Depressive Symptoms, Cardiac Structure and Function, and Risk of Incident Heart Failure With Preserved Ejection Fraction and Heart Failure With Reduced Ejection Fraction in Late Life

Background Depressive symptoms are associated with heightened risk of heart failure (HF), but their association with cardiac function and with HF with preserved ejection fraction (HFpEF) and HF with reduced ejection fraction (HFrEF) in late life is unclear. We aimed to determine the prevalence of depression in HFpEF and in HFrEF in late life, and the association of depressive symptoms with cardiac function and incident HFpEF and HFrEF. Methods and Results We studied 6025 participants (age, 75.3±5.1 years; 59% women; 20% Black race) in the ARIC (Atherosclerosis Risk in Communities) study at visit 5 who underwent echocardiography and completed the Center for Epidemiologic Studies Depression Scale questionnaire. Among HF-free participants (n=5086), associations of Center for Epidemiologic Studies Depression Scale score with echocardiography and incident adjudicated HFpEF and HFrEF were assessed using multivariable linear and Cox proportional hazards regression. Prevalent HFpEF, but not HFrEF, was associated with a higher prevalence of depression compared with HF-free participants (P<0.001 and P=0.59, respectively). Among HF-free participants, Center for Epidemiologic Studies Depression Scale score was not associated with cardiac structure and function after adjusting for demographics and comorbidities (all P>0.05). Over 5.5-year follow-up, higher Center for Epidemiologic Studies Depression Scale score was associated with heightened risk of incident HFpEF (hazard ratio [HR] [95% CI], 1.06 [1.04-1.12]; P=0.02), but not HFrEF (HR [95% CI], 1.02 [0.96-1.08]; P=0.54), independent of echocardiographic measures, NT-proBNP (N-terminal pro-B-type natriuretic peptide), troponin, and hs-CRP (high-sensitivity C-reactive protein) (HR [95% CI], 1.06 [1.00-1.12]; P=0.04). Conclusions Worse depressive symptoms predict incident HFpEF in late life, independent of common comorbidities, cardiac structure and function, and prognostic biomarkers. Further studies are necessary to understand the mechanisms linking depression to risk of HFpEF.

Systemic Treatment Safety Symposium 2014: Oral Chemotherapy

The second Systemic Treatment Safety Symposium, which took place February 21, 2014, in Toronto, aimed to identify opportunities for improving the delivery of systemic cancer treatment in Ontario based on regional needs, while providing a venue for collaboration and knowledgesharing. The agenda included a series of panel sessions followed by discussions, presentations of regional improvement projects and results, and breakout sessions. Based on the discussion that took place at the symposium, a provincial goal of zero handwritten or verbal oral chemotherapy orders by June 30, 2015, has now been established, and regions will be provided with funding for safe prescribing initiatives to support achievement of that aim. Building on the lessons learned from the 2014 System Treatment Safety Symposium, a common measurement strategy will be identified, and Cancer Care Ontario (cco) will also support the work by identifying the recommended key elements of a safe oral chemotherapy prescription. Additionally, cco will identify areas for improving systemic treatment computerized prescriber order entry systems to better enable prescribing of oral agents within such systems. Among the most prominent of the lessons learned during the symposium was the importance of having a focused topic (such as oral chemotherapy) while maintaining a province-wide scope. Another significant takeaway was that attendees appreciate the opportunity to hear from colleagues across the province about the work underway in various regions. Future safety symposia will also explore opportunities for enhanced engagement with participants through greater use of technology.

Screening for hepatitis B surface antigen before chemotherapy: current practice and opportunities for improvement

INTRODUCTION

Hepatitis B virus (hbv) reactivation is a recognized complication of chemotherapy. The U.S. Centers for Disease Control and Prevention recommend that all patients be screened for the hbv surface antigen (hbsag) before chemotherapy. We sought to determine the frequency of hbsag testing before chemotherapy at our hospital and to increase the frequency of testing to more than 90% of patients starting chemotherapy.

