Can paraoxonase activity serve as a comparable marker than high density lipoprotein in the follow-up of patients of coronary artery disease?

Funding Acknowledgements

Type of funding sources: None.

Background

Human serum paraoxonase (PON1) produced by the liver and residing almost exclusively on high density lipoproteins (HDL), has been demonstrated to prevent the oxidation of low density lipoprotein (LDL), which is  the central initiating factor in the causation of atherosclerosis. (1,2) Thus, PON1 along with HDL, plays an important role in the pathophysiology of atherosclerosis and consequently coronary artery disease. Statins are commonly used in clinical practice for the management of dyslipidemia , a known risk factor for coronary artery disease (CAD).Keeping this in mind,  it was deemed necessary to set up an observational study to explore whether the changes in PON1 activity after 3 months of statin therapy could help in the follow up of CAD patients.

Purpose

The purpose of the study was to evaluate the alterations in the PON1 activity along with the concentrations of HDL and LDL in patients of CAD before and after 3 months of statin therapy and to explore whether PON1 can be used as a comparable marker for assessment of the atherosclerotic risk in the follow up of these patients.

Materials and Methods

The study included 30 new patients who were put on statin therapy following the diagnosis of acute coronary syndrome in the Cardiology outpatients department. The activity of PON1 and the lipid profile parameters were estimated before starting statin therapy and again three months later. Patients with co-morbidities like diabetes, chronic kidney disease, chronic liver disease and other cardiac diseases of infectious etiology were excluded from the study. The data thus obtained was compiled and tabulated in Excel and statistically analyzed.

Results

The mean, median and standard deviation of the PON1, LDL and HDL, both before and after starting statin therapy, were calculated and the distribution of the individual parameters were determined. Analysis of the compiled data revealed that there was a statistically significant increase in both PON1 (p < 0.05) and HDL (p < 0.001) and a decrease (p <0.05, also statistically significant) in LDL after 3 months of statin therapy. The results both before and after 3 months of statin therapy are summarised in the table attached.(Table 1)

Conclusion

It may be concluded from the above study that the activity of PON1 may be used to indicate the changes in the lipid profile in the follow up of patients of CAD being treated with statins. It is however necessary to conduct larger, well designed studies in future to explore whether it may be used as a comparable marker better than HDL in the follow up of these patients. Abstract Figure.

An indian clinician outlook on hypertension care during Covid-19 pandemic

Funding Acknowledgements

Type of funding sources: None.

Background

Hypertension (HTN) has been found to increase the risk of Covid-19 mortality when compared with normotensives, and those discontinuing the antihypertensive treatment have an additional fatality risk.

Objective

The survey was carried out to seek the opinion of Indian healthcare practitioners (HCPs) on the risk factors, challenges and management of HTN during the ongoing Covid-19 pandemic.

Method

This was a structured web-based objective questionnaire survey involving 2545 HCPs PAN-India. The survey comprised questions related to the risk factors for HTN, home blood pressure monitoring (HBPM), BP control, treatment, complications and challenges of uncontrolled HTN during Covid-19.

Results

This study showed that tobacco use, obesity and comorbidities are top three modifiable risk factors for HTN followed by emotional stress, during Covid-19 pandemic. A majority of HCPs (44%) reported that <30% of their hypertensive patients check BP at home while 36% and 20% reported that 30-50% and >50% of their patients respectively, practice HBPM. 20%, 63%, and 17% of HCPs respectively, reported that <20%, 20-40% and >40% of their patients presented with BP > 150/100 mmHg during lockdown. Of all the HCPs, 53% and 33% respectively, reported BP increase in <20% and 20-40% of their patients on monotherapy while 14% of HCPs reported BP increase in >40% of their patients on monotherapy during the lockdown. As compared to high dose monotherapy, dual and triple combination therapies (TDC) were selected as most preferred for the management of uncontrolled BP opted by 56% and 34% of the HCPs, respectively. The dual combination antihypertensives were ranked as angiotensin receptor blockers (ARB) + diuretic (DU) > ARB + calcium channel blockers (CCB) > ARB + beta-blocker. The TDC with ARB + CCB + DU was the most favored TDC antihypertensive therapy during Covid-19 era. Acute coronary syndrome was anticipated as the most common complication of HTN in the Covid-19 pandemic, followed by renal dysfunction, cerebral ischemia and cerebral hemorrhage reported by 47%, 17%, 14% and 14% of HCPs, respectively. Multiple challenges in HTN care during Covid-19 as opined by HCPs included BP measurement while avoiding the risk of infection (57%), advising treatment via teleconsultation (48%), dose modification (41%), patient compliance (32%) and transport-related issues (30%). Most of the HCPs believed that self-monitoring of BP (32%) and economical medicines (24%) can improve medication adherence in patients with HTN.

