Neutrophil-to-lymphocyte ratio and prognosis in patients undergoing percutaneous coronary intervention for acute coronary syndrome

OBJECTIVE

The purpose of this study was to characterize Acute Coronary Syndrome (ACS)-associated inflammation by investigating correlates of the neutrophil-to-lymphocyte ratio (NLR), a surrogate marker of inflammation, and its relation to 1-year mortality in a cohort of patients undergoing percutaneous coronary intervention (PCI) for ACS at a single institution.

METHODS

We performed a single-institution, retrospective, observational study of all-comer ACS patients who underwent PCI and were discharged home before the COVID-19 pandemic between September 23, 2011 and July 31, 2017 for who outcomes data were available.

RESULTS

NLRhigh group tended to be older, white patients, less likely to smoke, more likely to have a history of heart failure and cardiac arrest, higher creatinine values, lower LVEF, and higher CK-MB (a surrogate for infarct size). Linear regression model demonstrated a strong correlation between increasing NLR and white race (B = 1.103, p = 0.001, hemoglobin (B = -0.30, p < 0.001), peak CK-MB (B = 0.004, p = 0.02), LVEF (B = -0.048, p < 0.001), and serum creatinine (B = 0.47, p = 0.03). There were a total of 87 deaths at one year. NLR > 3.4 was associated with worse one-year survival post-PCI (91.4 % vs. 95.4 %, log-rank p < 0.004), which was confirmed on multivariate analysis.

CONCLUSION

Our data confirm the independent prognostic significance of inflammation to mortality after ACS and may provide some insight into the putative benefits of inflammation modulation.

Titin: The Missing Link in Cardiac Physiology

Titin, an extraordinary protein known for its colossal size and multifaceted roles, is a cornerstone in the structural and functional dynamics of striated muscle tissues, including the heart and skeletal muscles. Its sheer enormity, with a molecular weight exceeding 3000 kDa, is paralleled only by the immense influence it exerts on muscle physiology. This review will delve into the remarkable structural organization of Titin and the genetics of this molecule, including the common mutations resulting in various cardiomyopathies. We will delve deeper into its role in dilated cardiomyopathy, familial restrictive cardiomyopathy, hypertrophic cardiomyopathy, and left ventricular noncompaction cardiomyopathy. This review culminates by discussing the prospects of therapeutic strategies targeting Titin. While these interventions remain primarily theoretical, the possibilities are intriguing. Patients with Titin truncation mutations present unique challenges, but innovative approaches like gene therapy or preemptive treatments with drugs such as angiotensin-converting enzyme inhibitors or beta-blockers offer hope. This multi-pronged approach highlights the significance of understanding Titin's multifaceted role and its potential as a target for future therapeutic interventions.

Pegozafermin Is a Potential Master Therapeutic Regulator in Metabolic Disorders: A Review

Pegozafermin (PGZ), a novel glycopegylated version of human fibroblast growth factor 21 (FGF21), has demonstrated potential for addressing metabolic comorbidities, including severe hypertriglyceridemia, insulin resistance, nonalcoholic fatty liver disease, and obesity. FGF21 is a naturally occurring peptide hormone primarily produced by the liver, with a half-life of 0.5 to 2 hours. It can influence metabolic processes through endocrine cellular effects. FGF21 receptors are found in the liver, adipose, skeletal muscles, and pancreatic tissues. Those receptors rely on the beta klotho (KLB) coreceptors, a transmembrane protein, to activate the FGF21 signaling pathway and FGF21's associated transcription factors. PGZ, through its extended half-life of 55 to 100 hours, has evidenced significant improvements in metabolic functions. Its mechanism of action includes promoting adiponectin levels, enhancing insulin sensitivity, increasing triglyceride uptake, and reducing de novo lipogenesis. This emerging pharmaceutical compound has shown promise in treating liver fibrosis and inflammation linked to nonalcoholic steatohepatitis. The ENTRIGUE trial, a phase 2 clinical trial of PGZ, has demonstrated a 57% reduction in triglyceride level compared to placebo; a 45% reduction in liver hepatic steatosis; improved insulin sensitivity; reductions in nonhigh-density lipoprotein-cholesterol; and reductions in apolipoprotein B-100.

