint of predicting CVE, i.e., myocardial infarction, ischemic stroke, and cardiovascular death. Baseline clinical data were analyzed and explored. Multivariate Cox regression analysis showed that platelet decrease was independently associated with CVE. Thrombocytopenia was correlated with the disuse of antiplatelet therapy (APT) and macrocytosis. These findings are possibly associated with platelet activation and senescent hematopoiesis. The prognostic significance of thrombocytopenia was more prominent in patients undergoing APT, implying the presence of APT-resistant platelets in such patients. To fully explain these results, we hypothesized that HD-activated platelets induce the biological aging of hematopoiesis, which is presumably extramedullary in the lung, where activated platelets could deliver massive amounts of inflammatory cytokines and reactive oxidative species. This results in the production of qualitatively altered and hyper-reactive platelets, a process that could form a vicious cycle that induces CVE-associated thrombocytopenia. Further investigations focusing on the dynamics of the biological aging of platelets in HD patients are warranted.

P5370Pulmonary pressure overload stimulates cardiac stem or progenitor cell-derived cardiac regeneration in the right ventricular area

Introduction and purpose

The number of patients with right heart failure due to pulmonary hypertension has been increasing. Although several drugs have reportedly improved pulmonary hypertension, no treatments have been established for decompensated right heart failure. The heart has an innate ability to regenerate, and cardiac stem or progenitor cells (e.g., side population [SP] cells) have been reported to contribute to the regeneration process. However, their contribution to right ventricular pressure overload has not been clarified. Here, this regeneration process was evaluated using a genetic fate-mapping model.

Methods and results

We used Cre-LacZ mice, in which more than 99.9% of the cardiomyocytes in the left ventricular field were positive for 5-bromo-4-chloro-3-indolyl-β-D-galactoside (X-gal) staining immediately after tamoxifen injection. Then, we performed either a pulmonary binding (PAB) or sham operation on the main pulmonary tract. In the PAB-treated mice, the right ventricular cavity was significantly enlarged (right-to-left ventricular [RV/LV] ratio, 0.24±0.04 in the sham group and 0.68±0.04 in the PAB group). Increased peak flow velocity in the PAB group (1021±80 vs 1351±62 mm/sec) was confirmed by echocardiography. One month after the PAB, the PAB-treated mice had more X-gal-negative (newly generated) cells than the sham mice (94.8±34.2 cells/mm2 vs 23.1±10.5 cells/mm2; p<0.01). The regeneration was biased in the RV free wall (RV free wall, 225.5±198.7 cells/mm2; septal area, 88.9±56.5/mm2; LV lateral area, 46.8±22.0/mm2; p<0.05). To examine the direct effects of PAB on the cardiac progenitor cells, bromodeoxyuridine was administered to the mice daily until 1 week after the PAB operation. Then, the hearts were isolated and SP cells were harvested. The SP cell population increased from 0.65±0.23% in the sham mice to 1.87% ± 1.18% in the PAB-treated mice. Immunostaining analysis revealed a significant increase in the number of BrdU-positive SP cells, from 11.6±2.0% to 44.0±18%, therefore showing SP cell proliferation.

Conclusions

Pulmonary pressure overload stimulated cardiac stem or progenitor cell-derived regeneration with a RV bias, and SP cell proliferation may partially contribute to this process.

Acknowledgement/Funding

JSPS KAKENHI Grant Number JP 17K17636, GSK Japan Research Grant 2016

Successful intermuscular implantation of subcutaneous implantable cardioverter defibrillator in a Japanese patient with pectus excavatum

The entirely subcutaneous implantable cardioverter-defibrillator (ICD) system was developed to provide a life-saving defibrillation therapy that does not affect the heart and vasculature. The subcutaneous ICD is preferred over the transvenous ICD for patients with a history of recurrent infection presenting major life-threatening rhythms. In this case report, we describe the first successful intermuscular implantation of a completely subcutaneous ICD in a Japanese patient with pectus excavatum. There were no associated complications with the device implantation or lead positioning. Further, the defibrillation threshold testing did not pose any problem with the abnormal anatomy of the patient.

Abstract 519: Therapeutic Angiogenesis by Peripheral Blood Mononuclear Cells and its Rationale for Designing a New Trial

Background: Clinical trials of therapeutic angiogenesis that treat chronic critical limb ischemia (CLI) are revealing mixed results. This may partly be due to unapt patient selection or suboptimal study protocols. Here, from our registry, we report demographic and procedural characteristics of patients who underwent major limb amputation despite therapeutic angiogenesis.

Methods: Registry of CLI patients who were treated by peripheral blood mononuclear cell (PBMNC) implantation was retrospectively analyzed. Cases that underwent major limb amputation within 6 months of the therapy were further investigated to clarify any features that might have affected their limb outcomes.

Results and Discussions: Among total of 112 patients in the registry, eight cases lost to follow up and were excluded from this study. Sixteen patients (16/104, 15.4%) underwent major limb amputation within 6 months after therapeutic angiogenesis. Six amputees had active infection in the treated limb. Unlike excellent outcome by bone marrow derived cells, any patients with systemic sclerosis treated by PBMNC had poor limb salvage. However, half (8/16) of the amputees had experienced blood flow recovery, at least for transient period of two weeks. Among these patients, five limbs showed significant recovery of crural blood flow, while in the ipsilateral foot, distal blood flow deteriorated, indicating the flow steal phenomenon induced by cell therapy, which induces strong vasodilatation. Excluding patients with active infection or systemic sclerosis halved the limb amputation rate. Careful selection of sites to implant cells according to anatomical distribution of arterial blood flow could even have improved the limb salvage rate.

Conclusion: When designing a clinical trial of therapeutic angiogenesis, (1) excluding patients with active infections, (2) proper treatment site considering anatomical distribution of arterial blood flow to avoid steal phenomenon, and (3) selection of cell source according to etiology of CLI, may clarify the efficacy of therapeutic angiogenesis.

