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Chew-Harris J, Frampton C, Greer C, Appleby S, Pickering JW, Kuan WS, Ibrahim I, Chan SP, Li Z, Liew OW, Adamson PD, Troughton R, Tan LL, Lin W, Ooi SBS, Richards AM, Pemberton CJ. Prognostic performance of soluble urokinase plasminogen activator receptor for heart failure or mortality in Western and Asian patients with acute breathlessness. Int J Cardiol 2024; 406:132071. [PMID: 38643805 DOI: 10.1016/j.ijcard.2024.132071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 03/28/2024] [Accepted: 04/17/2024] [Indexed: 04/23/2024]
Abstract
AIMS The performance of circulating soluble urokinase plasminogen activator receptor (suPAR) for predicting the composite endpoint of subsequent heart failure (HF) hospitalisation and/or death at 1 year was assessed in (i) patients with undifferentiated breathlessness, and generalisability was compared in (ii) disparate Western versus Asian sub-cohorts, and in (iii) the sub-cohort adjudicated with HF. METHODS AND RESULTS Patients with acute breathlessness were recruited from the emergency departments in New Zealand (NZ, n = 612) and Singapore (n = 483). suPAR measured in the presentation samples was higher in patients incurring the endpoint (n = 281) compared with survivors (5.2 ng/mL vs 3.1 ng/mL, P < 0.0001). The discriminative power of suPAR for endpoint prediction was c-statistic of 0.77 in the combined population, but was superior in Singapore than NZ (c-statistic: 0.83 vs 0.71, P < 0.0001). Although the highest suPAR tertile (>4.37 ng/mL) was associated with risks of >4-fold in NZ, >20-fold in Singapore, and ≥3-fold in HF for incurring the outcome, there was no interaction between country and suPAR levels after adjustment. Multivariable analysis indicated suPAR to be robust in predicting HF/death at 1-year [hazard ratio: 1.9 (95% CI:1.7 to 2.0) per SD increase] and improved risk discrimination for outcome prediction in HF (∆0.06) and for those with NT-proBNP >1000 pg/mL (∆0.02). CONCLUSION suPAR is a strong independent predictor of HF and/or death at 1 year in acutely breathless patients, in both Asian and Western cohorts, and in HF. suPAR may improve stratification of acutely breathless patients, and in acute HF, for risk of later onset of heart failure or mortality.
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Affiliation(s)
- Janice Chew-Harris
- Christchurch Heart Institute, University of Otago, Christchurch, New Zealand.
| | - Chris Frampton
- Christchurch Heart Institute, University of Otago, Christchurch, New Zealand
| | - Charlotte Greer
- Christchurch Heart Institute, University of Otago, Christchurch, New Zealand
| | - Sarah Appleby
- Christchurch Heart Institute, University of Otago, Christchurch, New Zealand
| | - John W Pickering
- Christchurch Heart Institute, University of Otago, Christchurch, New Zealand; Emergency Care Foundation, Emergency Department, Christchurch Hospital, New Zealand
| | - Win Sen Kuan
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore; Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Irwani Ibrahim
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore; Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Siew Pang Chan
- Cardiovascular Research Institute, National University Heart Centre Singapore, National University Health System, Singapore; Centre for Behavioural and Implementation Science Interventions, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Institute of Geriatrics & Active Ageing, Tan Tock Seng Hospital, Singapore
| | - Zisheng Li
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore
| | - Oi Wah Liew
- Cardiovascular Research Institute, National University Heart Centre Singapore, National University Health System, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Philip D Adamson
- Christchurch Heart Institute, University of Otago, Christchurch, New Zealand; BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Richard Troughton
- Christchurch Heart Institute, University of Otago, Christchurch, New Zealand
| | - Li Ling Tan
- Cardiovascular Research Institute, National University Heart Centre Singapore, National University Health System, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Weiqin Lin
- Cardiovascular Research Institute, National University Heart Centre Singapore, National University Health System, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Shirley Beng Suat Ooi
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore; Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - A Mark Richards
- Christchurch Heart Institute, University of Otago, Christchurch, New Zealand; Cardiovascular Research Institute, National University Heart Centre Singapore, National University Health System, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Cardiology Department, National University Heart Centre, National University Hospital, Singapore
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Appleby S, Aitken-Buck HM, Holdaway MS, Byers MS, Frampton CM, Paton LN, Richards AM, Lamberts RR, Pemberton CJ. Cardiac effects of myoregulin in ischemia-reperfusion. Peptides 2024; 174:171156. [PMID: 38246425 DOI: 10.1016/j.peptides.2024.171156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 01/15/2024] [Accepted: 01/17/2024] [Indexed: 01/23/2024]
Abstract
Myoregulin is a recently discovered micropeptide that controls calcium levels by inhibiting the intracellular calcium pump sarco-endoplasmic reticulum Ca2+-ATPase (SERCA). Keeping calcium levels balanced in the heart is essential for normal heart functioning, thus myoregulin has the potential to be a crucial regulator of cardiac muscle performance by reducing the rate of intracellular Ca2+ uptake. We provide the first report of myoregulin mRNA expression in human heart tissue, absence of expression in human plasma, and the effects of myoregulin on cardiac hemodynamics in an ex vivo Langendorff isolated rat heart model of ischemia/reperfusion. In this preliminary study, myoregulin provided a cardio-protective effect, as assessed by preservation of left ventricular contractility and relaxation, during ischemia/reperfusion. This study provides the foundation for future research in this area.
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Affiliation(s)
- Sarah Appleby
- Christchurch Heart Institute, University of Otago, Christchurch, 2 Riccarton Avenue, Christchurch 8011, New Zealand.
| | - Hamish M Aitken-Buck
- Department of Physiology, HeartOtago, University of Otago, 270 Great King St, Dunedin 9016, New Zealand.
| | - Mark S Holdaway
- Christchurch Heart Institute, University of Otago, Christchurch, 2 Riccarton Avenue, Christchurch 8011, New Zealand.
| | - Mathew S Byers
- Christchurch Heart Institute, University of Otago, Christchurch, 2 Riccarton Avenue, Christchurch 8011, New Zealand.
| | - Chris M Frampton
- Christchurch Heart Institute, University of Otago, Christchurch, 2 Riccarton Avenue, Christchurch 8011, New Zealand.
| | - Louise N Paton
- Christchurch Heart Institute, University of Otago, Christchurch, 2 Riccarton Avenue, Christchurch 8011, New Zealand.
| | - A Mark Richards
- Christchurch Heart Institute, University of Otago, Christchurch, 2 Riccarton Avenue, Christchurch 8011, New Zealand; Department of Cardiology, Te Whatu Ora Waitaha, 2 Riccarton Avenue, Christchurch 8011, New Zealand; Cardiovascular Research Institute, National University of Singapore, 1E Kent Ridge Road, Singapore.
| | - Regis R Lamberts
- Department of Physiology, HeartOtago, University of Otago, 270 Great King St, Dunedin 9016, New Zealand.
| | - Christopher J Pemberton
- Christchurch Heart Institute, University of Otago, Christchurch, 2 Riccarton Avenue, Christchurch 8011, New Zealand.
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Appleby S, Frampton C, Holdaway M, Chew-Harris J, Liew OW, Chong JPC, Lewis L, Troughton R, Ooi SBS, Kuan WS, Ibrahim I, Chan SP, Richards AM, Pemberton CJ. Circulating erythroferrone has diagnostic utility for acute decompensated heart failure in patients presenting with acute or worsening dyspnea. Front Cardiovasc Med 2024; 10:1195082. [PMID: 38259307 PMCID: PMC10800458 DOI: 10.3389/fcvm.2023.1195082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 12/20/2023] [Indexed: 01/24/2024] Open
Abstract
Objectives In dyspneic patients with atrial fibrillation (AF) or obesity, the diagnostic performance of NT-proBNP for acute heart failure is reduced. We evaluated the erythroblast derived protein erythroferrone (ERFE) as an ancillary biomarker for the diagnosis of acute decompensated heart failure (ADHF) in these comorbid subgroups in both Western and Asian populations. Methods The diagnostic performance of ERFE (Intrinsic Lifesciences) and NT-proBNP (Roche Cobas e411) for ADHF was assessed in 479 New Zealand (NZ) and 475 Singapore (SG) patients presenting with breathlessness. Results Plasma ERFE was higher in ADHF, compared with breathlessness from other causes, in both countries (NZ; 4.9 vs. 1.4 ng/ml, p < 0.001) and (SG; 4.2 vs. 0.4 ng/ml, p = 0.021). The receiver operating characteristic (ROC) areas under the curve (AUCs) for discrimination of ADHF were reduced in the NZ cohort compared to SG for ERFE (0.75 and 0.84, p = 0.007) and NT-proBNP (0.86 and 0.92, p = 0.004). Optimal cut-off points for ERFE yielded comparable sensitivity and positive predictive values in both cohorts, but slightly better specificity, negative predictive values and accuracy in SG compared with NZ. In patients with AF, the AUC decreased for ERFE in each cohort (NZ: 0.71, n = 105, SG: 0.61, n = 44) but increased in patients with obesity (NZ: 0.79, n = 150, SG: 0.87, n = 164). Conclusions Circulating ERFE is higher in patients with ADHF than in other causes of new onset breathlessness with fair diagnostic utility, performing better in Asian than in Western patients. The diagnostic performance of ERFE is impaired in patients with AF but not patients with obesity.
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Affiliation(s)
- Sarah Appleby
- Department of Medicine, Christchurch Heart Institute, University of Otago Christchurch, Christchurch, New Zealand
| | - Chris Frampton
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - Mark Holdaway
- Department of Medicine, Christchurch Heart Institute, University of Otago Christchurch, Christchurch, New Zealand
| | - Janice Chew-Harris
- Department of Medicine, Christchurch Heart Institute, University of Otago Christchurch, Christchurch, New Zealand
| | - Oi Wah Liew
- Cardiovascular Research Institute, National University of Singapore, Singapore, Singapore
| | - Jenny Pek Ching Chong
- Cardiovascular Research Institute, National University of Singapore, Singapore, Singapore
| | - Lynley Lewis
- Department of Medicine, Christchurch Heart Institute, University of Otago Christchurch, Christchurch, New Zealand
| | - Richard Troughton
- Department of Medicine, Christchurch Heart Institute, University of Otago Christchurch, Christchurch, New Zealand
- Department of Cardiology, Te Whatu Ora, Christchurch, New Zealand
| | | | - Win Sen Kuan
- Emergency Department, National University Hospital, Singapore, Singapore
| | - Irwani Ibrahim
- Emergency Department, National University Hospital, Singapore, Singapore
| | - Siew Pang Chan
- Cardiovascular Research Institute, National University of Singapore, Singapore, Singapore
| | - A. Mark Richards
- Department of Medicine, Christchurch Heart Institute, University of Otago Christchurch, Christchurch, New Zealand
- Cardiovascular Research Institute, National University of Singapore, Singapore, Singapore
- Department of Cardiology, Te Whatu Ora, Christchurch, New Zealand
| | - Christopher J. Pemberton
- Department of Medicine, Christchurch Heart Institute, University of Otago Christchurch, Christchurch, New Zealand
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Chew-Harris J, Kuan WS, Ibrahim I, Chan SP, Li Z, Liew OW, Appleby S, Frampton C, Troughton R, Chong JPC, Tan LL, Lin W, Ooi SBS, Richards AM, Pemberton CJ. Comparative performances of soluble urokinase plasminogen activator receptor and Mid-regional proADM to predict composite death and new heart failure rehospitalisation in acutely breathless patients. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Soluble urokinase plasminogen activator receptor (suPAR) is a pleotropic receptor, capable of orchestrating plaque vulnerability and vascular immune dysfunction. Mid-regional pro-adrenomedullin (MR-proADM) is the stable peptide precursor of adrenomedullin, with concentrations reflective of vasodilation and cardiac remodelling. We compared the prognostic performances of suPAR and MR-proADM for the composite clinical endpoint of death and new heart failure (HF) in patients with undifferentiated breathlessness.