Cardiovascular Manifestations of Hemochromatosis: A Review of Pathophysiology, Mechanisms, and Treatment Options

Hemochromatosis is a genetic disorder characterized by excessive absorption and accumulation of iron in the body. It is one of the most common inherited disorders. The excess iron deposition can cause damage to various organs, including the liver, heart, pancreas, and joints. If left untreated, hemochromatosis can lead to serious complications such as cirrhosis, diabetes, heart failure, and increased risk of certain cancers. Iron overload in hemochromatosis significantly affects the cardiovascular system, leading to morbidity and mortality. This article reviews the current literature describing the pathogenesis and various cardiovascular manifestations of hemochromatosis, including dilated cardiomyopathy, conduction abnormalities, heart failure, cardiac fibrosis, myocardial infarction, and valvular heart disease. This article aims to provide a detailed understanding of the cardiovascular manifestations associated with hemochromatosis and their underlying mechanisms through a review of current literature in publicly available databases.

Risk factors for cardiogenic shock in thyroid storm: a retrospective and case-series study

Aim: Thyroid storm (TS) occurs in 10% of thyrotoxicosis patients and 1% of TS patients experience cardiogenic shock (CS), which is associated with poor prognosis. Methods: This is a single institution, retrospective study in which 56 patients with TS were evaluated. Results: BMI (p = 0.002), history of heart failure (OR 8.33 [1.91, 36.28]; p = 0.004), pro-BNP elevation (p = 0.04), chest x-ray showing interstitial edema (OR 3.33 [1.48, 7.52]; p = 0.01) and Burch-Wartofsky score (62.5 vs 40; p = 0.004) showed association with CS. CS patients had increased length of stay (16.5 vs 4 days; p = 0.01) and higher in-hospital mortality (OR 24.5 [2.90, 207.29]; p < 0.001). Conclusion: These risk factors are useful to risk stratify TS patients on admission, institute therapy in a timely manner and decrease mortality.

The Relationship of Duffy Gene Polymorphism, High Sensitivity C-Reactive Protein, and Long-term Outcomes

Background

Black adults have higher incidence of all-cause death and worse cardiovascular outcomes when compared to other populations. The Duffy chemokine receptor is not expressed in a large majority of Black adults and the clinical implications of this are unclear.

Methods

Here, we investigated the relationship of Duffy receptor status, high-sensitivity C-reactive protein (hs-CRP), and long-term cardiovascular outcomes in Black members of two contemporary, longitudinal cohort studies (the Jackson Heart Study and Multi-Ethnic Study of Atherosclerosis). Data on 4,307 Black participants (2,942 Duffy null and 1,365 Duffy receptor positive, as defined using Single Nucleotide Polymorphism (SNP) rs2814778) were included in this analysis.

Results

Duffy null was not independently associated with elevated levels of serum hs-CRP levels once conditioning for known CRP locus alleles in linkage disequilibrium with the Duffy gene. Duffy null status was not found to be independently associated with higher incidence of all-cause mortality or secondary outcomes after adjusting for possible confounders in Black participants.

Conclusions

These findings suggest that increased levels of hs-CRP found in Duffy null individuals is due to co-inheritance of CRP alleles known to influence circulating levels hs-CRP and that Duffy null status was not associated with worse adverse outcomes over the follow-up period in this cohort of well-balanced Black participants.

The Critical Role of the Adipocytokine NOV in Obstructive Sleep Apnea Induced Cardiometabolic Dysfunction: A Review

Obstructive sleep apnea (OSA) is highly prevalent and associated with oxidative stress, chronic inflammation, and adverse cardiovascular consequences. The comorbid condition of obesity remains epidemic. Both obesity and OSA are highly comorbid in patients with cardiovascular disease including atrial fibrillation, resistant hypertension, congestive heart failure, and coronary artery disease. Patients with these preexisting cardiovascular conditions should be screened for OSA with a low threshold to treat, even if OSA severity is mild. Nephroblastoma overexpressed (NOV/CCN3) protein has been identified in multiple chronic inflammatory states, most notably in obesity and more recently in OSA, even in the absence of obesity. As such, NOV may represent an important biomarker for oxidative stress in OSA and may lead to a deeper understanding of the relationship between OSA and its clinical sequelae.

