Relation of lymphopenia to comorbidity burden and its prognostic value in patients with acute decompensated heart failure with preserved left ventricular ejection fraction: a multicentre study

Background

Systemic inflammation resulting from comorbidities is postulated to play a central role in the pathophysiology of heart failure (HF) with preserved ejection fraction (HFpEF). Lymphopenia is a common manifestation of systemic inflammation and a prognostic factor in patients with HF. However, the association of lymphopenia with the comorbidity burden is unknown, and its prognostic value in patients with HFpEF admitted due to acute decompensated heart failure (ADHF) also remains elusive.

Purpose

We sought to clarify the relation of lymphopenia with the comorbidity burden, as well as its prognostic value and complementarity with the Get with the Guidelines-Heart Failure (GWTG-HF) risk score in ADHF patients with HFpEF.

Methods

Patients' data were extracted from the Prospective mUlticenteR obServational stUdy of patIenTs with Heart Failure with Preserved Ejection Fraction (PURSUIT-HFpEF), which is a prospective multicentre registry for patients with ADHF with a LVEF ≥50%. We analysed data of patients admitted between June 2016 and December 2020 who survived to discharge. The total lymphocyte count (per μL) and GWTG-HF risk score were obtained on admission, as previously reported. Comorbidity burden was defined as the number of comorbidities from the following: atrial fibrillation, hypertension, diabetes mellitus, coronary artery disease, chronic kidney disease, chronic obstructive pulmonary disease, anaemia, and obesity. The study endpoint was all-cause death.

Results

Over a median follow-up of 417 days, 181 of the 1013 included patients died. The proportion of patients with a total lymphocyte count in the lowest tertile was increasing with the increase in comorbidity burden (Figure 1). In the multivariate Cox analysis, a total lymphocyte count in the intermediate (hazard ratio [HR] 1.55, 95% confidence interval [CI] 1.00–2.41, p=0.0486) and lowest tertile (HR 2.23, 95% CI 1.47–3.38, p=0.0002) was independently associated with all-cause death. There was a significant difference in the all-cause death rate among the groups stratified by total lymphocyte count tertile (Figure 2). The total lymphocyte count had a higher C-statistic value (0.627) for the prediction of all-cause death than the GWTG-HF risk score, and the C-statistic value of the GWTG-HF risk score was improved when the total lymphocyte count was added (0.613 to 0.636, p=0.0260).

Conclusions

Lymphopenia was significantly associated with comorbidity burden. Furthermore, it was a useful marker of poor prognosis in hospitalised patients with acute HFpEF and was shown to be complementary to the contemporary HF prognostic score.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Roche Diagnostics K.K.Fuji Film Toyama Chemical Co. Ltd.

Growth stimulation in inflorescences of an Arabidopsis tubulin mutant under microgravity conditions in space

Cortical microtubules are involved in plant resistance to hypergravity, but their roles in resistance to 1 g gravity are still uncertain. To clarify this point, we cultivated an Arabidopsis α-tubulin 6 mutant (tua6) in the Cell Biology Experiment Facility on the Kibo Module of the International Space Station, and analyzed growth and cell wall mechanical properties of inflorescences. Growth of inflorescence stems was stimulated under microgravity conditions, as compared with ground and on-orbit 1 g conditions. The stems were 10-45% longer and their growth rate 15-55% higher under microgravity conditions than those under both 1 g conditions. The degree of growth stimulation tended to be higher in the tua6 mutant than the wild-type Columbia. Under microgravity conditions, the cell wall extensibility in elongating regions of inflorescences was significantly higher than the controls, suggesting that growth stimulation was caused by cell wall modifications. No clear differences were detected in any growth or cell wall property between ground and on-orbit 1 g controls. These results support the hypothesis that cortical microtubules generally play an important role in plant resistance to the gravitational force.

