Comparison of Recurrence Rate of Wrist Ganglion Between Seton and Open Surgical Excision in Military Hospitals of Pakistan

Objective: To evaluate the recurrence following open surgical excision and Seton placement in treating symptomatic wrist ganglions in Military Hospitals in a six-month follow-up study. Study Design: Quasi-experimental study Place and Duration of Study: Department of General Surgery, Combined Military Hospital, Bahawalpur Pakistan, Combined Military Hospital, Dera Nawab Sahib Pakistan and Pakistan Airforce Force Hospital, Shorkot Pakistan, from Jun 2015 to Dec 2020. Methodology: The patients were divided into two groups after informed consent. A consultant general surgeon carried out every procedure. The findings were recorded on a uniform proforma, and recurrence was recorded at ten days, six weeks and six months for both groups. Results: The mean age of the patients was 29.45±8.13 years in Group-A (Seton-Group) and 28.56±8.32 years in Group-B (OpenSurgery). There was no difference in the recurrence rates between the Seton-Group (n=7, 4.35%) and Open Surgery-Group (n=2, 4.65%, p=0.931). Conclusion: Seton insertion for treating Ganglions of the wrist is a simple, economical and cosmetic procedure which can be done in the outpatient department. It is a safe alternative to open resection for successful treatment of the wrist Ganglion.Keywords: Ganglion, Open surgery, Recurrence, Seton, Wrist.

Treatment of Refractory No-Reflow in Cardiac Catheterization Laboratory; Role of Intracoronary Verapamil (A Case Report)

The no reflow phenomenon is a feared complication in Percutaneous Coronary Intervention (PCI) procedures including elective as well as primary PCI (Percutaneous Coronary Intervention), and results in worse prognosis. A number of etiological factors are involved in pathogenesis of no reflow phenomenon. These include distal athero embolization, ischemic and reperfusion injury, microvascular spasm and endothelial dysfunction. The treatment of no reflow depends on underlying mechanism and includes pharmacological as well as non-pharmacological interventions. Pharmacological agents include vasodilators like adenosine, sodium nitroprusside, verapamil, in addition to adrenaline (intracoronary) and, GpIIa/IIIb inhibitors. Non pharmacological measures include mechanical thrombus aspiration. Among pharmacological agents, Verapamil is usually the least preferred agent because of its negative ionotropic effect. Here, we describe a case of refractory no reflow in a patient undergoing primary PCI to right coronary artery (RCA), which was treated with a no. of pharmacological agents as well as aspiration thrombectomy but without much success and finally responded to intracoronary verapamil.

Development of a multi-item Operational Excellence scale: Exploratory and confirmatory factor analysis

Purpose

Considering the relevance of operational excellence as a business strategy, organizations are striving to improve themselves by adopting best practices and universally accepted principles through the process of continuous improvement, and these principles should be embedded in the culture of an organization. Organizations pursue to align themselves by continuously improving their processes by adopting scientifically proven techniques and cultural transformation throughout the organization. However, there is a lack of scientific instruments for the assessment of operational excellence. The objective of this study is to develop a scale for the assessment of practices of operational excellence principles in the organizations. Further reliability and validity of the developed scale are measured by testing the relationship between Human Resource Practices (HRP) and Operational Excellence (OE).

Design/methodology/approach

This study comprises quantitative design through exploratory and confirmatory studies and also includes qualitative analysis to develop a scale for the assessment of Operational Excellence (OE). Interviews from industry experts have been conducted to identify the major components for which organizations are striving for OE. Previous literature and excellence models, especially principles of the Shingo Operational Excellence Model (SOEM), have been reviewed and considered to finalize the scale items. Data were collected in two stages from both Telecommunication subsectors (Cellular Mobile Operators and Fixed Local Loop Operators) of Pakistan through the cross-sectional survey. In the first stage, exploratory factor analysis (EFA) was performed on the sample of 611 respondents from both Cellular Mobile and Fixed Local Loop operators of Pakistan. In the second stage, confirmatory factor analysis (CFA) was performed on the sample of 423 respondents from the Fixed local loop operators. EFA was conducted by using SPSS version 23 to finalize the OE scale, and for confirmatory factor analysis, PLS-SEM using Smart PLS was used to confirm the reliability and validity of the OE Scale.

Findings

The results of EFA reveal that OE is a multidimensional construct with three dimensions and 23 items. The dimensions of the developed OE Scale explored in this study are cultural enablers (CE), continuous process improvement (CPI) and enterprise alignment (EA). The confirmatory factor analysis of OE confirmed the scale dimensionality, reliability and validity along with the hypothesis testing to measure the impact of antecedent variable HRP on OE.

Research limitations/implications

Organizations pursue to improve and align their operational processes but usually unable to confirm the implementation of their desired objectives. Based on the developed OE scale, managers may assess the implementation of OE principles in their organizations. This research has been conducted in the telecommunication sector of Pakistan only, and the developed instrument needs to be further tested in other organizations.

