Successful prediction of left bundle branch block-induced cardiomyopathy and treatment effect by artificial intelligence-enabled electrocardiogram

BACKGROUND

Left bundle branch block (LBBB) induced cardiomyopathy is an increasingly recognized disease entity.  However, no clinical testing has been shown to be able to predict such an occurrence.

CASE REPORT

A 70-year-old male with a prior history of LBBB with preserved ejection fraction (EF) and no other known cardiovascular conditions presented with presyncope, high-grade AV block, and heart failure with reduced EF (36%). His coronary angiogram was negative for any obstructive disease. No other known etiologies for cardiomyopathy were identified. Artificial intelligence-enabled ECGs performed 6 years prior to clinical presentation consistently predicted a high probability (up to 91%) of low EF. The patient successfully underwent left bundle branch area (LBBA) pacing with correction of the underlying LBBB. Subsequent AI ECGs showed a large drop in the probability of low EF immediately after LBBA pacing to 47% and then to 3% 2 months post procedure. His heart failure symptoms markedly improved and EF normalized to 54% at the same time.

CONCLUSIONS

Artificial intelligence-enabled ECGS may help identify patients who are at risk of developing LBBB-induced cardiomyopathy and predict the response to LBBA pacing.

Case Report: ST-Elevation Myocardial Infarction Secondary to Acute Atherothrombotic Occlusion Treated With No Stent Strategy

Background

Intravascular imaging plays a vital role in the pathophysiology-based diagnosis and treatment of patients with ST-elevation myocardial infarction (STEMI). We present a case of STEMI due to plaque erosion, which was managed with a no stent approach.

Case Summary

A 43-year-old female with a history of tobacco abuse presented with an anterior STEMI. Coronary angiography revealed acute thrombotic occlusion of the left anterior descending artery with spontaneous recanalization. Intravascular imaging with optical coherence tomography (OCT) demonstrated plaque erosion as the underlying etiology for the acute thrombotic occlusion. A no stent strategy with aspiration thrombectomy and dual antiplatelet therapy was used to manage the patient given that there was no evidence of plaque rupture. Repeat coronary imaging was done at 2 months to assess the status of the lesion.

Conclusion

A 43-year-old female with STEMI due to plaque erosion was successfully managed only by thrombus aspiration and not by angioplasty and stent placement. Individualized treatment approaches in patients with acute coronary syndromes, can not only achieve optimal management goals but also avoid unnecessary complications associated with interventions. This case illustrates how intracoronary imaging and pathophysiology-guided treatment can dramatically change management. In this young patient, STEMI was managed purely by thrombus aspiration. Intravascular imaging obviated the need for stent placement possibly preventing stent-related complications including restenosis and thrombosis.

A 37-Year-Old Woman with Hypertrophic Cardiomyopathy with a Dual-Chamber Implantable Cardioverter-Defibrillator Requiring Percutaneous Transvenous Lead Extraction and Multidisciplinary Management

Patient: Female, 37-year-old

Final Diagnosis: Hypertrophic cardiomyopathy

Symptoms: None

Medication:—

Clinical Procedure: Percutaneous ICD lead extraction • Surgical ICD lead extraction

Specialty: Cardiac Electrophysiology • Cardiac Surgery • Cardiology

Two Limitations of Subcutaneous Implantable Cardioverter Defibrillator in the Same Patient Warranting Its Explant

BACKGROUND A subcutaneous implantable cardioverter defibrillator (S-ICD) is preferred over a transvenous implantable cardioverter defibrillator (TV-ICD) in selected cases owing to a lower rate of lead-related complications such as infections and venous thrombosis. However, the S-ICD has its own limitations, including inappropriate shocks due to oversensed events, and the inability to treat ventricular tachycardia (VT) below a heart rate of 170 beats per minutes (bpm). We present a patient case which showed manifestations of both of these limitations, warranting explant of the device. CASE REPORT A 50-year-old man with a history of nonischemic cardiomyopathy and VT had a S-ICD placed at an outside facility. However, he continued to have VT despite on anti-arrhythmic drugs and required recurrent S-ICD shocks. Device interrogation showed that he was intermittently receiving appropriate shocks for slower VT (with a heart rate ranging from 150 bpm to 160 bpm) due to oversensing of T waves. However, treatment was delayed for other VT episodes owing to appropriate sensing and the patient's heart rate being below the lowest detection zone for S-ICD. Due to slower VT cycle length and frequent oversensed events, the S-ICD was ultimately replaced by a TV-ICD system. CONCLUSIONS This case report emphasizes the importance of S-ICD pre-implant vector screening and the need for paying attention to VT cycle length to prevent inappropriate device shocks and/or delayed therapies.

Myocardial infarction secondary to coronary embolus in a patient with left ventricular non-compaction cardiomyopathy: a case report

Background

Coronary embolism is a rare cause of myocardial infarction (MI). We present a case report which emphasizes the importance of intracoronary imaging in these cases to identify the pathophysiological mechanism of MI.

Case summary

A 53-year-old male with no past medical history presented to the hospital with typical angina. Electrocardiogram and serum troponin I level trend confirmed non-ST-elevation myocardial infarction. Coronary angiography showed no evidence of any obstructive coronary artery disease, but two small thrombi were noted in the distal first obtuse marginal branch. Optical coherence tomography imaging confirmed this finding in absence of any underlying atherosclerotic plaque rupture or erosion. Cardiac magnetic resonance imaging revealed the diagnosis of non-compaction cardiomyopathy with severely depressed left ventricular function. Transmural MI was revealed by late gadolinium enhancement in the mid-lateral wall. Based on the pathophysiology of the MI confirmed by intracoronary imaging, antiplatelet medications were discontinued, and the patient was discharged on warfarin. Medical therapy was initiated for his cardiomyopathy. The patient recovered well and was asymptomatic at 1-year follow-up visit.

Discussion

Intracoronary imaging plays an important role to supplement coronary angiography to confirm the pathophysiology of MI in coronary embolism cases. This is important as it alters management in these patients.