Back Up at the Pump? I Have a Gut Feeling About This: A Review of the Gastrointestinal Manifestations From Congestive Heart Failure

Heart failure, which is a clinical syndrome characterized by the heart's inability to maintain adequate cardiac output, is known to affect various organ systems in the body due to its ischemic nature and activation of the systemic immune response, but the resultant complications specifically on the gastrointestinal tract and the liver are not well discussed and poorly understood. Gastrointestinal-related phenomena are common symptoms experienced in patients with heart failure and frequently found to increase morbidity and mortality in these populations. The relationship between the gastrointestinal tract and heart failure are strongly linked and influence each other much so that the bidirectional association of the two is oftentimes referred to as cardiointestinal syndrome. Manifestations include gastrointestinal prodrome, bacterial translocation and protein-losing gastroenteropathy by gut wall edema, cardiac cachexia, hepatic insult and injury, and ischemic colitis. More attention is needed from a cardiology perspective to recognize these common presenting gastrointestinal phenomena that affect much of our patient population with heart failure. In this overview, we describe the association between heart failure and the gastrointestinal tract, the pathophysiology, lab findings, clinical manifestations and complications, and the management involved.

Silencing the Adipocytokine NOV: A Novel Approach to Reversing Oxidative Stress-Induced Cardiometabolic Dysfunction

Objective: NOV/CCN3 is an adipocytokine recently linked to obesity, insulin resistance, and cardiometabolic dysfunction. NOV is manufactured and secreted from adipose tissue, with blood levels highly correlated with BMI. NOV levels are increased in obesity and a myriad of inflammatory diseases. Elevated NOV levels cause oxidative stress by increasing free radicals, decreasing antioxidants, and decreasing heme oxygenase (HO-1) levels, resulting in decreased vascular function. Silencing NOV in NOV knockout mice improved insulin sensitivity. We wanted to study how suppressing NOV expression in an obese animal model affected pathways and processes related to obesity, inflammation, and cardiometabolic function. This is the first study to investigate the interaction of adipose tissue-specific NOV/CCN3 and cardiometabolic function. Methods: We constructed a lentivirus containing the adiponectin-promoter-driven shNOV to examine the effect of NOV inhibition (shNOV) in adipose tissue on the heart of mice fed a high-fat diet. Mice were randomly divided into three groups (five per group): (1) lean (normal diet), (2) high-fat diet (HFD)+ sham virus, and (3) HFD + shNOV lentivirus. Blood pressure, tissue inflammation, and oxygen consumption were measured. Metabolic and mitochondrial markers were studied in fat and heart tissues. Results: Mice fed an HFD developed adipocyte hypertrophy, fibrosis, inflammation, and decreased mitochondrial respiration. Inhibiting NOV expression in the adipose tissue of obese mice by shNOV increased mitochondrial markers for biogenesis (PGC-1α, the nuclear co-activator of HO-1) and functional integrity (FIS1) and insulin signaling (AKT). The upregulation of metabolic and mitochondrial markers was also evident in the hearts of the shNOV mice with the activation of mitophagy. Using RNA arrays, we identified a subgroup of genes that highly correlated with increased adipocyte mitochondrial autophagy in shNOV-treated mice. A heat map analysis in obese mice confirmed that the suppression of NOV overrides the genetic susceptibility of adiposity and the associated detrimental metabolic changes and correlates with the restoration of anti-inflammatory, thermogenic, and mitochondrial genes. Conclusion: Our novel findings demonstrate that inhibiting NOV expression improves adipose tissue function in a positive way in cardiometabolic function by inducing mitophagy and improving mitochondrial function by the upregulation of PGC-1α, the insulin sensitivity signaling protein. Inhibiting NOV expression increases PGC-1, a key component of cardiac bioenergetics, as well as key signaling components of metabolic change, resulting in improved glucose tolerance, improved mitochondrial function, and decreased inflammation. These metabolic changes resulted in increased oxygen consumption, decreased adipocyte size, and improved cardiac metabolism and vascular function at the structural level. The crosstalk of the adipose tissue-specific deletion of NOV/CCN3 improved cardiovascular function, representing a novel therapeutic strategy for obesity-related cardiometabolic dysfunction.