Methods
Patients presenting to hospital with the primary complaint of acute dyspnoea were recruited in New Zealand (n=612) and in Singapore (n=483)]. Baseline plasma measurements were undertaken for suPAR (ViroGates) and MR-proADM (Thermo Scientific). Cardiac biomarker levels of NT-proBNP (Roche) was available on all patients. Statistical assessment was made using SPSS v28 (IBM), with all biomarkers treated as continuous variables and presented as median [interquartile range (IQR)]. Prognostic performance of suPAR, MR-proADM and NT-proBNP to predict the composite clinical endpoint of death/new HF at 90-days and 1-yr were assessed using receiver operator curve (ROC) area under the curve (AUC) analysis (Z-scores) and Cox hazard regression analysis (per doubling of biomarker concentrations) after adjustment for traditional risk factors. P-value <0.05 was considered statistically significant.
Results
In the entire acutely breathless cohort [median age: 65 years (IQR: 52.9–76.0), 63.1% males], 343/1095 of patients had the final adjudication of ADHF. suPAR and MR-proADM concentrations were higher with increasing age (Spearmans rho, r>0.46, P<0.0001), lower eGFR (r>0.58, P<0.0001) and in those with ADHF (r>0.40, P<0.0001). During the follow-up period, 122 patients were categorised with death/new HF by 90-days, rising to 281 at 1-year. suPAR and MR-proADM were able to predict death/new HF at 90-days (both ROC-AUC >0.77) and at 1-year (both ROC-AUC ≥0.78) (Table 1). All markers were however less accurate in predicting this endpoint in the presence of ADHF (ROC-AUC <0.71). After adjustment in Cox-regression modelling, suPAR obtained HR >1.35 per doubling of suPAR concentrations (P=0.001) for outcomes at 90-days and at 1-year (Table 2), achieving the highest prognostic performance for this clinical endpoint, followed by NT-proBNP (HR >1.29) (Table 2), whilst MR-proADM was not an independent predictor of death/HF in this cohort. suPAR was also an independent predictor of death/HF for patients with ADHF, obtaining HR >1.35 per doubling of concentrations. Above a cut-off concentration of 3.6 ng/mL, suPAR was associated with a HR of 2.1 (95% CI: 1.55–2.91) for death/HF at 1-year for acutely dyspnoeic patients.
Conclusion
suPAR concentrations is superior than MR-proADM in predicting the clinical end-point of death/HF at 1-year in this cohort. It may aid in risk-stratification strategies for the management of acutely breathless patients.
Funding Acknowledgement
Type of funding sources: Foundation. Main funding source(s): National Heart Foundation of New ZealandHealth Research Council of New Zealand
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Affiliation(s)
- J Chew-Harris
- University of Otago Christchurch, Medicine , Christchurch , New Zealand
| | - W S Kuan
- National University Health System , Singapore , Singapore
| | - I Ibrahim
- National University Health System , Singapore , Singapore
| | - S P Chan
- National University Heart Centre , Singapore , Singapore
| | - Z Li
- National University Health System , Singapore , Singapore
| | - O W Liew
- National University Heart Centre , Singapore , Singapore
| | - S Appleby
- University of Otago Christchurch, Medicine , Christchurch , New Zealand
| | - C Frampton
- University of Otago Christchurch, Medicine , Christchurch , New Zealand
| | - R Troughton
- University of Otago Christchurch, Medicine , Christchurch , New Zealand
| | - J P C Chong
- National University Heart Centre , Singapore , Singapore
| | - L L Tan
- National University Heart Centre , Singapore , Singapore
| | - W Lin
- National University Heart Centre , Singapore , Singapore
| | - S B S Ooi
- National University Health System , Singapore , Singapore
| | - A M Richards
- University of Otago Christchurch, Medicine , Christchurch , New Zealand
| | - C J Pemberton
- University of Otago Christchurch, Medicine , Christchurch , New Zealand
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Lewis LK, Raudsepp SD, Whitlow JC, Appleby S, Pemberton CJ, Yandle TG, Mark Richards A. Assays Specific for BNP1-32 and NT-proBNP Exhibit a Similar Performance to Two Widely Used Assays in the Diagnosis of Heart Failure. Clin Chem 2022; 68:1292-1301. [PMID: 35932191 DOI: 10.1093/clinchem/hvac126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 06/29/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Secretion of cardioprotective B-type natriuretic peptide 1-32 (BNP1-32) is increased proportionately with cardiac dysfunction, but its measurement in plasma is difficult. Therefore, less specific BNP and amino-terminal proBNP (NT-proBNP) assays that detect the precursor molecule proBNP alongside BNP or NT-proBNP metabolites were developed to reflect BNP1-32 secretion and are now mandated in the diagnosis of heart failure (HF). We compared the diagnostic performance of 2 widely used clinical assays: the Roche proBNPII assay, and Abbott BNP assay, against our recently developed in-house assays that measure either intact BNP1-32 or NT-proBNP. METHODS EDTA plasma samples obtained from patients presenting with breathlessness (n = 195, 60 [31%] with clinically adjudicated HF) were assayed using the Roche NT-proBNP and our specific in-house BNP1-32 and NTBNP assays. A subset (n = 75) were also assessed with the Abbott BNP assay. RESULTS Roche NT-proBNP was highly correlated with BNP1-32 and NTBNP (Spearman rho = 0.92 and 0.90, respectively, both Ps < 0.001), and all 3 assays similarly discriminated acute HF from other causes of breathlessness (ROC analysis areas under the curve 0.85-0.89). The Abbott BNP assay performed similarly to the other assays. Roche NT-proBNP and BNP1-32 assays had similar sensitivity (83% and 80%), specificity (83% and 84%), positive (70% and 71%) and negative (91% and 90%) predictive values, and accuracy (both 83%) at their optimal cutoffs of 1536 and 12 ng/L, respectively. CONCLUSIONS Since all assays exhibited similar performance in the diagnosis of HF, currently mandated assays provide a reliable proxy for circulating concentrations of active BNP1-32 in HF diagnosis.
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Affiliation(s)
- Lynley K Lewis
- Christchurch Heart Institute, Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Sara D Raudsepp
- Christchurch Heart Institute, Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Joanna C Whitlow
- Christchurch Heart Institute, Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Sarah Appleby
- Christchurch Heart Institute, Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Christopher J Pemberton
- Christchurch Heart Institute, Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Timothy G Yandle
- Christchurch Heart Institute, Department of Medicine, University of Otago, Christchurch, New Zealand
| | - A Mark Richards
- Christchurch Heart Institute, Department of Medicine, University of Otago, Christchurch, New Zealand.,Cardiovascular Research Institute, National University Heart Centre, National University of Singapore, Singapore, Singapore
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Lewis L, Raudsepp S, Whitlow J, Appleby S, Pemberton C, Richards AM. Do more specific assays for B-type natriuretic peptides better predict heart failure in breathless patients than the currently used assays? Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehab849.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Heart Foundation of New Zealand Health Research Council of New Zealand
Introduction
The cardioprotective B-type natriuretic peptide (BNP1-32) and its inactive congener N-terminal proBNP1-76 (NTBNP1-76) are produced from their precursor peptide proBNP, proportionate to cardiac dysfunction, underpinning their now-universal endorsement as markers for heart failure (HF) diagnosis. ProBNP concentrations are also increased in patients with HF. BNP1-32 is difficult to measure in plasma due to its low concentration and short half-life. Thus, less specific BNP and NT-proBNP assays are routinely used in the diagnosis and prognosis of HF. However, these assays also variably detect proBNP, BNP metabolites, and glycosylated proBNP or glycosylated NT-proBNP. How well these assays compare to highly specific assays that only detect BNP1-32 or NTBNP1-76 has not been assessed.
Purpose
We will compare the performance of assays specific for BNP1-32 and NTBNP1-76 only with that of a less specific commercially available NT-proBNP assay that is widely used for the diagnosis of heart failure.
Methods
Plasma samples obtained from patients presenting to the Emergency Department with breathlessness (n = 195) were assayed using a commercially available NT-proBNP assay and our specific in-house BNP1-32 (1) and NTBNP1-76 (2) assays. The diagnostic performance for clinically adjudicated acute HF (AHF, 60/195 patients, 31%) was assessed for each assay using receiver operator curve (ROC) analysis.
Results
Median (IQR) concentrations (n = 195) of NT-proBNP (101.7 [29.7, 353] pmol/L) and NTBNP1-76 (108.6 [25, 442] pmol/L) were markedly higher than BNP1-32 concentrations (1.9 [0.3-6.6] pmol/L) (p < 0.001 for both comparisons). Peptide concentrations were higher in patients with heart failure (n = 60) than those without heart failure for NT-proBNP (559 [247,1097] vs 46 [16,123] pmol/L), NTBNP1-76 (441.9 [155,1205] vs 37.9 [15,131] pmol/L) and BNP1-32 (7.8 [4,17] vs 0.5 [0.2,2.4] pmol/L) (all P < 0.001).
NT-proBNP assay results were highly correlated with our specific NTBNP1-76 and BNP1-32 assays (Spearman’s rho = 0.91 and 0.92, respectively, both P < 0.001, n = 195).
NT-proBNP, NTBNP1-76 and BNP1-32 assays performed similarly in the diagnosis of AHF (AUC [95%CI] = 0.88 [0.84-0.93], 0.85 [0.79-0.91] and 0.89 [0.84-0.94] respectively (all p < 0.001).
Discussion
Despite the differences in assay specificity all 3 assays performed similarly in the diagnosis of AHF in patients presenting with breathlessness.
Conclusions
All three assays diagnosed heart failure similarly, providing evidence that the widely used NT-proBNP assay can reliably be used as a proxy for active BNP1-32 in the diagnosis of acute heart failure. Whether this less specific NT-proBNP assay and our specific NTBNP1-76 and BNP1-32 assays (i) offer similar prognostic information and whether (ii) their marker performance is differentially altered by common confounders including age, renal dysfunction, obesity and atrial fibrillation, remain to be ascertained.
