P5534Causes and predictors of short, intermediate and long-term mortality in patients after PCI

Background

Causes of death after percutaneous coronary intervention (PCI) along multiple time-periods are poorly described.

Objective

To describe causes and predictors of short-term, intermediate-term, and long-term mortality after PCI.

Methods

Consecutive men and women admitted for PCI from 2008 to 2011 were prospectively included and followed-up in this cohort study. A dedicated follow-up by independent reviewers was performed to collect the outcomes and adjudicate the causes of death. A log-rank analysis was used to compare the occurrence of cardiovascular and non-cardiovascular death at 30 days, one year and up to 8 years. Last detailed cardiovascular and vital status were collected in January 2019.

Results

A total of 3524 patients including 2720 men (77.2%) and 804 women (22.8%) were followed-up for a median time of 7.0 years (IQ1: 5.4; IQ 3: 7.2). The rate of complete follow-up was 97.6%. All-cause death occurred for 30.3% (n=1070) of patients in the cohort, in a median time of 2.5 years after PCI, with a rate of 5.3 deaths per 100 patient-years. Overall, mortality was mostly related to cardiovascular causes than non-cardiovascular causes (17.7% versus 12.6%, log-rank <0.001) (Figure). This trend was strong within 30 days (4.7% vs. 0.3%, p<0.0001) and the first year after PCI (3.1% vs. 2.2 p=0.01), but became non-significant beyond one year (9.9% vs. 10.2%, P=0.67). Of note, cancer was the major cause of non-cardiovascular death (5.6%; 1 per 100 patient-years). Diabetes (adHR = 1.48 95% [1.29–1.71], p<0.001), active smoking (adHR = 1.37, 95% [1.16–1.62]) and chronic kidney disease (adHR = 1.97, 95% [2.55–3.45], p<0.001) were the strongest risk factors for all-cause death.

Survival after PCI

Conclusions

In this long-term cohort study, cardiovascular death was more frequent than non-cardiovascular death in patients treated with PCI in the short and intermediate-term but not beyond one year. Cancer accounted for one fifth of the overall mortality.

P1523Comparative long-term outcomes among men and women after percutaneous coronary intervention

Background

Comparative long-term outcomes among women and men treated with percutaneous intervention (PCI) are unknown.

Objective

To describe and compare mortality and predictors of poor outcomes among men and women who underwent PCI.

Methods

Consecutive men and women admitted for PCI between 2008 and 2011 were prospectively included and followed-up in this cohort study. Major adverse cardiovascular and cerebrovascular events (MACCE) and causes of death were collected through consultations, calls and death certificate. The primary endpoint was all-cause mortality according to gender. Secondary endpoints were cardiovascular death, non-cardiovascular death and MACCEs. Last detailed cardiovascular and vital status were collected in January 2019.

Results

A total of 3524 patients including 2720 men (77.1%) and 804 women (22.8%) were followed-up for a median time of 7.0 years (IQ1: 5.4; IQ 3: 7.2). The follow-up rate was 97.6%. Women were older at baseline (70±13.1 vs. 64.6±12), smoked less often (18.9% vs. 30.4%) but suffered more frequently of hypertension (67.9% vs. 58.1%) and chronic kidney disease (42.6% vs. 22.7%). All-cause death occurred for 30.3% (n=1070) and MACCE for 40.9% (n=1443) of patients in the cohort. In unadjusted analyses, women had a higher risk of all-cause mortality (35% vs 29%, HR = 1.25, 95% CI [1.09–1.43], p=0.0015) and cardiovascular mortality (61% vs. 57%, HR = 1.31, 95% CI [1.10–1.56]) but there was no difference on occurrence of MACCE (HR = 1.079, 95% CI = [0.9271–1.221]). After adjustments for baseline cardiovascular risk factors, presentation and severity of coronary disease, women and men shared a similar risk of mortality along time (adHR = 0.90, 95% CI [0.77–1.05]).

Survival curves in women vs. men

Conclusions

In this long-term follow-up, women had a higher risk of all-cause and cardiovascular mortality after PCI in unadjusted analyses. However, gender was not independently associated with mortality after adjustment for cardiovascular risk factors.