METHODS

Using a retrospective electronic chart review, we identified the frequency of hbsag testing for patients initiated on intravenous chemotherapy at out institution between March 2006 and March 2007. The frequency of left ventricular function testing in the subgroup of patients receiving potentially cardiotoxic chemotherapy was identified as a comparator. An educational intervention was developed and delivered to the multidisciplinary oncology team. The frequency of hbsag testing was determined post intervention. Qualitative interviews were conducted with the members of the oncology team to identify risk perception and barriers to testing.

RESULTS

Of 208 patients started on intravenous chemotherapy between March 2006 and March 2007, only 28 (14%) were tested for hbsag. All 138 patients scheduled for cardiotoxic chemotherapy (100%) underwent left ventricular function testing. In the post-intervention phase, of 74 patients started on intravenous chemotherapy, 24 (31%) underwent hbsag testing, with 1 patient testing positive.

CONCLUSIONS

The frequency of testing for hbsag before chemotherapy was very low at our institution. An educational intervention resulted in only a modest improvement. Potential barriers to routine screening include lack of awareness about existing guidelines, controversy about the evidence that supports hbsag testing guidelines, and a perception by physicians that hbv reactivation does not occur with solid tumours.

Ultrasound-based liver computer assisted surgery

Ongoing research toward development of a computer-assisted, ultrasound-based software/hardware tool to improve instrument positioning in moving organs during minimally invasive abdominal surgery is presented. The main objective of this research is to calculate, in real time and without user intervention, the pre-/intra-operative 3D/2D image misalignment due to patient respiration and the shift induced by the surgical instrument. Our methodology applied to the particular case of the liver, and partial results related to the image registration approach, based on organ segmentation and shape description, are presented. Preliminary results are highly encouraging. Among other benefits, use of this tool will increase surgeon confidence and improve surgery outcomes.

Stereospecific versus nonstereospecific assessments for the bioequivalence of two formulations of racemic chlorpheniramine

Chlorpheniramine (chlorphenamine, CPAM) is a racemic antihistaminic H1 drug containing two enantiomers. The aim of this study was to assess the bioequivalence of two formulations (reference and Vietnamese-tested formulation) of racemic chlorpheniramine combined with phenylpropanolamine in an open-labeled, randomized, crossover two-period study, after administration of 8 mg of racemic chlorpheniramine in 12 healthy Vietnamese subjects. First, dissolution of both formulations was tested in vitro according to USP requirements. Then the 12 subjects received both formulations after an overnight fast and a 7-day wash-out period. Plasma samples were collected up to 168 h. Plasma concentrations of total chlorpheniramine and its individual enantiomers were determined with a validated chiral HPLC method and pharmacokinetic parameters were estimated using model-independent analysis. For the reference formulation, Cmax and AUC values were higher for (+)S-chlorpheniramine ((+)S-CPAM) compared to (-)R-chlorpheniramine ((-)R-CPAM) (13.3 vs. 6.8 ng/ml and 409 vs. 222 ng/ml/h, respectively) while Clt/F and Vd/F were lower (9.8 vs. 17.6 l/h and 321 vs. 627 l, respectively). No difference was observed for Tmax, t(1/2), and MRT. Pharmacokinetic parameters were similar for the reference and the Vietnamese-tested formulation. Bioequivalence was assessed by Schuirmann test, as recommended by the current FDA and European Community criteria. Dissolution tests showed that both formulations were equivalent. A nonstereospecific, but not a stereospecific, approach indicated bioequivalence between the formulations.