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Affiliation(s)
- L Lewis
- University of Otago Christchurch, Christchurch, New Zealand
| | - S Raudsepp
- University of Otago Christchurch, Christchurch, New Zealand
| | - J Whitlow
- University of Otago Christchurch, Christchurch, New Zealand
| | - S Appleby
- University of Otago Christchurch, Christchurch, New Zealand
| | - C Pemberton
- University of Otago Christchurch, Christchurch, New Zealand
| | - A M Richards
- University of Otago Christchurch, Christchurch, New Zealand
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Chew-Harris J, Appleby S, Adamson P, Troughton R, Richards A, Pemberton C. Prognostic Performance of Soluble Urokinase Plasminogen Activator Receptor (suPAR) in Predicting Mortality in Asian and Western Patients With Acute Breathlessness. Heart Lung Circ 2021. [DOI: 10.1016/j.hlc.2021.05.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Holdaway M, Lewis L, Chew-Harris J, Richards M, Pemberton C, Appleby S. Erythroferrone can Diagnose Acute Decompensated Heart Failure in Patients Presenting With Breathlessness. Heart Lung Circ 2021. [DOI: 10.1016/j.hlc.2021.05.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Chew-Harris J, Appleby S, Adamson P, Troughton R, Richards A, Pemberton C. Soluble Urokinase Plasminogen Activator Receptor (suPAR) Predicts Mortality in Patients With Acute Chest Pain. Heart Lung Circ 2021. [DOI: 10.1016/j.hlc.2021.05.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Chew-Harris J, Appleby S, Troughton R, Richards A, Pemberton C. Soluble urokinase plasminogen activator receptor (suPAR) can predict long-term mortality in patients with acute chest pain. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.1695] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Soluble urokinase plasminogen activator receptor (suPAR) is an inflammatory protein associated with plaque instability. Its modulation may reflect on immune dysfunction related to cardiovascular disease burden. We describe the prognostic performance of suPAR in patients presenting with chest pain suspicious of acute myocardial infarction (AMI).
Methods
suPAR concentrations were measured at presentation using the ViroGates CE-marked ELISA in 812 patients with the primary complaint of acute chest pain. Standard cardiac markers including hsTnT and NT-proBNP (both Roche) were also measured. Data for all biomarkers were treated as continuous and expressed as median [interquartile range (IQR)]. Statistical assessment was made using SPSS v25 (IBM). Groups were compared by Mann-Whitney U test/Spearman's rho. Prognostic performance of suPAR was assessed using receiver operator curve (ROC) area under the curve (AUC), Cox-proportional hazards regression and Kaplan-Meier analyses.
Results
In this chest pain cohort [median age: 63 yrs (IQR: 54–74), 34% female], 156/812 of patients had adjudicated AMI [STEMI (n=22)/NSTEMI (n=134)]. Total all-cause mortality was 18% within 10 yrs. Although median suPAR concentrations were elevated in AMI patients versus all other diagnoses [3.2 ng/mL (IQR:2.4–4.3) vs 2.7 ng/mL (IQR:2.2–3.6) (P<0.0001)], it did not assist in AMI diagnosis (ROC-AUC=0.60). In the entire chest pain cohort, suPAR (AUC≥0.82) had comparable discrimination to that of NT-proBNP (AUC≥0.84) for the prediction of mortality within 2 yrs (n=52), 4 yrs (n=77) and 10 yrs (n=149), and was better than hsTnT (AUC≤0.70). Addition of suPAR improved the mortality ROC curve of NT-proBNP (0.84 to 0.87) and for hsTnT (0.70 to 0.81) for 2-yr death prediction (Figure). Alone, suPAR was the strongest predictor (AUC=0.77) of new unstable angina at 2-yrs (n=52). The fully adjusted hazard ratio (HR) using Cox models showed suPAR (HR: 1.2) and NT-proBNP (HR: 1.3) to be the only independent biomarkers associated with death at 4 and 10-yrs (P<0.0001). Stratification of baseline suPAR by Kaplan-Meier plots for all-cause mortality showed the highest tertile of suPAR, compared to the lowest, was associated with a HR of 5.7 and 5.1 for 4-yr and 10-yr death, respectively.
Conclusion
suPAR is a strong prognostic indicator of long-term mortality and its usage alongside current cardiac biomarkers may assist in the risk stratification of AMI patients.
Funding Acknowledgement
Type of funding source: Foundation. Main funding source(s): Health Research Council of New Zealand, National Heart Foundation of New Zealand
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Affiliation(s)
- J Chew-Harris
- University of Otago Christchurch, Medicine, Christchurch, New Zealand
| | - S Appleby
- University of Otago Christchurch, Medicine, Christchurch, New Zealand
| | - R.W Troughton
- University of Otago Christchurch, Medicine, Christchurch, New Zealand
| | - A.M Richards
- University of Otago Christchurch, Medicine, Christchurch, New Zealand
| | - C.J Pemberton
- University of Otago Christchurch, Medicine, Christchurch, New Zealand
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11
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Chew-Harris J, Appleby S, Troughton R, Richards A, Pemberton C. Soluble urokinase plasminogen activator receptor (suPAR) predicts 2-year cardiovascular events in patients after acute chest pain. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.1696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Soluble urokinase plasminogen activator receptor (suPAR) is an emerging biomarker of sub-inflammation related to plaque instability. Its modulation may reflect on immune dysfunction related to cardiovascular (CVD) outcomes. We assessed the prognostic performance of suPAR to predict 2-year clinical outcomes in patients with acute chest pain, suspicious of acute coronary syndromes.
Methods
A total of 812 patients presenting to the emergency department with the primary complaint of acute chest pain were prospectively recruited. Baseline suPAR concentrations were measured at presentation using the ViroGates CE-marked ELISA. Standard cardiac markers including hsTnT and NT-proBNP (both Roche) were also measured. Data for all biomarkers were treated as continuous and expressed as median [interquartile range (IQR)]. Statistical assessment was made using SPSS v25 (IBM). Groups were compared by Mann-Whitney U test/Spearman's rho. Prognostic performance of suPAR in comparison with hsTnT and NT-proBNP to predict the primary outcomes of new myocardial infarction (MI), new heart failure (HF), all cause readmission, and the composite of major adverse cardiac events (MACE) were assessed using binary logistic regression after the adjustment of traditional risk factors.
Results
In the entire chest pain cohort [median age: 63 yrs (IQR: 54–74), 34% female], 156/812 of patients had adjudicated AMI [STEMI (n=22)/NSTEMI (n=134)]. suPAR concentrations were found to be lower in males (Spearman's Rho, r=−0.17, P<0.0001) and in those with eGFR ≥60mL/min/1.73m2 (n=439) (r=−0.40, P<0.0001), but elevated in those older than 65 years (n=372) (r=0.55, P<0.0001). During the 2-year follow-up period, there were 54 fatalities, 287 recorded as having new CVD events, 46 diagnosed with new heart failure, 71 with new MI (66 NSTEMI/5 STEMI), 54 with new unstable angina, 126 patients classified with MACE and 190 patients who were readmitted into hospital within 1-year from presentation. In logistic regression analyses, the odds ratio (OR) of suPAR; 8.5 (95% CI:1.8–40.9) to predict a 2-year event (for example new total CVD events) was stronger than hsTnT; OR: 1.2 (95% CI: 0.9–1.5) and NT-proBNP; OR: 0.8 (95% CI:0.8–1.3) (P<0.0001) (Figure). Further, incorporation of baseline suPAR values into multivariate models for predicting events, such as MACE at 2-years (adjusted for age, gender and eGFR), resulted in an improvement in the C-statistic from 0.72 to 0.76.
Conclusion
In this acute chest pain cohort, suPAR concentrations are independent predictors of cardiovascular outcomes at 2 years. suPAR may add value in the risk assessment of patients with acute chest pain.
Funding Acknowledgement
Type of funding source: Foundation. Main funding source(s): Health Research Council of New Zealand, National Heart Foundation of New Zealand
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Affiliation(s)
- J Chew-Harris
- University of Otago Christchurch, Medicine, Christchurch, New Zealand
| | - S Appleby
- University of Otago Christchurch, Medicine, Christchurch, New Zealand
| | - R.W Troughton
- University of Otago Christchurch, Medicine, Christchurch, New Zealand
| | - A.M Richards
- University of Otago Christchurch, Medicine, Christchurch, New Zealand
| | - C.J Pemberton
- University of Otago Christchurch, Medicine, Christchurch, New Zealand
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12
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Chew-Harris J, Appleby S, Kuan W, Ibrahim I, Chan S, Li Z, Liew O, Frampton C, Troughton R, Chong J, Tan L, Lin W, Ooi S, Richards A, Pemberton C. Prognostic performance of soluble urokinase plasminogen activator receptor for 1-year mortality in Asian and Western patients with acute breathlessness. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.1202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Soluble urokinase plasminogen activator receptor (suPAR) is a pleotropic receptor, capable of orchestrating plaque vulnerability and vascular immune dysfunction. We have previously reported on the prognostic ability of suPAR in cardiovascular disease (CVD). However the performance of suPAR to predict death in an Asian population with undifferentiated breathlessness has not been described.
Methods
Patients presenting to hospital with the primary complaint of breathlessness were recruited according to identical criteria in New Zealand [(NZ), n=612] and in Singapore (n=483)]. Baseline measurements of suPAR plasma concentrations were undertaken with a CE-marked ELISA (ViroGates). NT-proBNP, hsTnT (both Roche) and standard biochemistry analytes were also measured. Statistical assessment was made using SPSS v25 (IBM), with all biomarkers treated as continuous variables and presented as median [interquartile range (IQR)]. Group comparisons were made by Mann-Whitney U test. Prognostic performance of suPAR, NT-proBNP and hsTnT for 1-yr mortality prediction was assessed using receiver operator curve (ROC) area under the curve (AUC) analysis (Z-scores) and Cox hazard regression analysis (log-values). P-value <0.05 was considered significant.
Results
The adjudicated diagnosis of ADHF was more common in NZ than in Singapore (37 vs. 25%, P<0.0001) in concordance with the higher median age (16 yrs older) of NZ patients and poorer kidney function. Diabetes was however more prevalent amongst Singaporean patients. There were a total of 143 deaths [NZ, n=113 (18%); Singapore, n=30 (6%)] within 1 year from hospital admission. In both cohorts, median suPAR concentrations were higher in those who died vs those who survived (P<0.0001) (Figure). For the Singapore cohort, suPAR (AUC=0.85) discriminated 1-yr mortality better than hs-TnT (AUC=0.78) and NT-proBNP (AUC=0.79). For the NZ cohort, suPAR (AUC=0.71) was similar to hs-TnT (AUC=0.73) and NT-proBNP (AUC=0.69) for 1-yr death prediction. In the combined cohort, after the adjustment of conventional risk factors, suPAR (P=0.007) was the superior biomarker for 1-year death prediction in the subgroup of ADHF patients only (n=51/343). suPAR concentrations above a cut-off value of 3.1 ng/mL, were associated with hazard ratios of 7.4 (95% CI:1.6–17.4) (P=0.009) for Singapore patients and 2.8 (95% CI:1.5–5.3) (P=0.001) for NZ patients for death within 1 year.