Low level exercise echocardiography helps diagnose early stage heart failure with preserved ejection fraction: a study of echocardiography versus catheterization

BACKGROUND

Increased left ventricular end-diastolic pressure (LVEDP) with exercise is an early sign of heart failure with preserved left ventricular ejection fraction (LVEF). The abnormal exercise increase in LVEDP is nonlinear, with most change occurring at low-level exercise. Data on non-invasive approach of this condition are scarce. Our objective was assessing E/e' to estimate low level exercise LVEDP using a direct invasive measurement as the reference method.

METHODS AND RESULTS

Sixty patients with LVEF >50 % prospectively underwent both exercise cardiac catheterization and echocardiography. E/e' was measured at rest and during low-level exercise. Abnormal LVEDP was defined as >16 mmHg. Patients with a history of coronary artery disease and/or abnormal LV morphology were classified as having apparent cardiac disease (CD). Thirty-four (57 %) patients had elevated LVEDP only during exercise. Most of the change in LVEDP occurred since the first exercise level (25 W). There was a correlation between LVEDP and septal E/e' at rest and during exercise. Lateral E/e' and E/average e' ratio had worse correlations with LVEDP. In the whole population, exercise septal E/e' at 25 W had the best accuracy for abnormal exercise LVEDP, area under curve (AUC) = 0.79. However, while low-level exercise septal E/e' had a high accuracy in CD patients (n = 26, AUC = 0.96), E/e' was not linked to LVEDP in patients without CD (n = 34).

CONCLUSION

Low-level exercise septal E/e' is valuable for predicting abnormal exercise LVEDP in patients with preserved LVEF and apparent CD. However, this new diagnosis approach appears not reliable in patients with normal LV morphology and without coronary artery disease.

CLINICAL TRIAL REGISTRATION

https://clinicaltrials.gov . Unique identifier: NCT01714752.

Primary percutaneous coronary intervention for ST elevation myocardial infarction in nonagenarians

Objective

To assess outcomes following primary percutaneous coronary intervention (PCI) for ST-segment elevation acute myocardial infarction (STEMI) in nonagenarian patients.

Methods

We conducted a multicentre retrospective study between 2006 and 2013 in five international high-volume centres and included consecutive all-comer nonagenarians treated with primary PCI for STEMI. There were no exclusion criteria. We enrolled 145 patients and collected demographic, clinical and procedural data. Severe clinical events and mortality at 6 months and 1 year were assessed.

Results

Cardiogenic shock was present at admission in 21%. Median (IQR) delay between symptom onset and balloon was 3.7 (2.4–5.6) hours and 60% of procedures were performed through the transradial approach. Successful revascularisation of the culprit vessel was obtained in 86% of the cases (thrombolysis in myocardial infarction flow of 2 or 3). Major or clinically relevant bleeding was observed in 4% of patients. Median left ventricular ejection fraction post PCI was 41.5% (32.0–50.0). The in-hospital mortality was 24%, with 6 months and 1-year survival rates of 61% and 53%, respectively.

Conclusions

In our study, primary PCI in nonagenarians with STEMI was achieved and feasible through a transradial approach. It is associated with a high rate of reperfusion of the infarct-related artery and 53% survival at 1 year. These results suggest that primary PCI may be offered in selected nonagenarians with acute myocardial infarction.

Stopping or continuing clopidogrel 12 months after drug-eluting stent placement: the OPTIDUAL randomized trial

AIM

This open-label, randomized, and multicentre trial tested the hypothesis that, on a background of aspirin, continuing clopidogrel would be superior to stopping clopidogrel at 12 months following drug-eluting stent (DES) implantation.

METHODS AND RESULTS

Patients (N = 1799) who had undergone placement of ≥1 DES for stable coronary artery disease or acute coronary syndrome were included in 58 French sites (January 2009-January 2013). Patients (N = 1385) free of major cardiovascular/cerebrovascular events or major bleeding and on aspirin and clopidogrel 12 months after stenting were eligible for randomization (1:1) between continuing clopidogrel 75 mg daily (extended-dual antiplatelet therapy, DAPT, group) or discontinuing clopidogrel (aspirin group). The primary outcome was net adverse clinical events defined as the composite of death, myocardial infarction, stroke, or major bleeding. Follow-up was planned from a minimum of 6 to a maximum of 36 months after randomization. Owing to slow recruitment, the study was stopped after enrolment of 1385 of a planned 1966 patients. Median follow-up after stenting was 33.4 months. The primary outcome occurred in 40 patients (5.8%) in the extended-DAPT group and 52 in the aspirin group (7.5%; hazard ratio 0.75, 95% confidence interval 0.50-1.28; P = 0.17). Rates of death were 2.3% in the extended-DAPT group and 3.5% in the aspirin group (HR 0.65, 95% CI 0.34-1.22; P = 0.18). Rates of major bleeding were identical (2.0%, P = 0.95).