Predictors of myocardial recovery in arrhythmia-induced cardiomyopathy: A multicenter study

BACKGROUND

Arrhythmia-induced cardiomyopathy (AIC) is characterized by improvement in left ventricular ejection fraction (LVEF) following arrhythmia treatment. Predictors of recovery in LVEF are not well understood.

OBJECTIVE

We evaluated predictors of AIC recovery in a large multicenter cohort.

METHODS

In total, 243 patients (age 65 ± 11, 73% male) with AIC caused by atrial fibrillation (49%), atrial tachycardia (20%), and premature ventricular contractions (PVCs; 31%) were treated and included. LVEF was assessed before and after treatment. Patients were stratified by arrhythmia duration (known [KN, n = 132] vs. unknown [UKN, n = 111]), arrhythmia type, LVEF, and presence of structural heart disease (SHD).

RESULTS

Arrhythmia treatment was rhythm control in 95%. Median arrhythmia duration in the KN group was 47 months (25-75th percentile, 24-80 months). Post treatment LVEF was higher in KN group (55.9 ± 7 vs. 46.2 ± 12%; p < .0001) but the degree of LVEF improvement was similar (21.2 ± 9 vs. 19.4 ± 11; p = .16). Comparing highest quartile (longest arrhythmia duration) versus the rest of the KN group, the extent of LVEF improvement was similar (21.5 ± 8 vs. 21 ± 9%; p = .1). Patients in lowest index LVEF quartile (n = 74) had more PVC-induced AIC, greater EF improvement after treatment (24 ± 17 vs. 19 ± 7%; p < .0001) but lower post treatment EF (45 ± 14 vs. 54 ± 8%; p < .0001) versus other patients. Patients with SHD had lower index EF (28 ± 8 vs. 34 ± 8%; p < .0001) and lower final EF (47 ± 12 vs. 56 ± 7; p ≪ .0001). In multivariate regression, low index LVEF predicted myocardial recovery (odds ratio, 11.4; p < .005).

CONCLUSIONS

In this AIC cohort, LVEF improved regardless of arrhythmia duration or type but those with PVCs had lower index LVEF and had less recovery. Low index LVEF predicted LVEF recovery following arrhythmia treatment.

Meta-Analysis of Transradial vs Transfemoral Access for Percutaneous Coronary Intervention in Patients With ST Elevation Myocardial Infarction

Transradial access (TRA) has emerged as an alternative to transfemoral access (TFA) for percutaneous coronary intervention (PCI) in ST elevation myocardial infarction (STEMI) patients. However, the rate of TRA adoption has been much slower in the acute coronary syndrome (ACS) patient population. This meta-analysis was conducted to assess clinical outcomes of TRA compared with TFA in STEMI patients undergoing PCI. A manual search of PubMed, EMBASE, Cochrane library database, Cumulative Index to Nursing and Allied Health Literature (CINAHL), ClinicalTrials.gov, and recent major scientific conference sessions from inception to October 15th, 2019 was performed. Primary outcomes in our analysis were all-cause mortality and trial-defined major bleeding. Secondary outcomes included vascular complications, myocardial infarction, stroke, procedure, and fluoroscopy time. 17 randomized controlled trials (RCTs) (N = 12,018) met inclusion criteria. TRA was associated with lower all-cause mortality (risk ratio [RR]: 0.71, 95% confidence interval [CI]: 0.57 to 0.88), major bleeding (RR: 0.59, 95%CI: 0.45 to 0.77), and vascular complications (RR: 0.42, 95%CI: 0.32 to 0.56) compared with TFA. There was no difference in the incidence of myocardial infarction (MI), stroke, or procedure duration between the 2 groups. The difference in all-cause mortality between TRA and TFA was statistically nonsignificant when major bleeding was held constant. In conclusion, TRA was associated with lower risk of all-cause mortality, major bleeding, and vascular complications compared with TFA in STEMI patients undergoing PCI.

Coronary artery bypass grafting versus percutaneous coronary intervention for left main disease in chronic kidney disease patients: a meta-analysis

Background

Limited data exist on the optimal revascularization strategy for patients with left main coronary artery disease (LMCAD) and chronic kidney disease (CKD). We conducted a meta-analysis to compare the outcomes of coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) in this population.

Methods

Multiple electronic databases were queried for studies comparing CABG and PCI in CKD patients undergoing LMCAD (&gt;50% diameter stenosis) revascularization. CKD was defined as estimated glomerular filtration rate of &lt;60 ml/min/1.73 m2. The primary outcome was long-term major adverse cardiac and cerebrovascular events (MACCE), which was a composite of cardiovascular death, myocardial infarction (MI), stroke and repeat revascularization. Secondary outcomes included all-cause mortality, MI, stroke and repeat revascularization. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. The analysis was performed using the DerSimonian and Laird random effect model.

Results

Six studies (4 observational, 2 randomized controlled trials) met inclusion criteria with a total of 2051 patients (CABG: 977, PCI: 1074). Patients undergoing CABG had a higher incidence of multi-vessel disease (74.7% vs 65.7%, p=0.01). At a mean follow-up of 3.4±1.1 years, MACCE was significantly lower in the CABG group (OR = 0.70, 95% CI 0.57–0.87; p=0.001) (Figure 1). The odds of MI or repeat revascularization were lower with CABG, whereas the odds of stroke were higher; no statistically-significant difference was seen in all-cause mortality.

Conclusion

This meta-analysis shows that CABG is associated with lower rates of MACCE and MI but with a higher rate of stroke compared to PCI in LMCAD patients with CKD.

Funding Acknowledgement

Type of funding source: None

Impact of perioperative right ventricular assist device on ventricular arrhythmias in patients with continuous flow left ventricular assist device

Background

Patients with continuous flow left ventricular assist device (LVAD) may develop right ventricular failure in perioperative period of LVAD implantation. Some of these patients require temporary support with right ventricular assist device (RVAD). There is paucity of data regarding the impact of RVAD support on incidence of ventricular arrhythmias (VA) in LVAD patients.

Purpose

To assess the impact of perioperative RVAD support on the incidence of VA in the first 6 months after LVAD implant.