Notch signaling regulates the lifespan of vascular endothelial cells via a p16-dependent pathway

Evolutionarily conserved Notch signaling controls cell fate determination and differentiation during development, and is also essential for neovascularization in adults. Although recent studies suggest that the Notch pathway is associated with age-related conditions, it remains unclear whether Notch signaling is involved in vascular aging. Here we show that Notch signaling has a crucial role in endothelial cell senescence. Inhibition of Notch signaling in human endothelial cells induced premature senescence via a p16-dependent pathway. Conversely, over-expression of Notch1 or Jagged1 prolonged the replicative lifespan of endothelial cells. Notch1 positively regulated the expression of inhibitor of DNA binding 1 (Id1) and MAP kinase phosphatase 1 (MKP1), while MKP1 further up-regulated Id1 expression by inhibiting p38MAPK-induced protein degradation. Over-expression of Id1 down-regulated p16 expression, thereby inhibiting premature senescence of Notch1-deleted endothelial cells. These findings indicate that Notch1 signaling has a role in the regulation of endothelial cell senescence via a p16-dependent pathway and suggest that activation of Notch1 could be a new therapeutic target for treating age-associated vascular diseases.

Brain-derived neurotrophic factor protects against cardiac dysfunction after myocardial infarction via a central nervous system-mediated pathway

OBJECTIVE

The central nervous system is thought to influence the regulation of the cardiovascular system in response to humoral and neural signals from peripheral tissues, but our understanding of the molecular mechanisms involved is still quite limited.

METHODS AND RESULTS

Here, we demonstrate a central nervous system-mediated mechanism by which brain-derived neurotrophic factor (BDNF) has a protective effect against cardiac remodeling after myocardial infarction (MI). We generated conditional BDNF knockout mice, in which expression of BDNF was systemically reduced, by using the inducible Cre-loxP system. Two weeks after MI was induced surgically in these mice, systolic function was significantly impaired and cardiac size was markedly increased in conditional BDNF knockout mice compared with controls. Cardiomyocyte death was increased in these mice, along with decreased expression of survival molecules. Deletion of the BDNF receptor (tropomyosin-related kinase B) from the heart also led to the exacerbation of cardiac dysfunction after MI. The plasma levels of BDNF were markedly increased after MI, and this increase was associated with the upregulation of BDNF expression in the brain, but not in the heart. Ablation of afferent nerves from the heart or genetic disruption of neuronal BDNF expression inhibited the increase of plasma BDNF after MI and led to the exacerbation of cardiac dysfunction. Peripheral administration of BDNF significantly restored the cardiac phenotype of neuronal BDNF-deficient mice.

CONCLUSIONS

These results suggest that BDNF expression is upregulated by neural signals from the heart after MI and then protects the myocardium against ischemic injury.

p53-induced adipose tissue inflammation is critically involved in the development of insulin resistance in heart failure

Several clinical studies have shown that insulin resistance is prevalent among patients with heart failure, but the underlying mechanisms have not been fully elucidated. Here, we report a mechanism of insulin resistance associated with heart failure that involves upregulation of p53 in adipose tissue. We found that pressure overload markedly upregulated p53 expression in adipose tissue along with an increase of adipose tissue inflammation. Chronic pressure overload accelerated lipolysis in adipose tissue. In the presence of pressure overload, inhibition of lipolysis by sympathetic denervation significantly downregulated adipose p53 expression and inflammation, thereby improving insulin resistance. Likewise, disruption of p53 activation in adipose tissue attenuated inflammation and improved insulin resistance but also ameliorated cardiac dysfunction induced by chronic pressure overload. These results indicate that chronic pressure overload upregulates adipose tissue p53 by promoting lipolysis via the sympathetic nervous system, leading to an inflammatory response of adipose tissue and insulin resistance.

Abstract P246: Inhibition of Endothelial Senescence Ameliorates Insulin Resistance of Obese Mice

Various stimuli can induce irreversible cell growth arrest, termed cellular senescence. This response is controlled by negative regulators of the cell cycle such as p53. Accumulating evidence suggests a potential relationship between cellular senescence and age-associated diseases including type 2 diabetes. Here we show a crucial role for endothelial p53 in the regulation of insulin resistance. We found that treatment of endothelial cells with high glucose and palmitate synergistically increased p53 expression. Consistent with the in vitro results, endothelial expression of p53 was markedly up-regulated when the mice were fed a high-calorie diet, suggesting that excessive calorie intake promotes endothelial senescence. To investigate the role of endothelial p53 in type 2 diabetes, we analyzed metabolic parameters in endothelial cell-specific p53 conditional knockout (ECp53CKO) mice on a high-calorie diet. In spite of no difference in dietary intake, ECp53CKO mice had a significantly smaller weight and less fat accumulation than control mice. Moreover, ECp53CKO mice showed better insulin sensitivity and glucose tolerance than control littermates. ECp53CKO demonstrated a significant increase in oxygen consumption and had a higher core body temperature compared with control mice. Next we considered some assumed mechanisms of relationship of endothelial cell p53 expression and metabolic disorders. As a result, we found that ECp53CKO mice had higher glucose uptake in skeletal muscles than control. These results indicate that inhibition of endothelial senescence ameliorates insulin resistance by increasing energy consumption via glucose uptake and suggest that endothelial p53 will be a novel therapeutic target for type 2 diabetes.

Role of Jagged1 in Arterial Lesions After Vascular Injury

Objective—

Impaired regeneration of endothelial cells (EC) and overactivity of vascular smooth muscle cells (VSMC) are hallmarks of the arterial lesions associated with aging. The occurrence of 2 opposing cellular processes in the same arterial milieu makes pharmaceutical treatment difficult to develop. We previously reported that endothelial expression of a Notch ligand (Jagged1) was reduced in aged animals and that growth of the neointima was enhanced in these animals.

Methods and Results—

Similar to aged animals, Tie2-cre + Jagged1 lox/+ mice (with heterologous knockout of Jagged1 in EC) showed exaggerated intimal and medial thickening after carotid artery ligation. Unexpectedly, these mice showed little increase of Jagged1 expression not only in EC but also in VSMC, in contrast to a significant upregulation of Jagged1 in wild-type arteries after ligation. Coculture of VSMC with Jagged1-null EC resulted in the transition of VSMC from the contractile to the synthetic phenotype, along with decreased Jagged1 expression by VSMC. Conversely, overexpression of Jagged1 by EC or VSMC was shown to prevent the unfavorable phenotypic transition of VSMC, under both monoculture and coculture conditions.