Conclusion

The study underlined that the provision of economic medicines, single pill combinations, doctor-patient digital connect, and patient education can help in improving medication adherence leading to better outcomes in patients with HTN during Covid-19.  The study also suggested the need to enhance HBPM and the use of ARB-based dual and triple combination therapies to improve BP control in patients uncontrolled on monotherapy during Covid-19 pandemic.

Cardiological society of India document on safety measure during echo evaluation of cardiovascular disease in the time of COVID-19

An echocardiographic investigation is one of the key modalities of diagnosis in cardiology. There has been a rising presence of cardiological comorbidities in patients positive for COVID-19. Hence, it is becoming extremely essential to look into the correct safety precautions, healthcare professionals must take while conducting an echo investigation. The decision matrix formulated for conducting an echocardiographic evaluation is based on presence or absence of cardiological comorbidity vis-à-vis positive, suspected or negative for COVID-19. The safety measures have been constructed keeping in mind the current safety precautions by WHO, CDC and MoHFW, India.

Dipstick Method versus Spot Urinary Protein Creatinine Ratio for Evaluation of Massive Proteinuria in Childhood Nephrotic Syndrome

Measurement of massive proteinuria is vital for diagnosis of childhood Nephrotic syndrome. Quantification of 24 hours urinary protein is the gold standard test. Dipstick method of urinary protein measurement gives instant result for massive proteinuria. Spot urinary protein creatinine ratio measurement is variable. This was a hospital based prospective cross sectional study done at Department of Paediatric Nephrology, Rangpur Medical College Hospital from January 2014 to December 2015 to evaluate accuracy of dipstick method versus spot urinary protein-creatinine ratio in estimation of massive proteinuria in childhood nephrotic syndrome. Total 100 children diagnosed as Nephrotic syndrome fulfilling the inclusion and exclusion criteria were enrolled into the study. After collection of spot urine sample, proteinuria was estimated by dipstick method and same sample was sent to laboratory for measuring protein creatinine ratio. All data were collected in individual predetermined case record form and analyzed by SPSS version 17.Dipstick had sensitivity 97%, specificity 70%, positive predictive value 96.7%, negative predictive value 77% and efficacy 95%. There was a significant correlation between spot urinary protein creatinine ratio and dipstick testing of Nephrotic range of proteinuria (p<0.05).The dipstick result of proteinuria significantly correlates with spot urinary protein creatinine ratio. Dipstick method of urinary protein measurement yields accurate result instantly.

Abstract P5-11-04: Therapy-induced priming of natural killer cells predicts patient-specific tumor rejection in multiple breast cancer indications

Background: Predicting patient-specific clinical response to anticancer therapy is the holy grail of treatment-selection. It is now clear that response or resistance to therapy depends on the heterogeneous tumor microenvironment, which is comprised of malignant cells, normal stroma, soluble ligands, and tumor-immune contexture; attributes that are unique to each individual patient. This is particularly true for emerging anticancer drugs, such as immune checkpoint inhibitors, which recalibrate the body's own immune defense largely by modulating exhaustion of cytotoxic lymphocytes including T cells and natural killer (NK) cells. However, clinical response to therapy varies enormously. There is a critical gap in our understanding for the mechanisms that drive response or resistance to conventional drugs and immunotherapies at the individual patient level.