Conclusion
This is a first report confirming the strong prognostic ability of suPAR in mortality prediction for acutely breathless patients in an Asian population despite the presence of several demographic and clinical differences compared to a Western population. The inclusion of suPAR may add value to risk stratification models in acutely dyspnoeic patients.
suPAR concentrations in 1-yr outcomes
Funding Acknowledgement
Type of funding source: Foundation. Main funding source(s): Health Research Council of New Zealand, National Heart Foundation of New Zealand
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Affiliation(s)
- J Chew-Harris
- University of Otago Christchurch, Medicine, Christchurch, New Zealand
| | - S Appleby
- University of Otago Christchurch, Medicine, Christchurch, New Zealand
| | - W.S Kuan
- National University Hospital, Singapore, Singapore
| | - I Ibrahim
- National University Hospital, Singapore, Singapore
| | - S.P Chan
- National University Heart Centre, Singapore, Singapore
| | - Z Li
- National University Health System, Singapore, Singapore
| | - O.W Liew
- National University Heart Centre, Singapore, Singapore
| | - C Frampton
- University of Otago Christchurch, Medicine, Christchurch, New Zealand
| | - R.W Troughton
- University of Otago Christchurch, Medicine, Christchurch, New Zealand
| | - J.P.C Chong
- National University Heart Centre, Singapore, Singapore
| | - L.L Tan
- National University Heart Centre, Singapore, Singapore
| | - W Lin
- National University Heart Centre, Singapore, Singapore
| | - S.B.S Ooi
- National University Hospital, Singapore, Singapore
| | - A.M Richards
- University of Otago Christchurch, Medicine, Christchurch, New Zealand
| | - C.J Pemberton
- University of Otago Christchurch, Medicine, Christchurch, New Zealand
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13
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Appleby S, Chew-Harris J, Troughton RW, Richards AM, Pemberton CJ. Analytical and biological assessment of circulating human erythroferrone. Clin Biochem 2020; 79:41-47. [PMID: 32032568 DOI: 10.1016/j.clinbiochem.2020.02.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 01/16/2020] [Accepted: 02/03/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND Erythroferrone (ERFE) is an erythroid hormone putatively involved in stress erythropoiesis. Its regional clearance and circulating form in humans, as well as levels in normal health and coronary disease remain unclear. METHODS To establish a reference interval, ERFE was measured in 155 healthy volunteers using the Intrinsic LifeSciences ELISA. To identify trans-organ gradients in ERFE, regional blood sampling was undertaken in patients (n = 13) undergoing clinically indicated cardiac catheterisation. The Intrinsic ELISA was assessed for reproducibility, stability, linearity and possible cross-reactivity, interference and anticoagulant effects. Circulating forms of ERFE were evaluated by HPLC. RESULTS In healthy individuals, the median concentration of ERFE was 0.51 ng/mL (IQR: 0.12-1.25), with men (n = 78) having higher levels than women (n = 77) (0.67 vs 0.32 ng/mL, p = 0.0001). ERFE concentrations in trans-organ sampling revealed no clear organ of clearance or production. Samples with high endogenous ERFE levels were suppressed by haemoglobin (≥2 g/L), bilirubin (≥200 µmol/L), lipaemia (>1 g/L), and freeze thawing (≥2 cycles), but this was not observed with low ERFE concentrations. Endogenous ERFE immunoreactivity was 46% higher in EDTA plasma compared with serum and lithium heparin plasma. On SE-HPLC, ERFE eluted as intact and cleaved forms. CONCLUSION We provide a useful reference range for ERFE in EDTA plasma. We found no specific site of secretion or clearance. The Intrinsic ELISA performed adequately but is limited by interference and stability when endogenous levels are high. Circulating forms are multiple and complex.
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Affiliation(s)
- Sarah Appleby
- Christchurch Heart Institute, University of Otago, 2 Riccarton Avenue, Christchurch 8011, New Zealand.
| | - Janice Chew-Harris
- Christchurch Heart Institute, University of Otago, 2 Riccarton Avenue, Christchurch 8011, New Zealand.
| | - Richard W Troughton
- Christchurch Heart Institute, University of Otago, 2 Riccarton Avenue, Christchurch 8011, New Zealand; Department of Cardiology, Canterbury District Health Board, 2 Riccarton Avenue, Christchurch 8011, New Zealand.
| | - A Mark Richards
- Christchurch Heart Institute, University of Otago, 2 Riccarton Avenue, Christchurch 8011, New Zealand; Department of Cardiology, Canterbury District Health Board, 2 Riccarton Avenue, Christchurch 8011, New Zealand; Cardiovascular Research Institute, National University of Singapore, 1E Kent Ridge Road, 119228, Singapore.
| | - Christopher J Pemberton
- Christchurch Heart Institute, University of Otago, 2 Riccarton Avenue, Christchurch 8011, New Zealand.
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14
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Delgadillo J, Appleby S, Booth S, Burnett G, Carey A, Edmeade L, Green S, Griffin P, Johnson E, Jones R, Parker P, Reeves-McLaren L, Lutz W. The Leeds Risk Index: Field-Test of a Stratified Psychological Treatment Selection Algorithm. Psychother Psychosom 2020; 89:189-190. [PMID: 31940642 DOI: 10.1159/000505193] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Accepted: 12/02/2019] [Indexed: 11/19/2022]
Affiliation(s)
- Jaime Delgadillo
- Clinical Psychology Unit, Department of Psychology, University of Sheffield, Sheffield, United Kingdom,
| | - Sarah Appleby
- Leeds Community Healthcare NHS Trust, Leeds, United Kingdom
| | - Sarah Booth
- Leeds Community Healthcare NHS Trust, Leeds, United Kingdom
| | | | - Amy Carey
- Northpoint Wellbeing, Leeds, United Kingdom
| | - Laura Edmeade
- Leeds Community Healthcare NHS Trust, Leeds, United Kingdom
| | | | - Pat Griffin
- Leeds Community Healthcare NHS Trust, Leeds, United Kingdom
| | - Emma Johnson
- Leeds Community Healthcare NHS Trust, Leeds, United Kingdom
| | - Robert Jones
- Leeds Community Healthcare NHS Trust, Leeds, United Kingdom
| | | | | | - Wolfgang Lutz
- Department of Psychology, University of Trier, Trier, Germany
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15
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Pemberton CJ, Lee JA, Aldous S, Appleby S, Chew-Harris J, Than M, Troughton RW, Richards AM. P3408The signal peptide of CNP is a novel predictor of MI, MACE and bleeding risk in chest pain patients. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz745.0283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Aim
CNP is an important vascular and cardiac derived member of the natriuretic peptide family. We have previously provided the first reports that the signal peptide of CNP (CNPsp) is present in the human circulation and is elevated in those with chest pain suspicious of ACS. Here, show that CNPsp levels are highly predictive of new MI, MACE and post-index bleeding in patients presenting with potential ACS.
Methods
We prospectively recruited 493 patients presenting with the primary complaint of acute chest pain to our hospital ED. Patients were adjudicated as ACS by 2 independent cardiologists in accordance with ESC guidelines with hsTnI as biomarker. Plasma EDTA samples taken at presentation and 2 hours after were interrogated for CNPsp measurements using our validated, specific assay. Clinical data/variables, standard biochemistry analytes, hsTnT and NT-proBNP (both Roche Cobas e411) were also measured. Statistical assessments were made using SPSS v23. Data for all biomarkers were treated as continuous variables and are presented as median (interquartile range, (IQR)). Statistical assessment of the comparative abilities of CNPsp, hsTnT, NT-proBNP and hsTnI (log values) to predict new MACE, MI, bleeding and mortality within 2 yrs of index presentation was undertaken using a logistic regression base model (95% CI) that included all clinical variables and hsTnI and hsTnT and NT-proBNP, with CNPsp added to into the multivariate analyses.
Results
Of the 493 recruited patients (median age 63 (IQR: 54–73, 35% female), 148 were adjudicated to have ACS (30%, 109 MI, 39 UAP). Presentation CNPsp levels were not higher in those with adjudicated ACS versus non-ACS (51, (45–65) vs. 50, (42–63) pmol/L, P=0.412), did not correlate with hsTnI, hsTnT or NT-proBNP, but were significantly lower in those with a history of MI (49, (42–59) vs. 51, (43–64) pmol/L, P=0.044). In contrast, they were significantly higher in those with ECG ST-depression (56, (47–85) vs. 50 (42–62) pmol/L, P=0.038). In the multivariate regression model of all 493 patients, lower values of CNPsp were a significant multivariate predictor of new MI (n=37, 95% CI: 0.06–0.89, P=0.038), MACE (n=64, 95% CI: 0.08–0.81, P=0.020) and new bleeding (n=40, 95% CI: 0.05–0.63, P=0.005) within 2 years of presentation. This predictive ability was additive and independent from NT-proBNP and troponin.
Conclusion
This is the first report that CNPsp measurement provides meaningful and independent risk assessment of important outcomes in ACS patients. In particular, the fact that lower levels of CNPsp are predictive of negative MI, MACE and bleeding outcomes suggests that CNPsp may have an unappreciated protective role in the cardiovascular system.
Acknowledgement/Funding
Health Research Council of New Zealand; Heart Foundation of New Zealand
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Affiliation(s)
- C J Pemberton
- University of Otago, Christchurch School of Medicine & Health Sciences, Christchurch, New Zealand
| | - J A Lee
- University of Otago, Christchurch School of Medicine & Health Sciences, Christchurch, New Zealand
| | - S Aldous
- Christchurch Hospital, Christchurch, New Zealand
| | - S Appleby
- University of Otago, Christchurch School of Medicine & Health Sciences, Christchurch, New Zealand
| | - J Chew-Harris
- University of Otago, Christchurch School of Medicine & Health Sciences, Christchurch, New Zealand
| | - M Than
- Christchurch Hospital, Christchurch, New Zealand
| | - R W Troughton
- University of Otago, Christchurch School of Medicine & Health Sciences, Christchurch, New Zealand
| | - A M Richards
- University of Otago, Christchurch School of Medicine & Health Sciences, Christchurch, New Zealand
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Chew-Harris JS, Appleby S, Richards AM, Troughton RW, Pemberton CJ. P2616Soluble urokinase plasminogen activator receptor (suPAR) predicts 1 year mortality in patients with acute breathlessness. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.0939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Aim
Soluble urokinase plasminogen activator receptor (suPAR) is a pleotropic receptor, capable of orchestrating plaque vulnerability and vascular immune dysfunction. Its concentration in circulation may reflect on CVD associated burden. We examined the prognostic ability of suPAR to predict death in patients suspicious of ADHF.
Methods
suPAR measurements were undertaken with a CE-marked ELISA (ViroGates) in 444 patients presenting to hospital with the primary complaint of breathlessness to our hospital ED. A second sample at 12–48 hours post ED admission was available for 378 patients. Standard biochemistry analytes; MR-proADM (BRAHMS), NTproBNP and hsTnT (both Roche) were also measured. Statistical assessment was made using SPSS v25 (IBM), with all biomarkers treated as continuous variables and presented as median [interquartile range (IQR)]. Group comparisons were made by Mann-Whitney U test. The singular or combined clinical performances of suPAR, NT-proBNP, hsTnT and MR-proADM were assessed using receiver operator curve (ROC) area under the curve (AUC) (Z-scores) and Cox hazard regression (log-values) analyses. P-value <0.05 was considered significant.