Methods

This is a retrospective study including 316 patients undergoing LVAD implantation at the University of Nebraska Medical Center, USA since 2012. Patients were divided into 2 groups- those who required perioperative RVAD support (BiVAD group) and those who did not require it (LVAD only group). VA was defined as any sustained ventricular tachyarrhythmia lasting more than 30 seconds or requiring therapy from implantable cardioverter-defibrillator. Incidence of VA in the first 6 months post-LVAD implantation was analyzed and compared between the groups using Cox proportional hazards regression analysis.

Results

Out of 316 total patients, 52 (16%) patients required RVAD support. The difference in age, gender, race and medications between the two groups was not statistically significant. The patients in BiVAD group had a higher incidence of post-LVAD VA (35%) as compared to LVAD only group (21%). On Cox proportional hazards regression analysis, the difference was found to be statistically significant even after adjusting for history of pre-LVAD VAs (HR: 2.27; p=0.02) (Figure 1).

Conclusion

In this large single center cohort of LVAD patients, we noticed a statistically higher incidence of VA in subgroup of patients requiring perioperative RVAD support.

Figure 1

Funding Acknowledgement

Type of funding source: None

Meta-analysis Comparing Transradial Versus Transfemoral Secondary Access in Transcatheter Aortic Valve Implantation

Up to a quarter of vascular complications during transcatheter aortic valve implantation (TAVI) result from secondary access via the femoral artery (FA). The radial artery (RA) is increasingly used as an alternative to the FA for secondary access in TAVI. Limited data exist on the outcomes of RA secondary access versus FA secondary access. We therefore conducted a systematic review and meta-analysis comparing secondary access sites. PubMed, EMBASE, Scopus, Cochrane library and CINAHL were searched systematically for studies comparing RA and FA as secondary access sites for TAVI. Primary outcomes of interest were vascular complications and major bleeding. Secondary outcomes included all-cause mortality, stroke and myocardial infarction (MI). Risk ratio (RR), standardized mean difference and corresponding 95% confidence intervals (CI) were calculated using a random effects model. Six observational studies comprising 6,373 patients (RA: 1,514, FA: 4,859) met inclusion criteria. Secondary access was utilized for aortography during valve deployment and to manage primary access site complications. Procedural characteristics were similar in both groups. RA was associated with a lower risk of major bleeding (RR: 0.51, 95% CI: 0.40 to 0.64, p <0.00001). No statistically significant difference was observed in the incidence of overall vascular complications, however, the risk of major vascular complications was lower with RA (RR: 0.45, 95% CI: 0.32 to 0.63, p <0.00001). The incidence of stroke and all-cause mortality was lower in RA, whereas no difference was observed in the risk of MI. In conclusion, our meta-analysis suggests that RA secondary access is associated with better outcomes for TAVI than FA.

Continued versus Suspended Cardiac Resynchronization Therapy after Left Ventricular Assist Device Implantation

Cardiac resynchronization therapy (CRT) improves outcomes in heart failure patients with wide QRS complex. However, CRT management following continuous flow Left Ventricular Assist Device (LVAD) implant vary: some centers continue CRT while others turn off the left ventricular (LV) lead at LVAD implant. We sought to study the effect of continued CRT versus turning off CRT pacing following continuous flow LVAD implantation. A comprehensive retrospective multicenter cohort of 295 patients with LVAD and pre-existing CRT was studied. CRT was programmed off after LVAD implant in 44 patients. We compared their outcomes to the rest of the cohort using univariate and multivariate models. Mean age was 60 ± 12 years, 83% were males, 52% had ischemic cardiomyopathy and 54% were destination therapy. Mean follow-up was 2.4 ± 2.0 years, and mean LVAD support time was 1.7 ± 1.4 years. Patients with CRT OFF had a higher Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) mean profile (3.9 vs 3.3, p = 0.01), more secondary prevention indication for a defibrillator (64.9% vs 44.5%, p = 0.023), and more pre-LVAD ventricular arrhythmias (VA) (77% vs 60%, p = 0.048). There were no differences between the CRT OFF and CRT ON groups in overall mortality (Log rank p = 0.32, adjusted HR = 1.14 [0.54-2.22], p = 0.71), heart transplantation, cardiac and noncardiac mortality, all cause hospitalizations, hospitalizations for ICD shocks, and number and frequency of ICD shocks or anti-tachycardia pacing therapy. There were no differences in post LVAD atrial arrhythmias (AA) (Adjusted OR = 0.45 [0.18-1.06], p = 0.31) and ventricular arrhythmias (OR = 0.65 [0.41-1.78], p = 0.41). There was no difference in change in LVEF, LV end diastolic and end systolic diameters between the 2 groups. Our study suggests that turning off CRT pacing after LVAD implantation in patients with previous CRT pacing did not affect mortality, heart transplantation, device therapies or arrhythmia burden. A prospective study is needed to confirm these findings.

Questionable utility of digoxin in left-ventricular assist device recipients: A multicenter, retrospective analysis

Background

While clinical experience with left ventricular assist devices (LVAD) continues to grow and evolve, little is known regarding the ongoing use of certain medications in this population. We sought to evaluate the utility of digoxin in LVAD recipients and its association with outcomes.

Methods

A total of 505 patients who underwent continuous-flow LVAD implantation at 5 centers from 2007–2015 were included. Patients were divided into 4 groups: not on digoxin at any time (ND; n = 257), received digoxin pre implant (PreD; n = 144), received digoxin pre and post implant (ContD; n = 55), and received digoxin only post implant (PostD; n = 49). Survival and all-cause readmission were compared between the 4 groups.

Results

There was no difference in survival at 1 year nor at 3 years between groups (ND = 88%, 66%, respectively; PreD = 85%, 66%; ContD = 86%, 57%; PostD = 90%, 51%; p = 0.7). Readmission per 100 days also was not different between groups (ND = 0.5, PreD = 0.6, ContD = 0.5, PostD = 0.7; p = 0.1).

Conclusions

In this large, multicenter cohort, use of digoxin was not associated with any significant benefit in regard to mortality or hospitalization in patients supported with a continuous-flow LVAD. Importantly, its discontinuation post implant did not worsen all-cause hospitalization or survival.