Relation of Left Ventricular Hypertrophy Subtype to Long-Term Mortality in Those With Subclinical Cardiovascular Disease (from the Multiethnic Study of Atherosclerosis [MESA])

The clinical and biochemical profile of differing Left ventricular hypertrophy phenotypes and its effect on long-term outcomes is ill-defined. The study investigated the differences in risk profiles and prognostic effect of concentric (CH) and eccentric hypertrophy (EH) on long-term adverse outcomes in a contemporary, ethnically diverse cohort. We analyzed follow-up data over 15 years from the Multiethnic Study of Atherosclerosis study. A total of 4,979 participants with cardiac magnetic resonance performed at baseline enrollment were included. Descriptive statistics, Kaplan-Meier curves, and regression models were applied. Independent variables associated with CH were black and Hispanic race/ethnicity, systolic blood pressure, and metabolic syndrome. Independent variables associated with EH were systolic blood pressure and urine creatinine, whereas serum creatinine had an inverse association. The primary end point of all-cause death (n = 1,137, 22.8%) occurred in 21.7%, 47.4%, and 56.6% of participants with no, CH, or EH, respectively (p- < 0.001). Age (hazard ratio [HR] per year = 1.10 [1.09 to 1.11], p <0.001), male gender (HR = 1.48 [1.29 to 1.69], p <0.001), black race (HR = 1.17 [1.005 to 1.36], p = 0.04), fasting glucose (HR = 1.005 [1.003 to 1.007], p <0.001), baseline creatinine (HR per mg/100 ml = 1.29 [1.15 to 1.46], p <0.001), left ventricular ejection fraction (HR per 1% = 0.98 [0.98 to 0.99], p = 0.005), IL-6 (HR per pg/ml = 1.17 [1.12 to 1.22], p <0.001), CH (HR = 1.84 [1.41 to 2.41], p <0.001), and EH (HR = 2.58 [1.77 to 3.76], p <0.001) were significant predictors of all-cause mortality. In conclusion, CH and EH are 2 distinct clinical phenotypes of left ventricular hypertrophy with differing gender and racial predisposition, both of which are associated with worse long-term adverse outcomes.

Cancer and cardiovascular-related perceived risk in a diverse cancer center catchment area

Purpose

Despite cancer and cardiovascular disease (CVD) sharing several modifiable risk factors, few unified prevention efforts exist. We sought to determine the association between risk perception for cancer and CVD and engagement in healthy behaviors.

Methods

Between May 2019 and August 2020, we conducted a cross-sectional survey of adults ≥ 40 years residing in Brooklyn neighborhoods with high cancer mortality. We considered one’s perceived risk of cancer and CVD compared to age counterparts as the primary exposures. The primary study outcome was a weighted health behavior score (wHBS) composed of 5 domains: physical activity, no obesity, no smoking, low alcohol intake, and healthy diet. Modified Poisson regression models with robust error variance were used to assess associations between perceived risk for cancer and CVD and the wHBS, separately.

Results

We surveyed 2448 adults (mean [SD] age, 61.4 [12.9] years); 61% female, 30% Non-Hispanic White, and 70% racial/ethnic minorities. Compared to their age counterparts nearly one-third of participants perceived themselves to be at higher CVD or cancer risk. Perceiving higher CVD risk was associated with an 8% lower likelihood of engaging in healthy behaviors (RR 0.92; 95% CI 0.86–0.99). Perceiving greater cancer risk was associated with a 14% lower likelihood of engaging in healthy behaviors (RR 0.86; 95% CI 0.79–0.95). The association between cancer risk and wHBS attenuated but remained significant (aRR 0.90; 95% CI 0.82–0.98) after adjustment.

Conclusion

Identifying high-risk subgroups and intervening on shared risk behaviors could have the greatest long-term impact on reducing CVD and cancer morbidity and mortality.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10552-022-01560-3.

Heme-oxygenase and lipid mediators in obesity and associated cardiometabolic diseases: Therapeutic implications

Obesity-mediated metabolic syndrome remains the leading cause of death worldwide. Among many potential targets for pharmacological intervention, a promising strategy involves the heme oxygenase (HO) system, specifically its inducible form, HO-1. This review collects and updates much of the current knowledge relevant to pharmacology and clinical medicine concerning HO-1 in metabolic diseases and its effect on lipid metabolism. HO-1 has pleotropic effects that collectively reduce inflammation, while increasing vasodilation and insulin and leptin sensitivity. Recent reports indicate that HO-1 with its antioxidants via the effect of bilirubin increases formation of biologically active lipid metabolites such as epoxyeicosatrienoic acid (EET), omega-3 and other polyunsaturated fatty acids (PUFAs). Similarly, HO-1and bilirubin are potential therapeutic targets in the treatment of fat-induced liver diseases. HO-1-mediated upregulation of EET is capable not only of reversing endothelial dysfunction and hypertension, but also of reversing cardiac remodeling, a hallmark of the metabolic syndrome. This process involves browning of white fat tissue (i.e. formation of healthy adipocytes) and reduced lipotoxicity, which otherwise will be toxic to the heart. More importantly, this review examines the activity of EET in biological systems and a series of pathways that explain its mechanism of action and discusses how these might be exploited for potential therapeutic use. We also discuss the link between cardiac ectopic fat deposition and cardiac function in humans, which is similar to that described in obese mice and is regulated by HO-1-EET-PGC1α signaling, a potent negative regulator of the inflammatory adipokine NOV.