Results
In the breathless cohort [median age 72 yrs (IQR: 62–81, 43% female)], 35.1% had ADHF and 94/444 patients died within the 1st yr of ED presentation. In those who died within this 1st yr, median suPAR concentrations at both time-points; 5.2 ng/mL (IQR: 2.8–5.5) vs. 5.1 ng/mL (IQR: 1.7–2.3) were higher than those who did not die (3.5 ng/mL; IQR: 2.7–5.1) (P<0.0001). Plasma suPAR, for both time points, respectively, could predict death at 30d (n=22, ROC-AUC = 0.77 and 0.76), 90d (n=41, ROC-AUC = 0.77 and 0.75) and 1 yr (ROC-AUC = 0.73 and 0.72). Improvement in 90d mortality prediction was achieved with the inclusion of suPAR in models; for e.g. using ED values, for NTproBNP; ROC-AUC of 0.67 increased to 0.71, for hsTnT; ROC-AUC of 0.69 to 0.76, and for MR-proADM, ROC-AUC of 0.72 to 0.75. Both suPAR time-points (ROC-AUC 0.70) could predict 1 yr new heart failure (HF) (n=68) but did not assist in improving HF prediction when used in combination with NT-proBNP, hsTnT or MR-proADM. After adjustment for conventional risk factors, Cox hazard regression analyses however revealed suPAR as the only biomarker capable of predicting 1 yr mortality (P=0.005) with hazard ratios of 2.8 (CI: 1.4–5.9) and 3.5 (CI: 1.1–11.3) for the ED and inpatient time-points, respectively. In terms of best window for prognostic assessment, suPAR concentrations at ED, outperformed the inpatient concentrations as the superior time-point in predicting 1 yr mortality.
Conclusion
suPAR exhibits excellent prognostic ability in mortality prediction, proving better than NTproBNP, hsTnT and MR-proADM in acutely breathless patients. The usage of suPAR in complementary with current candidate cardiac biomarkers could dramatically improve the prognostic tools available to guide risk management in HF.
Acknowledgement/Funding
New Zealand Heart Foundation, Health Research Council of New Zealand
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Affiliation(s)
- J S Chew-Harris
- University of Otago Christchurch, Medicine, Christchurch, New Zealand
| | - S Appleby
- University of Otago Christchurch, Medicine, Christchurch, New Zealand
| | - A M Richards
- University of Otago Christchurch, Medicine, Christchurch, New Zealand
| | - R W Troughton
- University of Otago Christchurch, Medicine, Christchurch, New Zealand
| | - C J Pemberton
- University of Otago Christchurch, Medicine, Christchurch, New Zealand
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17
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Chew-Harris J, Appleby S, Richards AM, Troughton RW, Pemberton CJ. Analytical, biochemical and clearance considerations of soluble urokinase plasminogen activator receptor (suPAR) in healthy individuals. Clin Biochem 2019; 69:36-44. [PMID: 31129182 DOI: 10.1016/j.clinbiochem.2019.05.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 05/21/2019] [Accepted: 05/22/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND Soluble urokinase plasminogen activator receptor (suPAR) is an emerging marker of cardiovascular disease burden. Appropriate assessment of assay performance and reference interval are required to enable interpretation of results to facilitate its clinical application. METHODS suPAR was measured using the suPARnostic® ELISA in 155 healthy volunteers. Assay performance was assessed for anticoagulant effect, recovery, interference, linearity and cross-reactivity. The identity of immunoreactive suPAR was confirmed by size-exclusion HPLC. To establish anatomical sites of release and uptake, we measured suPAR in regional samples from subjects undergoing cardiac catheterization. RESULTS The median concentration of suPAR was 2.1 ng/mL (IQR:1.7-2.3) in health. In comparison with EDTA, suPAR measurements were affected by lithium heparin (>10% change) and increased with serum usage. suPAR reactivity also increased in the presence of haemolysis (10 g/L), but was suppressed with urokinase and lipids (4 g/L). In multiple regression analyses, suPAR associated independently with body weight, NT-proBNP and MR-proADM (P = .03) for healthy individuals. Regional plasma sampling showed lower suPAR concentrations in the coronary sinus and renal vein compared with concentrations in femoral arterial samples. Immunoreactive circulating suPAR species had Mr of 10-39 kDa. CONCLUSION The suPARnostic® assay performs acceptably for a clinical assay but is limited in the presence of high levels of hemolysis, lipids and urokinase. We provide the first evidence for the heart and kidneys as organs of suPAR clearance in humans. Additional investigations are warranted to determine whether there is a need to compare the marker performance of differing circulating forms of suPAR.
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Affiliation(s)
- Janice Chew-Harris
- Christchurch Heart Institute, University of Otago, Christchurch, New Zealand.
| | - Sarah Appleby
- Christchurch Heart Institute, University of Otago, Christchurch, New Zealand
| | - A Mark Richards
- Christchurch Heart Institute, University of Otago, Christchurch, New Zealand; Cardiovascular Research Institute, National University of Singapore, Singapore; Department of Cardiology, Canterbury District Health Board, Christchurch, New Zealand
| | - Richard W Troughton
- Christchurch Heart Institute, University of Otago, Christchurch, New Zealand; Department of Cardiology, Canterbury District Health Board, Christchurch, New Zealand
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18
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Appleby S, Pearson JF, Aitchison A, Spittlehouse JK, Joyce PR, Kennedy MA. Mean telomere length is not associated with current health status in a 50-year-old population sample. Am J Hum Biol 2016; 29. [DOI: 10.1002/ajhb.22906] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Revised: 04/28/2016] [Accepted: 08/04/2016] [Indexed: 01/21/2023] Open
Affiliation(s)
- Sarah Appleby
- Gene Structure and Function Laboratory; Department of Pathology; University of Otago; Christchurch New Zealand
| | - John F. Pearson
- Biostatistics and Computational Biology Unit; University of Otago; Christchurch New Zealand
| | - Alan Aitchison
- Gene Structure and Function Laboratory; Department of Pathology; University of Otago; Christchurch New Zealand
| | | | - Peter R. Joyce
- Department of the Dean; University of Otago; Christchurch New Zealand
| | - Martin A. Kennedy
- Gene Structure and Function Laboratory; Department of Pathology; University of Otago; Christchurch New Zealand
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Garcia-Martinez V, Lopez Sanchez C, Hamed W, Hamed W, Hsu JH, Ferrer-Lorente R, Alshamrani M, Pizzicannella J, Vindis C, Badi I, Korte L, Voellenkle C, Niculescu LS, Massaro M, Babaeva AR, Da Silva F, Woudstra L, Berezin A, Bae MK, Del Giudice C, Bageghni SA, Krobert K, Levay M, Vignier N, Ranieri A, Magenta A, Orlandi A, Porro B, Jeon ES, Omori Y, Herold J, Barnett GA, Grochot-Przeczek A, Korpisalo P, Deffge C, Margariti A, Rong W, Maring JA, Gambardella J, Mitrofan CG, Karpinska O, Morbidelli L, Wilkinson FL, Berezin A, Kostina AS, De Mey JGR, Kumar A, Lupieri A, Pellet-Many C, Stamatiou R, Gromotowicz A, Dickhout A, Murina M, Roka-Moiia YM, Malinova L, Diaz-Canestro C, Vigliarolo T, Cuzzocrea S, Szantai A, Medic B, Cassambai S, Korda A, Revnic CR, Borile G, Diokmetzidou A, Murfitt L, Budko A, Fiordelisi A, De Wijs-Meijler DPM, Gevaert AB, Noriega De La Colina A, Benes J, Guillermo Solache Berrocal GSB, Gafarov V, Zhebel VM, Prakaschandra R, Stepien EL, Smith LE, Carluccio MA, Timasheva Y, Paci M, Dorofeyeva NA, Chimed CH, Petelina TI, Sorop O, Genis A, Parepa IR, Tscharre M, Krestjyaninov MV, Maia-Rocha C, Borges L, Sasonko ML, Kapel SS, Stam K, Sommariva E, Stojkovic S, O'reilly J, Chiva-Blanch G, Malinova L, Evtushenko A, Skopal J, Sunderland N, Gegenava T, Charnaia MA, Di Lascio N, Tarvainen SJ, Malandraki-Miller S, Uitterdijk A, Benzoni P, Ruivo E, Humphrey EJ, Arokiaraj MC, Franco D, Garcia-Lopez V, Aranega A, Lopez-Sanchez C, Franco D, Garcia-Lopez V, Aranega A, Garcia-Martinez V, Tayel S, Khader H, El-Helbawy N, Tayel S, Alrefai A, El-Barbary H, Wu JR, Dai ZK, Yeh JL, Sanjurjo-Rodriguez C, Richaud-Patin Y, Blanco FJ, Badimon L, Raya A, Cahill PA, Diomede F, Merciaro I, Trubiani O, Nahapetyan H, Swiader A, Faccini J, Boya P, Elbaz M, Zeni F, Burba I, Bertolotti M, Capogrossi MC, Pompilio G, Raucci A, Widmer-Teske R, Dutzmann J, Bauersachs J, Donde K, Daniel JM, Sedding DG, Simionescu N, Sanda GM, Carnuta MG, Stancu CS, Popescu AC, Popescu MR, Vlad A, Dimulescu DR, Sima AV, Scoditti E, Pellegrino M, Calabriso N, Carluccio MA, Storelli C, De Caterina R, Solodenkova KS, Kalinina EV, Usachiova MN, Lappalainen J, Lee-Rueckert MDEC, Kovanen PT, Biesbroek PS, Emmens RWE, Van Rossum AC, Juffermans LJM, Niessen JWM, Krijnen PAJ, Kremzer A, Samura T, Berezina T, Gronenko E, Kim MK, Park HJ, Bae SK, Sorriento D, Ciccarelli M, Vernieri E, Campiglia P, Trimarco B, Iaccarino G, Hemmings KE, Porter KE, Ainscough JF, Drinkhill MJ, Turner NA, Hiis HG, Cosson MV, Levy FO, Wieland T, Macquart C, Chatzifrangkeskou M, Evans A, Bonne G, Muchir A, Kemp E, Avkiran M, Carlomosti F, D'agostino M, Beji S, Zaccagnini G, Maimone B, Di Stefano V, De Santa F, Cordisco S, Antonini A, Ciarapica R, Dellambra E, Martelli F, Avitabile D, Capogrossi MC, Scioli MG, Bielli A, Agostinelli S, Tarquini C, Tarallo V, De Falco S, Zaninoni A, Fiorelli S, Bianchi P, Teruzzi G, Squellerio I, Turnu L, Lualdi A, Tremoli E, Cavalca V, Lee YJ, Ju ES, Choi JO, Lee GY, Lim BK, Manickam MANOJ, Jung SH, Omiya S, Otsu K, Deffge C, Nowak S, Wagner M, Braun-Dullaeus RC, Kostin S, Daniel JM, Francke A, Subramaniam S, Kanse SM, Al-Lamee K, Schofield CJ, Egginton S, Gershlick AH, Kloska D, Kopacz A, Augustyniak A, Dulak J, Jozkowicz A, Hytonen J, Halonen P, Taavitsainen J, Tarvainen S, Hiltunen T, Liimatainen T, Kalliokoski K, Knuuti J, Yla-Herttuala S, Wagner M, Weinert S, Isermann B, Lee J, Braun-Dullaeus RC, Herold J, Cochrane A, Kelaini S, Bojdo J, Vila Gonzalez M, Hu Y, Grieve D, Stitt AW, Zeng L, Xu Q, Margariti A, Reglin B, Xiang W, Nitzsche B, Maibier M, Pries AR, Vrijsen KR, Chamuleau SAJ, Verhage V, Metz CHG, Lodder K, Van Eeuwijk ECM, Van Dommelen SM, Doevendans PA, Smits AM, Goumans MJ, Sluijter JPG, Sorriento D, Bova M, Loffredo S, Trimarco B, Iaccarino G, Ciccarelli M, Appleby S, Morrell N, Baranowska-Kuczko M, Kloza M, Ambrozewicz E, Kozlowski