Cardiac Resynchronization Therapy and Clinical Outcomes in Continuous Flow Left Ventricular Assist Device Recipients

Background

Many patients with heart failure continue cardiac resynchronization therapy (CRT) after continuous flow left ventricular assist device (CF‐LVAD) implant. We report the first multicenter study to assess the impact of CRT on clinical outcomes in CF‐LVAD patients.

Methods and Results

Analysis was performed on 488 patients (58±13 years, 81% male) with an implantable cardioverter defibrillator (ICD) (n=223) or CRT‐D (n=265) who underwent CF‐LVAD implantation at 5 centers from 2007 to 2015. Effects of CRT on mortality, hospitalizations, and ventricular arrhythmia incidence were compared against CF‐LVAD patients with an ICD alone. Baseline differences were noted between the 2 groups in age (60±12 versus 55±14, P<0.001) and QRS duration (159±29 versus 126±34, P=0.001). Median biventricular pacing in the CRT group was 96%. During a median follow‐up of 478 days, Kaplan–Meier analysis showed no difference in survival between groups (log rank P=0.28). Multivariate Cox regression demonstrated no survival benefit with type of device (ICD versus CRT‐D; P=0.16), whereas use of amiodarone was associated with increased mortality (hazard ratio 1.77, 95% confidence interval 1.1–2.8, P=0.01). No differences were noted between CRT and ICD groups in all‐cause (P=0.06) and heart failure (P=0.9) hospitalizations, ventricular arrhythmia incidence (43% versus 39%, P=0.3), or ICD shocks (35% versus 29%, P=0.2). During follow‐up, 69 (26%) patients underwent pulse generator replacement in the CRT‐D group compared with 36 (15.5%) in the ICD group (P=0.003).

Conclusions

In this large, multicenter CF‐LVAD cohort, continued CRT was not associated with improved survival, hospitalizations, incidence of ventricular arrhythmia and ICD therapies, and was related to a significantly higher number of pulse generator changes.

Arrhythmia-Induced Cardiomyopathy: Prevalent, Under-recognized, Reversible

Arrhythmia-induced cardiomyopathy (AIC) is a clinical condition in which a persistent tachyarrhythmia or frequent ectopy contribute to ventricular dysfunction leading to systolic heart failure. AIC can be partially or completely corrected with adequate treatment of the culprit arrhythmia. Several molecular and cellular alterations by which tachyarrhythmias lead to cardiomyopathy have been identified. AIC can affect children and adults, can be clinically silent in the form of asymptomatic tachycardia with cardiomyopathy, or can present with manifest heart failure. A high index of suspicion for AIC and aggressive treatment of the culprit arrhythmia can result in resolution of heart failure symptoms and improvement in cardiac function. Recurrent arrhythmia, following recovery from the index episode, can hasten the left ventricular dysfunction and result in HF, suggesting persistent adverse remodeling despite recovery of left ventricular function. Several aspects of AIC, such as predisposing factors, early diagnosis, preventive measures to avoid adverse remodeling, and long-term prognosis, remain unclear, and need further research.

Importance of hospital entry: walk-in STEMI and primary percutaneous coronary intervention

INTRODUCTION

Patients with ST elevation myocardial infarction (STEMI) require rapid identification and triage to initiate reperfusion therapy. Walk-in STEMI patients have longer treatment times compared to emergency medical service (EMS) transported patients. While effective triage of large numbers of critically ill patients in the emergency department is often cited as the reason for treatment delays, additional factors have not been explored. The purpose of this study was to evaluate baseline demographic and clinical differences between walk-in and EMS-transported STEMI patients and identify factors associated with prolonged door to balloon (D2B) time in walk-in STEMI patients.

METHODS

We performed a retrospective review of 136 STEMI patients presenting to an urban academic teaching center from January 2009 through December 2010. Baseline demographics, mode of hospital entry (walk-in versus EMS transport), treatment times, angiographic findings, procedures performed and in-hospital clinical events were collected. We compared walk-in and EMS-transported STEMI patients and identified independent factors of prolonged D2B time for walk-in patients using stepwise logistic regression analysis.

RESULTS

Walk-in patients (n=51) were more likely to be Latino and presented with a higher heart rate, higher systolic blood pressure, prior history of diabetes mellitus and were more likely to have an elevated initial troponin value, compared to EMS-transported patients. EMS-transported patients (n=64) were more likely to be white and had a higher prevalence of left main coronary artery disease, compared to walk-in patients. Door to electrocardiogram (ECG), ECG to catheterization laboratory (CL) activation and D2B times were significantly longer for walk-in patients. Walk-in patients were more likely to have D2B time >90 minutes, compared to EMS- transported patients; odds ratio 3.53 (95% CI 1.03, 12.07), p=0.04. Stepwise logistic regression identified hospital entry mode as the only independent predictor for prolonged D2B time.

CONCLUSION

Baseline differences exist between walk-in and EMS-transported STEMI patients undergoing primary percutaneous coronary intervention (PCI). Hospital entry mode was the most important predictor for prolonged treatment times for primary PCI, independent of age, Latino ethnicity, heart rate, systolic blood pressure and initial troponin value. Prolonged door to ECG and ECG to CL activation times are modifiable factors associated with prolonged treatment times in walk-in STEMI patients. In addition to promoting the use of EMS transport, efforts are needed to rapidly identify and expedite the triage of walk-in STEMI patients.

Percutaneous aortic balloon valvuloplasty performed in a patient with distal aortic occlusion

We present a case of successful percutaneous aortic balloon valvuloplasty performed via surgical cut down of the right brachial artery in a patient with distal aortic occlusion. We describe the procedural technique and review the literature on alternative access sites that have been used to perform percutaneous aortic balloon valvuloplasty.