CONCLUSIONS

Extended DAPT did not achieve superiority in reducing net adverse clinical events compared to 12 months of DAPT after DES placement. The power of the OPTIDUAL trial was however low and reduced by premature termination of enrolment.

CLINICALTRIALSGOV NUMBER

NCT00822536.

FoxO1-dependent induction of acute myeloid leukemia by osteoblasts in mice

Osteoblasts, the bone forming cells, affect self-renewal and expansion of hematopoietic stem cells (HSCs), as well as homing of healthy hematopoietic cells and tumor cells into the bone marrow. Constitutive activation of β-catenin in osteoblasts is sufficient to alter the differentiation potential of myeloid and lymphoid progenitors and to initiate the development of acute myeloid leukemia (AML) in mice. We show here that Notch1 is the receptor mediating the leukemogenic properties of osteoblast-activated β-catenin in HSCs. Moreover, using cell-specific gene inactivation mouse models, we show that FoxO1 expression in osteoblasts is required for and mediates the leukemogenic properties of β-catenin. At the molecular level, FoxO1 interacts with β-catenin in osteoblasts to induce expression of the Notch ligand, Jagged-1. Subsequent activation of Notch signaling in long-term repopulating HSC progenitors induces the leukemogenic transformation of HSCs and ultimately leads to the development of AML. These findings identify FoxO1 expressed in osteoblasts as a factor affecting hematopoiesis and provide a molecular mechanism whereby the FoxO1/activated β-catenin interaction results in AML. These observations support the notion that the bone marrow niche is an instigator of leukemia and raise the prospect that FoxO1 oncogenic properties may occur in other tissues.

The occurrence of the tropical bedbug (Cimex hemipterus, Fabricius) in poultry barns in Israel

The occurrence of the tropical bedbug (Cimex hemipterus Fabricius) in poultry houses in Israel is described. Despite the heavy infestation serious losses have not been registered and no clinical signs observed. Treatment of the barns and accessories with 2% malathion emulsion gave good results. The parasite invaded human habitations as well.

The bioethics and utility of selling kidneys for renal transplantation

In the 53 years since kidney transplantation was first performed, this procedure has evolved from a highly speculative biomedical endeavor to a medically viable and often standard course of therapy. Long-term survival is markedly improved among patients who receive a kidney compared with patients who remain on the waiting list for such an organ. As outcomes have improved and more clinical indications have emerged, the number of people awaiting transplantation has grown significantly. In stark contrast to the robust expansion of the waiting list, the number of available deceased donors has remained relatively constant over the last several years. The current mechanism for procuring kidneys relies on voluntary donations by the general public, with the primary motivation being altruism. However, in light of the ever-increasing waiting list, it is the researchers' belief that the current system needs to be revised if supply is ever going to meet demand. In response to this critical organ shortage, different programs have been developed in an attempt to increase organ donation. At present, however, no solution to the problem has emerged. This report begins by outlining the scope of the problem and current legislation governing the procurement of transplantable organs/tissues in the United States. It continues with an overview of different proposals to increase supply. It concludes by exploring some of the controversy surrounding the proposal to increase donation using financial incentives. Though the following discussion certainly has implications for other transplantable organs, this report focuses on kidney transplantation because the waiting list for kidneys is by far the longest of all waiting lists for solid organs; and, as kidney transplant carries the smallest risk to living donors, it is the least ethically problematic.

Treatment outcome after induction chemotherapy before allogeneic hematopoietic SCT in patients with advanced MDS