Practical implications

The instrument developed in this study will help both researchers and practitioners to assess the principles of operational excellence in their organizations and enable them to design the strategies for improving organizational performance.

Social implications

The results of this study will create awareness about the principles of operational excellence. The developed OE instrument will assist in identifying the gaps in organizational norms and values from the perspective of paying respect to every individual inside and outside the organization. OE instrument will be further helpful in the identification and assurance of health, safety, protection of the environment and community issues.

Originality/value

This study provides a reliable and validated scale for the scientific area of operation management and helps managers with the assessment of operational excellence in their organizations. This newly developed scale is also valid to test and use in different studies and industries by researchers and practitioners.

Quality of life after amputation in patients with advanced complex regional pain syndrome: a systematic review

The majority of included studies (8 out of 11, n = 54) supported the concept of considering amputation for selected, unresponsive cases of complex regional pain syndrome (CRPS) as a justifiable alternative to an unsuccessful multimodality nonoperative option.Of patients who underwent amputation, 66% experienced improvement in quality of life (QOL) and 37% were able to use a prosthesis, 16% had an obvious decline in QOL and for 12% of patients, no clear details were given, although it was suggested by authors that these patients also encountered deterioration after amputation.Complications of phantom limb pain, recurrence of CRPS and stump pain were predominant risks and were noticed in 65%, 45% and 30% of cases after amputation, respectively and two-thirds of patients were satisfied.Amputation can be considered by clinicians and patients as an option to improve QOL and to relieve agonizing, excruciating pain of severe, resistant CRPS at a specialized centre after multidisclipinary involvement but it must be acknowledged that evidence is limited, and the there are risks of aggravating or recurrence of CRPS, phantom pain and unpredictable consequences of rehabilitation.Amputation, if considered for resistant CRPS, should be carried out at specialist centres and after MDT involvement before and after surgery. It should only be considered if requested by patients with poor quality of life who have failed to improve after multiple treatment modalities.Further high quality and comprehensive research is needed to understand the severe form of CRPS which behaves differently form less severe stages. Cite this article: EFORT Open Rev 2019;4:533-540. DOI: 10.1302/2058-5241.4.190008.

Bacteriological patterns and antibiotic sensitivities in calculus cholecystitis

BACKGROUND

Calculus cholecystitis with its complications dominates the diseases of the biliary tract. There is an inherent difficulty in identifying patients having infected gall bladders who may have the risk of wound infection or gram negative septicaemia after cholecystectomy. This study was conducted to ascertain the bacteriological patterns and antibiotic sensitivities of bile in calculus cholecystitis patients presenting at a tertiary care hospital and formulate guidelines for prophylactic antibiotic therapy.

METHODS

This descriptive study was conducted in Combined Military Hospital, Rawalpindi from 20th Dec 2006 to 19th Sep 2008. A total number of 150 patients presenting at CMH Rawalpindi for elective cholecystectomy were included in the study. Prophylactic antibiotics were given after the induction of anaesthesia, 5 ml of bile was aspirated from their intact gall bladder was subjected to bacteriological examination at Armed Forces Institute of Pathology. A pro forma was designed to record all the information regarding isolated bacteria and their sensitivities to various antibiotics. Data was analyzed using SPSS-11.

RESULTS

Growth of bacteria was seen in 57 (38%) cases and no growth was seen in 93 (62%). Most common organism cultured was: Pseudomonas aeruginosa followed by Escherichia coli (E. Coli) and Klebsiella pneumoniae. The most effective antibiotic was Imipenem followed by Piperacillin- Tazobactum combination and Amikacin.

CONCLUSIONS

Imipenem, Piperacillin-Tazobactum combination and Amikacin should be used for prophylaxis in cases of cholelithiasis undergoing elective cholecystectomy.

Outcomes with first- versus second-generation drug-eluting stents in coronary chronic total occlusions (CTOs): a systematic review and meta-analysis

OBJECTIVE

The objective of the present study was to perform a systematic review and meta-analysis of studies reporting outcomes after first- and second-generation drug-eluting stent (DES) implantation in chronic total occlusions (CTOs).

BACKGROUND

The effect of second- vs first-generation DESs on the outcomes after CTO percutaneous coronary intervention (PCI) has received limited study.

METHODS

As of May 2013, thirty-one published studies reported outcomes after DES implantation in CTOs: thirteen uncontrolled studies (3161 patients), three randomized (220 patients) and ten non-randomized (2150 patients) comparative studies with bare-metal stents (BMSs), and two non-randomized (685 patients) and three randomized (489 patients) comparative studies between first- and second-generation DESs. Data from the five studies comparing first with second-generation DESs were pooled using random-effects meta-analysis models.