Conclusion—

These findings suggest a unidirectional effect of Jagged1 on both EC and VSMC that contributes to inhibition of arterial lesions after vascular injury. Our data also indicate that Jagged1 may be a novel therapeutic target for aging-related vascular diseases.

Excessive cardiac insulin signaling exacerbates systolic dysfunction induced by pressure overload in rodents

Although many animal studies indicate insulin has cardioprotective effects, clinical studies suggest a link between insulin resistance (hyperinsulinemia) and heart failure (HF). Here we have demonstrated that excessive cardiac insulin signaling exacerbates systolic dysfunction induced by pressure overload in rodents. Chronic pressure overload induced hepatic insulin resistance and plasma insulin level elevation. In contrast, cardiac insulin signaling was upregulated by chronic pressure overload because of mechanical stretch-induced activation of cardiomyocyte insulin receptors and upregulation of insulin receptor and Irs1 expression. Chronic pressure overload increased the mismatch between cardiomyocyte size and vascularity, thereby inducing myocardial hypoxia and cardiomyocyte death. Inhibition of hyperinsulinemia substantially improved pressure overload-induced cardiac dysfunction, improving myocardial hypoxia and decreasing cardiomyocyte death. Likewise, the cardiomyocyte-specific reduction of insulin receptor expression prevented cardiac ischemia and hypertrophy and attenuated systolic dysfunction due to pressure overload. Conversely, treatment of type 1 diabetic mice with insulin improved hyperglycemia during pressure overload, but increased myocardial ischemia and cardiomyocyte death, thereby inducing HF. Promoting angiogenesis restored the cardiac dysfunction induced by insulin treatment. We therefore suggest that the use of insulin to control hyperglycemia could be harmful in the setting of pressure overload and that modulation of insulin signaling is crucial for the treatment of HF.

Inhibition of semaphorin as a novel strategy for therapeutic angiogenesis

RATIONALE

The axon-guiding molecules known as semaphorins and their receptors (plexins) regulate the vascular pattern and play an important role in the development of vascular network during embryogenesis. Semaphorin (Sema)3E is one of the class 3 semaphorins, and plexinD1 is known to be its receptor. Although these molecules have a role in embryonic vascular development, it remains unclear whether the Sema3E/plexinD1 axis is involved in postnatal angiogenesis.

OBJECTIVE

The objective of this study was to elucidate the role of Sema3E/plexinD1 in postnatal angiogenesis.

METHODS AND RESULTS

Sema3E inhibited cell growth and tube formation by suppressing the vascular endothelial growth factor (VEGF) signaling pathway. Expression of Sema3E and plexinD1 was markedly upregulated in ischemic limbs of mice (2.5- and 4.5-fold increase for Sema3E and plexinD1, respectively), and inhibition of this pathway by introduction of the plexinD1-Fc gene or disruption of Sema3E led to a significant increase of blood flow recovery (1.6- and 1.5-fold increase for the plexinD1-Fc gene treatment and Sema3E disruption, respectively). Hypoxia activated the tumor suppressor protein p53, thereby upregulating Sema3E expression. Expression of p53 and Sema3E was enhanced in diabetic mice compared with normal mice (2- and 1.3-fold increase for p53 and Sema3E, respectively). Consequently, neovascularization after VEGF treatment was poor in the ischemic tissues of diabetic mice, whereas treatment with VEGF plus plexinD1-Fc markedly improved neovascularization.

CONCLUSIONS

These results indicate that inhibition of Sema3E may be a novel strategy for therapeutic angiogenesis, especially when VEGF is ineffective.

Cardiac 12/15 lipoxygenase-induced inflammation is involved in heart failure

To identify a novel target for the treatment of heart failure, we examined gene expression in the failing heart. Among the genes analyzed, Alox15 encoding the protein 12/15 lipoxygenase (LOX) was markedly up-regulated in heart failure. To determine whether increased expression of 12/15-LOX causes heart failure, we established transgenic mice that overexpressed 12/15-LOX in cardiomyocytes. Echocardiography showed that Alox15 transgenic mice developed systolic dysfunction. Cardiac fibrosis increased in Alox15 transgenic mice with advancing age and was associated with the infiltration of macrophages. Consistent with these observations, cardiac expression of monocyte chemoattractant protein 1 (MCP-1) was up-regulated in Alox15 transgenic mice compared with wild-type mice. Treatment with 12-hydroxy-eicosatetraenoic acid, a major metabolite of 12/15-LOX, increased MCP-1 expression in cardiac fibroblasts and endothelial cells but not in cardiomyocytes. Inhibition of MCP-1 reduced the infiltration of macrophages into the myocardium and prevented both systolic dysfunction and cardiac fibrosis in Alox15 transgenic mice. Likewise, disruption of 12/15-LOX significantly reduced cardiac MCP-1 expression and macrophage infiltration, thereby improving systolic dysfunction induced by chronic pressure overload. Our results suggest that cardiac 12/15-LOX is involved in the development of heart failure and that inhibition of 12/15-LOX could be a novel treatment for this condition.

Long-Term Outcome of Therapeutic Neovascularization Using Peripheral Blood Mononuclear Cells for Limb Ischemia

Background— Injection of bone marrow mononuclear cells has been reported to promote neovascularization of ischemic tissues effectively. We found that peripheral blood mononuclear cells were as efficient as bone marrow mononuclear cells for the treatment of limb ischemia in animals and showed that this treatment was feasible and safe in no-option patients with limb ischemia. However, the long-term outcome of such therapy has not been investigated.

Methods and Results— We retrospectively analyzed the data for 42 patients who were treated between July 2002 and December 2005 by using the log-rank test, the Kaplan-Meier method, and the Cox proportional hazard model. Improvement of ischemic symptoms was observed in 60% to 70% of the patients. The annual rate of major amputation was decreased markedly by treatment. Improvement of ischemic symptoms was less marked in arteriosclerosis obliterans (ASO) patients on dialysis compared with nonhemodialysis ASO or thromboangiitis obliterans patients. Indeed, the survival rate of these patients was lower than that of nonhemodialysis ASO or thromboangiitis obliterans patients. Major adverse events such as death, major amputation, and cardiovascular events occurred mostly in ASO patients, and most of them were on dialysis. There was no significant difference in the cardiovascular event-free rate between responders and nonresponders. The survival rate of younger responders was better than that of nonresponders.