The pivotal role of heme Oxygenase-1 in reversing the pathophysiology and systemic complications of NAFLD

The pathogenesis and molecular pathways involved in non-alcoholic fatty liver disease (NAFLD) are reviewed, as well as what is known about mitochondrial dysfunction that leads to heart disease and the progression to steatohepatitis and hepatic fibrosis. We focused our discussion on the role of the antioxidant gene heme oxygenase-1 (HO-1) and its nuclear coactivator, peroxisome proliferator-activated receptor-gamma coactivator (PGC1-α) in the regulation of mitochondrial biogenesis and function and potential therapeutic benefit for cardiac disease, NAFLD as well as the pharmacological effect they have on the chronic inflammatory state of obesity. The result is increased mitochondrial function and the conversion of white adipocyte tissue to beige adipose tissue ("browning of white adipose tissue") that leads to an improvement in signaling pathways and overall liver function. Improved mitochondrial biogenesis and function is essential to preventing the progression of hepatic steatosis to NASH and cirrhosis as well as preventing cardiovascular complications.

OX-HDL: A Starring Role in Cardiorenal Syndrome and the Effects of Heme Oxygenase-1 Intervention

In this review, we will evaluate how high-density lipoprotein (HDL) and the reverse cholesterol transport (RCT) pathway are critical for proper cardiovascular-renal physiology. We will begin by reviewing the basic concepts of HDL cholesterol synthesis and pathway regulation, followed by cardiorenal syndrome (CRS) pathophysiology. After explaining how the HDL and RCT pathways become dysfunctional through oxidative processes, we will elaborate on the potential role of HDL dysfunction in CRS. We will then present findings on how HDL function and the inducible antioxidant gene heme oxygenase-1 (HO-1) are interconnected and how induction of HO-1 is protective against HDL dysfunction and important for the proper functioning of the cardiovascular-renal system. This will substantiate the proposal of HO-1 as a novel therapeutic target to prevent HDL dysfunction and, consequently, cardiovascular disease, renal dysfunction, and the onset of CRS.

Can charcoal improve outcomes in COVID-19 infections?

COVID-19 infection causes considerable morbidity and mortality, especially to those who are aged, have impaired renal function and are obese. We propose to examine the potential utility of oral activated charcoal with the hypothesis that such treatment would lower absorption of microbiome derived toxins and ameliorate systemic oxidant stress and inflammation.

Cold Press Pomegranate Seed Oil Attenuates Dietary-Obesity Induced Hepatic Steatosis and Fibrosis through Antioxidant and Mitochondrial Pathways in Obese Mice

Aim: Obesity is associated with metabolic syndrome, hypertension, dyslipidemia, nonalcoholic fatty liver disease (NAFLD), and type 2 diabetes. In this study, we investigated whether the dietary supplementation of pomegranate seed oil (PSO) exerted a protective effect on liver lipid uptake, fibrosis, and mitochondrial function in a mouse model of obesity and insulin resistance. Method: In this in vivo study, eight-week-old C57BL/6J male mice were fed with a high fat diet (HFD) for 24 weeks and then were divided into three groups as follows: group (1) Lean; group (n = 6) (2) HF diet; group (n = 6) (3) HF diet treated with PSO (40 mL/kg food) (n = 6) for eight additional weeks starting at 24 weeks. Physiological parameters, lipid droplet accumulation, inflammatory biomarkers, antioxidant biomarkers, mitochondrial biogenesis, insulin sensitivity, and hepatic fibrosis were determined to examine whether PSO intervention prevents obesity-associated metabolic syndrome. Results: The PSO group displayed an increase in oxygen consumption, as well as a decrease in fasting glucose and blood pressure (p < 0.05) when compared to the HFD-fed mice group. PSO increased both the activity and expression of hepatic HO-1, downregulated inflammatory adipokines, and decreased hepatic fibrosis. PSO increased the levels of thermogenic genes, mitochondrial signaling, and lipid metabolism through increases in Mfn2, OPA-1, PRDM 16, and PGC1α. Furthermore, PSO upregulated obesity-mediated hepatic insulin receptor phosphorylation Tyr-⁹⁷², p-IRB tyr¹¹⁴⁶, and pAMPK, thereby decreasing insulin resistance. Conclusions: These results indicated that PSO decreased obesity-mediated insulin resistance and the progression of hepatic fibrosis through an improved liver signaling, as manifested by increased insulin receptor phosphorylation and thermogenic genes. Furthermore, our findings indicate a potential therapeutic role for PSO in the prevention of obesity-associated NAFLD, NASH, and other metabolic disorders.