RESULTS

The median and mean duration of follow-up were 12 and 14.4 months, respectively. Compared to first-generation DESs, second-generation DESs were associated with lower incidence of death (odds ratio [OR], 0.37; 95% confidence intervals [CI], 0.15-0.91), target vessel revascularization (OR, 0.59; 95% CI, 0.40-0.87), binary angiographic restenosis (OR, 0.68; 95% CI, 0.46-1.01) and reocclusion (OR, 0.35; 95% CI, 0.17-0.71), but similar incidence of myocardial infarction (OR, 0.45; 95% CI, 0.10-1.95) and stent thrombosis (OR, 0.34; 95% CI, 0.07-1.59).

CONCLUSIONS

Compared to first-generation DESs, second-generation DESs are associated with improved angiographic and clinical outcomes in CTO PCI and are the preferred stents for these challenging lesions.

Clinical presentation and management of patients with hyperadrenergic postural orthostatic tachycardia syndrome. A single center experience

BACKGROUND

We present our single center experience of 27 patients of hyperadrenergic postural orthostatic tachycardia syndrome (POTS).

METHODS

In a retrospective analysis, we reviewed the charts of 300 POTS patients being followed at our autonomic center from 2003 to 2010, and found 27 patients eligible for inclusion in this study. POTS was defined as symptoms of orthostatic intolerance (of greater than six months' duration) accompanied by a heart rate increase of at least 30 bpm (or a rate that exceeds 120 bpm) that occurs in the first 10 min of upright posture or head up tilt test (HUTT) occurring in the absence of other chronic debilitating disorders. Patients were diagnosed as having the hyperadrenergic form based on an increase in their systolic blood pressure of ≥ 10 mm Hg during the HUTT (2) with concomitant tachycardia or their serum catecholamine levels (serum norepinephnrine level ≥ 600 pg/mL) upon standing.

RESULTS

Twenty seven patients, aged 39 ± 11 years, 24, (89%) of them female and 22 (82%) Caucasian were included in this study. Most of these patients were refractory to most of the first and second line treatments, and all were on multiple combinations of medications.

CONCLUSIONS

Hyperadrenergic POTS should be identified and differentiated from neuropathic POTS. These patients are usually difficult to treat and there are no standardized treatment protocols known at this time for patients with hyperadrenergic POTS.

Pediatric renal transplantation

Although the number of children with end-stage renal disease (ESRD) in need for renal transplantation is small compared with adults, the problem associated with renal transplant in children are numerous, varied, and often peculiar. Pre-emptive transplantation has recently been growing in popularity as it avoids many of the associated long-term complications of ESRD and dialysis. Changes in immunosuppression to more potent agents over the years will have affected transplant outcome; there is also evidence that tacrolimus is more effective than cyclosporine. This review will discuss the short- and long-term complications such as acute and chronic rejection, hypertension, infections, and malignancies as well as factors related to long-term graft function. Chronic allograft nephropathy is the leading cause of renal allograft loss in pediatric renal transplant recipients. It is likely that it reflects a combination of both immune and nonimmune injury occurring cumulatively over time so that the ultimate solution will rely on several approaches. Transplant and patient survival have shown a steady increase over the years. The major causes of death after transplantation are cardiovascular disease, infection and malignancy. Transplantation in special circumstances such as children with abnormal urinary tracts and children with diseases that have the potential to recur after transplantation will also be discussed in this review. Non-compliance with therapeutic regimen is a difficult problem to deal with and affects patients and families at all ages, but particularly so at adolescence. Growth may be severely impaired in children with ESRD which may result in major consequences on quality of life and self-esteem; a better height attainment at transplantation is recognized as one of the most important factors in final height achievement. Although pediatric kidney transplantation is active in some parts of many developing countries, it is still inactive in many others and mostly relying on living donors. The lacking deceased programs in most of these countries is one of the main issues to be addressed to adequately respond to organ shortage. In conclusion, transplantation is currently the best option for children with ESRD. Although improvement in immunosuppression demonstrated excellent results and has led to greater 1-year graft survival rates, chronic graft loss remains relatively unchanged and opportunistic infectious complications remain a problem.

Paclitaxel-eluting stents reduce neointimal hyperplasia compared to bare metal stents in saphenous vein grafts: intravascular ultrasonography analysis of the SOS (Stenting of Saphenous Vein Grafts) trial

AIMS

To compare the intravascular ultrasonography (IVUS) findings between saphenous vein grafts (SVG) treated with paclitaxel-eluting stents (PES) vs. bare metal stents (BMS) in the Stenting Of Saphenous Vein Grafts (SOS) trial.

METHODS AND RESULTS

Of the 80 SOS trial patients, 38 had both baseline and follow-up IVUS examination and were included in this substudy: 17 patients received 28 BMS in 26 lesions and 21 patients received 30 PES in 28 lesions. Quantitative IVUS analysis was performed to determine the volume of in-stent neointimal hyperplasia (NIH) - defined as the difference between stent volume and lumen volume in the stented segments. Baseline characteristics were similar between patients who did and did not undergo baseline and follow-up IVUS. Patients receiving BMS and PES had similar stent and lumen volumes immediately after stenting. At 12-month follow-up, compared to BMS, PES-treated lesions had significantly less NIH volume (3.4 vs. 21.9 mm³, p<0.001) and neointima hyperplasia progression (1.6 vs. 17.1 mm³, p<0.001). No significant differences were seen in the 5 mm segment proximal and distal to the stent.