Conclusions— Although this study was not placebo-controlled and these initial results were from a retrospective analysis, injection of peripheral blood mononuclear cells might be safe and potentially effective for the treatment of limb ischemia, but caution is needed when managing ASO patients on dialysis.

Protective role of SIRT1 in diabetic vascular dysfunction

OBJECTIVE

Calorie restriction (CR) prolongs the lifespan of various species, ranging from yeasts to mice. In yeast, CR extends the lifespan by increasing the activity of silencing information regulator 2 (Sir2), an NAD(+)-dependent deacetylase. SIRT1, a mammalian homolog of Sir2, has been reported to downregulate p53 activity and thereby prolong the lifespan of cells. Although recent evidence suggests a link between SIRT1 activity and metabolic homeostasis during CR, its pathological role in human disease is not yet fully understood.

METHODS AND RESULTS

Treatment of human endothelial cells with high glucose decreases SIRT1 expression and thus activates p53 by increasing its acetylation. This in turn accelerates endothelial senescence and induces functional abnormalities. Introduction of SIRT1 or disruption of p53 inhibits high glucose-induced endothelial senescence and dysfunction. Likewise, activation of Sirt1 prevents the hyperglycemia-induced vascular cell senescence and thereby protects against vascular dysfunction in mice with diabetes.

CONCLUSIONS

These findings represent a novel mechanism of vascular cell senescence induced by hyperglycemia and suggest a protective role of SIRT1 in the pathogenesis of diabetic vasculopathy.

Cell therapy for cardiovascular diseases

There have been great progresses in our knowledge of patho-physiology on various cardiovascular diseases, which enabled us to develop the field of regenerative medicine for previously untreatable patients. Among several strategies in cardiovascular regenerative medicine, cell transplantation is one of the best studied and the best clinically practiced. In this review we will first summarize the mechanisms of cell therapy, and then go through lists of cells and diseases that can be applied. Later we will introduce some of the clinical experiences published so far, with some discussion regarding the problems and perspectives of this novel therapeutics.

Vascular Endothelial Growth Factor Receptor-1 Regulates Postnatal Angiogenesis Through Inhibition of the Excessive Activation of Akt

Vascular endothelial growth factor (VEGF) binds both VEGF receptor-1 (VEGFR-1) and VEGF receptor-2 (VEGFR-2). Activation of VEGFR-2 is thought to play a major role in the regulation of endothelial function by VEGF. Recently, specific ligands for VEGFR-1 have been reported to have beneficial effects when used to treat ischemic diseases. However, the role of VEGFR-1 in angiogenesis is not fully understood. In this study, we showed that VEGFR-1 performs “fine tuning” of VEGF signaling to induce neovascularization. We examined the effects of retroviral vectors expressing a small interference RNA that targeted either the VEGFR-1 gene or the VEGFR-2 gene. Deletion of either VEGFR-1 or VEGFR-2 reduced the ability of endothelial cells to form capillaries. Deletion of VEGFR-1 markedly reduced endothelial cell proliferation and induced premature senescence of endothelial cells. In contrast, deletion of VEGFR-2 significantly impaired endothelial cell survival. When VEGFR-1 expression was blocked, VEGF constitutively activated Akt signals and thus induced endothelial cell senescence via a p53-dependent pathway. VEGFR-1 +/− mice exhibited an increase of endothelial Akt activity and showed an impaired neovascularization in response to ischemia, and this impairment was ameliorated in VEGFR-1 +/− Akt1 +/− mice. These results suggest that VEGFR-1 plays a critical role in the maintenance of endothelial integrity by modulating the VEGF/Akt signaling pathway.

p53-induced inhibition of Hif-1 causes cardiac dysfunction during pressure overload

Cardiac hypertrophy occurs as an adaptive response to increased workload to maintain cardiac function. However, prolonged cardiac hypertrophy causes heart failure, and its mechanisms are largely unknown. Here we show that cardiac angiogenesis is crucially involved in the adaptive mechanism of cardiac hypertrophy and that p53 accumulation is essential for the transition from cardiac hypertrophy to heart failure. Pressure overload initially promoted vascular growth in the heart by hypoxia-inducible factor-1 (Hif-1)-dependent induction of angiogenic factors, and inhibition of angiogenesis prevented the development of cardiac hypertrophy and induced systolic dysfunction. Sustained pressure overload induced an accumulation of p53 that inhibited Hif-1 activity and thereby impaired cardiac angiogenesis and systolic function. Conversely, promoting cardiac angiogenesis by introducing angiogenic factors or by inhibiting p53 accumulation developed hypertrophy further and restored cardiac dysfunction under chronic pressure overload. These results indicate that the anti-angiogenic property of p53 may have a crucial function in the transition from cardiac hypertrophy to heart failure.

Angiotensin II Induces Premature Senescence of Vascular Smooth Muscle Cells and Accelerates the Development of Atherosclerosis via a p21-Dependent Pathway

BACKGROUND

Angiotensin II (Ang II) has been reported to contribute to the pathogenesis of various human diseases including atherosclerosis, and inhibition of Ang II activity has been shown to reduce the morbidity and mortality of cardiovascular diseases. We have previously demonstrated that vascular cell senescence contributes to the pathogenesis of atherosclerosis; however, the effects of Ang II on vascular cell senescence have not been examined.

METHODS AND RESULTS

Ang II significantly induced premature senescence of human vascular smooth muscle cells (VSMCs) via the p53/p21-dependent pathway in vitro. Inhibition of this pathway effectively suppressed induction of proinflammatory cytokines and premature senescence of VSMCs by Ang II. Ang II also significantly increased the number of senescent VSMCs and induced the expression of proinflammatory molecules and of p21 in a mouse model of atherosclerosis. Loss of p21 markedly ameliorated the induction of proinflammatory molecules by Ang II, thereby preventing the development of atherosclerosis. Replacement of p21-deficient bone marrow cells with wild-type cells had little influence on the protective effect of p21 deficiency against the progression of atherogenesis induced by Ang II.