Genetic Polymorphisms Complicate COVID-19 Therapy: Pivotal Role of HO-1 in Cytokine Storm

Coronaviruses are very large RNA viruses that originate in animal reservoirs and include severe acute respiratory distress syndrome (SARS) and Middle East respiratory syndrome (MERS) and other inconsequential coronaviruses from human reservoirs like the common cold. SARS-CoV-2, the virus that causes COVID-19 and is believed to originate from bat, quickly spread into a global pandemic. This RNA virus has a special affinity for porphyrins. It invades the cell at the angiotensin converting enzyme-2 (ACE-2) receptor and binds to hemoproteins, resulting in a severe systemic inflammatory response, particularly in high ACE-2 organs like the lungs, heart, and kidney, resulting in systemic disease. The inflammatory response manifested by increased cytokine levels and reactive oxygen species results in inhibition of heme oxygenase (HO-1), with a subsequent loss of cytoprotection. This has been seen in other viral illness like human immunodeficiency virus (HIV), Ebola, and SARS/MERS. There are a number of medications that have been tried with some showing early clinical promise. This illness disproportionately affects patients with obesity, a chronic inflammatory disease with a baseline excess of cytokines. The majority of the medications used in the treatment of COVID-19 are metabolized by cytochrome P450 (CYP) enzymes, primarily CYP2D6. This is further complicated by genetic polymorphisms of CYP2D6, HO-1, ACE, and ACE-2. There is a potential role for HO-1 upregulation to treat/prevent cytokine storm. Current therapy must focus on antivirals and heme oxygenase upregulation. Vaccine development will be the only magic bullet.

Targeting the Heme-Heme Oxygenase System to Prevent Severe Complications Following COVID-19 Infections

SARS-CoV-2 is causing a pandemic resulting in high morbidity and mortality. COVID-19 patients suffering from acute respiratory distress syndrome (ARDS) are often critically ill and show lung injury and hemolysis. Heme is a prosthetic moiety crucial for the function of a wide variety of heme-proteins, including hemoglobin and cytochromes. However, injury-derived free heme promotes adhesion molecule expression, leukocyte recruitment, vascular permeabilization, platelet activation, complement activation, thrombosis, and fibrosis. Heme can be degraded by the anti-inflammatory enzyme heme oxygenase (HO) generating biliverdin/bilirubin, iron/ferritin, and carbon monoxide. We therefore postulate that free heme contributes to many of the inflammatory phenomena witnessed in critically ill COVID-19 patients, whilst induction of HO-1 or harnessing heme may provide protection. HO-activity not only degrades injurious heme, but its effector molecules possess also potent salutary anti-oxidative and anti-inflammatory properties. Until a vaccine against SARS-CoV-2 becomes available, we need to explore novel strategies to attenuate the pro-inflammatory, pro-thrombotic, and pro-fibrotic consequences of SARS-CoV-2 leading to morbidity and mortality. The heme-HO system represents an interesting target for novel "proof of concept" studies in the context of COVID-19.

The Effects of Heme Oxygenase Upregulation on Obesity and the Metabolic Syndrome

Significance: Obesity is a chronic condition that is characterized by inflammation and oxidative stress with consequent cardiovascular complications of hypertension, dyslipidemia, and vascular dysfunction. Obesity-induced metabolic syndrome remains an epidemic of global proportions. Recent Advances: Gene targeting of the endothelium with a retrovirus using an endothelium-specific promoter vascular endothelium cadherin (VECAD)-HO-1 offers a potential long-term solution to adiposity by targeting the endothelium. This has resulted in improvements of both vascular function and adiposity attenuation. Critical Issues: Heme oxygenase plays an ever-increasing role in the understanding of human biology in the complex conditions of obesity and the metabolic syndrome. The heme oxygenase 1 (HO-1) system creates biliverdin/bilirubin, which functions as an antioxidant, and carbon monoxide, which has antiapoptotic properties. Future Directions: Upregulation of HO-1 has been shown to improve adiposity as well as vascular function in both animal and human studies.

