Prognosis following interventional therapy for acute myocardial infarction: utility of dipyridamole thallium scintigraphy.

A variety of methods for risk stratification after acute myocardial infarction have been successfully employed, however, little attention has been focused on patients who have received reperfusion therapy. The present report examines the utility of dipyridamole thallium scintigraphy in the prediction of late cardiac death or recurrent myocardial infarction in patients who have received thrombolytic therapy. Prospectively, 71 patients who presented with myocardial infarction and were treated with recombinant tissue plasminogen activator (and frequently percutaneous transluminal coronary angioplasty) were enrolled in the study. The primary end points during the follow-up period of nearly 2 years were recurrent infarction or death, which occurred in 10 patients. Although cardiac events were significantly related to either the performance of late myocardial revascularization or the presence of a residual coronary artery stenosis at discharge, no scintigraphic variable was found to be predictive of myocardial infarction or death. Thus, this report is the first to suggest limitation of scintigraphic techniques with regard to prognostic value in myocardial infarction survivors treated with reperfusion techniques. This selected population may have physiologic differences as compared with post-infarction studies performed before the advent of thrombolytic agents. Caution is therefore advised in extrapolating results of earlier reports to the ever increasing percentage of patients receiving recannalization therapy.     

Use of aspirin, beta-blockers, and lipid-lowering medications before recurrent acute myocardial infarction: missed opportunities for prevention?

BACKGROUND: For patients who have had a previous myocardial infarction (MI), the use of aspirin, beta-blockers, and lipid-lowering agents reduces the risk of recurrent MI and death. OBJECTIVE: To examine trends in and determinants of receipt of these 3 medications before hospitalization for recurrent acute MI (AMI). METHODS: The study population consisted of 1710 patients with a previous history of MI hospitalized with a validated recurrent AMI in all hospitals in Worcester, Mass, during 1986, 1988, 1990, 1991, 1993, and 1995. Logistic regression analyses were used to assess the effect of demographic, clinical, and temporal factors on the receipt of aspirin, beta-blockers, and lipid-lowering medications before hospital admission for recurrent AMI. RESULTS: More than 47% of patients in each study year were not receiving each medication before admission, although significant increases in use were noted over time for aspirin (from 13.5% to 52.6%), beta-blockers (from 33.2% to 44.4%), and lipid-lowering medications (from 0.8% to 11.7%). In multivariate analyses, advancing age was associated with not receiving aspirin (odds ratio [OR], 0.67; 95% confidence interval [CI], 0.51-0.89), lipid-lowering medications (OR, 0.14; 95% CI, 0.08-0.25), and beta-blockers (OR, 0.75; 95% CI, 0.57-1.00), although this effect was of borderline significance for beta-blockers. Being a woman was associated with not receiving aspirin (OR, 0.78; 95% CI, 0.62-0.98) but was positively associated with receiving lipid-lowering medications (OR, 1.59; 95% CI, 1.04-2.43). Coexisting medical conditions and concurrent use of other cardiovascular medications were also associated with receipt of each medication. CONCLUSION: Despite encouraging increases over time, the low absolute levels of receipt of medications shown to be efficacious in the long-term treatment of patients after an MI, and their variation by age and sex, suggest that substantial opportunities may exist to prevent recurrent AMIs through the increased use of aspirin, beta-blockers, and lipid-lowering medications.     

Delayed haemolytic transfusion reaction caused by anti-M antibody in a patient receiving interleukin-2 and interferon for metastatic renal cell cancer

Anti-M is usually a naturally occurring cold-reactive immunoglobulin M (IgM) antibody, often with an immunoglobulin G (IgG) component, and is seldom implicated in delayed haemolytic transfusion reactions (DHTR). However, cases have been reported. In the majority, a DHTR is not suspected until further blood is requested and a new antibody is detected on pretransfusion testing. We describe the case of a young man receiving therapy with interleukin-2 (IL-2) and interferon-alpha (IFN-alpha) for metastatic renal cell cancer who developed a clinically suspected DHTR that was confirmed serologically to be caused by anti-M, reactive at 37 degrees C. We discuss the possible role of his biochemotherapy in the development of the DHTR.     

Severe acute diarrhea

Acute diarrhea is commonly caused by an infection. Severe acute diarrhea warrants immediate medical evaluation and hospitalization. Indications for stool studies include fever; bloody diarrhea; recent travel to an endemic area; recent antibiotics; immunosuppression; and occupational risks, such as food handlers. Noninfectious causes include inflammatory bowel disease, radiation enteritis, and intestinal ischemia. Management of severe acute diarrhea includes intravenous fluid rehydration and empiric antibiotics. Use of antidiarrheal agents is controversial when invasive pathogens are suspected.     