Cellular proliferation, estrogen receptor, progesterone receptor, and bcl-2 expression in GnRH agonist-treated uterine leiomyomas

Gonadotropin-releasing hormone (GnRH) agonists are commonly used in the treatment of uterine leiomyomas, but little is known about their histological and cellular effects on these neoplasms. We examined a cellular proliferation index as determined by the nuclear antigen Ki-67 and proliferating cell nuclear antigen (PCNA) expression, estrogen receptor (ER), and progesterone receptor (PR) expression in 27 leiomyomas from patients treated with the GnRH agonist leuprolide acetate (LA) and compared them with 33 untreated controls. All leiomyomas were removed by myomectomies from premenopausal woman after 2 to 6 months of LA treatment or in the follicular phase of the menstrual cycle in the untreated controls. Histological features examined included cellularity, nuclear atypia, vascular changes (dilated, thickened, or thrombosed vessels), edema, calcification, hemorrhage, necrosis, hyalinization, and mitotic activity. Although no difference was found between GnRH-treated and nontreated groups with respect to most histological features examined, immunohistochemical studies showed a significant decrease in the cellular proliferation index, ER, and PR expression in the LA-treated cases compared with nontreated controls. The cellular proliferation index, ER, and PR expression decreased by 85%, 49%, and 36%, respectively, in the LA-treated group as compared with controls (P < .001). A subset of cases from the LA-treated and nontreated groups were also analyzed with respect to bcl-2 (an inhibitor of apoptosis) expression, and no significant difference between the LA-treated and nontreated groups was observed with both groups showing a strong (> 75% of cells) cytoplasmic staining pattern. Results of this study show that LA treatment of leiomyomas results in a decrease in number of cycling cells.

Timing of onset of contraceptive effectiveness in Norplant implant users. Part I. Changes in cervical mucus

OBJECTIVE

To provide scientific data regarding the changes in cervical mucus within the first hours to days after Norplant implant insertion and to estimate when the cervical mucus is hostile enough to suggest a contraceptive effect.

DESIGN

Multicenter, clinical descriptive study.

SETTING

Family planning clinics.

PATIENT(S)

Forty-two women who were between days 8 and 13 of their menstrual cycle and who had requested Norplant implants were admitted to the study.

INTERVENTION(S)

Cervical mucus and blood samples were obtained.

MAIN OUTCOME MEASURE(S)

Cervical mucus scores, sperm penetration distances, and serum levels of progesterone, estradiol, and levonorgestrel.

RESULT(S)

The median cervical mucus score observed at baseline was 6 ("fair"), indicating that the mucus was already somewhat hostile before insertion of the Norplant implants. The median scores declined to 5 at 12 and 24 hours and continued to decrease through day 7 to 2 ("poor"), a score that is judged as hostile to sperm penetration. Overall, 73% of all subjects had a poor cervical mucus score by 3 days after insertion; at 7 days after insertion, 90% exhibited poor mucus and none had a good score. There was a substantial drop in the overall median distance traveled by the vanguard sperm after 12 hours for each cervical mucus score grouping. The distance traveled decreased rapidly between 12 and 24 hours to < 0.5 cm in subjects with fair and poor mucus, and by day 3, 91% of the subjects exhibited poor sperm penetration.

CONCLUSION(S)

On the basis of our findings, deterioration of the quality of the cervical mucus and sperm penetration is evident by 24 hours after insertion, although not to a level that would suggest adequate protection until 72 hours after insertion. Therefore, we are confident in recommending that backup methods of contraception (e.g, condoms) need not be used for more than 3 days after insertion, even when the implants are inserted close to ovulation. These findings provide policy makers, clinic managers, and clinicians with important information about how they can improve client access to Norplant implants.

Homocysteine-induced nitric oxide production in vascular smooth-muscle cells by NF-kappa B-dependent transcriptional activation of Nos2