6502

Background: The need for induction chemotherapy (IC) before allogeneic hematopoietic stem cell transplant (alloSCT) in advanced myelodysplatic syndrome (MDS) remains controversial. Methods: This is a retrospective analysis of the remission rate in 99 patients with advanced MDS (≥5% marrow blasts) and acute myeloid leukemia (AML, ≥ 20% blasts) evolving from MDS, who were treated with IC before receiving cytoreduction for SCT. These patients were referred to MSKCC for alloSCT from 6/1980 to 10/2004, and subsequently underwent an unmodified or T cell-depleted (TCD) SCT from a matched or mismatched related or unrelated donor after myeloablative cytoreduction in the majority. Results: All patients had MDS at diagnosis: 33% had high risk (HR), 22% intermediate risk (IR) and 42% good risk (GR) cytogenetics; 38% had HR, 32% IR-2 and 25% IR-1 IPSS. The median age was 43 (range 2–66). 76% had primary and 24% had secondary MDS (chemotherapy or radiation). At the time of IC, 64% had frank AML, 33% RAEB-1 and 2, and 3% CMML-2. A combination of an anthracycline (Ac) and standard dose (SD) cytarabine (AraC) was administered to 53% of the patients. Other regimens included Ac with high dose (HD) AraC (15%), Ac with SD AraC and etoposide (15%), HD AraC alone (8%), and HD AraC with etoposide (4%). 26% of patients required a second line regimen and 4% went on to a third. None of the patients died of complications due to IC. CR was achieved in 60% of patients overall (64% in those receiving Ac + SD AraC ± etoposide and 52% for HD AraC ± Ac ± etoposide). The CR rate was 65% in primary and 42% in secondary MDS, and was similar in adults (60%) and children (56%). CR rates were 44% in HR, 68% in IR, and 65% in GR cytogenetics; 58% in HR, 59% in IR-2, and 60% in IR-1 IPSS. According to disease status at IC, the CR rate was 60% for RAEB-1 and 2 and 59% for AML. 12% of complete responders relapsed prior to cytoreduction for SCT. 49% of all patients underwent a TCD SCT from an HLA identical sibling. There are no long term survivors after SCT in patients who did not achieve CR after IC, in contrast to 47% overall survival at 10 years for responders. Conclusions: IC in advanced MDS is associated with a high rate of CR. IC before cytoreduction for SCT is an effective approach to reduce the burden of disease particularly prior to TCD SCT.

No significant financial relationships to disclose.

Pilot trial of a synthetic breakpoint peptide vaccine in patients with chronic myeloid leukemia (CML) and minimal disease

6514

Background: CML is characterized by a tumor-specific fusion oncoprotein, BCR-ABL. Peptides spanning the B3A2 breakpoint of BCR-ABL can elicit MHC restricted T cell responses and clinical responses. No such data have previously been reported for vaccines targeting B2A2. Methods: We initiated a clinical trial administering synthetic analog breakpoint specific peptide vaccines for either B3A2 or B2A2 breakpoints to CML patients with major or complete cytogenetic remission. Measurable minimal disease was determined by either quantitative polymerase chain reaction (RQ-PCR) or nested PCR for BCR-ABL. Vaccine was administered with GM-CSF and Montanide ISA 51 subcutaneously. Eleven vaccinations were planned over the course of 1 year with the first 5 doses administered bi-weekly. Results: Eleven of 20 planned patients have been accrued to the study. Eight had documented cytogenetic remission and 3 were BCR-ABL positive via FISH analysis. Seven of the 11 patients had measurable BCR-ABL transcript levels as determined by RQ-PCR and all 11 were positive using the nested technique. Of the 5 patients positive for BCR-ABL (by RQ-PCR) before vaccination, 3 converted from RQ-PCR positive to negative while the transcript levels in the other patients decreased by approximately 1 log after 5 doses. All 5 of these patients remained positive using the nested PCR technique. Vaccination was well tolerated with local skin reactions at the injection sites. Immunologic reactivity was assessed ex vivo by CD4 autologous proliferation assay and T cell interferon (IFN) secretion (ELISPOT) assay. Ten of 11 patients were immunologically unreactive to the peptides prior to the vaccinations. Following the 5th dose of vaccine, 8/8 patients (including 2 with B2A2) tested showed significant immunologic responses by one of the above assays. Conclusions: These preliminary results suggest vaccination with synthetic analog peptides derived from CML proteins results in immunologic responses and may be associated with molecular improvement. Clinical efficacy of these vaccines in reducing/ eliminating minimal disease has yet to be established.