CONCLUSIONS

We demonstrated that Ang II promotes vascular inflammation by inducing premature senescence of VSMCs both in vitro and in vivo. Our results suggest a critical role of p21-dependent premature senescence of VSMCs in the pathogenesis of atherosclerosis.

Critical Roles of Muscle-Secreted Angiogenic Factors in Therapeutic Neovascularization

The discovery of bone marrow–derived endothelial progenitors in the peripheral blood has promoted intensive studies on the potential of cell therapy for various human diseases. Accumulating evidence has suggested that implantation of bone marrow mononuclear cells effectively promotes neovascularization in ischemic tissues. It has also been reported that the implanted cells are incorporated not only into the newly formed vessels but also secrete angiogenic factors. However, the mechanism by which cell therapy improves tissue ischemia remains obscure. We enrolled 29 “no-option” patients with critical limb ischemia and treated ischemic limbs by implantation of peripheral mononuclear cells. Cell therapy using peripheral mononuclear cells was very effective for the treatment of limb ischemia, and its efficacy was associated with increases in the plasma levels of angiogenic factors, in particular interleukin-1β (IL-1β). We then examined an experimental model of limb ischemia using IL-1β–deficient mice. Implantation of IL-1β–deficient mononuclear cells improved tissue ischemia as efficiently as that of wild-type cells. Both wild-type and IL-1β–deficient mononuclear cells increased expression of IL-1β and thus induced angiogenic factors in muscle cells of ischemic limbs to a similar extent. In contrast, inability of muscle cells to secrete IL-1β markedly reduces induction of angiogenic factors and impairs neovascularization by cell implantation. Implanted cells do not secret angiogenic factors sufficient for neovascularization but, instead, stimulate muscle cells to produce angiogenic factors, thereby promoting neovascularization in ischemic tissues. Further studies will allow us to develop more effective treatments for ischemic vascular disease.

Application of Hematopoietic Cells to Therapeutic Angiogenesis

Despite considerable progress in the field of cardiovascular medicine and surgery, ischemic heart disease is still the leading cause of death in advanced countries. In this context, it is no wonder why therapeutic angiogenesis, a way to ameliorate ischemic tissue from suffering dysfunction by increasing new blood vessels, gains so much attention from both clinicians and patients. In this review, we will briefly go through a decade of history in therapeutic angiogenesis including unraveling of its mechanisms, results obtained from clinical trials, and lessons learned from earlier investigations. We will then focus on an emerging, yet rapidly evolving field of hematopoietic cell therapy. Recent excellent studies seem to have brought us to the place where we might save so many patients from burden of ischemia, we should be aware that there are some controversies, and sometimes misunderstandings, regarding how or why this treatment does actually work, and what better way should we explore in order to get the best of its efficacy. With these caveats in mind, we will investigate the works elucidating the mechanisms and clinical efficacies of hematopoietic cell therapy.

Cellular senescence impairs circadian expression of clock genes in vitro and in vivo

Circadian rhythms are regulated by a set of clock genes that form transcriptional feedback loops and generate circadian oscillation with a 24-hour cycle. Aging alters a broad spectrum of physiological, endocrine, and behavioral rhythms. Although recent evidence suggests that cellular aging contributes to various age-associated diseases, its effects on the circadian rhythms have not been examined. We report here that cellular senescence impairs circadian rhythmicity both in vitro and in vivo. Circadian expression of clock genes in serum-stimulated senescent cells was significantly weaker compared with that in young cells. Introduction of telomerase completely prevented this reduction of clock gene expression associated with senescence. Stimulation by serum activated the cAMP response element-binding protein, but the activation of this signaling pathway was significantly weaker in senescent cells. Treatment with activators of this pathway effectively restored the impaired clock gene expression of senescent cells. When young cells were implanted into young mice or old mice, the implanted cells were effectively entrained by the circadian rhythm of the recipients. In contrast, the entrainment of implanted senescent cells was markedly impaired. These results suggest that senescence decreases the ability of cells to transmit circadian signals to their clocks and that regulation of clock gene expression may be a novel strategy for the treatment of age-associated impairment of circadian rhythmicity.

Usefulness of rapid quantitative measurement of myoglobin and troponin T in early diagnosis of acute myocardial infarction

BACKGROUND

New equipment, the Cardiac Reader(TM), which can measure blood concentrations of troponin T (T) and myoglobin (M) in only 15 min at the bedside was evaluated for early diagnosis of acute myocardial infarction (AMI).

METHODS AND RESULTS

A total of 34 consecutive patients with AMI who came to hospital within 24 h after onset were studied. Blood samples were collected from the patients at admission and 6, 12, 24, 48 h after onset to qualitatively and quantitatively measure T, M and creatine kinase-MB fraction. There were 20 patients with positive results by qualitative troponin T test and 29 with positive results by quantitative test. Of the patients who visited hospital within 3 h of onset, 17% were positive by the qualitative test and 67% cases had positive results in the quantitative test. The patients were divided into 2 groups according to the flow grade in the infarct-related coronary artery. In the TIMI 0-1 group (n=28), serum myoglobin concentrations were higher than in the TIMI 3-4 group (n=6) at admission and at their peak.

CONCLUSION

The rapid quantitative test of T and M is useful for early diagnosis of AMI and as an indicator of its severity, which can be evaluated from the myoglobin concentration in the hyper-acute phase.

Akt-induced cellular senescence: implication for human disease

Reduction-of-function mutations in components of the insulin/insulin-like growth factor-1/Akt pathway have been shown to extend the lifespan in organisms ranging from yeast to mice. It has also been reported that activation of Akt induces proliferation and survival of mammalian cells, thereby promoting tumorigenesis. We have recently shown that Akt activity increases with cellular senescence and that inhibition of Akt extends the lifespan of primary cultured human endothelial cells. Constitutive activation of Akt promotes senescence-like arrest of cell growth via a p53/p21-dependent pathway, leading to endothelial dysfunction. This novel role of Akt in regulating the cellular lifespan may contribute to various human diseases including atherosclerosis and diabetes mellitus.