Positive Effects of Heme Oxygenase Upregulation on Adiposity and Vascular Dysfunction: Gene Targeting vs. Pharmacologic Therapy

Objective: Heme oxygenase (HO-1) plays a critical role in adipogenesis and it is important to understand its function in obesity. Many studies have shown that upregulation of HO-1 can affect the biologic parameters in obesity-mediated diabetes, hypertension and vascular endothelial cell function. Thus, we aimed to explore the hypothesis that upregulation of HO-1, using a pharmacologic approach as well as gene targeting, would improve both adiposity and endothelial cell dysfunction by direct targeting of endothelial cells. Our second aim was to compare the short-term effect of a HO-1 inducer, cobalt-protoporphrin IX (CoPP), with the long-term effects of gene targeted therapy on vascular and adipocyte stem cells in obese mice. Method: We examined the effect of CoPP on fat pre-adipocytes and mesenchymal stem cells (MSC) in mice fed a high-fat diet (HFD). We also used a lentiviral construct that expressed heme oxygenase (HO-1) that was under the control of an endothelium specific promoter, vascular endothelium cadherin (VECAD) heme oxygenase (VECAD-HO-1). We targeted endothelial cells using vascular endothelium cadherin/green fluorescent protein fusion construct (VECAD-GFP) as the control. Conditioned media (CM) from endothelial cells (EC) was added to fat derived adipocytes. Additionally, we treated renal interlobar arteries with phenylephrine and dosed cumulative increments of acetylcholine both with and without exposure to CoPP. We did the same vascular reactivity experiments with VECAD-HO-1 lentiviral construct compared to the control. Results: CoPP improved vascular reactivity and decreased adipogenesis compared to the control. MSCs exposed to CM from EC transfected with VECAD-HO-1 showed decreased adipogenesis, smaller lipid droplet size and decreased PPAR-γ, C/EBP and increased Wnt 10b compared to the control. HO-1 upregulation had a direct effect on reducing adipogenesis. This effect was blocked by tin mesoporphrin (SnMP). EC treated with VECAD-HO-1 expressed lower levels of ICAM and VCAM compared to the control, suggesting improved EC function. This also improved ACH induced vascular reactivity. These effects were also reversed by SnMP. The effect of viral transfection was much more specific and sustained than the effects of pharmacologic therapy, CoPP. Conclusion: This study demonstrates that a pharmacological inducer of HO-1 such as CoPP improves endothelial cell function while dampening adipogenesis, but long-term HO-1 expression by direct targeting of endothelial cells by gene transfer therapy may offer a more specific and ideal solution. This was evidenced by smaller healthier adipocytes that had improved insulin sensitivity, suggesting increased adiponectin levels. HO-1 upregulation reestablished the “crosstalk” between perivascular adipose tissue and the vascular system that was lost in the chronic inflammatory state of obesity. This study demonstrates that gene targeting of EC may well be the future direction in treating obesity induced EC dysfunction, with the finding that targeting the vasculature had a direct and sustained effect on adipogenesis.

Racial Disparities with Esophageal Cancer Mortality at a High-Volume University Affiliated Center: An All ACCESS Invitation

BACKGROUND

Esophageal cancer (EC) has a dismal prognosis with 5-year survival < 19%. Black patients with EC have higher mortality than white patients, but the cause of this disparity is unclear. We sought to investigate the impact of race upon overall mortality (OM) among EC patients at our institution.

METHODS

We performed a single-center retrospective review of all patients diagnosed with EC between January 2010 through December 2016 with follow-up through October 2017. We compared the difference among categorical variables and mortality using Fisher's exact test. Odds ratios (OR) and hazard regression (HR) were constructed to analyze treatment options by race. The Kaplan-Meier method was used to plot OM curves by race. We also used a logistic regression analysis to construct a predictive model for mortality based on histology and race.