Increased plasma levels of homocysteine are an independent risk factor for atherothrombosis. While the endothelial cytotoxicity of homocysteine has been attributed to oxidative stress associated with the reactivity of the thiol group, the oxidative effect of homocysteine on vascular smooth-muscle cells has not been investigated. Recent evidence suggests that expression of inducible nitric oxide synthase (iNOS), or Nos2 gene product, in vascular smooth-muscle cells may, in part, promote atherosclerosis by increasing local oxidative stress. We therefore hypothesized that homocysteine contributes to atherosclerosis by affecting cytokine-induced production of nitric oxide (NO) by vascular smooth-muscle cells. Confluent rat aortic smooth-muscle cells were exposed to a range of concentrations of homocysteine for 4 hr, then were treated with interferon-gamma, interleukin-1 beta, and lipopolysaccharide to induce iNOS. Media NOx content (nitrite plus S-nitrosothiol) was measured over 24 hr using the Saville reaction. As compared to controls, 5, 50, and 500 microM homocysteine produced a dose-dependent increase in media NOx content, an effect that was primarily a consequence of increased S-nitrosothiol production. iNOS enzyme activity and iNOS protein levels were increased significantly in the homocysteine-treated cells as compared with controls. Northern analysis showed that homocysteine treatment increased steady-state Nos2 mRNA levels by 61% at 6 hr as compared with controls, an effect that was not caused by changes in message stability. By electrophoretic mobility shift assay, homocysteine activated NF-kappa B and also potentiated cytokine activation of NF-kappa B. These data demonstrate that exposure of vascular smooth-muscle cells to pathophysiologically relevant concentrations of homocysteine prior to cytokine stimulation leads both to an increase in NO production and to an NF-kappa B-mediated increase in Nos2 transcription. Upregulation of Nos2 may contribute to the inflammatory response that characterizes early atherogenesis and may, in part, account for the adverse vascular effects of hyperhomocysteinemia.

Operative laparoscopy for the treatment of ectopic pregnancy in a residency program

OBJECTIVE

To compare the effectiveness and safety of operative laparoscopy (OL) when used for the treatment of ectopic pregnancy in the setting of a residency training program.

STUDY DESIGN

We retrospectively reviewed records of all patients with diagnostic laparoscopy documenting the presence of an ectopic pregnancy. Patients who met the following criteria were selected: hemodynamic stability, tubal distortion no greater than 5 cm and adequate visualization of the pelvis. The cases performed via OL were compared to the cases performed via laparotomy (LAP). All the surgery had been performed by resident physicians with the attending gynecologist as first assistant/supervisor.

RESULTS

Ninety-five cases performed from March 1989 to April 1992 met the above criteria. Group 1 consisted of 61 patients treated with LAP. Group 2 consisted of 34 patients treated with OL. The operating time (76.8 +/- 19.0 vs 76.0 +/- 23.0 min, mean +/- SD) and the estimated blood loss (275.0 +/- 183.7 vs. 70.5 +/- 75.2 ml) were similar for both groups. The hospital stay for the LAP group was longer than for the OL group (3.7 +/- 1.2 vs. 1.4 +/- 0.6 days, P < .001). The surgical complication rate was also higher in the LAP group (23% vs 2.9%, P = .16).

CONCLUSION

In our residency program the introduction of OL for the management of ectopic pregnancy has resulted in shorter hospital stays and lower morbidity without increased duration of the surgical episode or increased blood loss.

Pregnancy after failed tubal sterilization

OBJECTIVE

To review the pregnancy outcome in patients with failed tubal sterilization treated in our hospital and to compare the incidence of ectopic pregnancy in our study group with the experience at other military hospitals and with the incidence of ectopic pregnancy in similar patients reported in the literature.

STUDY DESIGN

A registry of failed tubal sterilization was started at our hospital in 1989. We entered all information regarding the type of procedure and pregnancy outcome as the patients presented for care. Information on the experience at other military hospitals was obtained through review of data provided by the epidemiology section of the Health Services Command, San Antonio, Texas.

RESULTS

From 1989 to 1991, 12 patients with failed tubal sterilization received care at our hospital. Eight patients (67%) had ectopic pregnancies. Of 137 patients identified through the Health Services Command, 49 (36%) had ectopic pregnancies.