The Role of Vascular Cell Senescence in Atherosclerosis: Antisenescence as a Novel Therapeutic Strategy for Vascular Aging

Vascular cells have a finite lifespan when cultured in vitro and eventually enter an irreversible growth arrest called "cellular senescence." It has been reported that many of the changes in senescent vascular cell behavior are consistent with the changes seen in age-related vascular diseases. Recently, senescent vascular cells have been demonstrated in human atherosclerotic lesions but not in non-atherosclerotic lesions. Moreover, these cells express increased levels of proinflammatory molecules and decreased levels of endothelial nitric oxide synthase, suggesting that cellular senescence in vivo contributes to the pathogenesis of human atherosclerosis. One widely discussed hypothesis of senescence is the telomere hypothesis. An increasing body of evidence has established the critical role of the telomere in vascular cell senescence. Introduction of telomere malfunction has been shown to lead to vascular dysfunction that promotes atherogenesis, whereas telomere lengthening extends cell lifespan and protects against vascular dysfunction associated with senescence. Indeed, recent studies have demonstrated that telomere attrition occurs in the blood vessels and is associated with human atherosclerosis. More recent evidence suggests that telomere-independent mechanisms are implicated in vascular cell senescence. Activation of Ras, an important signaling molecule involved in atherogenic stimuli, induces vascular cell senescence and thereby, promotes vascular inflammation in vitro and in vivo. Although a causal link between vascular aging and vascular cell senescence remains elusive, a large body of data is consistent with cellular senescence contributing to age-associated vascular disorders. This review considers the clinical relevance of vascular cell senescence in vivo and discusses the potential of antisenescence therapy for human atherosclerosis.

Vascular cell senescence and vascular aging

Vascular cells have a finite lifespan when cultured in vitro and eventually enter an irreversible growth arrest called "cellular senescence". A number of genetic animal models carrying targeted disruption of the genes that confer the protection against senescence in vitro have been reported to exhibit the phenotypes of premature aging. Similar mutations have been found in the patients with premature aging syndromes. Many of the changes in senescent vascular cell behavior are consistent with the changes seen in age-related vascular diseases. We have demonstrated the presence of senescent vascular cells in human atherosclerotic lesions but not in non-atherosclerotic lesions. Moreover, these cells express increased levels of pro-inflammatory molecules and decreased levels of endothelial nitric oxide synthase, suggesting that cellular senescence in vivo contributes to the pathogenesis of human atherosclerosis. One widely discussed hypothesis of senescence is the telomere hypothesis. An increasing body of evidence has established the critical role of the telomere in vascular cell senescence. Another line of evidence suggests that telomere-independent mechanisms are also involved in vascular cell senescence. Activation of Ras, an important signaling molecule involved in atherogenic stimuli, induces vascular cell senescence and thereby promotes vascular inflammation in vitro and in vivo. It is possible that mitogenic-signaling pathways induce telomere-dependent and telomere-independent senescence, which results in vascular dysfunction. Further understanding of the mechanism underlying cellular senescence will provide insights into the potential of antisenescence therapy for vascular aging.

Akt negatively regulates the in vitro lifespan of human endothelial cells via a p53/p21-dependent pathway

The signaling pathway of insulin/insulin-like growth factor-1/phosphatidylinositol-3 kinase/Akt is known to regulate longevity as well as resistance to oxidative stress in the nematode Caenorhabditis elegans. This regulatory process involves the activity of DAF-16, a forkhead transcription factor. Although reduction-of-function mutations in components of this pathway have been shown to extend the lifespan in organisms ranging from yeast to mice, activation of Akt has been reported to promote proliferation and survival of mammalian cells. Here we show that Akt activity increases along with cellular senescence and that inhibition of Akt extends the lifespan of primary cultured human endothelial cells. Constitutive activation of Akt promotes senescence-like arrest of cell growth via a p53/p21-dependent pathway, and inhibition of forkhead transcription factor FOXO3a by Akt is essential for this growth arrest to occur. FOXO3a influences p53 activity by regulating the level of reactive oxygen species. These findings reveal a novel role of Akt in regulating the cellular lifespan and suggest that the mechanism of longevity is conserved in primary cultured human cells and that Akt-induced senescence may be involved in vascular pathophysiology.

Ras induces vascular smooth muscle cell senescence and inflammation in human atherosclerosis

BACKGROUND

Vascular cells have a finite cell lifespan and eventually enter an irreversible growth arrest, cellular senescence. The functional changes associated with cellular senescence are thought to contribute to human aging and age-related vascular disorders. Ras, an important signaling molecule involved in atherogenic stimuli, is known to promote aging in yeast and cellular senescence in primary human fibroblasts. The aim of this study was to investigate the role of Ras-induced vascular smooth muscle cell (VSMC) senescence in atherogenesis.

METHODS AND RESULTS

We introduced an activated ras allele (H-rasV12) into human VSMCs using retroviral infection. Introduction of H-rasV12 induced a growth arrest with phenotypic characteristics of cellular senescence, such as enlarged cell shapes and increases in expression of cyclin-dependent kinase inhibitors and senescence-associated beta-galactosidase (SA-beta-gal) activity. Activation of Ras drastically increased expression of proinflammatory cytokines, in part through extracellular signal-regulated kinase activation. To determine whether Ras activation induces cellular senescence in vivo, we transduced the adenoviral vector encoding H-rasV12 into rat carotid arteries injured by a balloon catheter. Introduction of Ras into the arteries enhanced vascular inflammation and senescence compared with mock-infected injured arteries. Moreover, SA-beta-gal-positive VSMCs were detected in the intima of advanced human atherosclerotic lesions and exhibited increased levels of extracellular signal-regulated kinase activity and proinflammatory cytokine expression.

CONCLUSIONS

Our results suggest that atherogenic stimuli mediated by Ras induce VSMC senescence and vascular inflammation, thereby contributing to atherogenesis. This novel mechanism of atherogenesis may provide insights into a new antisenescence treatment for atherosclerosis.