RESULTS

We identified 77 patients (62% male) diagnosed with EC. There was no difference in treatments offered based on race. After adjusting for age, histology and stage, we found mortality was significantly higher in blacks when compared to whites (HR 14.07, 95% CI [2.33-129.70] p < 0.008). Our predictive model revealed that blacks had a higher probability of mortality at all stages of EC.

CONCLUSIONS

We found race to be an independent risk factor for OM in EC patients. This likely reflects differences in healthcare utilization or access, as evidenced by higher prevalence of Stage IV EC in black patients. Continued investigation is needed to address this disparity locally and nationally.

Oxidized HDL, Adipokines, and Endothelial Dysfunction: A Potential Biomarker Profile for Cardiovascular Risk in Women with Obesity

OBJECTIVE

High BMI predicts adverse cardiovascular outcomes and positively correlates with increased levels of adipokines. The relationship among BMI, IL-6, TNFα, adiponectin, and oxidized high-density lipoprotein (Ox-HDL) with circulating endothelial cells (CECs) and endothelial progenitor cells (EPCs) has not been well studied. Elevated CEC levels have been described in both humans and mice with obesity and diabetes. Ox-HDL has been shown to be a potent driver of adipogenesis in vivo and in vitro. In this study, elevated BMI was examined in 2 groups of women studied in Brooklyn, New York, and Huntington, West Virginia, respectively.

METHODS

Twenty-six females with obesity and five lean controls without overt cardiovascular disease were enrolled, 13 from Huntington and 13 from Brooklyn. Cytokine levels, EPCs, and CECs were determined.

RESULTS

Females with obesity had elevated levels of leptin, IL-6, and Ox-HDL, increased CEC levels, and decreased EPC and adiponectin levels (all P < 0.01). The Ox-HDL levels were higher in women from Brooklyn versus Huntington (P < 0.01), possibly from higher TNFα levels in Brooklyn or higher adiponectin levels in Huntington. Seventy-five percent of the variance in Ox-HDL levels could be predicted in this population (P < 0.01).

CONCLUSIONS

This study reveals a unique inflammatory biomarker profile in females with obesity.

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

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

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

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

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

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

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

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

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

Milestones: a rapid assessment method for the Clinical Competency Committee

INTRODUCTION

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

INTRODUCTION

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Operationalizing the internal medicine milestones-an early status report

BACKGROUND

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

INNOVATION

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

MEASURES

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

RESULTS

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

CONCLUSIONS

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Heme oxygenase gene targeting to adipocytes attenuates adiposity and vascular dysfunction in mice fed a high-fat diet

We examined the hypothesis that adipocyte dysfunction in mice fed a high-fat (HF) diet can be prevented by lentiviral-mediated and adipocyte specific-targeting delivery of the human heme oxygenase-1 (aP2-HO-1). A bolus intracardial injection of aP2-HO-1 resulted in expression of human HO-1 for up to 9.5 months. Transduction of aP2-HO-1 increased human HO-1 expression in fat tissues without affecting murine HO-1. In mice fed a HF diet, aP2-HO-1 transduction attenuated the increases in body weight, blood glucose, blood pressure, and inflammatory cytokines, as well as the content of both visceral and subcutaneous fat. Transduction of aP2-HO-1 increased the numbers of adipocytes of small cell size (P<0.05), insulin sensitivity (P<0.05), adiponectin levels, as well as vascular relaxation to acetylcholine compared with HF mice administered the aP2-green fluorescent protein. Adipocytes of mice fed a HF diet expressed high levels of peroxisome proliferator activator receptor, aP2, C/EBP, and Wnt5b proteins and displayed marked increases in Peg1/Mesoderm specific transcript (P<0.03). Transduction of aP2-HO-1 lowered the elevated levels of these proteins and increased Sonic hedgehog, Wnt10b, and β-catenin (P<0.05). Inhibition of HO activity by administration of tin mesoporphyrin to HF-fed mice transduced with the aP2-HO-1 reversed the decrease in Peg1/Mesoderm-specific transcript, TNFα, and MCP-1 levels. Collectively, this novel study demonstrates that adipocyte-specific overexpression of HO-1 attenuates HF-mediated adiposity and vascular dysfunction; increases insulin sensitivity; and improves adipocyte function by increasing adiponectin, Shh, and WNT10b, and by decreasing inflammatory cytokines. These effects are reversed by the HO activity inhibitor, stannous mesoporphyrin.