Ezetimibe improves postprandial hyperlipidaemia in patients with type IIb hyperlipidaemia

BACKGROUND

Postprandial hyperlipidaemia is known to be a high-risk factor for atherosclerotic disease because of rapid and lasting accumulations of triglyceride-rich lipoproteins and remnants. The Niemann-Pick C1-Like 1 (NPC1L1) protein acts as an intestinal cholesterol transporter and ezetimibe, which inhibits NPC1L1, has been used in patients with hypercholesterolaemia. We investigated effects of ezetimibe on fasting lipid and lipoprotein profiles and postprandial hyperlipidaemia in patients with type IIb hyperlipidaemia.

MATERIALS AND METHODS

Ezetimibe 10 mg per day was administered in ten patients with type IIb hyperlipidaemia for 2 months, and lipid and lipoprotein profiles were examined during fasting and after an oral fat loading (OFL) test.

RESULTS

In the fasting state, ezetimibe significantly decreased not only total cholesterol, low density lipoprotein (LDL)-cholesterol and apolipoproteinB-100 (apoB-100) levels but triglycerides (TG), apoB-48 and remnant lipoprotein cholesterol (RemL-C) levels. High performance liquid chromatography analysis showed that ezetimibe decreased cholesterol and TG levels in the very low density lipoprotein (VLDL) and LDL size ranges as well as apoB-100 levels, suggesting a decrease in numbers of VLDL and LDL particles. After OFL, ezetimibe decreased the area under the curve for TG, apoB-48 and RemL-C. Ezetimibe decreased postprandial elevations of cholesterol and TG levels in the chylomicrons (CM) size range, suggesting that the postprandial production of CM particles was suppressed by ezetimibe.

CONCLUSIONS

These findings suggest that ezetimibe improves fasting lipoprotein profiles and postprandial hyperlipidaemia by suppressing intestinal CM production in patients with type IIb hyperlipidaemia and such treatment may prove to be effective in reducing atherosclerosis.

Learning is different on the Web: a theory-based course redesign effort

There has been recent growth in professional clinical informatics education delivered via distance learning. In some instances the instructional design model is to simply port the classroom to the web. Given the unique capabilities and constraints inherent to distance learning, we elected to redesign our introductory informatics course building on a well-studied andragogical design model (AMIGO3) specifically designed for the distance learning environments.

Diffusion-weighed MR imaging of pancreatic carcinoma

PURPOSE

The aim of this study was to demonstrate the feasibility of body diffusion-weighted (DW) MR imaging in the evaluation of a pancreatic carcinoma.

MATERIAL AND METHODS

In nine normal volunteers and in eight patients with pancreatic carcinoma, DW images were obtained on the axial plane scanning with a multisection spin-echo-type single-shot echo planar sequence with a body coil. Moreover, we measured the apparent diffusion coefficient (ADC) value in a circular region of interest (ROI) within the normal pancreas, pancreatic carcinoma, and tumor-associated chronic pancreatitis.

RESULTS

On the DW images, all eight carcinomas were clearly shown as high signal intensity relative to the surrounding tissue. The ADC value (x10(-3) mm(2)/s) in the carcinoma was 1.44 +/- 0.20, which was significantly lower compared to that of normal pancreas (1.90 +/- 0.06) and tumor-associated chronic pancreatitis (2.31 +/- 0.18).

CONCLUSION

Diffusion-weighted (DW) images can be helpful in detecting the pancreatic carcinoma and accessing the extent of the tumor.

Enhanced external counterpulsation improved myocardial perfusion and coronary flow reserve in patients with chronic stable angina; evaluation by(13)N-ammonia positron emission tomography

AIMS

The mechanism by which enhanced external counterpulsation therapy exerts its beneficial effects on chronic and symptomatic stable angina is largely unknown. To clarify the mechanism of action of enhanced external counterpulsation, we used(13)N-ammonia positron emission tomography to evaluate myocardial perfusion.