[Table: see text]

Levels of phospholipid metabolites in breast cancer cells treated with antimitotic drugs: a 31P-magnetic resonance spectroscopy study

Magnetic resonance spectroscopy (MRS) methods have provided valuable information on cancer cell metabolism. In this study, we characterized the 31P-MR spectra of breast cancer cell lines exhibiting differences in hormonal response, estrogen receptors (positive/negative), and metastatic potential. A correlation was made between the cytotoxic effect of antimitotic drugs and changes in cell metabolism pattern. Because most anticancer drugs are more effective on proliferating cells, our study attempted to elucidate the metabolic profile and specific metabolic changes associated with the effect of anticancer drugs on proliferating breast cancer cell lines. Accordingly, for the 31P-MRS experiments, cells were embedded in Matrigel to preserve their proliferation profile and ability to absorb drugs. The MRS studies of untreated cells indicated that the levels of phosphodiesters and uridine diphosphosugar metabolites were significantly higher in estrogen receptor-positive and low metastatic potential cell lines. 31P-MRS observations revealed a correlation between the mode of action of anticancer drugs and the observed changes in cell metabolic profiles. When cells were treated with antimicrotubule drugs (paclitaxel, vincristine, colchicine, nocodazole), but not with methotrexate and doxorubicin, a profound elevation of intracellular glycerophosphorylcholine (GPC) was recorded that was not associated with changes in phospholipid composition of cell membrane. Remarkably, the rate of elevation of intracellular GPC was much faster in cell population synchronized at G2-M compared with the unsynchronized cells. The steady-state level of GPC for paclitaxel-treated cells was reached after approximately 4 h for synchronized cells and after approximately 24 h (approximate duration of one cell cycle) for the unsynchronized ones. These observations may indicate a correlation between microtubule status and cellular phospholipid metabolism. This study demonstrates that 31P-MRS may have diagnostic value for treatment decisions of breast cancer and reveals new aspects of the mechanism of action of antimicrotubule drugs.

Recent advances in the treatment of acute leukemia: 1999

This review briefly summarizes literature noteworthy in the field of adult acute leukemia published during 1999. The relationship between specific cytogenetic abnormalities and response to treatment was explored within a clinical framework. In particular, detailed analyses of the abnormalities seen in acute promyelocytic leukemia were examined. Two case reports of special interest were published: one shed light on the role of histone deacetylase inhibitors in combination with all-trans retinoic acid, and the other, on the role of granulocyte colony-stimulating factor in this disease. The clinical activity of arsenic was also reported and its mechanism of action explored. In acute lymphoblastic leukemia, attention was focused on occult translocations, and the importance of minimal residual disease was again emphasized. Lastly, results of early clinical trials using an anti-CD19 antibody were reported, with provocative results.

Psychoanalytic supervision: the intersubjective development

The author argues that an intersubjective perspective on the analytic process makes the notion of purely didactic supervision, avoiding countertransference issues, untenable and that countertransference is both a clue to the analysand's psychic reality and a factor in its evolution. Supervision is seen as a highly personal learning process for both supervisor and supervisee and its emotional climate as a crucial factor in its evolution into a transitional space, generating new meanings. Supervision is portrayed as the crossroads of a matrix of object relations of three persons, of a complex network of transference/countertransference patterns. The avoidance or denial of the supervisor's subjective role in it, maintaining 'a myth of the supervisory situation', may make supervision stilted or even oppressive and stand in the way of resolving supervisory crises and stalemates. It is argued that several factors contribute to the conflictuality of supervision for all partners (often including the analysand): the continuous process of mutual evaluation, the reciprocal fears of exposing one's weaknesses, the impact of the institute as a setting and the transferences it arouses and the inherent conflicts of loyalty for each participant in the analytic/supervisory triad. The resulting dynamics and relational patterns could become a legitimate and freeing topic in supervisory discourse.

Characterization of two novel sublines established from a human megakaryoblastic leukemia cell line transfected with p210(BCR-ABL)

Disease progression in chronic myelogenous leukemia (CML) is usually accompanied by chromosomal abnormalities such as an additional Ph chromosome, trisomies of chromosome 8 or 19, or i(17) in addition to the standard translocation t(9;22) (q34;q11). However, detailed studies of the various steps involved during this evolution are difficult to perform, thereby making the study of cell lines that contain the transposed genes BCR-ABL, especially those of human origin, an important focus. In this analysis we investigated the human megakaryoblastic cell line MO7e and its subline transfected with BCR-ABL, MO7e/p210. Initial studies demonstrated that the phenotype of the MO7e line was consistent with a megakaryocytic lineage as originally described and was growth factor dependent in liquid culture. The MO7e/p210 subline, however, was growth factor independent and could be further separated into two distinct sublines based on expression of glycophorin A using the monoclonal antibody R10. The subline R10 negative (R10-) was similar to the parent line MO7e but R10 positive (R10+) cells had a distinct erythroid phenotype. In addition, the R10- and R10+ sublines demonstrated strikingly different colony morphology when cultured in semisolid medium. Furthermore, R10+ cells had additional chromosomal abnormalities not detected in the R10- population. These results demonstrate that the insertion of the BCR-ABL in this human leukemia cell line resulted in two distinct subpopulations of cells, each now growth factor independent, but one with a phenotype and karyotype identical to the parent cell line and the other with a different phenotype and additional chromosomal abnormalities. These two subpopulations derived from the MO7e/p210 transfected cell line may prove useful in further understanding the multistep events that occur in the progression of this disease.