Use of Mutant-Assisted Gene Identification and Characterization (MAGIC) to identify novel genetic loci that modify the maize hypersensitive response

The partially dominant, autoactive maize disease resistance gene Rp1-D21 causes hypersensitive response (HR) lesions to form spontaneously on leaves and stems in the absence of pathogen recognition. The maize nested association mapping (NAM) population consists of 25 200-line subpopulations each derived from a cross between the maize line B73 and one of 25 diverse inbred lines. By crossing a line carrying the Rp1-D21 gene with lines from three of these subpopulations and assessing the F(1) progeny, we were able to map several novel loci that modify the maize HR, using both single-population quantitative trait locus (QTL) and joint analysis of all three populations. Joint analysis detected QTL in greater number and with greater confidence and precision than did single population analysis. In particular, QTL were detected in bins 1.02, 4.04, 9.03, and 10.03. We have previously termed this technique, in which a mutant phenotype is used as a "reporter" for a trait of interest, Mutant-Assisted Gene Identification and Characterization (MAGIC).

Biochemical and genetic requirements for function of the immune response regulator BOTRYTIS-INDUCED KINASE1 in plant growth, ethylene signaling, and PAMP-triggered immunity in Arabidopsis

Arabidopsis thaliana BOTRYTIS-INDUCED KINASE1 (BIK1) regulates immune responses to a distinct class of pathogens. Here, mechanisms underlying BIK1 function and its interactions with other immune response regulators were determined. We describe BIK1 function as a component of ethylene (ET) signaling and PAMP-triggered immunity (PTI) to fungal pathogens. BIK1 in vivo kinase activity increases in response to flagellin peptide (flg22) and the ET precursor 1-aminocyclopropane-1-carboxylic acid (ACC) but is blocked by inhibition of ET perception. BIK1 induction by flg22, ACC, and pathogens is strictly dependent on EIN3, and the bik1 mutation results in altered expression of ET-regulated genes. BIK1 site-directed mutants were used to determine residues essential for phosphorylation and biological functions in planta, including PTI, ET signaling, and plant growth. Genetic analysis revealed flg22-induced PTI to Botrytis cinerea requires BIK1, EIN2, and HUB1 but not genes involved in salicylate (SA) functions. BIK1-mediated PTI to Pseudomonas syringae is modulated by SA, ET, and jasmonate signaling. The coi1 mutation suppressed several bik1 phenotypes, suggesting that COI1 may act as a repressor of BIK1 function. Thus, common and distinct mechanisms underlying BIK1 function in mediating responses to distinct pathogens are uncovered. In sum, the critical role of BIK1 in plant immune responses hinges upon phosphorylation, its function in ET signaling, and complex interactions with other immune response regulators.

Comparison of health care resource use before and after docetaxel treatment among prostate cancer patients

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Background: Docetaxel is standard of care among late-stage prostate cancer patients. We analyzed patterns of health care resource utilization (RU) among patients before and after exposure to docetaxel using a large commercial claims database.

Methods: A random sample of patients (N = 336) with a diagnosis of prostate cancer (ICD 9 code: 185.X) and a claim for docetaxel (2003–2009) was identified from the PharMetrics database, a nationally representative, non-payer-owned integrated commercial U.S. claims database. All patients had ≥ 12 months of enrollment prior to initiation of docetaxel. Patients were followed from their first docetaxel claim until lost to follow-up or June 30, 2009 (censored). RU was defined as all-cause hospitalization, ER, physician, and ambulatory visits. Incidence rates were derived.

Results: Mean age of patients was 67.9 years (SD 10.6); mean number of docetaxel prescriptions was 9.9 (SD 10.3). Mean time to study end/lost to follow-up was 15.41 (SD 12.49) months from the index date. The table shows health care RU for the 12 months before, and over the follow-up period after docetaxel initiation. Hospitalizations, ER, physician, and ambulatory visits were significantly higher in the follow-up period. The average length of hospital stay was significantly longer after docetaxel treatment (8.2 vs 5.5 days). Prior to docetaxel, two-thirds of the patients were on hormonal therapy; 51% on analgesics, and 31% on bisphosphonates. After docetaxel, the proportions were 62%, 58%, and 54%, respectively.

Conclusions: The significantly higher RU with disease progression in prostate cancer patients suggests a need for new treatment options that can effectively manage and improve patient outcomes.

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Health-related quality of life/patient-reported outcomes in relapsed ovarian cancer: Results from a randomized phase III study of trabectedin with pegylated liposomal doxorubicin (PLD) versus PLD alone

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Background: In an open-label, multicenter, randomized phase III study comparing the combination of trabectedin and PLD to PLD alone in patients with relapsed ovarian cancer, the combination demonstrated significantly improved progression free survival and response rates, manageable non-cumulative toxicity, and fewer PLD-associated adverse events. We studied the impact of the combination of trabectedin with PLD on the quality of life (QoL)/patient-reported outcomes (PRO) evaluated as part of the trial. Methods: QoL/PRO questionnaires, EORTC-QLQ C30, OV28, and EQ-5D were completed by patients at screening and on Day 1 of every other treatment cycle starting with Cycle 1, and at the end-of-treatment visit. Global health status/QoL, fatigue, rain subscales from QLQ C30, and abdominal pain/GI symptoms scale from OV28 were chosen a priori for primary analyses. Other scales of the three questionnaires were analyzed on a supportive basis. Results: A total of 672 patients were randomized. 663 (98%) completed at least the baseline questionnaires. Median cycles of treatment was 6 (131 days) for the combination arm and 5 (143 days) for the monotherapy arm. Mixed effects models (using a covariance structure of AR[1]) predicting the score at baseline and follow-up scores as a function of treatment, days after baseline, and interaction between treatment and days after baseline showed no significant differences between the treatment arms for any of the prespecified scales. Similar analyses of other scales, including EQ-5D Health Index scores and Health State on the Visual Analog Scale, support the findings. Conclusions: The addition of trabectedin to PLD results in superior efficacy in patients with relapsed ovarian cancer, with no added decrement to overall health status as assessed by PRO.