Endotoxin-induced lung maturation in preterm lambs is not mediated by cortisol

Antenatal exposure to glucocorticoids, amnionitis, intraamniotic interleukin (IL)-1alpha, or endotoxin can improve postnatal lung function after preterm delivery. The relationship between early lung maturation and the dose and duration of a proinflammatory stimulus has not been evaluated. The effects of proinflammatory stimuli on fetal plasma cortisol also have not been evaluated. We hypothesized that intraamniotic endotoxin would induce early lung maturation in fetal sheep without increasing fetal cortisol. Intraamniotic injections of 1, 4, 20, or 100 mg of Escherichia coli 055:beta5 endotoxin caused 2-fold increases in compliance, 4- to 5-fold increases in lung gas volumes, and 20-fold increases in alveolar saturated phosphatidylcholine (Sat PC) when given 7 d before preterm delivery at 125 d gestation. Animals treated with 20 mg endotoxin for treatment to delivery intervals of 5 h to 15 d had no significant elevations in cord plasma cortisol levels. Increases in Sat PC in lung tissue and alveolar washes were detected 2 d after endotoxin treatment and lung function improved 4 d after endotoxin treatment. Two doses of endotoxin given 3 and 7 d or 7 and 15 d before treatment resulted in lung maturation responses equivalent to single dose comparison groups without elevations in cortisol. Early lung maturation induced by intraamniotic endotoxin in fetal sheep occurred without an increase in fetal plasma cortisol, indicating that endotoxin promoted lung maturation by a mechanism independent of cortisol.     

Ultra‐deep T cell receptor sequencing reveals the complexity and intratumour heterogeneity of T cell clones in renal cell carcinomas

The recognition of cancer cells by T cells can impact upon prognosis and be exploited for immunotherapeutic approaches. This recognition depends on the specific interaction between antigens displayed on the surface of cancer cells and the T cell receptor (TCR), which is generated by somatic rearrangements of TCR α‐ and β‐chains (TCRb). Our aim was to assess whether ultra‐deep sequencing of the rearranged TCRb in DNA extracted from unfractionated clear cell renal cell carcinoma (ccRCC) samples can provide insights into the clonality and heterogeneity of intratumoural T cells in ccRCCs, a tumour type that can display extensive genetic intratumour heterogeneity (ITH). For this purpose, DNA was extracted from two to four tumour regions from each of four primary ccRCCs and was analysed by ultra‐deep TCR sequencing. In parallel, tumour infiltration by CD4, CD8 and Foxp3 regulatory T cells was evaluated by immunohistochemistry and correlated with TCR‐sequencing data. A polyclonal T cell repertoire with 367–16 289 (median 2394) unique TCRb sequences was identified per tumour region. The frequencies of the 100 most abundant T cell clones/tumour were poorly correlated between most regions (Pearson correlation coefficient, –0.218 to 0.465). 3–93% of these T cell clones were not detectable across all regions. Thus, the clonal composition of T cell populations can be heterogeneous across different regions of the same ccRCC. T cell ITH was higher in tumours pretreated with an mTOR inhibitor, which could suggest that therapy can influence adaptive tumour immunity. These data show that ultra‐deep TCR‐sequencing technology can be applied directly to DNA extracted from unfractionated tumour samples, allowing novel insights into the clonality of T cell populations in cancers. These were polyclonal and displayed ITH in ccRCC. TCRb sequencing may shed light on mechanisms of cancer immunity and the efficacy of immunotherapy approaches. Copyright © 2013 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.     

Genome sequencing of mucosal melanomas reveals that they are driven by distinct mechanisms from cutaneous melanoma

Mucosal melanoma displays distinct clinical and epidemiological features compared to cutaneous melanoma. Here we used whole genome and whole exome sequencing to characterize the somatic alterations and mutation spectra in the genomes of ten mucosal melanomas. We observed somatic mutation rates that are considerably lower than occur in sun‐exposed cutaneous melanoma, but comparable to the rates seen in cancers not associated with exposure to known mutagens. In particular, the mutation signatures are not indicative of ultraviolet light‐ or tobacco smoke‐induced DNA damage. Genes previously reported as mutated in other cancers were also mutated in mucosal melanoma. Notably, there were substantially more copy number and structural variations in mucosal melanoma than have been reported in cutaneous melanoma. Thus, mucosal and cutaneous melanomas are distinct diseases with discrete genetic features. Our data suggest that different mechanisms underlie the genesis of these diseases and that structural variations play a more important role in mucosal than in cutaneous melanomagenesis. Copyright © 2013 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.     

Comparing downstream consequences of normal exercise stress echocardiograms and cardiac computed tomography angiography scans in patients suspected of having of obstructive coronary artery disease: a retrospective cohort study of Tricare beneficiaries

The International Journal of Cardiovascular Imaging - To compare overall number of downstream tests and total costs between negative exercise stress echocardiograms (ESE) or cardiac computed...