Enhancement of 5-fluorouracil anabolism by methotrexate and trimetrexate in two rat solid tumor models, Walker 256 carcinosarcoma and Novikoff hepatoma, as evaluated by 19F-magnetic resonance spectroscopy

Although 5-fluorouracil (5-FU) is one of the most effective single agents in treating solid tumors, its low effectiveness as a single agent has led to development of a number of modulators intended to enhance its therapeutic effectiveness. Of these, methotrexate (MTX) and trimetrexate (TMTX) have been shown to have synergistic anticancer activity with 5-FU. The effect of these two drugs on the uptake and the intratumoral metabolism of 5-FU was studied in two rat tumor models using 19F-nuclear magnetic resonance spectroscopy: on excised samples of Walker 256 carcinosarcoma and noninvasively (in vivo) in Novikoff hepatoma. In the rats bearing the Walker 256 tumor, a 4-hr pretreatment with MTX showed the maximal increase in the rate of conversion from 5-FU to its fluorinated nucleotides/nucleosides. In the rats bearing the Novikoff hepatoma, both modulators increased the amounts of cyctotoxic anabolites of 5-FU, but at the doses administered, the cumulative amounts of 5-FU anabolites formed after MTX were significantly higher than those formed after TMTX or after saline control. On the other hand, the increase in the levels of the fluorinated nucleotides/nucleosides after TMTX peaked at a later time. The possible significance of these findings is that timing of administration of a modulator is important because it affects both transport and metabolism of 5-FU. The two modulators studied, both antifolates, act differently on transport and on metabolism: MTX affects both, whereas TMTX, at the level studied, appears to affect predominantly the metabolic process. In addition, significant differences exist between tumor models. These data suggest possible mechanisms and processes that should be studied further in humans, using these noninvasive pharmacokinetic imaging methods for monitoring 5-FU targeting and metabolism.

Diffusion and perfusion magnetic resonance imaging following closed head injury in rats

Diffusion-, perfusion-, T1-, and T2-weighted magnetic resonance imaging (MRI) were performed at 1-2 h, 24 h, and 1 week following closed head injury (CHI) in rats, and data was compared with hematoxylin and eosin histology. At 1-2 h, large areas of low perfusion in the damaged hemisphere overestimate the histological damage. In the first 2 h, the histological damage seems to be a superposition of abnormalities in the T1- and diffusion-weighted images. In areas with more than 10% reduction in the apparent diffusion coefficients (ADCs), reduced regional cerebral blood volume (r-CBV) was also observed. The decrease in ADCs and rCBV correlated with r = 0.78. Changes in the MRI parameters revealed the following: (a) Further reduction in ADC occurred from 83+/-15% at 1-2 h after trauma to 69+/-9% at 24 h, and 1 week later a marked elevation in the ADC values is observed. (b) Blood perfusion measurements performed 1-2 h posttrauma revealed a pronounced reduction in r-CBV (53+/-18%) in the damaged hemisphere in all rats. At 24 h postimpact, areas of hyper- and hypoperfusion were observed. One week later, similar perfusion was found in both hemispheres of all rats. (c) T2 hyperintensity at 24 h overestimated the histological damage found at 1 week. At one week following the trauma, the T2 hyperintensity underestimated the histological damage. It is concluded that CHI, which is a heterogeneous insult, should be studied by a combination of MRI techniques. The superposition of the abnormalities seen on T1 and on the diffusion-weighted MR images at early time point represents best the histological damage. Both T2 and rCBV images are less informative in terms of actual histological damage.