Automatic detection of atrial fibrillation using the coefficient of variation and density histograms of RR and deltaRR intervals

The paper describes a method for the automatic detection of atrial fibrillation, an abnormal heart rhythm, based on the sequence of intervals between heartbeats. The RR interval is the interbeat interval, and deltaRR is the difference between two successive RR intervals. Standard density histograms of the RR and deltaRR intervals were prepared as templates for atrial fibrillation detection. As the coefficients of variation of the RR and deltaRR intervals were approximately constant during atrial fibrillation, the coefficients of variation in the test data could be compared with the standard coefficients of variation (CV test). Further, the similarities between the density histograms of the test data and the standard density histograms were estimated using the Kolmogorov-Smirnov test. The CV test based on the RR intervals showed a sensitivity of 86.6% and a specificity of 84.3%. The CV test based on the deltaRR intervals showed that the sensitivity and the specificity are both approximately 84%. The Kolmogorov-Smirnov test based on the RR intervals did not improve on the result of the CV test. In contrast, the Kolmogorov-Smirnov test based on the ARR intervals showed a sensitivity of 94.4% and a specificity of 97.2%.

Extensor musculature of the cervical spine after laminoplasty: morphologic evaluation by coronal view of the magnetic resonance image

STUDY DESIGN

A radiographic study in 22 patients using magnetic resonance imaging was conducted.

OBJECTIVE

To describe the relation between postoperative cervical alignment and morphologic evaluation of the cervical extensor musculature, especially semispinalis cervics in laminoplasty.

SUMMARY OF BACKGROUND DATA

Cervical laminoplasty has been widely accepted as a treatment for cervical myelopathy. Posterior procedures, however, involve the extensor musculature of the cervical spine.

METHODS

In this study, 22 patients who underwent laminoplasty for repair of the extensor musculature were reviewed prospectively. The semispinalis cervics was evaluated by coronal view of the magnetic resonance image 1 month, 12 months, and 24 months after surgery. Cervical alignment at last follow-up assessment was compared with preoperative alignment using the lateral view of cervical radiographs.

RESULTS

In 18 patients (82%), morphologic repair of semispinalis cervics had been maintained (Group A), but in 4 patients (18%), but it had not been maintained at the last follow-up assessment (Group B). Cervical alignment in Group A had been maintained, but maximum loss of cervical lordosis occurred in Group B. Moreover, Group B consisted of elderly women.

CONCLUSIONS

The findings from this magnetic resonance imaging study suggest that the degree of semispinalis cervics repair affects postoperative cervical alignment, and significant loss of cervical lordosis tends to occur in elderly women who undergo laminoplasty.

Nicorandil affords cardioprotection in patients with acute myocardial infarction treated with primary percutaneous transluminal coronary angioplasty: assessment with thallium-201/iodine-123 BMIPP dual SPECT

BACKGROUND

It has been reported that nicorandil restores blood flow to reperfused myocardium in patients with acute myocardial infarction. However, whether nicorandil might decrease infarct size remains unclear. The aim of this study was to assess the effect of nicorandil on infarct size with thallium-201/beta-methyl-p-iodophenyl pentadecanoic acid (BMIPP) dual-isotope single photon emission computed tomography.

METHODS

A total of 62 patients were randomly assigned to receive intravenous nicorandil (4 mg in 5 minutes at admission, immediately followed by 6 mg/hr over a 24-hour period) or placebo. All patients were divided into 4 groups: Group N-a, 16 patients with preexisting angina treated with nicorandil; N-b, 15 patients without preexisting angina treated with nicorandil; C-a, 14 patients with preexisting angina given placebo; C-b, 17 patients without preexisting angina given placebo. Tl-201/BMIPP imaging was performed in the 62 patients within 7 days after admission. Dual-isotope single photon emission computed tomographic images were quantified by severity index with a polar map.

RESULTS

The BMIPP severity index was similar among the 4 groups. Only the thallium severity index in the N-a group was significantly less (P<.05). The ratio of the thallium severity index to that of BMIPP in the N-a group was significantly decreased compared with those of the other groups.

CONCLUSION

Nicorandil has a protective effect in patients with acute myocardial infarction and preexisting angina treated with primary balloon angioplasty.

Influence of diabetes mellitus on left ventricular function in patients undergoing coronary artery bypass grafting

OBJECTIVES

Left ventricular function was assessed by two-dimensional echocardiography before and one year after coronary artery bypass grafting(CABG) in a series of patients with severe coronary artery disease with diabetes mellitus(DM) and without DM(non-DM).

METHODS

Twenty-three patients with DM and 50 patients without DM, all with no previous myocardial infarction, underwent two-dimensional echocardiography before CABG and one year after CABG, in a non-matched study. For a matched study, 31 patients without DM who had almost the same left ventricular function as DM patients at the baseline were selected to and compare the rate of improvement in left ventricular function between the DM group and the "matched" non-DM group.

RESULTS

In the non-matched study, patient characteristics were not significantly different between the 2 groups except for the incidence of congestive heart failure within one year before CABG, which was significantly higher in the DM group. Fractional shortening was significantly lower in the DM group at the baseline(p < 0.05) and also one year after CABG(p < 0.0001). Significant improvement in fractional shortening was seen in the non-DM group(p < 0.001), but not in the DM group. The left ventricular end-diastolic diameter(LVDd) was significantly larger in the DM group at the baseline(p < 0.01), and was still significantly larger in the DM group at one year after CABG(p < 0.01). No improvement in LVDd was seen in the DM group. In the matched study, fractional shortening of the non-DM group also showed significant improvement after CABG(p < 0.001). Moreover, the rate of improvement in fractional shortening was higher in the non-DM group than in the DM group(p < 0.05). LVDd tended to be larger in the DM group(p = NS).

CONCLUSIONS

Left ventricular dysfunction and left ventricular impaired improvement were seen in the patients with DM, and CABG improved left ventricular function in the patients without DM with poor left ventricular function. These findings indicate that CABG therapy may be inadequate for improving left ventricular function in patients with DM and severe left ventricular dysfunction at the baseline.