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HISTONE MONOUBIQUITINATION1 interacts with a subunit of the mediator complex and regulates defense against necrotrophic fungal pathogens in Arabidopsis

This work examines the role of the Arabidopsis thaliana RING E3 ligase, HISTONE MONOUBIQUITINATION1 (HUB1) in disease resistance. Loss-of-function alleles of HUB1 show increased susceptibility to the necrotrophic fungal pathogens Botrytis cinerea and Alternaria brassicicola, whereas HUB1 overexpression conferred resistance to B. cinerea. By contrast, responses to the bacterial pathogen Pseudomonas syringae are unaltered in hub1 plants. hub1 mutants have thinner cell walls but increased callose around an infection site. HUB1 acts independently of jasmonate, but ethylene (ET) responses and salicylate modulate the resistance of hub1 mutants to necrotrophic fungi. The ET response factor ETHYLENE INSENSITIVE2 is epistatic to HUB1 for A. brassicicola resistance but additive to HUB1 for B. cinerea resistance. HUB1 interacts with MED21, a subunit of the Arabidopsis Mediator, a conserved complex that regulates RNA polymerase II. RNA interference lines with reduced MED21 expression are highly susceptible to A. brassicicola and B. cinerea, whereas T-DNA insertion alleles are embryonic lethal, suggesting an essential role for MED21. However, HUB1-mediated histone H2B modification is independent of histone H3 and DNA methylation. In sum, histone H2B monoubiquitination is an important chromatin modification with regulatory roles in plant defense against necrotrophic fungi most likely through modulation of gene expression.

HISTONE MONOUBIQUITINATION1 interacts with a subunit of the mediator complex and regulates defense against necrotrophic fungal pathogens in Arabidopsis

This work examines the role of the Arabidopsis thaliana RING E3 ligase, HISTONE MONOUBIQUITINATION1 (HUB1) in disease resistance. Loss-of-function alleles of HUB1 show increased susceptibility to the necrotrophic fungal pathogens Botrytis cinerea and Alternaria brassicicola, whereas HUB1 overexpression conferred resistance to B. cinerea. By contrast, responses to the bacterial pathogen Pseudomonas syringae are unaltered in hub1 plants. hub1 mutants have thinner cell walls but increased callose around an infection site. HUB1 acts independently of jasmonate, but ethylene (ET) responses and salicylate modulate the resistance of hub1 mutants to necrotrophic fungi. The ET response factor ETHYLENE INSENSITIVE2 is epistatic to HUB1 for A. brassicicola resistance but additive to HUB1 for B. cinerea resistance. HUB1 interacts with MED21, a subunit of the Arabidopsis Mediator, a conserved complex that regulates RNA polymerase II. RNA interference lines with reduced MED21 expression are highly susceptible to A. brassicicola and B. cinerea, whereas T-DNA insertion alleles are embryonic lethal, suggesting an essential role for MED21. However, HUB1-mediated histone H2B modification is independent of histone H3 and DNA methylation. In sum, histone H2B monoubiquitination is an important chromatin modification with regulatory roles in plant defense against necrotrophic fungi most likely through modulation of gene expression.

An alternative strategy for universal infant hearing screening in tertiary hospitals with a high delivery rate, within a developing country, using transient evoked oto-acoustic emissions and brainstem evoked response audiometry

Objective: To formulate an alternative strategy for universal infants hearing screening in an Indian tertiary referral hospital with a high delivery rate, which could be extended to similar situations in other developing countries. The system should be able to diagnose, in a timely fashion, all infants with severe and profound hearing losses.

Methods: One thousand newborn were randomly selected. All underwent testing with transient evoked oto-acoustic emissions (TEOAE) in the first 48 hours of life. All TEOAE failures were followed up and repeat tests were performed at three weeks, three months and six months of age. Infants with acceptable TEOAE results at any of the four ages were discharged from the study. Infants with unacceptable TEOAE results at all the four ages underwent brainstem evoked response audiometry and oto-endoscopy. The ‘pass rate’ for TEOAE testing was calculated for all four ages. The time taken to perform TEOAE and brainstem evoked response audiometry was recorded for all subjects. These recordings were statistically analysed to find the most suitable strategy for universal hearing screening in our hospital.

Results: The pass rate for TEOAE was 79.0 per cent at ≤48 hours, 85.0 per cent at three weeks, 97.0 per cent at three months and 98.0 per cent at six months. The average time taken to perform the test was 12 minutes for TEOAE and 27 minutes for brainstem evoked response audiometry. Obstructed and collapsed external auditory canals were the two factors that significantly affected the specificity of TEOAE in infants ≤48 hours old.

Conclusion: The concept of screening all neonates within the first 48 hours of life is impractical because the specificity of TEOAE is lowest at that age. Many false positive results are generated, such that a larger number must undergo brainstem evoked response audiometry, wasting time and resources. This can easily be avoided by delaying TEOAE screening until three months of age, when it has a substantially lower false positive outcome. We expect that implementation of this alternative strategy in our hospital will maximise the benefits of such a programme.

Expression profiling and mutant analysis reveals complex regulatory networks involved in Arabidopsis response to Botrytis infection

The expression profiles of Botrytis-inoculated Arabidopsis plants were studied to determine the nature of the defense transcriptome and to identify genes involved in host responses to the pathogen. Normally resistant Arabidopsis wild-type plants were compared with coi1, ein2, and nahG plants that are defective in various defense responses and/or show increased susceptibility to Botrytis. In wild-type plants, the expression of 621 genes representing approximately 0.48% of the Arabidopsis transcriptome was induced greater than or equal to twofold after infection. Of these 621 Botrytis-induced genes (BIGs), 462 were induced at or before 36 h post-inoculation, and may be involved in resistance to the pathogen. The expression of 181 BIGs was dependent on a functional COI1 gene required for jasmonate signaling, whereas the expression of 63 and 80 BIGs were dependent on ethylene (ET) signaling or salicylic acid accumulation, respectively, based on results from ein2 and nahG plants. BIGs encode diverse regulatory and structural proteins implicated in pathogen defense and abiotic and oxidative-stress responses. Thirty BIGs encode putative DNA-binding proteins that belong to ET response, zinc-finger, MYB, WRKY, and HD-ZIP family transcription-factor proteins. Fourteen BIGs were studied in detail to determine their role in resistance to Botrytis. T-DNA insertion alleles of ZFAR1 (At2G40140), the gene encoding a putative zinc-finger protein with ankyrin-repeat domains, showed increased local susceptibility to Botrytis and sensitivity to germination in the presence of abscisic acid (ABA), supporting the role of ABA in mediating responses to Botrytis infection. In addition, two independent T-DNA insertion alleles in the WRKY70 gene showed increased susceptibility to Botrytis. The transcriptional activation of genes involved in plant hormone signaling and synthesis, removal of reactive oxygen species, and defense and abiotic-stress responses, coupled with the susceptibility of the wrky70 and zfar1 mutants, highlights the complex genetic network underlying defense responses to Botrytis in Arabidopsis.