Methods: Here, we used a fully patient-autologous, clinically-validated ex-vivo tumor model that recreates and preserves the native, patient tumor microenvironment (CANscriptTM), which incorporates an algorithm-driven method to predict clinical response to therapy (M-Score). Utilizing tissue from patients diagnosed with luminal, HER2 positive, and triple-negative (ER- PR- HER2-) breast cancers (N=10), we studied phenotypic alterations to the tumor-immune contexture under pressure of conventional standard-of-care regimens and immunotherapies including immune-checkpoint inhibitors, ex-vivo. To do this, we used a comprehensive panel of immunological assays to evaluate changes in cytotoxic lymphocytes by flow cytometry and multiplex immunohistochemistry (i.e. CD56, MHC class 1A/B, NKG2D/C, CD8, CD3, PD-1, CTLA-4, TIM-3, LAG-3, 4-1BB, granzyme A/B). In addition, we used multiplex cytokine analysis to study the soluble components of the tumor microenvironment.

Results: We identified that tumor response, predicted by M-Score, correlates to increased infiltration of NK cells, which associated a pro-inflammatory cytokine signature from the tumor microenvironment. Interestingly, these evidences were concordant with induction of the tumor-expressing biomarker MICA/B, which is known to attract and recruit active NK cells. Furthermore, we determined that therapy-induced expression of protein biomarkers associated with NK cell exhaustion inversely correlated to the expression of cytotoxic granzyme B in the tumor microenvironment.

Conclusions: Taken together, these data demonstrate an integral role that NK cells contribute to the antitumor effect of therapy including conventional and immuno-modulatory drugs. It further demonstrates how a novel ex-vivo platform can be harnessed to study the mechanisms of response and resistance, which couldn't otherwise be known in a drug naïve state. Such an advance in our preclinical methods to study anticancer drugs at the individual patient level can help guide treatment decisions for clinicians while simultaneously functioning as a platform to study clinical efficacy of novel and emerging agents.

Citation Format: Smalley M, Shanthappa BU, Gertje H, Lawson M, Ulaganathan B, Thayakumar A, Maciejko L, Radhakrishnan P, Biswas M, Thiyagarajan S, Majumder B, Gopinath KS, K GB, Goldman A. Therapy-induced priming of natural killer cells predicts patient-specific tumor rejection in multiple breast cancer indications [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-11-04.

Abstract P3-03-18: An ex-vivo platform predicts anti-tumor outcome of metabolically-targeted, algorithm-driven combination therapy in triple-negative breast cancer

Cancer cells undergo phenotypic cell state transitions in response to chemotherapy as a mechanism that can confer transient resistance. However, such cell state transitions can also unlock unique vulnerabilities that can be exploited using temporally-sequenced combination chemotherapy. Here, utilizing a primary breast cancer ex-vivo functional assay that captures tumor heterogeneity, we report that in response to a chemotherapeutic agent, a subset of cancer cells can mount an acutely-induced phenotypic adaptive resistance to future cytotoxic pressure via the transient acquisition of a unique metabolic state defined by augmented glycolysis together with mitochondrial proficiency. These cells activate two complex, temporally-interdependent pathways that enable a glucose shunt towards the pentose phosphate pathway (PPP), which confers an adaptive cross-tolerance to different chemotherapeutic agents. Mathematically modeling these pathways, and simulating drug schedules, we define a rationally-designed 3-drug combination therapy of metabolic inhibitors and cytotoxic agents, which results in improved cancer survival. Our findings highlight a new bioenergetics-based adaptive resistance mechanism through which cancer cells can survive combinations of chemotherapy. Administration of metabolic inhibitors in rational, temporal sequence with existing chemotherapy can emerge as a new paradigm in the treatment of cancer.