M, Malinowska B, Kozlowska H, Monti M, Terzuoli E, Ziche M, Mahmoud AM, Jones AM, Wilkinson JA, Romero M, Duarte J, Alexander MY, Kremzer A, Berezina T, Gronenko E, Faggian G, Kostareva AA, Malashicheva AB, Leurgans TM, Nguyen TN, Irmukhamedov A, Riber LP, Mcgeogh R, Comer S, Blanco Fernandez A, Ghigo A, Blaise R, Smirnova NF, Malet N, Vincent P, Limon I, Gayral S, Hirsch E, Laffargue M, Mehta V, Zachary I, Aidonidis I, Kramkowski K, Miltyk W, Kolodziejczyk P, Gradzka A, Szemraj J, Chabielska E, Dijkgraaf I, Bitsch N, Van Hoof S, Verhaegen F, Koenen R, Hackeng TM, Roshchupkin DI, Buravleva KV, Sergienko VI, Zhernossekov DD, Rybachuk VM, Grinenko TV, Furman N, Dolotovskaya P, Shamyunov M, Denisova T, Reiner M, Akhmedov A, Keller S, Miranda M, Briand S, Barile L, Kullak-Ublick G, Luscher T, Camici G, Guida L, Magnone M, Ameri P, Lazzarini E, Fresia C, Bruzzone S, Zocchi E, Di Paola R, Cordaro M, Crupi R, Siracusa R, Campolo M, Bruschetta G, Fusco R, Pugliatti P, Esposito E, Paloczi J, Ruivo E, Gaspar R, Dinnyes A, Kobolak J, Ferdinandy P, Gorbe A, Todorovic Z, Krstic D, Savic Vujovic K, Jovicic D, Basta Jovanovic G, Radojevic Skodric S, Prostran M, Dean S, Mee CJ, Harvey KL, Hussain A, Pena C, Paltineanu B, Voinea S, Revnic F, Ginghina C, Zaglia T, Ceriotti P, Campo A, Carullo P, Armani A, Coppini R, Vida V, Olivotto I, Stellin G, Rizzuto R, De Stefani D, Sandri M, Catalucci D, Mongillo M, Soumaka E, Kloukina I, Tsikitis M, Makridakis M, Varela A, Davos C, Vlachou A, Capetanaki Y, Iqbal MM, Bennett H, Davenport B, Pinali C, Cooper G, Cartwright E, Kitmitto A, Strutynska NA, Mys LA, Sagach VF, Franco A, Sorriento D, Trimarco B, Iaccarino G, Ciccarelli M, Verzijl A, Stam K, Van Duin R, Reiss IKM, Duncker DJ, Merkus D, Shakeri H, Orije M, Leloup AJ, Van Hove CE, Van Craenenbroeck EM, De Meyer GRY, Vrints CJ, Lemmens K, Desjardins-Creapeau L, Wu R, Lamarre-Cliche M, Larochelle P, Bherer L, Girouard H, Melenovsky M, Kvasilova A, Benes J, Ruskova K, Sedmera D, Ana Barral ABV, Martin Fernandez M, Pablo Roman Garcia PRG, Juan Carlos Llosa JCLL, Manuel Naves Diaz MND, Cesar Moris CM, Jorge B Cannata-Andia JBCA, Isabel Rodriguez IR, Voevoda M, Gromova E, Maximov V, Panov D, Gagulin I, Gafarova A, Palahniuk H, Pashkova IP, Zhebel NV, Starzhynska OL, Naidoo DP, Rawojc K, Enguita FJ, Grudzien G, Cordwell SJ, White MY, Massaro M, Scoditti E, Calabriso N, Pellegrino M, Martinelli R, Gatta V, De Caterina R, Nasibullin TR, Erdman VV, Tuktarova IA, Mustafina OE, Hyttinen J, Severi S, Vorobyov GG, Sagach VF, Batmyagmar KH, Lkhagvasuren Z, Gapon LI, Musikhina NA, Avdeeva KS, Dyachkov SM, Heinonen I, Van Kranenburg M, De Beer VJ, Octavia Y, Van Geuns RJ, Van Den Meiracker AH, Van Der Velden J, Merkus D, Duncker DJ, Everson FP, Ogundipe T, Grandjean T, De Boever P, Goswami N, Strijdom H, Suceveanu AI, Suceveanu AP, Mazilu L, Tofoleanu DE, Catrinoiu D, Rohla M, Hauser C, Huber K, Wojta H, Weiss TW, Melnikova MA, Olezov NV, Gimaev RH, Khalaf H, Ruzov VI, Adao R, Mendes-Ferreira P, Santos-Ribeiro D, Rademaker M, Leite-Moreira AF, Bras-Silva C, Alvarenga LAA, Falcao RSP, Dias RR, Lacchini S, Gutierrez PS, Michel JB, Gurfinkel YUI, Atkov OYU, Teichert M, Korn C, Mogler C, Hertel S, Arnold C, Korff T, Augustin HG, Van Duin RWB, De Wijs-Meijler DPM, Verzijl A, Duncker DJ, Merkus D, D'alessandra Y, Farina FM, Casella M, Catto V, Carbucicchio C, Dello Russso A, Stadiotti I, Brambilla S, Chiesa M, Giacca M, Colombo GI, Pompilio G, Tondo C, Ahlin F, Andric T, Tihanyi D, Wojta J, Huber K, O'connell E, Butt A, Murphy L, Pennington S, Ledwidge M, Mcdonald K, Baugh J, Watson C, Suades R, Crespo J, Estruch R, Badimon L, Dyachenko A, Ryabukho V, Evtushenko V, Saushkina YU, Lishmanov YU, Smyshlyaev K, Bykov A, Popov S, Pavlyukova E, Anfinogenova Y, Szigetfu E, Kapornai B, Forizs E, Jenei ZS, Nagy Z, Merkely B, Zima E, Cai A, Dworakowski R, Gibbs T, Piper S, Jegard N, Mcdonagh T, Gegenava M, Dementieva II, Morozov YUA, Barsanti C, Stea F, Lenzarini F, Kusmic C, Faita F, Halonen PJ, Puhakka PH, Hytonen JP, Taavitsainen JM, Yla-Herttuala S, Supit EA, Carr CA, Groenendijk BCW, Gorsse-Bakker C, Panasewicz A, Sneep S, Tempel D, Van Der Giessen WJ, Duncker DJ, Rys J, Daraio C, Dell'era P, Paloczi J, Pigler J, Eder A, Ferdinandy P, Eschenhagen T, Gorbe A, Mazo MM, Amdursky N, Peters NS, Stevens MM, Terracciano CM. Poster session 2Morphogenetic mechanisms290MiR-133 regulates retinoic acid pathway during early cardiac chamber specification291Bmp2 regulates atrial differentiation through miR-130 during early heart looping formationDevelopmental genetics294Association of deletion allele of insertion/deletion polymorphism in alpha 2B adrenoceptor gene and hypertension with or without type 2 diabetes mellitus295Association of G1359A polymorphism of the endocannabinoid type 1 receptor (CNR1) with coronary artery disease (CAD) with type 2 diabetes mellitusCell growth, differentiation and stem cells - Vascular298Gamma-secretase inhibitor prevents proliferation and migration of ductus arteriosus smooth muscle cells: a role of Notch signaling in postnatal closure of ductus arteriosus299Mesenchymal stromal-like cells (MLCs) derived from induced pluripotent stem (iPS) cells: a promising therapeutic option to promote neovascularization300Sonic Hedgehog promotes mesenchymal stem cell differentiation to vascular smooth muscle cells in cardiovacsular disease301Proinflammatory cytokine secretion and epigenetic modification in endothelial cells treated LPS-GinfivalisCell death and apoptosis - Vascular304Mitophagy acts as a safeguard mechanism against human vascular smooth muscle cell apoptosis induced by atherogenic lipidsTranscriptional control and RNA species - Vascular307MicroRNA-34a role in vascular calcification308Local delivery of a miR-146a inhibitor utilizing a clinically applicable approach attenuates neointima formation after vascular injury309Long noncoding RNA landscape of hypoxic endothelial cells310Specific circulating microRNAs levels associate with hypertension, hyperglycemia and dysfunctional HDL in acute coronary syndrome patientsCytokines and cellular inflammation - Vascular313Phosphodiesterase5A up-regulation in vascular endothelium under pro-inflammatory conditions: a newly disclosed anti-inflammatory activity for the omega-3polyunsaturated aatty acid docosahexaenoic acid314Cardiovascular risk modifying with extra-low dose anticytokine drugs in rhematoid arthritis315Conversion of human M-CSF macrophages into foam cells reduces their proinflammatory responses to classical M1-polarizing activation316Lymphocytic myocarditis coincides with increased plaque inflammation and plaque hemorrhage in coronary arteries, facilitating myocardial infarction317Serum osteoprotegerin level predictsdeclined numerous of circulating endothelial- derived and mononuclear-derived progenitor cells in patients with metabolic syndromeGrowth factors and neurohormones - Vascular320Effect of gastrin-releasing peptide (GRP) on vascular inflammationSignal transduction - Heart323A new synthetic peptide regulates hypertrophy in vitro through means of the inhibition of nfkb324Inducible fibroblast-specific knockout of p38 alpha map kinase is cardioprotective in a mouse model of isoproterenol-induced cardiac hypertrophy325Regulation of beta-adrenoceptor-evoked inotropic responses by inhibitory G protein, adenylyl cyclase isoforms 5 and 6 and phosphodiesterases326Binding to RGS3 and stimulation of M2 muscarinic acetylcholine receptors modulates the substrate specificity of p190RhoGAP in cardiac myocytes327Cardiac regulation of post-translational modifications, parylation and deacetylation in LMNA dilated cardiomyopathy mouse model328Beta-adrenergic regulation of the b56delta/pp2a holoenzyme in cardiac myocytes through b56delta phosphorylation at serine 573Nitric oxide and reactive oxygen species - Vascular331Oxidative stress-induced miR-200c disrupts the regulatory loop among SIRT1, FOXO1 and eNOS332Antioxidant therapy prevents oxidative stress-induced endothelial dysfunction and Enhances Wound Healing333Morphological and biochemical characterization of red blood cell in coronary artery diseaseCytoskeleton and mechanotransduction - Heart336Novel myosin activator, JSH compounds, increased myocardial contractility without chronotropic effect in ratsExtracellular matrix and fibrosis - Vascular339Ablation of Toll-like receptor 9 causes cardiac rupture after myocardial infarction by attenuating proliferation and differentiation of cardiac fibroblasts340Altered vascular remodeling in the mouse hind limb ischemia model in Factor VII activating protease (FSAP) deficiencyVasculogenesis, angiogenesis and arteriogenesis343Pro-angiogenic effects of proly-hydroxylase inhibitors and their potential for use in a novel strategy of therapeutic angiogenesis for coronary total occlusion344Nrf2 drives angiogenesis in transcription-independent manner: new function of the master regulator of oxidative stress response345Angiogenic gene therapy, despite efficient vascular growth, is not able to improve muscle function in normoxic or chronically ischemic rabbit hindlimbs -role of capillary arterialization and shunting346Effect of PAR-1 inhibition on collateral vessel growth in the murine hind limb model347Quaking is a key regulator of endothelial cell differentiation, neovascularization and angiogenesis348"Emerging angiogenesis" in the chick chorioallantoic membrane (CAM). An in vivo study349Exosomes from cardiomyocyte progenitor cells and mesenchymal stem cells stimulate angiogenesis in vitro and in vivo via EMMPRINEndothelium352Reciprocal regulation of GRK2 and bradykinin receptor stimulation modulate Ca2+ intracellular level in endothelial cells353The roles of bone morphogenetic proteins 9 and 10 in endothelial inflammation and atherosclerosis354The contribution of GPR55 to the L-alpha-lysophosphatidylinositol-induced vasorelaxation in isolated human pulmonary arteries355The endothelial protective ACE inhibitor Zofenoprilat exerts anti-inflammatory activities through H2S production356A new class of glycomimetic drugs to prevent free fatty acid-induced endothelial dysfunction357Endothelial progenitor cells to apoptotic endothelial cell-derived microparticles ration differentiatesas preserved from reduced ejection fractionheart failure358Proosteogenic genes are activated in endothelial cells of patients with thoracic aortic aneurysm359Endothelin ETB receptors