Fibrin microbeads (FMB) as biodegradable carriers for culturing cells and for accelerating wound healing

We have developed biodegradable fibrin-derived microbeads as potent cell carriers. The fibrin-derived microbeads, 50-200 microm in diameter, were tested for their attachment to a wide range of cell types. Fibrin-derived microbeads were shown to be greatly haptotactic to cells (such as endothelial cells, smooth muscle cells and fibroblasts), which respond to fibrinogen in contrast to keratinocytes and different cell lines derived from leukocytic lineage. The cells on fibrin-derived microbeads could be maintained for more than 10 d and achieved a high density. 31P-nuclear magnetic resonance was employed to monitor phosphate metabolism in cells, with densities on the order of 100 million cells per g of fibrin-derived microbeads. The 31P-nuclear magnetic resonance adenosine triphosphate and phosphocreatine signals, equivalent to the signal obtained with perfused normal skin, indicated that metabolism of cells on fibrin-derived microbeads was responsive to oxygenation and nutrients. Light, fluorescent, and confocal laser microscopy revealed that the porous fibrin-derived microbeads accommodate up to 200-300 cells due to their high surface area which minimized contact inhibition. Cells could degrade the fibrin-derived microbeads and be transferred to seed culture flasks without trypsinization. In a pig skin wound healing model, fibrin-derived microbeads + fibroblasts were transplanted into full thickness punch wounds. This procedure was compared with other treatment modalities, such as the addition of human platelet-derived growth factor BB or fibrin-derived microbeads alone. By the third day after wounding, only the wounds in which fibroblasts on fibrin-derived microbeads were added showed significant formation of granulation tissue. Based on the above, we project many uses of our novel fibrin-derived microbead technology for cell culturing, wound healing and tissue engineering.

Comparative effects of added sodium chloride, ammonium chloride, or potassium bicarbonate in the drinking water of broilers, and feed restriction, on the development of the ascites syndrome

A hypothesis that the ionic composition of drinking water might affect development of the ascites syndrome in broilers was investigated in two trials. The first trial comprised four groups of 650 male chicks. A control treatment was normal tap water and the other three treatments comprised the addition to the tap water of 1,000 mg/L sodium as NaCl, 5,000 mg/L NH4Cl, or 5,000 mg/L KHCO3, supplied from age 2 to 47 d. At Day 28, equally sized subsets of these groups were moved to individual cages, where they received a severe exposure to ambient cold. The development of the ascites syndrome was monitored by measurements of hematocrit and arterial blood oxygen saturation (PaO2) by oximetry, body weight, and examination of dead birds for cause of death. Mortality from ascites in cold-exposed birds from Days 28 to 47 was 28, 48, 40, and 16% in the tap water, NaCl, NH4Cl, and KHCO3 groups, respectively; only the NaCl mortality was significantly different from the tap water mortality. The KHCO3 treatment increased PaO2 (compared with tap water treatment) at Day 28 by 5.5% and at Day 35 by 10.5%, but not at Day 42. The KHCO3 caused a reduction in body weight, which was 13% less than the tap water group at Day 42, probably due to a chronic toxicity. The second trial specifically examined the same parameters with lower water levels of KHCO3 (3,000 and 1,000 mg/L), in comparison to a 10% feed restriction protocol, in order to clarify whether the increased PaO2 was due to a specific effect of the KHCO3 or was a metabolic manifestation of a reduced growth rate. The 3,000 mg/L KHCO3 treatment had no effect on PaO2, but the 1,000 mg/L treatment augmented PaO2 by 5.3% at Day 35 (but not at Days 28 or 42), without reducing the final body weight. The feed restriction group showed an elevated PaO2 of 5.4% at Day 35 (but not at Days 28 or 42), with no reduction in the final body weight. The inclusion of 1,000 mg/L of KHCO3 into the drinking water of broilers or a temporary 10% feed restriction may be means to augment PaO2.

Inter-trial neuronal activity in inferior temporal cortex: a putative vehicle to generate long-term visual associations

When monkeys perform a delayed match-to-sample task, some neurons in the anterior inferotemporal cortex show sustained activity following the presentation of specific visual stimuli, typically only those that are shown repeatedly. When sample stimuli are shown in a fixed temporal order, the few images that evoke delay activity in a given neuron are often neighboring stimuli in the sequence, suggesting that this delay activity may be the neural correlate of associative long-term memory. Here we report that stimulus-selective sustained activity is also evident following the presentation of the test stimulus in the same task. We use a neural network model to demonstrate that persistent stimulus-selective activity across the intertrial interval can lead to similar mnemonic representations (distributions of delay activity across the neural population) for neighboring visual stimuli. Thus, inferotemporal cortex may contain neural machinery for generating long-term stimulus-stimulus associations.