METHODS AND RESULTS

This was not a randomized controlled study. Eleven patients (eight male, age: 61.6+/-9.7) with angina pectoris underwent enhanced external counterpulsation therapy for 35 1 h sessions. They underwent a treadmill exercise test and(13)N-ammonia positron emission tomography, both at rest and with dipyridamole, before and after enhanced external counterpulsation therapy. Neurohumoral factors and nitric oxide were also evaluated. Myocardial perfusion increased at rest after therapy (0.69+/-0.27 to 0.85+/-0.47 ml x min(-1) x g(-1), P<0.05). In ischaemic regions, particularly the anterior region, myocardial perfusion at rest and with dipyridamole and coronary flow reserve improved significantly after therapy (at rest: 0.71+/-0.26 to 0.86+/-0.31;P<0.05, with dipyridamole: 1.26+/-0.65 to 1.84+/-0.94;P<0.02, coronary flow reserve: 1.75+/-0.24 to 2.08+/-0.28;P<0.04). Exercise time was prolonged and the time to 1-mm ST depression improved markedly (P<0.01). After therapy, nitric oxide levels increased (P<0.02) and neurohumoral factors decreased.

CONCLUSIONS

Enhanced external counterpulsation therapy improved myocardial perfusion at rest and with dipyridamole and was associated with an increased exercise tolerance with(13)N-ammonia positron emission tomography and increased nitric oxide levels. These results suggest that one of the enhanced external counterpulsation mechanisms is development and recruitment of collateral vessels.

Effects of exercise training on myocardial fatty acid metabolism in rats with depressed cardiac function induced by transient ischemia

The effects of exercise training on metabolic and functional recovery after myocardial transient ischemia were investigated in a rat model. Male Wistar Kyoto rats were subjected either to a 30-min left coronary artery occlusion followed by reperfusion or to a sham operation. At 4 weeks after operation, the rats were randomly assigned either to sedentary conditions or to exercise training for 6 weeks. In the ischemic rats, pinhole SPECT (single photon emission computed tomography) imaging with thallium-201 (201Tl) and 123I-(rho-iodophenyl)-3-R,S-methylpentadecanoic acid (BMIPP) showed a reduction of both myocardial perfusion and fatty acid metabolism in the risk zone of the left ventricle (LV). The LV was dilated and the ejection fraction was decreased after ischemic injury. The severity score showed a significant decrease on both 201Tl and BMIPP (201Tl, from 19.9+/-2.7 to 17.0+/-2.2, p<0.05; BMIPP, from 21.5+/-2.4 to 18.6+/-1.9, p<0.05) after exercise training in the ischemic trained rats, but did not change significantly in their sedentary counterparts. Plasma levels of free fatty acids normalized in the ischemic trained rats, but elevated in the ischemic sedentary rats (0.53+/-0.05 vs 0.73+/-0.06 mmol/L, p<0.05). Furthermore, the trained rats had a significant increase in LV stroke volume (0.25+/-0.02 vs 0.21+/-0.01 ml/beat, p<0.05) and adaptive cardiac hypertrophy. These findings demonstrate that adaptive improvements in myocardial perfusion, fatty-acid metabolism and LV function were induced by exercise training after transient ischemia.

Evaluation of coronary blood flow reserve by 13N-NH3 positron emission computed tomography (PET) with dipyridamole in the treatment of hypertension with the ACE inhibitor (Cilazapril)

PURPOSE

The purpose of this study was to evaluate the effect of treatment with an angiotensin-converting enzyme (ACE) inhibitor (Cilazapril) for early hypertensive patients in terms of coronary blood flow reserve evaluated by 13NH3-positron emission tomography (PET).

METHODS

Before and after 12 weeks of ACE inhibitor treatment, 13NH3-PET with dipyridamole provocation test was performed, and definite myocardial perfusion and coronary flow reserve (CFR) were calculated.

RESULTS

Compared to our normal subjects previously reported (2.61+/-0.74), average coronary flow reserve was decreased (1.70+/-0.64 in hypertensive patients), and improved after treatment (1.77+/-0.52), but not significantly. Of 12 patients, five (42%) showed improved coronary flow reserve from 1.34 to 1.99 without a significant change in the resting flow. Only one patient (8%) showed deterioration after the ACE inhibitor treatment. The coronary vascular resistance (CVR) after ACE inhibitor treatment of the patients with CFR < 2.0 decreased significantly compared with those with CFR> or = 2.0 (p < 0.03).