CONCLUSIONS

Compared to BMS, use of PES in SVG lesions is associated with significantly lower NIH formation, which may help explain the improved clinical outcomes with PES in these lesions.

Recurrent cardiovascular events with paclitaxel-eluting versus bare-metal stents in saphenous vein graft lesions: insights from the SOS (Stenting of Saphenous Vein Grafts) trial

The Stenting of Saphenous Vein Grafts (SOS) trial demonstrated a reduction in clinical and angiographic adverse events with paclitaxel-eluting stents (PES) compared to bare-metal stents (BMS) in saphenous vein graft (SVG) lesions, but the rate of recurrent adverse events has not been described.

METHODS

We performed a post hoc, landmark analysis to evaluate the risk of event recurrence following a non-fatal initial event among the SOS trial patients (pts).

RESULTS

During a median follow-up of 35 months, the 80 pts enrolled in SOS experienced a total of 78 major cardiovascular events (MACE): 51 in the BMS group and 27 in PES group. No MACE were found in 28 pts (35%) while 52 pts (65%) had at least one event. The initial event was death in 13 pts (16%). Among the 39 pts whose initial event was not fatal, 12 (31%) had one or more subsequent MACE (50% of which were definitely related to the study SVG). The mean and median number of MACE per patient was significantly higher in patients receiving BMS versus PES (1.3 ± 1.2 and 1 ± 1.26 versus 0.6 ± 0.7 and 1 ± 0.825, p = 0.005 and p = 0.008, respectively). The rate of a second MACE following an initial event was 17% in the PES group and 37% in the BMS group (p = 0.24). Ten of 12 pts with recurrent events had received a BMS (83%).

CONCLUSION

Pts undergoing SVG stenting had a high rate of recurrent events after an initial non-fatal event. These events were often related to the target vessel and most occurred in pts who had received a BMS, further supporting the benefit of PES over BMS in SVG lesions.

Autonomic dysfunction presenting as orthostatic intolerance in patients suffering from mitochondrial cytopathy

BACKGROUND

Disturbances in autonomic nervous system function have been reported to occur in patients suffering from mitochondrial cytopathies. However, there is paucity of literature on the occurrence of orthostatic intolerance (OI) in these patients. We report on a series of patients diagnosed with mitochondrial cytopathy who developed features of autonomic dysfunction in the form of OI.

METHODS

This was a single-center report on a series of 6 patients who were followed in our clinic for orthostatic intolerance. All of these patients had a diagnosis of mitochondrial cytopathy on the basis of muscle biopsy and were being followed at a center specializing in the treatment of mitochondrial disorders. This study was approved by our local institutional review board. Each of the patients had suffered from symptoms of fatigue, palpitations, near syncope, and syncope. The diagnosis of OI was confirmed by head-up tilt test. Collected data included demographic information, presenting symptoms, laboratory data, tilt-table response, and treatment outcomes.

RESULTS

Six patients (3 females) were identified for inclusion in this report. The mean age of the group was 48 ± 8 years (range, 40-60 years). All of these patients underwent head-up tilt table testing and all had a positive response that reproduced their clinical symptoms. Among those having an abnormal tilt-table pattern, 1 had a neurocardiogenic response, 1 had a dysautonomic response, and 4 had a postural orthostatic tachycardia response. All but 1 patient reported marked symptom relief with pharmacotherapy. The patient who failed pharmacotherapy received a dual-chamber closed-loop pacemaker and subsequently reported marked improvement in her symptoms with elimination of her syncope.

CONCLUSIONS

Orthostatic intolerance might be a significant feature of autonomic nervous system dysfunction in patients suffering from mitochondrial cytopathy.

Ventricular fibrillation associated with occult eating disorder - a clinical puzzle

Eating disorders are not infrequent in adolescents, and associated cardiac arrhythmias (CA) are well described in these patients. However, CA in adult eating disorders have been reported only rarely. We report a case of ventricular fibrillation in a patient presenting with fatigue and a recent history of vomiting.

Comparative clinical profile of postural orthostatic tachycardia patients with and without joint hypermobility syndrome

BACKGROUND

Autonomic dysfunction is common in patients with the joint hypermobility syndrome (JHS). However, there is a paucity of reported data on clinical features of Postural orthostatic tachycardia syndrome (POTS) in patients suffering from JHS.