mediate relaxing responses to insulin in pericardial resistance arteries from patients with cardiovascular disease (CVD)Smooth muscle and pericytes362CX3CR1 positive myeloid cells regulate vascular smooth muscle tone by inducing calcium oscillations via activation of IP3 receptors363A novel function of PI3Kg on cAMP regulation, role in arterial wall hyperplasia through modulation of smooth muscle cells proliferation364NRP1 and NRP2 play important roles in the development of neointimal hyperplasia in vivo365Azithromycin induces autophagy in aortic smooth muscle cellsCoagulation, thrombosis and platelets368The real time in vivo evaluation of platelet-dependent aldosterone prothrombotic action in mice369Development of a method for in vivo detection of active thrombi in mice370The antiplatelet effects of structural analogs of the taurine chloramine371The influence of heparin anticoagulant drugs on functional state of human platelets372Regulation of platelet aggregation and adenosine diphosphate release by d dimer in acute coronary syndrome (in vitro study)Oxygen sensing, ischaemia and reperfusion375Sirtuin 5 mediates brain injury in a mouse model of cerebral ischemia-reperfusion376Abscisic acid: a new player in cardiomyocyte protection from ischaemia?377Protective effects of ultramicronized palmitoylethanolamide (PEA-um) in myocardial ischaemia and reperfusion injury in vivo378Identification of stem cell-derived cardiomyocytes using cardiac specific markers and additional testing of these cells in simulated ischemia/reperfusion system379Single-dose intravenous metformin treatment could afford significant protection of the injured rat kidney in an experimental model of ischemia-reperfusion380Cardiotoxicity of long acting muscarinic receptor antagonists used for chronic obstructive pulmonary disease381Dependence antioxidant potential on the concentration of amino acids382The impact of ischemia-reperfusion on physiological parameters,apoptosis and ultrastructure of rabbit myocardium with experimental aterosclerosisMitochondria and energetics385MicroRNA-1 dependent regulation of mitochondrial calcium uniporter (MCU) in normal and hypertrophied hearts386Mitochondrial homeostasis and cardioprotection: common targets for desmin and aB-crystallin387Overexpression of mitofusin-2 (Mfn2) and associated mitochondrial dysfunction in the diabetic heart388NO-dependent prevention of permeability transition pore (MPTP) opening by H2S and its regulation of Ca2+ accumulation in rat heart mitochondria389G protein coupled receptor kinase 2 (GRK2) is fundamental in recovering mitochondrial morphology and function after exposure to ionizing radiation (IR)Gender issues392Sex differences in pulmonary vascular control; focus on the nitric oxide pathwayAging395Heart failure with preserved ejection fraction develops when feeding western diet to senescence-accelerated mice396Cardiovascular markers as predictors of cognitive decline in elderly hypertensive patients397Changes in connexin43 in old rats with volume overload chronic heart failureGenetics and epigenetics400Calcium content in the aortic valve is associated with 1G>2G matrix metalloproteinase 1 polymorphism401Neuropeptide receptor gene s (NPSR1) polymorphism and sleep disturbances402Endothelin-1 gene Lys198Asn polymorphism in men with essential hypertension complicated and uncomplicated with chronic heart failure403Association of common polymorphisms of the lipoprotein lipase and pon1 genes with the metabolic syndrome in a sample of community participantsGenomics, proteomics, metabolomics, lipidomics and glycomics405Gene expression quantification using multiplexed color-coded probe pairs to determine RNA content in sporadic cardiac myxoma406Large-scale phosphorylation study of the type 2 diabetic heart subjected to ischemia / reperfusion injury407Transcriptome-based identification of new anti-inflammatory properties of the olive oil hydroxytyrosol in vascular endothelial cell under basal and proinflammatory conditions408Gene polymorphisms combinations and risk of myocardial infarctionComputer modelling, bioinformatics and big data411Comparison of the repolarization reserve in three state-of-the-art models of the human ventricular action potentialMetabolism, diabetes mellitus and obesity414Endothelial monocyte-activating polypeptide-II improves heart function in type -I Diabetes mellitus415Admission glucose level is independent predictor of impaired left ventricular function in patients with acute myocardial infarction: a two dimensional speckle-tracking echocardiography study416Association between biochemical markers of lipid profile and inflammatory reaction and stiffness of the vascular wall in hypertensive patients with abdominal obesity417Multiple common co-morbidities produce left ventricular diastolic dysfunction associated with coronary microvascular dysfunction, oxidative stress and myocardial stiffening418Investigating the cardiovascular effects of antiretroviral drugs in a lean and high fat/sucrose diet rat model of obesity419Statins in the treatment of non-alcoholic steatohepatitis (NASH). Our experience from a 2-year prospective study in Constanta County, Romania420Epicardial adipose tissue as a predictor of cardiovascular outcome in patients with ACS undergoing PCI?Arterial and pulmonary hypertension423Dependence between heart rhythm disorers and ID polymorphism of ACE gene in hypertensive patients424Molecular mechanisms underlying the beneficial effects of Urocortin 2 in pulmonary arterial hypertension425Inhibition of TGf-b axis and action of renin-angiotensin system in human ascending aorta aneurysms426Early signs of microcirculation and macrocirculation abnormalities in prehypertension427Vascular smooth muscle cell-expressed Tie-2 controls vascular tone428Cardiac and vascular remodelling in the development of chronic thrombo-embolic pulmonary hypertension in a novel swine modelBiomarkers431Arrhythmogenic cardiomyopathy: a new, non invasive biomarker432Can circulating microRNAs distinguish type 1 and type 2 myocardial infarction?433Design of a high-throughput multiplex proteomics assay to identify left ventricular diastolic dysfunction in diabetes434Monocyte-derived and P-selectin-carrying microparticles are differently modified by a low fat diet in patients with cardiovascular risk factors who will and who will not develop a cardiovascular event435Red blood cell distribution width assessment by polychromatic interference microscopy of thin films in chronic heart failure436Invasive and noninvasive evaluation of quality of radiofrequency-induced cardiac denervation in patients with atrial fibrillation437The effect of therapeutic hypothermia on the level of brain derived neurotrophic factor (BDNF) in sera following cardiopulmonary resustitation438Novel biomarkers to predict outcome in patients with heart failure and severe aortic stenosis439Biological factors linking depression and anxiety to cardiovascular disease440Troponins and myoglobin dynamic at coronary arteries graftingInvasive, non-invasive and molecular imaging443Diet composition effects on the genetic typing of the mouse ob mutation: a micro-ultrasound characterization of cardiac function, macro and micro circulation and liver steatosis444Characterization of pig coronary and rabbit aortic lesions using IV-OCT quantitative analysis: correlations with histologyGene therapy and cell therapy447Enhancing the survival and angiogenic potential of mouse atrial mesenchymal cells448VCAM-1 expression in experimental myocardial infarction and its relation to bone marrow-derived mononuclear cell retentionTissue engineering451Advanced multi layered scaffold that increases the maturity of stem cell-derived human cardiomyocytes452Response of engineered heart tissue to simulated ischemia/reperfusion in the presence of acute hyperglycemic conditions453Serum albumin hydrogels prevent de-differentiation of neonatal cardiomyocytes454A novel paintbrush technique for transfer of low viscosity ultraviolet light curable cyan methacrylate on saline immersed in-vitro sheep heart. Cardiovasc Res 2016. [DOI: 10.1093/cvr/cvw149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Soon E, Crosby A, Southwood M, Yang P, Tajsic T, Toshner M, Appleby S, Shanahan CM, Bloch KD, Pepke-Zaba J, Upton P, Morrell NW. Bone morphogenetic protein receptor type II deficiency and increased inflammatory cytokine production. A gateway to pulmonary arterial hypertension. Am J Respir Crit Care Med 2016; 192:859-72. [PMID: 26073741 DOI: 10.1164/rccm.201408-1509oc] [Citation(s) in RCA: 101] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Mutations in bone morphogenetic protein receptor type II (BMPR-II) underlie most cases of heritable pulmonary arterial hypertension (PAH). However, disease penetrance is only 20-30%, suggesting a requirement for additional triggers. Inflammation is emerging as a key disease-related factor in PAH, but to date there is no clear mechanism linking BMPR-II deficiency and inflammation. OBJECTIVES To establish a direct link between BMPR-II deficiency, a consequentially heightened inflammatory response, and development of PAH. METHODS We used pulmonary artery smooth muscle cells from Bmpr2(+/-) mice and patients with BMPR2 mutations and compared them with wild-type controls. For the in vivo model, we used mice heterozygous for a null allele in Bmpr2 (Bmpr2(+/-)) and wild-type littermates. MEASUREMENTS AND MAIN RESULTS Acute exposure to LPS increased lung and circulating IL-6 and KC (IL-8 analog) levels in Bmpr2(+/-) mice to a greater extent than in wild-type controls. Similarly, pulmonary artery smooth muscle cells from Bmpr2(+/-) mice and patients with BMPR2 mutations produced higher levels of IL-6 and KC/IL-8 after lipopolysaccharide stimulation compared with controls. BMPR-II deficiency in mouse and human pulmonary artery smooth muscle cells was associated with increased phospho-STAT3 and loss of extracellular superoxide dismutase. Chronic lipopolysaccharide administration caused pulmonary hypertension in Bmpr2(+/-) mice but not in wild-type littermates. Coadministration of tempol, a superoxide dismutase mimetic, ameliorated the exaggerated inflammatory response and prevented development of PAH. CONCLUSIONS This study demonstrates that BMPR-II deficiency promotes an exaggerated inflammatory response in vitro and in vivo, which can instigate development of pulmonary hypertension.