CONCLUSIONS

These results indicate that hypertensive patients at the early stage show decreased coronary flow reserve despite having normal resting flow. Treatment with an ACE inhibitor (Cilazapril) for 12 weeks improved coronary flow reserve in 42% of our patients. The CVR of the patients with CFR < 2.0 showed improvement compared to those with CFR> or = 2.0. This result indicates that an ACE inhibitor (e.g., Cilazapril) should be one of the choices for improving CFR if hypertensive patients in early stage show signs of ischemia or diastolic dysfunction, which may be one of the sequels of reserve restriction.

Integrating knowledge resources at the point of care: opportunities for librarians

Health sciences librarians at the University of Washington (UW) are partners in the evolution of Internet-based clinical information systems for two medical centers, University of Washington Medical Center and Harborview Medical Center, as well as the UW Primary Care Network clinics. Librarians lead information resource and systems development projects and play a variety of roles including facilitator, publisher, integrator, and educator. These efforts have been coordinated with parallel development efforts by the Integrated Advanced Information Management Systems (IAIMS) clinical informatics group in developing electronic medical record systems and clinical decision support tools. The outcome is MINDscape, a very heavily used Web view of the patient medical record with tightly integrated knowledge resources as well as numerous Web-accessible information resources and tools. The goal of this article is to provide a case study of librarian involvement in institutional information systems development at UW and to illustrate the variety of roles that librarians can assume in hospital settings.

Improvement of regional myocardial and coronary blood flow reserve in a patient treated with enhanced external counterpulsation: evaluation by nitrogen-13 ammonia PET

Enhanced external counterpulsation (EECP) is a noninvasive treatment for chronic stable angina, which works by recruiting and developing the coronary collateral vessels. Coronary perfusion and coronary flow reserve (CFR) were evaluated by nitrogen-13 (13N) ammonia positron emission tomography (PET) in a patient who had undergone EECP. The patient, who had 3-vessel coronary artery disease, required a percutaneous transluminal coronary angioplasty (PTCA) for the right coronary artery. The PTCA was successful, but 6 months later he again felt chest oppression. The coronary angiography showed re-stenosis at the PTCA site, and other progressive coronary stenosis. The patient was again treated with EECP for 35 h. The 13N-ammonia PET was performed both at baseline and during dipyridamole provocation, before and after EECP treatment. Coronary perfusion of each myocardial wall increased at the baseline (anterior: 0.52-0.75; septal: 0.48-0.66; lateral: 0.61-0.68; inferior: 0.46-0.57 ml min(-1) g(-1), and the CFRs in the septal and inferior walls (septal: 2.07-2.15; inferior: 1.99-2.06) also increased after the treatment. Thus, the EECP treatment improved both coronary perfusion at baseline and CFR, which suggests that it may be one of the choices for treatment of angina.

A fluorometric assay for glycosyltransferase activities using sugars aminated and tagged with 7-hydroxycoumarin-3-carboxylic acid as substrates and high performance liquid chromatography

We developed a novel fluorometric assay method for the measurement of glycosyltransferase activities using mono- and di-saccharides aminated and tagged with 7-hydroxycoumarin-3-carboxylic acid (coumarin) as substrates, N-acetylglucosamine (GlcNAc)-coumarin for beta1,4-galactosyltransferase from bovine milk and Gal beta1-4GlcNAc-coumarin for alpha2,3- and alpha2,6-sialyltransferases from rat liver. Using Gal beta1-3GlcNAc and Gal beta1-4Glc-NAc-coumarin, alpha1,3/4- and alpha1,3-fucosyltransferase activities were also determined, respectively. These enzymatic products liberated by the reactions of glycosyltransferases in the presence of sugar nucleotides, were separated by a normal phase or an ion-pair reversed phase HPLC with an isocratic elution and fluorescence detection. We applied this assay method to determine the glycosyltransferase activities in 8 kinds of human tumor cell lines, including the cell lines derived from hepatocytes (HuH-7, HepG2), colonic cells (Colo205, HT-29), myelocytes (HL-60, U-937), B-lymphocytes (Daudi) and T-lymphocytes (Jurkat). This assay method is accurate and easy compared with other isotopic and non-isotopic assay methods, and is sensitive enough to measure glycosyltransferase activities in cell homogenates.