METHODS

This retrospective study was approved by our local Institutional Review Board (IRB). Over a period of 10 years, 26 patients of POTS were identified for inclusion in this study. All these patients had features of Joint Hypermobility Syndrome (by Brighton criterion). A comparison group of 39 patients with other forms of POTS were also followed in the autonomic clinic during the same time. We present a descriptive report on the comparative clinical profile of the clinical features of Postural Orthostatic Tachycardia patients with and without Joint Hypermobility syndrome. The data is presented as a mean+/-SD and percentages wherever applicable.

RESULTS

Out of 65 patients, 26 patients (all females, 20 Caucasians) had POTS and JHS. The mean age at presentation of POTS was 24+/-13 (range 10-53 years) vs 41+/-12 (range 19-65 years), P=0.0001, Migraine was a common co morbidity 73 vs 29% p=0,001. In two patients POTS was precipitated by pregnancy, and in three by surgery, urinary tract infection and a viral syndrome respectively. The common clinical features were fatigue (58%), orthostatic palpitations (54%), presyncope (58%), and syncope (62%).

CONCLUSIONS

Patients with POTS and JHS appear to become symptomatic at an earlier age compared to POTS patients without JHS. In addition patients with JHS had a greater incidence of migraine and syncope than their non JHS counterparts.

Current challenges of organ donation programs in syria

BACKGROUND

Renal transplantation is the optimal treatment for the majority of patients with end-stage renal disease.

OBJECTIVE

To examine the donor characteristics of kidney transplants in Syria and the impact of national Syrian legislation on the evolution of kidney transplantation activities in the private and public sectors.

METHODS

Available data on all kidney transplants performed in Syria over the last 2 decades was retrospectively analyzed to assess the characteristics of kidney donors and recipients with a focus upon transplants since 2003.

RESULTS

The kidney transplant rate has increased from 7 kidney transplants per million populations in 2002 to more than 17 in 2007. In the meantime, a substantial decline in the rate of kidney transplantation performed on Syrian nationals abroad was observed from 65% of all kidney transplantations in 1998 to less than 2% in 2007. Despite the prohibition to buy a kidney in Syria, vendors had found ways to sell their kidneys through disreputable brokers. Potential related donors were not inclined to donate kidneys to their relatives as long as kidneys could be bought from a non-related donor. By 2008, the percent of related donors in private sector represented only 8% of all donors, as compared to 50% in public hospitals. Consequently, in January 2008, the government of Syria issued a pronouncement restricting kidney transplantation to the public sector with a new national regulatory oversight of transplantation practices. Since this 2008 Administrative Order was promulgated, the kidney transplant rate in public hospitals has substantially increased by 55% with the establishment of new public transplant centers in the 3 largest cities in Syria.

CONCLUSION

The recommendations of the Istanbul Declaration and the Revised Guiding Principles of the World Health Organization have yet to be implemented in Syria but the expansion of kidney transplants in the public sector is an important initial step for initiating a deceased organ donation program as an essential component of a comprehensive approach to the problem of the organ shortage.

"Cardiac otalgia": acute coronary syndrome masquerading as bilateral ear pain

Patients presenting with acute coronary syndromes are classically described as having chest pressure with radiation to the left arm. However, pain can be referred to multiple sites including the face, the neck, the abdomen and the contra-lateral arm. We present a case of sudden bilateral ear pain as the sole presentation of acute coronary syndrome in an elderly man. The importance of recognizing these atypical presentations is vital, as outcomes may be worsened as appropriate therapy may be delayed or misdirected.

Prior coronary artery bypass graft surgery patients undergoing diagnostic coronary angiography have multiple uncontrolled coronary artery disease risk factors and high risk for cardiovascular events

Limited contemporary data exist on the cardiovascular risk of patients with prior coronary artery bypass grafting surgery (CABG) requiring diagnostic coronary angiography. We examined the prevalence and control of coronary artery disease risk factors and the outcomes of 367 prior CABG patients who underwent diagnostic coronary angiography between October 1, 2004 and May 31, 2007 at the Dallas Veterans Affairs Medical Center. Mean age was 65 +/- 9 years, 97% were men, and the mean time from CABG to diagnostic angiography was 8.2 +/- 6.1 years. Hypertension, low-density lipoprotein cholesterol, diabetes mellitus, smoking, and obesity were suboptimally controlled in 70%, 59%, 47%, 33%, and 50%, respectively. Intake of statins and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers was 88% and 81%, respectively. After a mean follow-up of 1.4 +/- 0.8 years, the incidence of death and major cardiovascular events was 10% and 32%, respectively. In spite of significant improvement compared to previous studies and good compliance with indicated medications, contemporary prior CABG patients undergoing coronary angiography still have multiple and poorly controlled coronary artery disease risk factors and high risk for cardiovascular events. Novel pharmacologic and behavioral treatment strategies are needed.

Association of Lipoprotein-Associated Phospholipase A2 Mass and Activity with Coronary and Aortic Atherosclerosis: Findings from the Dallas Heart Study

Background: Our aim was to characterize the association of lipoprotein-associated phospholipase A2 (Lp-PLA2) with coronary and aortic atherosclerosis in a large population-based study.