Persistency and treatment failure in newly diagnosed open angle glaucoma patients in the United Kingdom

AIM

To determine utilisation patterns and calculate treatment failure and discontinuation rates in patients with open angle glaucoma treated in the United Kingdom with any of six groups of intraocular pressure (IOP) lowering agents.

METHODS

The UK General Practice Research Database was used to identify newly diagnosed (after 1 January 1997) open angle glaucoma patients who were naive to therapy with any of six index drug groups: carbonic anhydrase inhibitors, latanoprost, miotics, sympathomimetics, timolol, and other (non-timolol) beta blockers. Analyses included drug treatment data for 1 year following diagnosis. Outcomes were (1) time to therapy failure, defined as either change in index drug (replacement or addition of therapy) or patient referral for surgery, and (2) time to therapy discontinuation, defined as either therapy failure or no refill of the index drug in a period twice that covered by the first prescription fill. Cox proportional hazard regression and Kaplan-Meier and life table methods were used to compare groups.

RESULTS

Among the 2001 eligible patients, a beta blocker other than timolol was the most widely prescribed (42%), followed by timolol (32%), carbonic anhydrase inhibitors (10%), and latanoprost (7%). Compared to latanoprost, those treated with any alternative agent were significantly more likely to fail (p < or = 0.005 for each comparison) and to discontinue (p < or = 0.05 for each comparison) therapy. Failure rates ranged from 13% (latanoprost) to 45% (sympathomimetics), and discontinuation rates ranged from 30% (latanoprost) to 63% (miotics).

CONCLUSION

Latanoprost treated patients demonstrated lower rates of therapy failure and therapy discontinuation compared with patients treated with other widely used IOP lowering medications, including beta blockers.

The prevalence of nocturia and its effect on health-related quality of life and sleep in a community sample in the USA

OBJECTIVE

To evaluate the prevalence of nocturia and its effects, with and without concomitant overactive bladder (OAB, i.e. urgency, frequency, urge incontinence and nocturia), on health-related quality of life (HRQoL) and sleep.

SUBJECTS AND METHODS

A national survey was conducted in the USA to assess the prevalence of OAB and nocturia. A nested case-control study was conducted among respondents with OAB symptoms and age- and gender-matched controls, with participants completing a series of questionnaires on HRQoL (OAB-q, Short Form-36, and Medical Outcomes Study (MOS) sleep scale). Descriptive analyses, t-tests, analysis of variance with post hoc comparisons and multivariate regressions were used to analyse the data.

RESULTS

In all, 5204 people participated in the survey, with 919 in the nested case-control study. The sample population had a mean age of 45.8 years, was 52.6% female and 80% Caucasian. In the community sample, 31% reported > 1 void/night and 14.2% reported > 2 voids/night. The prevalence of nocturia increased with age, with no gender differences. For OAB cases, 66.8% reported > 1 void/night and 42.2% reported > 2. In the case-control cohort there were significant HRQoL differences (P < 0.01), with increasing episodes of nocturia in all OAB-q subscales except social interaction. The amount of sleep per night was significantly correlated with the sleep, concern and social interaction OABq subscale scores. The number of nocturia episodes/night was also significantly (P = 0.02) associated with the number of hours of sleep/night.

CONCLUSION

Nocturia is widely prevalent and increases with age, affecting men and women equally. Incremental increases in the number of voids/night have further negative effects on sleep, symptom bother, and HRQoL.

Clinical and economic impacts of latanoprost 0.005% in first-line treatment of open-angle glaucoma and ocular hypertension in France

PURPOSE

To assess the cost-effectiveness of treatment strategies that utilize first-line latanoprost compared to those based on initial beta-blocker therapy in patients with open-angle glaucoma (OAG) or ocular hypertension (OH) in France.

METHODS

The study was based on a decision-analytic model that was populated with data from a retrospective chart review. A hypothetical cohort of patients newly diagnosed with OAG and/or OH was assessed over a period of 2 and 3 years. For each treatment strategy 10,000 patients were assumed.

RESULTS

First-line latanoprost therapy was significantly more effective than initial treatment with a beta-blocker, providing more days of intraocular pressure (IOP) control primarily due to its longer time until initial treatment failure. Latanoprost's higher acquisition cost was largely offset by reductions in costs associated with surgical procedures. The additional cost for latanoprost was estimated at approximately 41 Euro and 27 Euro over 2 and 3 years, respectively. The incremental cost per day of IOP control when latanoprost was used as first-line strategy compared to the first-line beta-blocker strategy was 0.82 Euro and 0.36 Euro over 2 and 3 years, respectively.

CONCLUSIONS

These results provide compelling evidence that first-line latanoprost therapy can provide superior clinical outcomes at a small additional cost in actual clinical practice.

Persistency and clinical outcomes associated with latanoprost and beta-blocker monotherapy: evidence from a European retrospective cohort study

PURPOSE

To evaluate persistency (time on initial therapy) and the clinical impact of latanoprost versus beta-blocker monotherapy in treating glaucoma.

METHODS

This observational, multicenter, retrospective medical chart review study conducted in four European countries included patients with primary open-angle glaucoma or ocular hypertension who began their first glaucoma treatment with latanoprost or a beta-blocker between November 1996 and November 1998. Persistency and glaucoma-related clinical outcomes data were abstracted for the 2 years following treatment initiation.