Relationship between broiler chicken haematocrit-selected parents and their progeny, with regard to haematocrit, mortality from ascites and bodyweight

A previous work of this group demonstrated that the relative haematocrit value of broilers is inherited and may serve as an indicator to susceptibility to the ascites syndrome in cold-stressed broilers. In this study, a full-pedigreed population was produced from male and female grandparent breeding stock that was selected by haematocrit and by normal selection parameters. Matings were made between low (L), medium (M) and high (H) haematocrit parents: L x L, M x M, and H x H. In their progeny, both before and after cold exposure, there was a statistically linear relationship between actual haematocrit and their H, M and L grouping (P<0.0001); heritability of the haematocrit was high (0.46-0.81). Both the low haematocrit parent and progeny groups showed an increased bodyweight. Exposure of the progeny from all the parental groups to an ascites-predisposing cold environment caused similar losses from ascites in the progeny of all three groups. Although this finding was not the same as in the previous trial where the H haematocrit group was associated with high ascites mortality, it is hypothesized that other factors, such as arterial blood saturation with oxygen, interacted in these birds at genetic or environmental levels.

Long-term follow-up of three randomized trials comparing idarubicin and daunorubicin as induction therapies for patients with untreated acute myeloid leukemia

BACKGROUND

Most clinical trials for acute leukemia have reported results after 2-3 years of follow-up. Comparisons between the original data and longer-term follow-up data may be of interest, particularly with regard to promising new therapies.

METHODS

In 1996, survival data were updated from three prospective, randomized comparisons of idarubicin and daunorubicin that began in 1984 and 1985. These were trials of the Memorial Sloan-Kettering Cancer Center (MSKCC), the U.S. Multicenter Study Group, and the Southeastern Cancer Study Group (SEG). The original results of these trials were reported in 1991 and 1992.

RESULTS

The original results of the SEG trial demonstrated no significant difference between idarubicin and daunorubicin. The updated survival analysis showed similar results. The MSKCC trial revealed a significant advantage of idarubicin compared with daunorubicin in both the original and the updated analyses. The U.S. Multicenter trial found a significant difference favoring idarubicin in the original analysis, but the difference was not significant in the updated analysis.

CONCLUSIONS

It is essential that the median length of follow-up be clearly stated in any clinical trial. When the results obtained with a particularly promising new drug or procedure are presented early in the course of study (within 1-2 years), the investigators should strongly consider a repeat evaluation after an additional 3-5 years of follow-up.

Hitchcock's "Vertigo": the collapse of a rescue fantasy

The author presents an interpretation of Hitchcock's 'Vertigo', focusing on the way in which its protagonist's drama resonates with the analyst's struggle with deep unconscious identifications, with the impossibility of maintaining detached objectivity or guaranteeing one's role as a reparative good object and with the dangers of grandiosity, omniscience and illusory control. The protagonist's 'countertransference love' crystallises around a rescue fantasy in which he is Orpheus striving to bring Eurydice back from Hades, or a Knight determined to behead an obscure Dragon endangering Beauty. Initially these key roles are sharply differentiated, through splitting and disavowal, which deprive the participants of their conflictual three-dimensionality. Eventually, however, the valiant Knight turns out to be as helpless and lonely as his Beauty, and in the final scene as ruthless and lethal as the Dragon. This interpretation is compared to numerous other views of the film offered in the literature. The survey and comparison of the various views leads to fundamental issues in the psychoanalytic study of art. Interpretations can be seen as unavoidably coloured by the (counter)transference of viewers. It is suggested that a film has no hidden true meaning, and a new individual significance emerges in the transitional space opened up by each viewer's encounter with the emotional universe of the film. A defensive emphasis on the pathology of artists and their work may alienate us from art, and blind us to ways in which we could learn from it personally and professionally.

In vivo cyclic AMP responses in rat brain are not modified by chronic electroconvulsive shock

In vivo microdialysis was used to determine the effects of chronic electroconvulsive shock (ECS), given daily for 10 days, on the cyclic AMP (cAMP) responses to noradrenaline (NA) and to forskolin in the cortex of freely-moving conscious rats. Microdialysis probes were inserted on the final day of ECS administration, and cAMP responses measured the following day. Chronic ECS did not modify the responses to either NA or forskolin. These results differ markedly from those previously obtained with incubated slices of rat brain. It is concluded that care is needed in interpreting results obtained by either ex vivo or in vitro methods.