Methods: Lp-PLA2 mass and activity were measured in 2171 subjects 30–65 years old participating in the Dallas Heart Study. We examined the association of Lp-PLA2 levels with 3 atherosclerosis phenotypes: coronary artery calcium (CAC) measured by electron-beam computed tomography and abdominal aortic plaque (AAP) and aortic wall thickness (AWT) measured by magnetic resonance imaging.

Results: CAC and AAP were detected in 21% and 40% of subjects, respectively, and mean AWT (SD) was 1.70 (0.32) mm. In univariable analyses, Lp-PLA2 mass (but not activity) was higher in both men (P = 0.04) and women (P = 0.02) with detectable CAC. Lp-PLA2 mass and activity were higher (P = 0.004 and P = 0.01, respectively) and AWT was greater (P &lt; 0.001 and P = 0.02, respectively) in women with aortic atheroma, but not in men. After adjustment for traditional atherosclerosis risk factors and C-reactive protein concentrations, Lp-PLA2 mass and activity were not associated with AAP or AWT in either sex, but Lp-PLA2 mass remained modestly associated with detectable CAC only in men (odds ratio 1.20 per 1 standard deviation increase, 95% CI 1.01–1.42, P = 0.04).

Conclusions: Although Lp-PLA2 mass was independently associated with CAC in men, it was not associated with AAP or AWT in men or with any of the atherosclerosis phenotypes in women. These findings suggest that if Lp-PLA2 independently influences clinical events, it does so by promoting atherosclerotic plaque instability rather than by stimulating atherogenesis.

Percutaneous coronary intervention in tortuous coronary arteries: associated complications and strategies to improve success

Percutaneous intervention of tortuous coronary arteries can be challenging. We describe four cases that illustrate complications associated with coronary tortuosity (coronary dissection and stent loss) and strategies that can improve procedural success (such as use of soft delivery catheters, deep guide intubation, meticulous vessel preparation, and use of short, thin-strut stents).

Dermal absorption of isopropyl alcohol from a commercial hand rub: implications for its use in hand decontamination

Isopropyl alcohol-containing hand rubs are widely used in healthcare for hand decontamination. Ten healthy adult volunteers applied a commercially available isopropyl alcohol-containing hand rub to their hands every 10 min over a 4 h period. Blood isopropyl alcohol levels were measured at the beginning and end of the study. At the end of the study, measurable blood isopropyl alcohol levels (range 0.5-1.8 mg/l) were recorded in nine subjects. We confirmed that isopropyl alcohol could be absorbed through the intact skin of adult humans. The social and medical implications are discussed.

Corticotropin-releasing hormone binding to the syncytiotrophoblast membranes

The human placenta secretes large amounts of corticotropin-releasing hormone (CRH) which was thought to exert a paracrine action in the placenta. We have recently characterized high-affinity binding sites for CRH in the human placenta. However, our studies utilized whole placental membranes, which did not identify the site of binding of CRH in the plasma membrane. In this study we investigated the characteristics of CRH binding to purified mother-facing, brush border membranes (BBM) and fetus-facing, basal plasma membranes (BPM) of the syncytiotrophoblast. The two membranes were separated by a series of differential and density-gradient centrifugations. The purity of the membranes was determined by measuring alkaline phosphatase, as a marker of BBM and Na+/K+ATPase as a marker of BPM. Each membrane showed specific and high-affinity binding. Scatchard analysis revealed a high-affinity binding site for CRH with Kd of 1.0 +/- 0.15 and 1.3 +/- 0.176 for BBM and BPM, respectively. The maximal number of binding sites was significantly different (P < 0.01) in the two plasma membranes: Bmax of 79 +/- 6.4 fmol/mg protein for BBM and 23 +/- 3.9 fmol/mg protein for BPM. Both the mother-facing and fetus-facing membranes of the syncytiotrophoblast contain binding proteins for CRH, with significantly more binding sites on the mother-facing membranes. The functional consequences of CRH binding could be different for the two polar membranes due to differential localization of second messenger systems between the two membrane types. It is proposed that partial purification of BBM and BPM provides a better system to study CRH action in the placenta, than whole placental membrane preparations.