RESULTS

In all, 260 patient charts were analyzed (94 latanoprost, 166 beta-blocker). Patients in the latanoprost group stayed on therapy twice as long as those who received a beta-blocker (p < 0.0001). After adjusting for baseline characteristics, patients receiving a beta-blocker as initial therapy were 3.8 times more likely to change therapy than those initially treated with latanoprost (p < 0.0001). Patients in the latanoprost group also experienced greater mean decreases in intraocular pressure (IOP) than those receiving a beta-blocker (7.4 mmHg versus 4.6 mmHg, respectively; p < 0.0001), and fewer had worsened optic nerve head excavation (1.7% versus 14.2%, respectively; p < 0.05) by the time of their first therapy change or last study visit, whichever came first.

CONCLUSIONS

Over a 2-year period, latanoprost was associated with significantly greater persistency and better clinical IOP outcomes compared with beta-blocker therapy.

Acute renal infarction secondary to left ventricular thrombus, masquerading as a renal calculus--a case report and brief review of literature

Acute embolic renal infarction is an entity that is often misdiagnosed as a renal calculus because of similar presenting symptoms. This leads to delay in the initiation of treatment and to increased morbidity. Few case reports exist relating cardiac emboli to acute renal infarction. The authors present a patient with a renal embolism secondary to left ventricular thrombus. A brief review of the literature highlighting the importance of clinical suspicion in making an accurate diagnosis, the utility of various diagnostic studies, and comparison of various treatment options is presented.

Glibenclamide vs gliclazide in reducing oxidative stress in patients of noninsulin dependent diabetes mellitus--a double blind randomized study

OBJECTIVE

Parameters of oxidative stress were quantitated in 50 patients with type 2 diabetes mellitus in uncontrolled state and after control using oral glibenclamide or gliclazide. The estimates were further compared between the two groups irrespective of drug used to evaluate the difference, if any.

METHODS

The study was a double blind, uncontrolled, noncrossover and randomized trial. Fifty patients of uncontrolled type 2 diabetes were divided in to two groups. Group I (25 patients) received capsule A (glibenclamide) while Group II (25 patients) received capsule B (gliclazide). The parameters studied were Superoxide dismutase (SOD), malonyl-dialdehyde (MDA) and reduced glutathione (GSH). They were done at (a) uncontrolled stage (FBS--165 +/- 16.7 mg/dl, PP--240 +/- 30.1 mg/dl and HbA1--10.5 +/- 0.9% in group I and FBS--150 +/- 15.8 mg/dl, PP--246 +/- 29.1 mg/dl HbA1 10.6 +/- 0.8% in group II) and during controlled stage at 12 weeks (FBS--120 +/- 18.5 mg/dl, PP--180 +/- 19.1 mg/dl and HbA1--8.4 +/- 0.29% in group I and FBS--118 +/- 17.6 mg/dl, PP--176 +/- 20.1 mg/dl and HbA1--8.5 +/- 0.39% in group II patients).

RESULTS

The significantly raised levels of MDA and SOD, and decreased levels of reduced glutathione (GSH) during uncontrolled stage of diabetes indicated free radical stress induced lipid peroxidation. The significant fall of MDA and SOD and increased levels of GSH in blood in both groups after control revealed beneficial effects of glycemic control on oxidative stress. The levels were not normalized and stayed higher than those in controls. On intergroup comparison; the control of diabetes with gliclazide (group II) showed improvement in oxidative stress (MDA, GSH) better (p < 0.001) than glibenclamide (group I).

CONCLUSION

Oxidative stress in uncontrolled diabetes is decreased with glycemic control. The control of diabetes with gliclazide reduced oxidative stress more than glibenclamide, indicating higher antioxidant properties of gliclazide. Normalization of oxidative stress was not achieved. Further studies are required to see long-term effect of drug therapy in combating oxidative stress after achieving acceptable control of diabetes.

Assessing health utilities in schizophrenia. A feasibility study

BACKGROUND

Utility, a concept derived from economics, is the desirability or preference that individuals exhibit for a certain health state. Utility measurement could be viewed as an alternative means of appraising the quality of life of individuals affected by a chronic illness such as schizophrenia. Traditional techniques of utility measurement involve 2 steps: (i) identifying the different health states experienced by individuals during the course of an illness; and (ii) assigning them numerical values known as utilities.

AIM

The study examined the feasibility issues and psychometric aspects of obtaining accurate health state descriptions and their utilities from symptomatically stable patients with schizophrenia.

METHODS

The study used a cross-sectional, case-controlled design, with a study group consisting of 120 clinically stabilised patients with schizophrenia and a control group of 32 treated and recovered patients with major depression. Patients were asked to provide detailed descriptions of 3 distinct health states associated with their illness: current state, worst state experienced since the onset of illness and a perfect state desired in the future. Further, patients were asked to assign utilities to these health states with the aid of a purpose-built evaluation protocol comprising Magnitude Estimation (ME), Rating Scale (RS), Standard Gamble (SG), Time Trade-Off (TTO) and Willingness-to-Pay (WTP) techniques. The battery was repeated after a 1-week interval. Independent raters assessed symptom severity, insight and quality of life, and nurse-clinicians involved in their care were asked to provide the utility ratings of their clients' mental health state. Patients' opinions about the acceptability of utility measurement techniques, and the respondent burden were also ascertained.

RESULTS

Compared with control patients with treated depression, patients with schizophrenia were able to distinguish and describe the specified health states with an equal degree of ease and accuracy. RS, TTO and WTP techniques emerged as the favoured methods of utility evaluation. The test-retest reliability of utility ratings (r = 0.87 to 0.97; p < 0.001) was high, and concurrent validity with the quality of life measures was acceptable. Reliability and validity of patients' appraisals were unaffected by symptoms severity and insight. The accuracy of nurse-clinicians' appraisals were dependent on their close familiarity with the patients and their illness.

CONCLUSION

Clinically stabilised patients with schizophrenia can provide accurate health state descriptions and assign them utilities with a fair degree of reliability and validity. Utility evaluations based on patients' self-appraisals can be seen as potential tools in outcome studies and clinical trials involving patients with schizophrenia, but the methodology requires further refinement to accommodate the limitations imposed by the patients' disturbed mental status.