Citation Format: Goldman A, Majumder B, Dhawan A, Kohandel M, Majumder P, Sengupta S. An ex-vivo platform predicts anti-tumor outcome of metabolically-targeted, algorithm-driven combination therapy in triple-negative breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-03-18.

An unusual case of aortic graft infection: a case report and review of the literature

Graft-appendiceal fistula is a rare variation of aorto-enteric fistula. We report on the presentation and management of a 70-year-old lady who presented ten years after an aortobifemoral graft with a discharging sinus in her right groin. Investigations suggested aortic graft infection and she was taken to theatre for a laparotomy. An inflamed appendix with a necrotic tip was found in contact with the aortic graft. The infected graft was excised and an appendicectomy was performed. The distal organs were revascularised with an axillobifemoral graft. We review similar case reports.

Early clinical experience with the Anaconda re-deployable endograft in 106 patients with abdominal aortic aneurism: the west of Scotland Anaconda registry

Endovascular repair of abdominal aortic aneurysm is a common procedure and not without complications. The aim of this study was to evaluate the early results of the Anaconda endograft (Vascutek Ltd., Inchinnan, Scotland, UK) in 106 patients in three hospitals in the west of Scotland. A prospective registry of 106 consecutive patients undergoing endoluminal repair of their abdominal aortic aneurysms using the Anaconda device was set up to record the clinical outcomes, with a mean follow-up of two years. There was no 30-day perioperative mortality in the 106 patients. Only type II endoleaks were detected on serial computed tomography scanning at follow-up. Technical success was achieved in 99% (105/106) in this study; one patient was converted to open surgical repair. Two cases of proximal device migration (>1 cm) were detected at one month and 19 months, respectively, with no associated endoleak or sac enlargement. Five cases of endograft limb thrombosis were noted in this study. Our early clinical experience with the Anaconda endograft compares favourably with other commercially available endografts in the treatment of abdominal aortic aneurysms. The main advantages of this device are that it is re-deployable and that it has a magnetic wire system which makes it easy to implant.

Reuse of pacemaker

Implantation of a permanent pacemaker is an expensive proposition for the poor patients of our country. Many patients on permanent pacemaker die prematurely due to diseases or conditions not related to pacemaker function. The purpose of this study was to reuse these pacemakers after thorough cleansing and proper sterilisation in other suitable patients and compare the efficiency of the reused pacemakers with that of newly implanted ones. Between April 1979 and April 1992, 642 patients implanted with reused pacemakers were studied. The study population consisted of patients ranging in age from 15-85 years and included patients of both sexes (M:F = 4:1). The mean period of follow-up was 7.5 +/- 5.6 years. Removal and reimplantation of the pulse generators was carried out after obtaining the State Government's approval, informed consent of the donors, relatives and recipients. The functional status of the pulse generators was tested by a "pacing system analyser". The clinical indications for reuse were chronic complete heart block, symptomatic bifascicular heart block, sick sinus syndrome and chronic complete heart block with congestive heart failure, in decreasing order of frequency. In terms of morbidity and mortality, the efficacy of reused pacemakers was highly comparable with that of newly implanted ones. The infection rate in cases of reuse from dead patients was comparable to that in cases of new implantation. However, pacemakers reused in the same patient showed a high rate of infection. With the aid of newer generations of antimicrobials, infection when matched with efficacy and economy (of reuse) does not seem to be a major factor against pacemaker reuse.

Some host factors and seasonal variations in the fatal road traffic accidents occurring in eastern suburban Calcutta

An extensive study of road traffic accident cases occurring within eastern suburban Calcutta during April 1992 to March 1993 was done. Of which 276 fatal cases having minimum medical aids were taken into consideration to avoid erroneous interpretation. Male pedestrians of age group of 50 years and above were mostly involved during the time period of 5 A.M. to 12 Noon. Fatal Accidents mostly occurred during winter and on the broader roads (Highways) and in majority of cases victims were at fault.