Inhibition of farnesyltransferase with A-176120, a novel and potent farnesyl pyrophosphate analogue

Farnesylation of Ras is required for its transforming activity in human cancer and the reaction is catalysed by the enzyme farnesyltransferase. Recently, we discovered a novel chemical series of potent farnesyl pyrophosphate (FPP) analogues which selectively inhibited farnesyltransferase. Our most potent compound to date in this series, A-176120, selectively inhibited farnesyltransferase activity (IC(50) 1.2+/-0.3 nM) over the closely related enzymes geranylgeranyltransferase I (GGTaseI) (IC(50) 423+/-1.8 nM), geranylgeranyltransferase II (GGTaseII) (IC(50) 3000 nM) and squalene synthase (SSase) (IC(50)>10000 nM). A-176120 inhibited ras processing in H-ras-transformed NIH3T3 cells and HCT116 K-ras-mutated cells (ED(50) 1.6 and 0.5 microM, respectively). The anti-angiogenic potential of A-176120 was demonstrated by a decrease in Ras processing, cell proliferation and capillary structure formation of human umbilical vein endothelial cells (HUVEC), and a decrease in the secretion of vascular endothelial growth factor (VEGF) from HCT116 cells. In vivo, A-176120 reduced H-ras NIH3T3 tumour growth and extended the lifespan of nude mice inoculated with H- or K-ras-transformed NIH3T3 cells. A-176120 also had an additive effect in combination with cyclophosphamide in nude mice inoculated with K-ras NIH3T3 transformed cells. Overall, our results demonstrate that A-176120 is a potent FPP mimetic with both antitumour and anti-angiogenic properties.

Discovery of a series of cyclohexylethylamine-containing protein farnesyltransferase inhibitors exhibiting potent cellular activity

Synthesis of a library of secondary benzylic amines based on the Sebti-Hamilton type peptidomimetic farnesyltransferase (FTase) inhibitor FTI-276 (1) led to the identification of 6 as a potent enzyme inhibitor (IC(50) of 8 nM) which lacked the problematic thiol residue which had been a common theme in many of the more important FTase inhibitors reported to date. It has previously been disclosed that addition of o-tolyl substitution to FTase inhibitors of the general description 2 had a salutary effect on both FTase inhibition and inhibition of Ras prenylation in whole cells. Combination of these two observations led us to synthesize 7, a potent FTase inhibitor which displayed an IC(50) of 0.16 nM for in vitro inhibition of FTase and an EC(50) of 190 nM for inhibition of whole cell Ras prenylation. Modification of 7 by classical medicinal chemistry led to the discovery of a series of potent FTase inhibitors, culminating in the identification of 25 which exhibited an IC(50) of 0.20 nM and an EC(50) of 4.4 nM. In vivo tests in a nude mouse xenograft model of human pancreatic cancer (MiaPaCa cells) showed that oral dosing of 25 gave rise to impressive attenuation of the growth of this aggressive tumor cell line.

Second-generation peptidomimetic inhibitors of protein farnesyltransferase demonstrating improved cellular potency and significant in vivo efficacy

The synthesis and evaluation of analogues of previously reported farnesyltransferase inhibitors, pyridyl benzyl ether 3 and pyridylbenzylamine 4, are described. Substitution of 3 at the 5-position of the core aryl ring resulted in inhibitors of equal or less potency against the enzyme and decreased efficacy in a cellular assay against Ras processing by the enzyme. Substitution of 4 at the benzyl nitrogen yielded 26, which showed improved efficacy and potency and yet presented a poor pharmacokinetic profile. Further modification afforded 30, which demonstrated a dramatically improved pharmacokinetic profile. Compounds 26 and 29 demonstrated significant in vivo efficacy in nude mice inoculated with MiaPaCa-2, a human pancreatic tumor-derived cell line.

Potent and orally bioavailable noncysteine-containing inhibitors of protein farnesyltransferase

Potent and orally bioavailable nonthiol-containing inhibitors of protein farnesyltransferase are described. Oral bioavailability was achieved by replacement of the pyridyl ether moiety of 1 with a 2-substituted furan ether to give 4. Potency was regained with 2,5-disubstituted furan ethers while maintaining the bioavailability inherent in 4. p-Chlorophenylfuran ether 24 is 0.7 nM in vitro (FTase) and is 32% bioavailable in the mouse, 30% bioavailable in rats, and 21% bioavailable in dogs.

Potent inhibitors of protein farnesyltransferase: heteroarenes as cysteine replacements

Synthesis and biological evaluation of heteroarenes as reduced cysteine replacements are described. Of the heteroaryl groups examined with respect to FT inhibitor FTI-276 (1), pyridyl was the replacement found to be most effective. Substitutions at C4 of the pyridyl moiety did not affect the in vitro activity. Compound 9a was found to have moderate in vivo bioavailability.

Potent and selective non-cysteine-containing inhibitors of protein farnesyltransferase

Potent and selective non-thiol-containing inhibitors of protein farnesyltransferase are described. FTI-276 (1) was transformed into pyridyl ether analogue 19. The potency of pyridyl ether 19 was improved by modification of the biphenyl core to that of an o-tolyl substituted biphenyl core to give 29. In addition to 0.4 nM in vitro potency, 29 displayed 350 nM potency in whole cells as the parent carboxylic acid. The o-tolyl biphenyl core dramatically and unexpectedly enhanced the potency of other compounds as exemplified by 46, 47, 48, and 49.