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Affiliation(s)
- Elaine Soon
- 1 Department of Medicine, University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, United Kingdom.,2 Pulmonary Vascular Diseases Unit, Papworth Hospital, Cambridge, United Kingdom
| | - Alexi Crosby
- 1 Department of Medicine, University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Mark Southwood
- 2 Pulmonary Vascular Diseases Unit, Papworth Hospital, Cambridge, United Kingdom
| | - Peiran Yang
- 1 Department of Medicine, University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Tamara Tajsic
- 1 Department of Medicine, University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, United Kingdom.,3 James Black Centre, Cardiovascular Division, King's College London, London, United Kingdom; and
| | - Mark Toshner
- 1 Department of Medicine, University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Sarah Appleby
- 1 Department of Medicine, University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Catherine M Shanahan
- 3 James Black Centre, Cardiovascular Division, King's College London, London, United Kingdom; and
| | - Kenneth D Bloch
- 4 Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Joanna Pepke-Zaba
- 2 Pulmonary Vascular Diseases Unit, Papworth Hospital, Cambridge, United Kingdom
| | - Paul Upton
- 1 Department of Medicine, University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Nicholas W Morrell
- 1 Department of Medicine, University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, United Kingdom
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Proudfoot A, Juss J, Appleby S, Morley P, Cordy J, Bayliffe A, Hind M, Chilvers E, Griffiths M, Summers C. S99 Effects Of Differential Tnf Receptor Signalling In Modulating Neutrophil-endothelial Interactions In The Pulmonary Microvasculature. Thorax 2014. [DOI: 10.1136/thoraxjnl-2014-206260.105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Close R, Gray S, Bennett S, Appleby S, Khan F, Payne C, Oliver I. What are the costs and benefits of patient notification exercises following poor infection control practices in dentistry? Public Health 2013; 127:1021-7. [DOI: 10.1016/j.puhe.2013.04.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Revised: 02/13/2013] [Accepted: 04/24/2013] [Indexed: 11/16/2022]
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Appleby S. Stress urinary incontinence: issues and answers for women. Ostomy Wound Manage 1999; 45:44-8, 50-3. [PMID: 10085971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Women's healthcare issues have become increasingly important. Specific healthcare issues, including management of high blood pressure, obesity, and menopause have been on the forefront for years. Today, urinary incontinence in women of all ages is seen as a major healthcare concern. The impetus for this increased awareness began in 1988 at the National Institutes of Health Consensus Conference on Adult Urinary Incontinence, which was followed by the publication of the Guideline for Adult Urinary Incontinence by the Agency for Health Care Policy and Research in 1992. Since that time, there has been an increased focus on the problem of urinary incontinence. Many hope that more women will seek professional guidance for the evaluation and management of urinary incontinence as a result of this increased awareness. Healthcare professionals need to be current on the various options available for the management of urinary incontinence, particularly stress urinary incontinence, as it commonly affects women.
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Affiliation(s)
- S Appleby
- Surgical Nursing Division, Penn State Geisinger Health System, USA
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Shen YT, Woltmann RF, Appleby S, Prahalada S, Krause SM, Kivilghn SD, Johnson RG, Siegl PK, Lynch JJ. Lack of beneficial effects of growth hormone treatment in conscious dogs during development of heart failure. Am J Physiol 1998; 274:H456-66. [PMID: 9486248 DOI: 10.1152/ajpheart.1998.274.2.h456] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The effects of chronic treatment with growth hormone (porcine GH, 0.56 mg.kg-1.day-1 s.c.) were examined in dogs with heart failure induced by rapid ventricular pacing (240 beats/min) for 4 wk. Fourteen conscious dogs were studied 2-3 wk after surgical instrumentation with catheters in the descending aorta and left atrium, a pressure gauge in the left ventricle (LV), a flow probe around the ascending aorta, pacing leads on the ventricular free wall and left atrium, and ultrasonic crystals on the opposing anterior and posterior endomyocardium of the LV. GH treatment for 4 wk significantly increased both body weight and plasma insulin-like growth factor 1 (IGF-1) compared with vehicle-treated dogs (P < 0.01, +2.0 +/- 0.5 vs. +0.3 +/- 1.1 kg; 1,043 +/- 218 vs. 241 +/- 64 ng/ml, respectively). However, the changes in resting LV systolic (i.e., both isovolumic and ejection phases) and diastolic function (i.e., isovolumic relaxation time constant tau) and the systemic vascular resistance were similar for the GH- and vehicle-treated groups during the development of heart failure. LV contractile reserve, assessed with step infusion of isoproterenol or dobutamine challenge, was markedly attenuated after heart failure, but there were no differences between the GH- and vehicle-treated groups. During the progression of heart failure, the increases in plasma atrial natriuretic peptide correlated (P < 0.01) directly with left atrial pressure and inversely with LV circumferential fiber shortening. However, GH treatment did not substantially modify these relationships. In addition, renal function and myocardial ultrastructure at the advanced stage of heart failure also showed similar changes for the GH- and vehicle-treated groups. We conclude that in conscious dogs during the development of congestive heart failure produced by rapid ventricular pacing, GH at a dose that increases body weight and plasma IGF-1 levels does not affect LV performance or systemic vascular dynamics.
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Affiliation(s)
- Y T Shen
- Department of Pharmacology, Merck Research Laboratories, West Point, Pennsylvania 19486, USA
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Ahmad N, Guo L, Mandarakas P, Farah V, Appleby S, Gibson T. Headspace gas-liquid chromatographic determination of dithiocarbamate residues in fruits and vegetables with confirmation by conversion to ethylenethiourea. J AOAC Int 1996; 79:1417-22. [PMID: 8946720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Ethylene-bis-dithiocarbamate (EBDC) residues were determined as carbon disulfide (CS2) by an improved headspace gas-liquid chromatographic (GLC) procedure. Among 837 samples of 30 agricultural commodities tested, 43% contained residues above the detection limit for the method: 100% of broccoli samples; 80% of cabbage, kiwifruit, and grape samples; and 71% of cucumber samples. Most of the residues in kiwifruit were on or near the skin. Elimination of false-positive detections by the improved method was confirmed with kiwifruit in 2 independent procedures. Whole fruits were washed with 5% EDTA to remove surface residues of EBDC. Analysis of washes for CS2 by the headspace procedure after treatment with acidic stannous chloride and for ethylene thiourea by LC after prolonged treatment at 60 degrees C qualitatively identified the EDTA-soluble residues as EBDC. Although the improved method does not produce false-positive results, peak area responses of CS2 and the internal standard, thiophene, are influenced by chemical composition of the matrix. With matrixes high in sugar or lipids, the apparent CS2 content may be overestimated by 4-fold. Accurate determination of EBDC residues in these sample types requires appropriate adjustments to matrixes.
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Affiliation(s)
- N Ahmad
- Biological and Chemical Research Institute, New South Wales Agriculture, Rydalmere, Australia
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Ahmad N, Guo L, Mandarakas P, Appleby S, Bugueno G. Passive diffusion through polymeric membranes: a novel cleanup procedure for analysis of azinphos-methyl and azinphos-ethyl residues in fruits and vegetables. J AOAC Int 1995; 78:1450-4. [PMID: 8664581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
A novel procedure is described for simple removal of coextractives prior to analysis of fruits and vegetables for azinphos-methyl and azinphos-ethyl residues. The solvent extract is concentrated, placed in a polymeric membrane tube, and then dialyzed in cyclohexane. Both azinphos-methyl and azinphos-ethyl diffuse into the surrounding solvent while coextractants remain inside the membrane. The dialyzing solvent is exchanged during concentration with n-hexane and analyzed without further cleanup by gas-liquid chromatography with a specific thermionic detector. The detection limit for a 25 g grape sample with final volume of extract made to 15 mL was 0.01 mg/kg. Recoveries of both residues from grapes averaged 107% (spike levels of 0.3 to 2.0 mg/kg). From a 20 g spinach sample, recoveries averaged 82% for azinphos-methyl and 72% for azinphos-ethyl when final volume of extract was made to 5 mL (spike levels of 0.1 to 1.0 mg/kg). Recoveries from 20 types of fruits and vegetables (20 g sample spiked at 1 mg/kg for both azinphos-methyl and azinphos-ethyl) were consistently greater than 70%, except for strawberries (61-67%) and avocado (28-34%). The high lipid content of avocado may impede diffusion of azinphos-methyl and azinphos-ethyl through the polymeric membrane. A field evaluation of the procedure showed a strong correlation (r = 0.957) between azinphos-methyl residues on grapes and treatments with 2 spray formulations. The membrane cleanup procedure is a simple and cost-effective alternative to other column or liquid-liquid partitioning procedures for azinphos-methyl and azinphos-ethyl residue analysis.
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Affiliation(s)
- N Ahmad
- New South Wales Department of Agriculture, Biological and Chemical Research Institute, Rydalmere, Australia
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Gibb DM, Faulknall W, Nokes L, Appleby S, Holland FJ, Berry T, Ades AE. Coverage of routine neonatal metabolic screening in children born to women known to be infected with HIV-1. Commun Dis Rep CDR Rev 1995; 5:R123-4. [PMID: 7663606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Unlinked anonymous HIV-1 testing of neonatal samples routinely collected for metabolic screening is now carried out in many parts of the United Kingdom. The purpose of this study was to assess the completeness of screening coverage in infants born to women known to be infected with HIV-1. Research nurses at family HIV clinics in three London hospitals searched for Guthrie cards from all infants born to known infected residents of North East, North West, and South West Thames regions over a 32 month period. If no card was found initially, mothers were approached for more information. Overall coverage was estimated to be 96.4% (94.6% in infants of African origin and 100% in white infants). These figures are similar to recent general population coverage estimates in inner London. We conclude that the anonymous newborn HIV testing programme is providing sufficiently accurate information on both absolute levels and time trends in maternal seroprevalence.
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Affiliation(s)
- D M Gibb
- Great Ormond Street Hospital for Children NHS Trust
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Appleby S. Estimating the cost of a telecommunications network using the fractal structure of the human population distribution. ACTA ACUST UNITED AC 1995. [DOI: 10.1049/ip-com:19951934] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Appleby S, Moore C. HIV/AIDS. Caring for families in the community. Health Visit 1993; 66:438-440. [PMID: 8276624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
Primary health care workers have a vital role in offering advice, support and comfort to families affected by Aids and HIV, write Sue Appleby and Corinne Moore. Here they describe the specialist health visiting service provided in Parkside, west London, for parents and children with HIV infection. But generic health visitors and school nurses must also be aware of the issues and alert to signs of undiagnosed infection as they are likely to be increasingly involved in providing a 'normal' service to families affected by Aids/HIV.
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Affiliation(s)
- T Hla
- Department of Molecular Biology, Holland Laboratory, American Red Cross, Rockville, Maryland 20855
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