Brugada syndrome characterized by the appearance of J waves

We describe a patient with Brugada syndrome. The ST-segment elevation in precordial leads was revealed during admission, but the appearance of J waves was characteristic before ventricular fibrillation (VF), rather than ST-segment elevation. J waves have been reported to be associated with the presence of an Ito-mediated prominent action potential notch in the epicardium. It is considered that one of the mechanisms of this VF is due to heterogeneous distribution of the refractory period according to changes in K+ channels including Ito.

Design Approaches for VCSEL's and VCSEL-Based Smart Pixels Toward Parallel Optoelectronic Processing Systems

The technical issues involved in applying vertical-cavitysurface-emitting lasers (VCSEL's) to parallel opticalinterconnection systems are discussed from the viewpoint of theirapplication to asynchronous transfer mode switching and parallelcomputer systems. We also discuss approaches to designing a VCSELarray structure for high-speed modulation and the effect ofpixel-performance homogeneity on the transmission bandwidth and powerconsumption. We review monolithic and hybrid integrationtechnologies for VCSEL-based smart-pixel arrays, and we estimate themaximum pixel number and input-output throughput allowed in a chip, considering the power consumption and pixel homogeneity. We showthat a one-chip optoelectronic parallel processing system comprisingmore than 1000 processor elements is possible when smart-pixel arraysare fabricated under the 0.25-mum complementary metal-oxide semiconductor design rule.

[Split-course radiation therapy in non-small cell lung cancer]

Split-course radiation therapy (Sp-RT) is based on theoretical differences between the kinetics of normal and malignant cells. A rest interval halfway through the course of treatment permits the normal tissues to recover, while the tumor shows vary little repopulation. Indeed, it shows mostly regression, resulting in shrinkage of the radiation field. From 1976 through 1985, 185 patients with localized but inoperable or unresectable (stage I-III) non-small cell carcinoma of the lung completed high-dose definitive RT delivered by continuous-course or split-course irradiation. Forty-seven patients who had large tumors or atelectases of the lung showing slow radioresponsiveness received Sp-RT over 60 Gy at 2 Gy per fraction. Rest periods were two or three weeks long in the interrupted schedules. The 5-year survival rate was 16% in the Sp-RT group and 13% in the continuous RT group. In the 33 patients that had differentiated epidermoid carcinoma with slow responsiveness to irradiation, the radiation fields could be shrunk by Sp-RT to the same extent as in the continuous group. Sp-RT was considered to be useful in the treatment of well-differentiated epidermoid carcinoma of the lung.

Plasma theophylline concentrations and airway function in asthmatic children receiving standard and modified RTC therapy

The effects of three different dosage schedules for sustained-release theophylline (Theolong) were investigated in children with asthma. With regimen II (unequal doses at 0800 h and 2000 h), the maximum plasma theophylline concentration following the evening dose was significantly higher than that following the morning dose, and also was larger than that following the evening dose with regimen I (equal doses at 0800 and 2000 h). With regimen III (equal doses at 0600 h and 2100 h), the mean theophylline concentration-time curve showed a single large peak at 1100 h, whereas with regimen I, there were two peaks at 2300 and at 1400 h. Knowledge that a change of the dosage schedule can affect the pharmacokinetics of theophylline in this way should aid physicians in its safe and effective use.

[Cough provocation test in asthmatic children]

The effects of pH and osmolarity on cough receptors were evaluated by inhalation of aqueous aerosol in 37 children with bronchial asthma. Each of 3 different pH solutions (low 1.85-3.25, neutral 6.9-7.1, high 8.0-8.4) was combined with 3 different osmolarities (hypo 0-31, iso 254-292, hyper 830-1117 mOsm/kg), and 9 solutions were prepared. To evaluate the effect of low chloride ion concentration, neutral pH and iso-osmolar solution including low chloride ion was also prepared. These aqueous aerosols were administered from a Devilbiss 646 nebulizer for 10 seconds. Coughing was induced in 28 subjects (76%) by inhalation of low pH and hyperosmolar solution, in one subject (3%) by low pH and iso-osmolar, in one (3%) by low pH and hypo-osmolar, in three (8%) by neutral pH and hypo-osmolar, and in none by any of the other solutions. It was suggested that the alteration of pH or osmolarity alone could not induce coughing effectively, and that the combination of pH and osmolarity was the important factor for the induction of coughing.

[Four cases of an extramedullary plasmacytoma of the head and neck]

From 1987 to 1988, four patients with solitary, extramedullary plasmacytomas of the head and neck were seen at the Gunma Cancer Center Hospital. With reference to such plasmacytomas, we have reviewed the medical literature regarding these tumors and mainly present the results of radiation therapy with respect to these patients. One patient, who had a local recurrence after surgical treatment, underwent radiation therapy (36Gy in four weeks) that resulted in good local control of the disease. Two patients developed multiple painful bone lesions during their long follow-up periods without manifesting any abnormal laboratory findings, suggesting multiple myeloma. It was found that radiation therapy (less than 30 Gy) was useful for the palliation of painful lesions.

[Three cases of thyroid cancer, including a component of squamous cell carcinoma]

A squamous cell carcinoma of the thyroid gland is rare and its prognosis is poor. Three cases of a rare thyroid cancer are reported, the first case being an adenosquamous cell carcinoma of a 75-year-old male and the second case being a pure squamous cell carcinoma of a 64-year-old male. These two cases were pathologically diagnosed on autopsy. The overall duration of these two cases was 6 months. The third case involved a 62-year-old male. His pathological diagnosis was a mixed squamous cell carcinoma and an undifferentiated carcinoma. Postoperatively 50 Gy of irradiation was performed. This patient is still alive and has shown no evidence of recurrence for 16 months.

[The effectiveness of radiation therapy in bone metastasis from breast cancer]

48 cases with bone metastasis from breast cancer were treated by radiation therapy. Result; 1) The effective ratio of radiation therapy on symptomatic relief of pain was 83%. 2) In 90% of effective cases, patients felt pain relief at 20 Gy. 3) For 3 of 7 cases which showed paralysis by vertebral metastasis, radiotherapy was very effective. 4) The patients with only bone metastasis have good prognosis. So, it is important radiotherapy is performed on different outlook.