Endothelin receptor in benign prostatic hyperplastic cells. Binding and functional studies

Endothelins (ETs) are 21-amino acid peptides that bind to membrane receptors to initiate pathophysiological effects. This report characterizes ET receptors in benign prostatic hyperplasia-1 (BPH-1) cells, a prostate cell line isolated from a specimen of a 60-yr-old man with benign prostatic hyperplasia. [(125)I]ET-1 or -3 binding was of high affinity, with B(max) and K(d) values of 48 fmol/1 x 10(6) cells and 0.16 nM for ET-1, and 2.9 fmol/1 x 10(6) cells and 0.033 nM for ET-3, respectively. ET-1, ET-3, FR139317, Ro 46-2005, and IRL1620 inhibited [(125)I]ET-1 binding to these cells with IC50 values of 0.22, 186, 0.20, 52.8, and 772.3 nM, respectively. Reverse transcription-polymerase chain reaction confirmed that BPH-1 cells expressed more ET(A) than ET(B) receptors. ET-1 did not have any effect on arachidonic acid release, but caused a modest stimulation of phosphatidylinositol hydrolysis, and induced a prominent, sustained elevation in intracellular Ca2+ concentrations. The functional effects of ET-1 were completely inhibited by the ET(A)-selective antagonists FR139317 and A-127722, suggesting that the effects were mediated by the ET(A) receptor. These results suggest that ET may play functional roles in benign prostatic hyperplasia.

Apoptotic program is initiated but not completed in LNCaP cells in response to growth in charcoal-stripped media

BACKGROUND

Morphological, proliferative, and genetic changes were studied in androgen-responsive LNCaP cells in response to growth in charcoal-stripped (CS) media.

METHODS AND RESULTS

Within 5 days of treatment, there were dramatic changes in the morphology and organization of LNCaP cells. The cells unclumped and acquired a distinct neuronal-like appearance with small cell bodies and multiple long, thin processes. Despite this appearance, the cells stained negative to monoclonal antibodies to neuronal markers such as microtubule-associated protein-2 (MAP-2) and glial fibrillary acidic protein (GFAP). In situ end-labeling assay indicated that the number of cells showing signs of apoptosis (DNA fragmentation) increased dramatically in CS media compared to the control. However, ultrastructural changes and the fragmented DNA ladder that are used to define apoptosis were not observed. Instead of cell death, the cells became cytostatic, which can be reversed, although not completely, by exogeneous addition of dihydrotestosterone in a dose-dependent manner. Presence of mRNA of several genes involved in the apoptotic process, i.e., Bcl-2, Bcl-X, ICE, Ich-1, and DAD-1, was studied in response to normal and CS media. We detected mRNA of Bcl-2, Bcl-XL, Bcl-XS, Ich-1L and DAD-1, while ICE and Ich-1S were not expressed in LNCaP cells.

CONCLUSIONS

This suggests that certain signals that may be essential for complete execution of the apoptotic program may be missing in this in vitro model. This may explain our observation that the growth of LNCaP cells in CS media does not fully mimic castration-mediated regression of the prostate gland in vivo.

Induction of apoptosis in prostatic tumor cell line DU145 by staurosporine, a potent inhibitor of protein kinases

We are interested in studying the possibility of modulating prostatic cell growth by manipulating apoptosis. Here we show that 1 microM staurosporine (STS) induces a human androgen-independent prostatic tumor cell line, DU145, to undergo dramatic changes in morphology and results in programmed cell death. Several genes involved in apoptosis were analyzed for expression in STS-treated and untreated DU145 cells. It was observed that these genes were differentially regulated. The expression level of bcl-2, bcl-xL, Ich-1L remains unchanged in treated and untreated cells. On the other hand, DAD1 and interleukin-1 beta-converting enzyme (ICE) were downregulated while bcl-xs and Ich-1s were upregulated. By blocking bcl-2 gene expression using antisense oligonucleotides, it was determined that the anti-bcl-2 oligonucleotides have no effect on the proliferation of DU145 or STS-treated DU145 cells. These results demonstrate that programmed cell death can be induced in an androgen-independent prostatic cancer cell line and BCL-2 was found not to play an important role in preventing STS-induced apoptosis in the DU145 cell line.

Combinatorial interaction of human bcl-2 related proteins: mapping of regions important for bcl-2/bcl-x-s interaction

Human bcl-2 family of genes including bcl-2, bcl-x-l, bcl-x-s, and bax has been shown to be functionally involved in apoptosis. We applied a yeast two-hybrid system to demonstrate that bcl-2, bcl-x-l, bcl-x-s, and bax proteins can interact with each other directly. All bcl-2 family members except bax were shown to be capable of homo-interactions. By using deletion and point mutations, the interaction domains for bcl-2 and bcl-x-s were elucidated. The BH1 domain and the membrane anchoring region at the C-terminal half of the bcl-2 protein are required for its interaction with bcl-x-s. On the other hand, the N-terminal region consisting of codons 24 to 78 of bcl-x-s interacts with bcl-2.