CONCLUSION

The literature reports a 5-90% incidence of ectopic pregnancy after failed tubal sterilization. The data from our registry and from the Health Services Command corroborate the increased likelihood of ectopic pregnancy in patients with failed tubal sterilization and underscore the need for close follow-up of these patients until the location of the pregnancy is documented.

Influence of the V(D)J recombination mechanism on the formation of the primary T and B cell repertoires

T and B cells exploit the mechanism of V(D)J recombination to make diverse or very restricted repertoires at varying times during ontogeny. Fetal repertoires are limited since there are no N nucleotides. Also, if short sequence homologies are present near the coding ends, junctions are preferentially made at that site. For gamma delta TCR, and to a lesser extent for Ig, this results in a very homogeneous population of junctions early in ontogeny. alpha beta TCR, however, have a paucity of homologous stretches, and maintain junctional diversity in the newborn. In both newborns and adults, some coding ends show very restricted nucleotide deletion, while others show heterogeneous and extensive deletion. It appears that the sequences of the coding ends have been selected through evolution as a mechanism to control repertoire formation.

Limited junctional diversity in kappa light chains. Junctional sequences from CD43+B220+ early B cell progenitors resemble those from peripheral B cells

Among all adult T and B cell Ag receptor chains, only Ig light chains lack N regions. It is thought that this is due to the fact that light chain genes rearrange after heavy chain genes, and that terminal deoxynucleotidyl transferase, the enzyme that adds N regions, is not longer expressed at that stage. However, this concept has been challenged recently by the demonstration that 3 to 10% of B cell precursors (CD43+B220+) appear to rearrange their light chains at approximately the same time as they undergo VH--&gt;DJ rearrangements. To examine N region addition in B cell precursors undergoing early kappa-chain rearrangement, we PCR amplified rearranged V kappa 21 genes from the CD43+B220+ bone marrow cells and compared them to sequences obtained from whole bone marrow and spleen. Unexpectedly, all three populations showed approximately 10% N region containing junctions, most consisting of only one N nucleotide. Thus, even the B cell precursors that rearrange light chains at this early stage of development lack much N region diversity. Twelve percent of the sequences unambiguously contained P regions, which were from 1 to 5 nucleotides in length. All but 2 of the 41 productive rearrangements had the commonly observed CDR3 length of nine amino acids. Many (71%) of the sequences were out of frame. CDR3 length was very restricted in nonproductive rearrangements too, and deletion of nucleotides from V kappa and J kappa gene segments was limited. Thus, even at the level of nonproductive rearrangements, junctional diversity is minimal for kappa-chains.

Limited junctional diversity in kappa light chains. Junctional sequences from CD43+B220+ early B cell progenitors resemble those from peripheral B cells

Among all adult T and B cell Ag receptor chains, only Ig light chains lack N regions. It is thought that this is due to the fact that light chain genes rearrange after heavy chain genes, and that terminal deoxynucleotidyl transferase, the enzyme that adds N regions, is not longer expressed at that stage. However, this concept has been challenged recently by the demonstration that 3 to 10% of B cell precursors (CD43+B220+) appear to rearrange their light chains at approximately the same time as they undergo VH-->DJ rearrangements. To examine N region addition in B cell precursors undergoing early kappa-chain rearrangement, we PCR amplified rearranged V kappa 21 genes from the CD43+B220+ bone marrow cells and compared them to sequences obtained from whole bone marrow and spleen. Unexpectedly, all three populations showed approximately 10% N region containing junctions, most consisting of only one N nucleotide. Thus, even the B cell precursors that rearrange light chains at this early stage of development lack much N region diversity. Twelve percent of the sequences unambiguously contained P regions, which were from 1 to 5 nucleotides in length. All but 2 of the 41 productive rearrangements had the commonly observed CDR3 length of nine amino acids. Many (71%) of the sequences were out of frame. CDR3 length was very restricted in nonproductive rearrangements too, and deletion of nucleotides from V kappa and J kappa gene segments was limited. Thus, even at the level of nonproductive rearrangements, junctional diversity is minimal for kappa-chains.